Exam 3 Nursing, Exam 4, Exam 2

Bereavement (BS) :

The subjective response experienced by the surviving loved ones.

Nutrition in Metabolism

The sum of all the interactions between an organism and the food it consumes. GI system aids in digestion, absorption, organ function and prevention of illness.

Grief (GT)

The total response to the emotional experience of loss. Permits the pt. to cope w the loss & accept it. A social process & is best shared.

Urination

Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. This occurs when the adult bladder contains be-tween 250 and 450 mL of urine. In children, 50 to 200 mL, stimulates these nerves

3 ML SYRINGE

Use 3ml syringe for amounts needed for whole numbers or if rounded to the tenths place.

Endotracheal tube (ET tube)

a hollow tube inserted in the trachea to establish and maintain a patent airway

Sensory Overload

generally occurs when a person is unable to process or manage the amount or intensity of sensory stimuli. Three factors contribute to sensory overload:

Sensory Deprivation

is a decrease in or lack of meaningful stimuli. Persons often experience alterations in perception, cognition, and emotion.

Impairment of coworker or team member

is most common situation combining unethical, unsafe, unprofessional conduct •Breach of privacy is a growing concern

Hypertensive Emergency

• BP > 180 mmHg systolic, 120 mmHg diastolic • Malignant hypertension • Treatment within 1 hour

FLUIDS

• Blood • Serum • Albumin • Urine • Bile • Hormones • Cerebrospinal fluid you can see it leaking through their noses or ears

• Effects of Perfusion for immobility

• Orthostatic hypotension • Blood pools in lower extremities and there is a decreased efficiency of orthostatic neurovascular reflexes • Patient becomes dizzy, lightheaded, may experience syncope (fainting) due to decreased cerebral perfusion. • If this occurs place in lying position in order to increase cerebral perfusion (protect the brain)

cyanosis

A bluish discoloration of the skin and mucous membranes.

Inflammation

A nonspecific but complex response to reduce the effects of what the body sees as harmful

ASSESSMENT of skin

•Higher the Score -Lower the risk 11 is high risk •Who and When to complete Braden •Scale==== RN •Recognize Risk Factors

Color classification of wounds

•R = red—protect •Y = yellow—cleanse •B = black—debride •Mixed wound—contains components of RY&B wounds treat the most serious color first .•1. Black •2. Yellow •3. Red Debride Black Covered with eschar •Debride•Surgical•Mechanical •Enzymatic•Autolytic

ASSESSMENT lab data for tissue integrity

•WBC •RBC •Platelets •Coagulation Studies •Serum Albumin (Normal, 3.5 -5.0g/dl 2.8 -3.5 g/dl indicate compromised protein status) •Wound cultures/sensitivity

Pressure Ulcer Transparent film

•adhesive plastic -transparent •semi permeable (allows oxygen to wound bed)•impermeable to bacteria and water•protects against bacterial contamination & friction/shearing stage I

Pressure Ulcer Hydrocolloid

•adhesive wafer -waterproof -occlusive seal•change every 7 to 10 days•inside layer has particles to absorb exudate/form gel over wound•absorb small amount exudate•protects against bacterial contamination & friction/shearing •provide moist environment to facilitate healing Østage II -IV -clean -granulating Øautolytic debridement of eschar

Suspending the Heel is Ideal

•tOTALLY relieve pressure on heels •Do not use donut type devices you stage and ulcer but NOT A WOUND

Moral

"Do as I say not as I do." What are your patient's morals? How do they differ from yours? The morals of a community, society, nation, etc.

Triple check system

(1) when you remove the medication from where it is stored, (PULL) (2) when you begin to prepare the medication, (PREP) (3) after you have prepared the medication (PASS)

Which of these interventions is most likely to minimize pain caused by the dressing change?

*.Pre-medicating the patient with an analgesic 30-45 minutes before the intervention* 2.Using distraction techniques to divert the patient during the procedure 3.Placing the patient in a comfortable position in preparation for the change 4.Providing the patient with a thorough explanation of the procedure

Obtaining Professional Liability Insurance

*Occurrence-based coverage* -Covers incidents that occurred while policy was in effect, regardless of when claim made *Claims-made policies* -Provide coverage if incident occurred and claim made during active policy period •Policies may be individual, group, or employer sponsored-Individual coverage provides broadest coverage for policyholder-Employer-sponsored coverage provides narrowest coverage for individual nurse •Nursing students generally required to carry liability insurance for duration of education program-Some programs insure students under broad institutional policy

Disclosure

*Patient's protected health information can be disclosed under certain conditions without patient's express permission* -Providing information to the patient-Providing information to other providers treating patient -Providing information to individuals involved in payment processing, other healthcare operations -When required by law or court order -When necessary to protect public health -When abuse or neglect suspected •Information disclosed should be limited to minimum necessary for situation •Informal patient permission may be enough for providing information to family, friends, others identified by patient •Incidental disclosure may occur, but safeguards should be in place to minimize •Nursing Students •NPAs address duties and responsibilities of nursing students in their state -Includes language allowing nursing students to practice without license while engaged in clinical practicum of approved nursing education program under supervision of qualified faculty

Stress and Coping

*Stress* refers to an event or demand made on the individual/family that causes the individual/family to appraise the event/demand for scope and meaning and to determine whether resources for management are exceeded and whether the event/demand is neutral (no stress), challenging or threatening *Coping* is the person's effort to manage psychological stress Types of Stressors Daily Hassles o Roles of living, work, bills, traffic, neighbors. Internal o physical, spiritual, cognitive, emotional, and psychological well-being of an individual and depends on the satisfaction of these basic human needs Environmental o triggers outside of the individual that demand change or disrupt homeostasis. *The Coping Process* Cognitive Appraisal Maslow's Hierarchy of Need Effective Coping o Problem-focused coping o Emotion-focused coping Reappraisal and Adaptation *Theoretical Models* Response-Based Models o General Adaptive Syndrome Transactional Model o Primary appraisal o Secondary appraisal o Coping o Reappraisal

Changes due to aging on sensory perception

-Ability of the iris to accommodate the darkness decreases -pupil reactions are symmetrical, but less brisk -peripheral vision diminishes -adaptation to light or glare diminishes -accommodation to far away objects improve -accommodation to near objects decreases -visual changes due to loss of elascity and diminishing transparency of the lens -color vision declines (purples and pastels)

Accountability and responsibility

-Accountability •Being answerable to self, others for outcomes of task or assignment •Nurses accountable for own actions and behaviors, may be accountable for actions of others-Subordinates-Trainees -Responsibility• Specific accountability or liability associated with performance of duties of a role •Belongs to the person performing the duties •Ethical nurse can explain rationale behind every action, recognize standards to which nurse will be held

Legal issues include the rights, responsibilities, scope of nursing practice

-As defined by state nurse practice acts -As legislated through criminal, civil laws •All patients have a legal right to expect competent nursing services •Nursing students must be equipped to provide safe nursing care consistent with legal requirements

Diagnosing (Fecal Elimination)

-Bowel Incontinence •Constipation •Risk for Constipation •Perceived Constipation •Diarrhea •Dysfunctional Gastrointestinal Motility *Causes* Risk for Deficient Fluid Volume Risk for Impaired Skin Integrity Situational Low Self-esteem Disturbed Body Image Deficient Knowledge (Bowel Training, Ostomy Management) Anxiety

3 Domains of Learning

-Cognitive learning -" thinking" domain What a patient knows and understands - apply knowledge and end with evaluation. -Affective learning -" feeling" domainIs didvided up into categories that specify the degree of an individual's depth of emotional response to tasks. -Psychomotor learning - "skill" domainAcquisition of skills that require knowledge- demonstration of skill

Factors affecting Voiding (urination)

-Developmental Factors -Psychosocial Factors (anxiety, privacy, normal position, running water) -Fluid and food intake -medications -muscle tone -pathologic conditions -surgical and diagnostic procedures. (spinal anesthetics)

Sensory aids for visual deficits

-Eyeglasses of the correct prescription -adequate lighting including night lights -bright contrasting colors -color code items for easier recognition -braille or books on tape - seeing eye dog

Essential parts of a drug order - seven parts of an order -

-Full name of the client -Date and time the order is written -Name of the drug to be administered -Dosage of the drug -Frequency of administration -Route of administration -Signature of the person writing the order

Principles and Practices of Ethical Decision Making

-Goal of ethical reasoning process: to arrive at a decision that is in patient's best interest, preserves integrity of all people involved -Nurses must weigh competing factors when making ethical decisions -Responsible ethical decision making is rational, systematic, based on ethical principles and codes of ethics •Not based on emotions, intuition, fixed policies, or precedent -First step: determine whether a moral dilemma exists -Moral dilemma meets these criteria •Difficult choice exists between actions that conflict with needs of one or more individuals •There are moral principles or frameworks that can be used to provide justification for one or more of the actions •Choice is guided by a process of weighing reasons •Decision is freely, consciously chosen Choice is affected by personal feeling, particular context of situation -When conditions are met, nurse should proceed with ethical reasoning -When conditions not met, nurse should refer to professional standards of practice for guidance in determining appropriate choice of action

Competency

-Health and wellness promotion -illness prevention -health restoration -caring for the dying

Oral Medication Administration

-Know the 6 rights -Prepare solid tablets or capsules in medicine cup -Only tablets that are pre-scored can be broken in half -use calibrated oral syringe for meds less than 10 ml -allow patients (if they can) to hold solid or liquid meds and take it

Sodium

-Most Abundant cation in ECF -Regulating Water Balance -Must be consumed in our diet Norm 136 - 145 mEq/L

legal records

-Nursing documentation serves as legal record of what occurred -Nurses should document defensively, be inclusive, not rely on their own or patient's memories of details of care

Assessing Urinary Functions

-Nursing history - Physical assesment of the genitourinary system, hydration status (palpating) -Relating the data obtained to the results of any diagnostic tests -assessing urine characteristics (normal urine consists of 96% water and 4% solutes) -urine output (60 ml/h or 1,500 ml/day) *urine ouput below 30 ml/h may indicate low blood volume or kidney malfunction*

Subcutaneous Injections

-Perform hand hygiene - 1 Ml is maximum for all subcutaneous injections - a. length 3/8" - 5/8" b. gauge 24-30 -apply clean gloves -*compress and stretch the skin before injecting* -hold syringe between thumb and index of dom hand (like a dart) -bunch or pinch skin for avg patient and inject needle at a 45-90 degree angle. Release pinched skin when injecting meds *continue to pinch skin when administering medications like insulin pen, heparin, lovenox -inject meds over 30 secs -*FOR OBESE PATIENTS SPREAD THE SKIN AND INJECT AT 90 DEGREE ANGLE* -once done apply gentle pressure and do no massage for heparin and lovenox apply pressure for 30-60 secs -bevel of needle needs to be facing up *SITES TO INJECT* Abdomen Anterior thigh Flank Scapular Buttocks Outer aspect of upper arm If needed, any area of the body can be used as long as the injection site chosen is free of skin lesions, bony prominences, and large underlying muscles or nerves. Absorption rate determined by site Abdomen>arms>thigh>buttocks

Privacy Rule

-Protects •Information that identifies individual •Access to medical records -Requires notice of privacy practices and opportunity for confidential communications -Limits use of medical information beyond sharing among healthcare providers directly involved in patient's care -Prohibits use of personal information for marketing •If patient feels that a healthcare plan or provider has violated patient's rights, may file formal complaint to the violating entity or Office for Civil Rights of DHHS Nurses must maintain understanding of current law to protect patient's privacy, avoid legal repercussions

Guidelines for clinical performance

-Provide safe patient care Understand program and facility policies, procedures before undertaking any clinical assignment -Demonstrate knowledge about patient's condition, interventions, medications, treatments -Perform care only to highest level of nursing knowledge •If unprepared for a clinical assignment, inform instructor -Seek help before beginning procedure if unsure *Nursing students accountable for same standards of care as licensed nurse*

Beneficence

-Requires that ones actions promote good -Includes principle of nonmaleficence •Nurses must do no harm, must safeguard patients •Can be risk of harm in performing interventions intended for good -Patients decides after being informed of potential benefits, risks

Autonomy

-Right to self-determination •Inward autonomy: ability to make choices •Outward autonomy: choices not limited or imposed by others •Patients have right to determine own care -Nurse honors this principle by respecting patient's decisions even if they conflict with what nurse believes is in patient's best interest -No one should be treated as an impersonal source of knowledge, training

Factors associated with medication errors include

-Similar names or packaging -Clonazepam vs Lorazepam, (Klonopin vs Ativan) -Clonidine vs Klonopin (Catapres vs Klonopin) -Those not commonly prescribed -Common med allergy -Antibiotics, opiates, nonsteroidal, anti-inflammatory drugs -Needed lab to ensure non-toxic therapeutic levels -Lithium, warfarin, theophylline, digoxin

AUTOMATIC STOP ORDERS

-When transferred from one service to another -When going to surgery -Orders for routine meds are good for 30 days or the length of hospital stay -Certain meds are OOD (out of date) automatically (pharmacy will indicate this on MAR and will no longer supply the med): antibiotics, anticoagulants (po, SQ, IV) controlled substances

Communicatio for visual deficits

-always announce your presence and identify yourself -stay in the patients field of vision -speak warmly and normal volume -explain before touching patients -explain sounds in the environment -provide them multiple methods to receive info -validate reception and understanding of communication

Contemporary Leadership Theories

-charismatic -transactional -transformational -shared leadership -shared governance

Three types of movements in the Large intestine

-haustral churning involves movement of the chyme back and forth within the haustra. In addition to mixing the contents, this action aids in the absorption of water and moves the contents forward to the next haustra. -colon peristalsis is wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls; it propels the intestinal contents forward. Colon peristalsis is very sluggish and is thought to move the chyme very little along the large intestine. -mass peristalsis is a wave of powerful muscular contraction that moves over large areas of the colon. Usually mass peristalsis occurs after eating, stimulated by the presence of food in the stomach and small in-testine. In adults it occurs only a few times a day.

Calcium

-normal serum level 9-10.5 -Cation most is found in the skeletal system -neuromuscular function cardiac function -blood clotting -Activates enzymes

Which of the following actions is most likely to protect the staff during the dressing change of an infected abdominal wound?

.Beginning antibiotic therapy before the surgical procedure *2.Using appropriate personal protective equipment* 3.Adhering to sterile technique during the intervention 4.Completing the dressing change in an effective, time-efficient manner

Disuse osteoporosis

• decrease in bone density caused by bone resorption, results from lack of weight bearing exercise, decreased muscular activity, complex endocrine and metabolic disturbances. Starts the second of third day of immobilization

Learning is

•An experience that occurs inside the learner .•The discovery of the personal meaning and relevance of ideas •A consequence of experience. •A collaboration and cooperative process .•An evolutionary process that builds on past learning and experiences. •A process that is both intellectual and emotional. •Compliance/Adherence

3 clinical stages of gout

1. Asymptomatic hyperuricemia 2.ACUTE GOUTY ARTHRITIS Acute stage -first stage of gouty arthritis SYMPTOMS: excruciating pain and inflammation of one or more small joints (usually the great toe). ESR usually increased Months and years may pass prior to another attack. Patient is asymptomatic and no abnormalities to joints upon exam 3.CHRONIC and TOPHACEOUS GOUT oDeposits of urate crystals under the skin and within major organs, due to repeated episodes oChronic tophaceous gout is the result of the repeated episodes of acute gout. Urate kidney stones are more common with chronic gout. oChronic gout can occur anywhere between 3 to 40 years after the initial gout symptoms occurred. can be repeated within 3-40 years

Alterations in Respiratory Function

1. Patency (Open airway) Think A, B, C 2. Movement of air in & out of lungs 3. Diffusion of O2 & CO2 between alveoli & pulmonary capillaries 4. Transport of O2 & CO2 via blood to tissues

Five (six) Rights

1. Patient 2. Drug 3. Dose 4. Route 5. Time 6. Documentation *ADDITIONAL RIGHTS* Education of patient Right to refuse Right assessment Right evaluation

Standards for patient advocacy

1. Safeguarding patients' autonomy : ■ Encouraging patients to share and document their goals, preferences, values, and beliefs ■ Supporting patient values and choices even when they conflict with those of individual healthcare providers ■ Providing patients with sufficient, timely information for making informed decisions about healthcare, assuring a match between patients' health information literacy and the information provided 2. Acting on behalf of patients ■ Monitoring the quality and safety of healthcare delivered to the patient ■ Taking action to intervene if the nurse has information that a treatment or intervention may violate the patient's wishes, directives, or best interests, when appropriate ■ Expressing patients' wishes when patients cannot do so for themselves (e.g., during procedures requiring anes-thesia/sedation) ■ Ensuring that patients who are incompetent to make autonomous decisions have appropriate legal representa-tion (e.g., power of attorney, guardianship). 3. Championing social justice in the provision of health-care ■ Helping individual patients achieve healthcare goals by mobilizing resources available in the agency and/or community ■ Acting on behalf of patients at policy and legislative lev-els, both within the agency and at the local, state, or fed-eral level or by advocating to eliminate disparities in any area of healthcare

Upper Airway and Lower Airway

1. Upper airway: Nose, pharynx, larynx i.e., foreign body, food, tongue, secretion 2. Lower airway: Bronchi, lungs, i.e., increased accumulation of mucus or inflammatory exudate.

Preparation for Med Administration The Seven Important Questions

1. What is the name of the medication? 2. What is the purpose of the medication? 3. What effect will the medication have? 4. How long will it take for the med to work? 5. What are the side effects, adverse reactions, &/or signs of over dosage?6. Are there any interactions with the medications that they are taking? 7. Are there any special administration or storage instructions for this medication? Remember: never give a medication if you do not have all of the information that you need to give the medication safely!

When changing a surgical dressing, the appropriate time to don sterile gloves is:

1.After performing the initial hand hygiene. 2.Before removing the inner layer of dressings. *3.After removing the original dressing materials.* 4.Before cleansing the wound with sterile water.

Which of the following interventions can the nurse delegateto ancillary staff regarding the care of a patient with a leg laceration that has been sutured and dressed?

1.Assessing the site for signs of redness or swelling *.Measuring the patient's temperature every 4 hours* 3.Removing the outer dressing when it becomes soiled 4.Opening sterile dressings during the dressing change

Which of the following observations noted of a surgicalsuture line during the initial dressing change is the best indicator of a complication that should be reported to the physician immediately?

1.Edema at the outer edges 2.Bruising around the wound 3.Redness around the sutures *.Frank bleeding from the wound*

Which of the following measures should be taken when the nurse observes additional bloody drainage on the initial abdominal dressing of a patient who had surgery 7 hours ago?

1.Notify the patient's physician of the bleeding. 2.Remove the dressing and assess the wound. 3.Assess the patient for signs of shock. *4.Reinforce the dressing externally.*

Orthostatic Hypotension

1.Place the client in a supine position for 10 minutes or sitting comfortably at edge of bed. 2.After 10 minutes record the patient's pulse and blood pressure. 3.Assist the client to sit at the edge of the bed, record pulse and blood pressure, repeat in the same position after 3 minutes -OR- 4.Have the patient slowly stand (CAREFUL!) and immediately check pulse and blood pressure, repeat in the same position after 3 minutes.

Which of the following actions will minimize the risk of cross-contamination during the cleansing process of an infected abdominal surgical wound?

1.Using sterile water for the cleansing process 2.Using dry gauze to blot the incisional area dry 3Using sterile gloves when cleansing the wound *.Using a new gauze pad for each cleansing stroke*

Nasal Cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.

The nurse is caring for a client from India who has extensive deep tissue damage. The nurse notes that the client is also vegan. Which dietary information should the nurse teach this client to enhance the healing process?

A high-carbohydrate, high-protein diet is best for healing. we need them to have high calories to produce energy to heal tissues Also increase fluid intake

GUIDELINES FOR ADMINISTERING MEDICATIONS ENTERALLY

A liquid form is the preferred drug preparation for enteral tube. If not available as a liquid, tablets can be crushed into a powder and capsules can be opened up. Not be given by enteral tube such as enteric coated, chewable, or sustained/controlled release medications. Medications should not be mixed with formula to make them liquids, to avoid interactions of the combination.

Arteriosclerosis:

A thickening, loss of elasticity, and calcification of arterial walls. The most common cause of Coronary Artery Disease (CAD).

Medication Administration Policy

A written policy should state: Who will give medication What medication will be given Where medication will be given and stored When medication will be given How confidentiality will be maintained. What procedures and forms are to be used for permission and documentation What procedures are used when giving medications (5 rights) What procedure should take place in the event of a medication error or incident

Chloride

98-106 meq/L -major anion ECF -REGUlates serum osmolality -Major component of stomach fluids -buffer in oxygen- carbon dioxide exchange

atelectasis

: A collapse of the alveoli of the lung caused by blockage of bronchioles with mucus or when the amount of surfactant is reduced. Signs & Symptoms • Tachycardia, anxiety, diaphoresis, pleural pain • Dyspnea, tachypnea, decreased oxygen saturation • Dull or absent breath sounds if large area of lung affected • Cyanosis, if severe Causes: Immobility, post-operative pts. with the elderly, smokers, premature births, receiving high level of oxygen. Treatment goals: Re-expand lung and prevent.

PREPARATION and procedure for enteral

A. Determine tube placement before administering any medications .B. Administer medications in a liquid form to prevent tube obstruction. C. Read medication labels carefully before crushing a tablet or opening a capsule D. Do not administer buccal, sublingual, enteric-coated tablets or sustained action medications through an enteral feeding tube. E. Do not mix medications with enteral feeding formula. F. Dissolve crushed tablets, powders, and soft gelatin capsules in warm water. (5-15 mL) Procedure: -Check for residual by aspirating gastric contents. If there is a large volume of aspirate, return aspirate to patient and withhold medication. -Hold syringe 6-18 inches above the head or abdominal area if using NG or PEG tube. -Keep HOB elevated when administering the medication and for 20-30 minutes after the procedure unless contraindicated. -Flush tube before medications are given with 30-50 mL warm H2O or follow agency guidelines. -Give each medication separately. -Rinse the tube with 5 mL of sterile H2O between medications. -Flush tube with 30-50 mL of warm H2O following administration

Beliefs

A. diet- permitted, prepared, fasting, may require specific preparation (kosher) B. illness and health- sin, distress, punishment, evil C. birth and death- rituals, ceremonies, assist fulfilling obligations especially with newborns or young children.

Oral Route (Swallowed) GUIIDELINES

ADVANTAGES: Convenient, Least expensive, Safe, Acceptable, Causes minimal anxiety DISADVANTAGES: Taste, Irritating, Difficult to verify absorption, Patient must be able to swallow CONTRAINDICATIONS: Unconscious, swallowing impaired, gastric suction, NPO 1. Follow medications with water 2. Tablets that are not enteric coated or time-released may be crushed for easier swallowing. 3. Administer effervescent powders and tablets immediately after dissolving in water. 4. Never allow patients to chew or swallow lozenges. 5. Mix powdered drugs with liquids and administer immediately 6. Avoid giving fluids immediately after a patient swallows a syrup. 7. Protect patients against aspiration *WHEN USING A SYRINGE USE A SLIP TIP SYRINGE TO PREVENT INADVERTENTLY ADMINISTERING AN IV*

ADPIE FOR spirituality

Assessment: Two-tiered approach- Does patient accept a spiritual reality? If yes, then: F, I, C, A. May bring objects to the hospital to use in prayer or other religious rituals. Assess further if patient manifests unhealthful spiritual need or is at risk for spiritual distress. Diagnosing: Spiritual or religious distress as the etiology—Fear; Chronic Low or Situational Low Self-Esteem;Ineffective Coping Decisional Conflict CUES: Environment, Behavior, Verbalization, affect and attitude, interpersonal relationships. (Sense of no purpose or joy in life; lack of connectedness to others; misperceived shame and guilt) Planning Supporting patients to practice their religious rituals Helping patients recognize and incorporate spiritual beliefs in health care decision making Helping patients to recognize positive meanings for health challenges Promoting a sense of hope and peace Provide spiritual resources otherwise unavailable, if the pt participates in a formal religion, involve members of the clergy or members of the church, temple, mosque, or synagogue in the plan of care Implementing Providing presence, either family or friends, member of their congregation, provides a sense of well-being sources of faith and hope .Conversing about spirituality Supporting religious practices-providing recognized dietary foods and ritual. Assisting patients with prayer? Referring patients for spiritual counseling Evaluation (always include the patient in evaluating the care provided.) Were expectations met? Were the outcomes successful in developing an increased or restored sese of connectedness with family, and maintaining, renewing, or re-informing a sense of purpose in life. How can spiritual well-being be enhanced? Were patient outcomes achieved? Need for caution when discussing the evaluation of spiritual care SUPPORT CLIENTS EXPERIENCING SPIRITUAL DISTRESS: Allow client to express feelings and thoughts about religious doubt or fears of abandonment; explore with client alternative or past effective religious or spiritual practice as an illness-prevention measure; encourage client to discuss thoughts and feelings with clergy or chaplain as desired.

Nursing Process and Grief :

Assessment: Develop a trusting relationship, Active Listening, Empathy/Open communication, Clarify, Conversations about meaning of loss often lead to other areas assessment, Coping style, Nature of family relationships, Social support systems, Nature of the loss. Diagnoses: Anticipatory grieving, Compromised family coping, Death anxiety , Fear, Impaired comfort, Ineffective denial, Grieving, Complicated grieving, Risk- prone health behavior, Risk for complicated grieving, Hopelessness, Pain (acute or chronic), Risk for loneliness, Spiritual distress, Readiness for enhanced spiritual well-being, Interrupted family processes Planning: Focus of care for the dying patient, Comfort, Preserving dignity & quality of life, Providing family with emotional, social, and spiritual support

Spiral of Gout or steps

Attack starts Crystals form WBC attack crystals pop the cell cell releases proteins Proteins call in more WBC and cause inflammation or pain Proteins lower ph making it possible for more crystals to form

Leadership

Autocratic Democratic Laissez-faire Bureaucratic Situational

Conditions Affecting Movement of Air

Breathing patterns: Rate, volume, rhythm, and effort of breathing. Rate: Tachypnea: Pain, fever, exercise, metabolic acidosis, hypoxemia. Bradypnea: CNS depressant medications, sedatives, increase intracranial pressure and resp. alkalosis.

Factors that affect defecation

- development - diet - fluid intake and output - activity - psychological factors - Defecation habits - medications - diagnostic procedures - anesthesia and surgery - pathologic conditions - pain

1. Hematologic System 2. Cardiovascular System 3. Respiratory System

The delivery of O2 and removal of CO2 requires the integration of these systems:

Increased use of the Valsalva Maneuver immobility

The immobilized person uses arms and upper body more when moving in bed.

Creatinine

The kidneys maintain the blood creatinine in a normal range. Elevated creatinine level signifies, impaired kidney function or kidney disease As the kidneys become impaired, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys Norm= 0.5-1.2 mg/dL

Sensory Reception

The process of receiving stimuli or data through the sensory organs. It can be either external or internal

Mood and Affect

The term mood is defined as the way a person feels . Subjective Data The term affect is defined as the observable response a person has to his or her own feelings. Objective Data

Delegation

The transfer of responsibility and authority for an activity to a competent individual Delegating to unlicensed personnel (UAP) are identified with a variety of titles: Certified Nursing Assistant, nurse extenders, home health aides, medical technicians, orderlies, and surgical technicians Examples of tasks that may be delegated -Vital, weights, transfers/ambulation, postmortem care, baths, and feedings *EXAMPLES OF TASKS THAT MAY NOT BE DELEGATED* Assessment, interpreting data, nursing diagnosis, evaluating care, patient education, care of invasive lines, and creating a nursing care plan Right Tast right circumstance right person right direction or communication right supervision and evaluation

Huff Cough

Type of forced expiration with an open glottis to replace coughing when pain limits normal coughing

Types of wounds

Untreated wounds are usually seen shortly after an injury (e.g., scene of an accident, in the Emergency department). •Control severe bleeding •Prevent infection •Control swelling and pain •Assess depth, quality, type

• Urinary elimination effects of immobility

Urinary stasis—stagnation of urine in kidneys or bladder • Bladder looses muscle tone making it difficult to empty • Lying position impedes emptying from bladder and kidney • Urinary stasis will contribute to formation of renal calculi and urinary tract infection • Immobilized patient more likely to have indwelling catheter, increased incidence of UTI • Urinary elimination effects Renal calculi—kidney stones • Increased calcium in urine • Urinary stasis, good medium for the calcium to precipitate and form stones • Symptoms - flank pain, Nausea, vomiting, hematuria • Bowel elimination effects • Constipation • Fecal impaction Lack of exercise • Muscle weakness • Decreased fluid intake • Inability to assume normal position for defecation, lack of privacy • Inability to maintain personal habits • Psychneurologic effects • Decrease in quality and quantity of sensory input • Patient has an increased awareness of limitations imposed by immobility • Can lead to behavioral, social, emotional, and intellectual changes Examples of changes are: boredom, depression, impaired coping, feeling of helplessness/hopelessness, changes in sleep/wake cycle

Urination

Urine collects in bladder. -Pressure stimulates special stretch receptors in bladder wall -Stretch receptors transmit impulses to spinal cord voiding reflex center. -Internal sphincter relaxes, stimulating urge to void. -If appropriate, conscious portion of the brain relaxes external urethral sphincter muscle. -Urine is eliminated through urethra at the meatus. -Pelvic floor tone aids voluntary control.

Ampule (open system)

Use Filter needle -Tap top of ampule to dislodge fluid in the neck -place gauze pad or unopened alcohol prep around the neck of ampule -snap neck of ampule away from body -use a filter needs -insert filter needle through opening in center of ampule. Hold ampule upside down or place on a flat surface -do not expel any air into vial -expel any air or excess medication into sink -make sure medication dose is accurate after expelling air or excess medication -Cover filter needle with a sheath. Remove filter needle -Replace with appropriate size needle for injection

Injections: Intradermal

Used for skin testing (TB, allergies) Slow absorption from dermis Skin testing requires the nurse to be able to clearly see the injection site for changes. Use a tuberculin or small hypodermic syringe for skin testing. Angle of insertion is 5 to 15 degrees with bevel of the needle pointed up. A small bleb will form as you inject. If it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid.

IM SITES

Ventrogluteal: An index finger on the anterior superioir illiac spine and the palm on the greater trochanter forming a "V" Vastus Lateralis: palpate one hand breath below the greater trochanter and one hand breath above the patella on the lateral side of the leg Deltoid: smallest muscle and close the radial vein and artery

Sensory Perception

Sensory perception is understanding gained through the use of one of the senses such as sight, touch, taste, or hearing -Awareness and interpretation of stimili that takes place in the brain What can cause alterations of sensory perceptions -normal aging process -genetic or congenital factors -underlying illness ot injury -distractions -lifestyle factors

Western vs Easterm

Western -Health is the absence of disease. -Prefer specialty practitioners. -Recognition of foods affects on the biophysical processes/function -Independence, individualism, freedom are valued. -Use of first names promotes familiarity, trust. Eastern -Health is a state of harmony, mind, body & spirit. -Healers from their culture of origin (herbalists, curandos) -Belief that food can restore imbalances. -Emphasis on family, community, group acceptance. -Use of first name is a sign of disrespect.

Nursing Management for spirituality

Spirituality cannot be handled like a physical condition or diagnosis. Nurses are spiritual care generalists. Spiritual care experts are chaplains, clergy, other spiritual mentors. Primary spiritual caregivers are friends and family. Never assume knowledge of client's beliefs; ask the client. Nursing Management The Joint Commission requires all patients admitted to inpatient facilities be assessed for SPIRITUAL AND CULTURAL influences on health.

Illness Behavior

Stage 1: Symptom Experiences Stage 2: Assumption of sick role Stage 3: Medical Care Contact Stage 4: Dependent Client Role Stage 5: Recovery or Rehabilitation

Stages of the wound healing process

Stage 1—Vascular, increased blood flow to the area (hyperemia), will see redness, warmth, and edema. Increased blood flow increases delivery of nutrients Stage 2—Exudate, neutrophils attack and destroy organisms and remove dead tissue through phagocytosis Stage 3—Tissue Repair, replacement of lost tissues or repair of damaged tissues by inducing the remaining healthy cells to divide. If scar tissue forms, function lost.

Religious versus Spiritual

When caring for patients, the nurse must understand the difference between religion and spirituality. Religious care helps individuals A. Maintain their belief systems and worship practices. B. Develop a relationship with a higher being. C. Establish a cultural connectedness with the purpose of life. D. Achieve the balance needed to maintain health and well-being. For example; cultural practices near the time of death are important for clients and their families. The nurse should respect the client and family wishes.

Diagnostics for inflammation

White Blood Count (WBC) •utilized to determine if neutrophil, lymphocytes or macrophages elevated C-Reactive protein (CRP) and erythrocyte sedimentation rate (ESR) •Non-specific blood tests that confirm presence of inflammation •ALT/AST-Medications for inflammation are metabolized in the liver. These are liver enzymes •BUN/Creatinine/Creatinine clearance-Medications for inflammation are excreted via the kidneys *The more the inflammation the higher these numbers will be*

Vial (closed system)

Wipe off rubber with alcohol prep -draw up air in syringe that is equal to the amount of medication that needs to be administered -inject airspace into vial -invert vial -expel any excess medication into vial before removing needle -expel any air in syringe

Potassium

-Major cation in ICF -Maintains ICF osmolality -Transmits nerves and other electrical impulses -Skeletal, cardiac, smooth muscle function Regulates acid base balance -must be ingested daily Normal 3.5 - 5 mEq/L

Planning

Steps in developing cultural competence 1 Become aware of own cultural heritage; ASKED mnemonic model page 2 Become aware of patient's heritage and health traditions. LEARN model 3 Become aware of adaptations patient made to live in another culture 4 Form nursing plan with the patient that incorporates cultural beliefs about health maintenance, protection, and restoration Nurses must recognize the root causes of gender inequities when designing a nursing plan of care. It is important that nurses not allow their own gender bias or preconceived beliefs to affect their ability to assess and plan appropriate care. Nurses should be alert to practices in their work environment that impact the quality of care offered to individuals of any ethnic group.

Safety Precautions: Oxygen

Oxygen is not a flammable gas but it does support combustion (rapid burning). Due to this the following rules should be followed: Place "Oxygen in Use" sign on door. Do not smoke on premises. Keep O2 system 10 feet from open flame. Use grounded electrical equipment. Keep cylinders secured & upright. Don't store cylinders in hot places. Be sure there is enough O2 in tank before transporting. Avoid using petroleum based products. Do not use aerosol sprays in the same room as the oxygen equipment. Turn off oxygen immediately when not in use. Oxygen is heavier than air and will pool in fabric making the material more flammable. Therefore, never leave the nasal prongs or mask under or on bed coverings or cushions while the oxygen is being supplied. Use only water based lubricants. Check nasal cannula and mask skin sites for irritation and skin breakdown.

Medications affecting urination

Particularly the ones affecting the autonomic nervous system, interfere with normal urination process and may cause retention. Diuretics (chlorothiazide and furosemide) increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream. *Specific meds affecting urination* • Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine • Antidepressant and antipsychotic agents, such as tricyclic antidepressants and MAO inhibitors • Antihistamine preparations, such as pseudoephedrine (Actifed and Sudafed) • Antihypertensives, such as hydralazine (Apresoline) and methyldopa (Aldomet) • Antiparkinsonism drugs, such as levodopa, trihexyphenidyl (Artane), and benztropine mesylate (Cogentin) • Beta-adrenergic blockers, such as propranolol (Inderal) • Opioids, such as hydrocodone (Vicodin)

Patient Centered Care

Patient is in control and a full partner; care is based on respect for patient's preferences, values, and neefs - consider patients cultural preferences -Provide pain relief -Involve families in care

Uneven Distribution of Services

Patients not always able to assess own need for care Results in delays in care Geographic populations underserved Increasing number of specializing healthcare providers Solutions Affordable Care Act Medicare for older adults Medicaid for those with lower incomes CHIP for children Local health departments Community health centers Change patient perception of need Physician shortages expected to worsen

Intramuscular injections

Perform hand hygiene -Deltoid 1 ml is max - ventrogluteal 4ml is max for well developed muscle -vastus lateralis- 4 ml is max for well developed muscle - a. length 1-3" b. gauge 20-23 -See if the skin is too hard or sensitive so palpate also look for inflamation or edema -apply clean gloves Deltoid -do not Z TRACK -spread skin taut -inject needle at 90 degree angle -aspirate to see any blood return (discard needle if there is) -inject needle at 1ml per 10 sec slowly Ventrogluteal and Vastus Lateralis -Z track method -position ulnar side of dominant hand below injection site and pull skin laterally away from the site. Hold this position until injection has been completed. Hold this position for another 10 sec after medication has been injected -inject at 90 degree angle -aspirate needle inject at 1 ml per 10 sec -wait 10 secs while needle is still in after injected -do not massage area Characteristics Faster absorption than Subcutaneous route Many risks, so verify injection is justified Insertion is at a 90 degree angle Deltoid absorption is fastest, then vastus lateralis, then ventrogluteal If rotating the best choice is the site appropriate for the VOLUME being given. Using the opposite from the last injection site will allow the first site time for recovery.

Cultural Concepts/Vocabulary

Subculture-usually composed of people who have a distinct identity and yet are related to a larger cultural group. Ethnocentrism-the belief that one's own culture or way of life is better than that of others. Multicultural-the presence or support of several distinct cultural or ethnic groups within a society. Prejudice-preconceived opinion that is not based on reason or actual experience. Diversity-the fact or state of being different Racism-prejudice, discrimination, or antagonism directed against someone of a different race based on the belief that one's own race is superior Race-classification of people according to shared biologic characteristics and physical features Discrimination-the differential treatment of individuals or groups. Ethnicity- belonging to a specific group of individuals who share a common social or cultural heritage. Generalizations-statements about common cultural patterns Nationality-the sovereign state or country where an individual has citizenship Stereotyping-making the assumption than an individual reflects all characteristics with being a member of a group. Religion- a system of beliefs, practices, and ethical values about divine or superhuman power worshipped as the creator and ruler of the universe.

Manifestations of Stress

Physiological Indictors o Respiratoryo Cardiac o Integumentary o Gastrointestinal o Urinary o Ophthalmic o Neurological o Musculoskeletal o Endocrine Psychological Indicators o Fear, o Anxiety o Anger o Depression Cognitive Indicators o Problem solving o Cognitive Structuring o Suppression o Self-Control o Fantasizing

Medication Administration

Prescriber's role: Orders medication Pharmacist's role: Prepares and distributes medication Nurse's role: Assess patient's ability to self-administer, determine whether patient should receive, administer medication correctly, and closely monitor effects THIS TASK CAN NOT BE DELEGATED

WAYS TO REDUCE INJECTION PAIN

Techniques to Minimize Pain When Administering Intradermal, Intramuscular, and Subcutaneous Injections: Encourage patient to relax the injection area. Use a new needle and syringe for each injection. Avoid injecting into sensitive or hardened tissue. Prevent antiseptic from clinging to needle during insertion by waiting until prepped skin area is completely air dried. Reduce puncture pain by "darting" needle quickly into tissue. Use as small a gauge needle as appropriate

Privacy Versus Confidentiality

Privacy -Right of individuals to keep their personal information from being disclosed -The individual decides when, where, with whom to share health information Confidentiality -Assurance patient has that private information will not be disclosed without patient's consent -Applies to both nature of information obtained from patient and how information is treated once disclosed -Obtaining information •Only information pertinent to health status of patients to whom nurse assigned -Disclosing information •Only to individuals directly involved in patient's healthcare -Advocating for confidentiality •Do not participate in gossip •Curb others from participating in breaches of confidentiality •Nurses should be familiar with their agency's policies and procedures for protecting patient privacy, confidentiality

Spiritual Health

Purposeful and pleasurable Seeks out life-sustaining and life-enriching options Occurs by choice Persons intentionally seek to strengthen their spiritual muscles. Prayer, meditation, service, fellowship with similar believers, learning from a spiritual mentor, worship, study, fasting Faith and hope are closely linked to a person's spiritual well being, providing an inner strength for dealing with illness and disability. Hope is energizing and helps a person deal with life stressors.

Cultural models of nursing Care

The HEALTH Traditions Model ( explores what one does to maintain, protect, and restore health (physical, mental, and spiritual) within a framework of one's own ethnoreligious cultural heritage. (Table 18-1) .Cultural phenomena that can affect health include environmental control (health practices and remedies), biologic variations (physical and genetic), social organization (holidays, special events such as births and funerals), communication (greetings, gestures, smiling, eye contact), personal space (body language and distance), and time orientation (punctuality, announced versus surprise visits from family and friends)

Elements of Medication Reconciliation

The Joint Commission (2013a) requires medication reconciliation to occur : • At admission: Collect a list of the medications the client is currently taking when he or she is admitted to the hospital or seen in an outpatient setting (p. 5). • At discharge: Consult the client's home medication list and current medication orders, and compare them with the discharge medication orders to ensure that medications are appropriately continued, resumed, or discontinued. Provide the client (or family) with written information about the medications the client should be taking when discharged from the hospital or outpatient setting. Explain the impor-tance of managing medication information to the client upon discharge (p. 6). The IHI (2011a) recommends that medication reconciliation also occur when transferring the client from one level of care to another. That is, compare the medication information the client brought to the hospital with the current medications ordered for the client by the hospital and to the transfer orders to identify and resolve any discrepancies (p. 9)

Religion

Religion is associated with a specific system of practice associated with various denomination, sect, or form of worship. Organized worship beliefs and practices, spiritual expression, collective study of scripture, performance of rituals, ways of taking care of one's spirit, offers a sense of community. Religious Practices Nurses should know Holy Days- religious observation-fasting, extended prayer, meditation or reflection. Sacred Texts and Symbols - metals, jewelry, writings (strength, peace)Prayer and Meditation- may need quiet time

Gold Standard of Pain

Remember: The patient's self-report is the most reliable indicator of pain.

Failure to thrive

Can occur at any age Risk Factors/Environmental factors Profile of family characteristics Adequate nutrition Socioeconomic status Illness and Injury and Violence Substance Abuse Environmental factors Screenings

Alterations to Mood and Affect

Categorized into several subtypes o Each has own pattern of symptoms Depressive disorders o Sadness, discouragement, hopelessness o Anhedonia, sleep disturbances Bipolar disorders o Mania, hypomania, depressive symptoms Anxious distress associated with both *Screening Tools* Beck Depression Inventory Mood Disorders Questionnaire (MDQ) Center for Epidemiological Studies-Depression Scale for Children (CES-DC) Geriatric Depression Scale (GDS) Edinburgh Postnatal Depression Scale (EPDS) *Diagnostics Screening* Thyroid Function Electrolyte, Urinalysis, Toxicology Liver Function Kidney Function Pregnancy Test

Hyperventilation

Causes an increased movement of air in & out of the lungs. Rate & depth increases with more CO2 eliminated than produced. A response to stress, or anxiety or metabolic acidosis (Kussmaul's Respirations)

Lack of a Usual Source of Care

Children, families Better served with usual source Seek ongoing relationship, high comfort level

Diet Progression and Therapeutic Diets

Clear liquid= jello, popsicle, apple juice, coke, coffee can be without milk, tea Full liquid= ice cream, milkshake, liquid, no chunks, jello, pudding, includes clear liquids Pureed= baby foods, Mechanical soft= mashed potatoes, for people with dentures High fiber Regular= no restrictions at all

Menopause

Clinical Manifestations: What are the signs and/or symptoms/complications? Vasomotor instability Osteoporosis Reduced vaginal lubrication Increase in vaginal pH Growth Defined Growth rates vary during different stages. Example: height and weight

6 C's of caring in nursing

Compassion Competence Confidence Conscience Commitment Comportment

Ego-Defense Mechanisms

Compensation Denial Displacement Identification Intellectualization Introjection Minimization Projection Rationalization Repression Assessment Behavioral Cognitive Emotional Physical

Chapter 35. Undergraduate and Graduate Nursing Education Degree Programs§3503. Definitions

Competency—an expected level of performance that results from an integration of knowledge, skills, abilities, and judgment. Knowledge encompasses the scope of practice, standards of practice, standards of professional performance, content from science and the humanities, practical experience and personal capabilities. Skills include psychomotor, communication, interpersonal, and diagnostic skills. Ability is the capacity to act effectively and requires listening, integrity, self-knowledge of strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback. Judgment includes critical thinking, problem solving, ethical reasoning, and decision-making.

Diagnostic Tests for Oxygenation

Complete Blood Count (CBC): Arterial Blood Gases (ABG's): Sputum: Chest X-ray (CXR): T.B. Test: Pulmonary Function Test: Bronchoscopy: Thoracentesis: Physical Examination: Pulse Oximetry: Indirectly measures the oxygen saturation of the arterial blood. Normal Range: Sites: Finger tip, earlobe (Has a greater accuracy at lower saturation levels and least affected by peripheral vasoconstriction.), bridge of nose, forehead, & sole of an infant's foot.

Components to a Nutritional Assessment

Component - anthropometric (nursing health history and physical examination) useful in identifying malnutrition and other nutrition problems Screening Data -height -weight -ideal body weight -body mass index Additional in-depth data -Triceps skinfold (TSF) -Mid-arm circumference (MAC) -Mid-arm muscle circumference (MAMC)

Nephrons of Kidney

Contain 6 parts -Glomerulus -Bowman's capsule -proximal convoluted tubule -loop of henle -distal convoluted tubule -collecting duct

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.

Delirium

Delirium characterized by confusion, rapidly changing mental states, disorientation, and personality changes. Delirium typically results from treatable physical or mental health problems. Reduced awareness o Limited attention span, focusing, limited response Impaired thinking skills o Impaired memory, disorganized, disorientated, impairments Changes in behavior o Hyper or hypoactive, hallucinations, agitation, fear, mood swings, withdrawal Assessment - Delirium Observation and Patient Interview o Age, pass medical Hx, infection or fever, vision/hearing, ETOH/drug, toxin, diet, Hx depression or mood disorders, recent changes in life . Physical Exam o Vital signs, perfusion, oxygenation, intracranial regulation, infection, inflammation, medication administration. Implementation - Delirium Independent o Safe environment o Orient patient o Limit stimuli o Educate o Dignity Collaborative o Community o Pharmacologic

Kübler-Ross' Stages of Dying (DABDA):

Denial Stage: Patient: "No, not me!" Nurse: Anger Stage: Patient: "Why, me?" Nurse: Bargaining Stage: Patient: If you will do this, then I will..." or "Yes, but..." Nurse: Depression Stage: Patient: "What's the use? It is me!" Nurse: Allow the pt. to express sadness. Acceptance Stage: Patient: "I've tied up all loose ends and can go in peace." or "It's my death and part of my life." Nurse:

Spiritual Distress

Disturbance in the belief or value system that provides strength, hope and meaning of life Factors that may contribute to spiritual distress- Physiologic problems, treatment-related concerns, situational concerns NANDA characteristics: expresses lack of hope, meaning and purpose in life, inability to forgive self. Feels abandoned by or having anger toward God. Refuses interaction with friends, family. Nurse does not try to resolve patient's spiritual problem. Nurse offers support to patient. Be open and "present". Care for physical needs.

THE DON'TS OF MEDICATION ADMINISTRATION

Do NOT be distracted when preparing medications. Do NOT give drugs poured by others. Do NOT pour drugs from containers with labels that are difficult to read, or whose labels are partially removed or fallen off. Do NOT transfer drugs from one container to another. Do NOT pour drugs into your hand. Do NOT give medications for which the expiration date has passed. Do NOT guess about drugs and drug doses. Ask when in doubt. Do NOT use drugs that have sediment, are discolored, or are cloudy (and should not be). Do NOT leave medications by the bedside or with visitors. Do NOT leave prepared medications out of sight. Do NOT give drugs if the patient says he or she has allergies to the drug or drug group. Do NOT call the patient's name as the sole means of identification. Do NOT give the drug if the patient states the drug is different from the drug he or she has been receiving. Check the order. Do NOT re-cap contaminated needles. Do NOT mix with large amount of food (pudding, ice cream or applesauce, etc.) Do NOT give with foods that are contraindicate

HOME CARE CONSIDERATIONS

Does patient have money and a means of travel to get prescriptions filled. Determine if special teaching or administration strategies are required. Assess client's or family members': 1. knowledge of drug therapy 2. sensory function 3.ability to read medication labels Instruct patient or family members regarding: purpose of medications, dosage schedule, common side effects, who should be called about problems, what to do about missed doses, drug safety (discard outdated drugs and keep drugs out of the reach of children)Devise learning aids if needed. Examples: Egg cartons with color-coded sections for medications to take at specific times Commercially prepared divided containers to provide one week of medication at a time.

Psychosocial

Erikson's Eight Stages of Development Young adulthood à 18-25 years Intimacy vs Isolation Adulthood à 25-65 years Generativity vs Stagnation Maturity à 65 years-death Integrity vs Despair *on the contrast* according to the book Young Adulthood (18-40 years) Middle Adulthood (40-65 years) Late Adulthood (>65 years)

Debridement of heel eschar

Eschars (scabs) often form over heel ulcers. They may slow their healing considerably. Knowing when to remove an eschar is important when treating a heel ulcer. Removing an eschar will cause the heel ulcer to worsen if blood flow is not satisfactory. Why is this? Because an eschar protects the tissue under it. If blood flow is limited and the eschar is removed, infection can enter the open wound. This is whyan eschar should only be removed if blood flow is adequate. If blood flow is not good enough, the eschar should stay in place until blood flow is restored or until it falls on its own.

Exemplar: Assessment for Cognition, Stress, Mood

Establish Therapeutic Rapport Nonjudgmental Small time intervals for assessment Refocus on topic at hand

QSEN Competency Safety

Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds and dangerous abbreviation) Demonstrate effective use of technology and standardized practices that support safety and quality Value the contributions of standardization/reliability to safety Appreciate the cognitive and physical limits of human performance

Responsibilities of Healthcare Team

Expected Outcomes:Dosage calculations are accurate. Medications are prepared using safe procedures. Medications are accurately labeled and safely administered .Complications and errors of medication administration are prevented. PATIENT SAFETY IS PRIMARY GOAL!!!

Allergy Identification:

FOLLOW FACILITY POLICY, REASSESS WITH EACH ADMINISTRATION

Maintaining Patient Safety

Failure to observe and take appropriate action -Falls •Nurse liable for malpractice if patient is injured as direct result of nurse action or inaction leading to fall •Most hospitals, nursing homes have policies regarding use of safety devices- -Ignoring patient complaints •Type of malpractice: failure to observe and take appropriate action -Incorrect identification of patient •Can lead to occurrences such as surgery on wrong patient Renders nurse liable for malpractice Poor communication coupled with a negative outcome increases chance of Malpractice Claim

Pressure Ulcers Risk Factors

Friction & Shearing •Immobility / pressure •Inadequate nutrition •Fecal & Urinary incontinence •Decreased Mental Status •Diminished Sensation •Excessive Body Heat •Advanced Age •Chronic Medical Conditions

Regulatory Agencies

Function to help providers and agencies operate Agencies typically enforce laws. Individuals regulated by licensure boards Federal, State & Local Agencies The U.S. Department of Health and Human Services Occupational Safety and Health Administration (OSHA) State health policies, regulations mandated in conjunction with federal policies State divisions of health and human services Local health departments

Local Signs of Inflammation

HEAT IMPAIRED FUNCTION INDURATION PAIN EDEMA REDNESS

Stages of Pressure Ulcers

HOW DEEP IS THE ULCER •Stage I—non blanchable erythema of intact skin. Erythema that does not go away and does not blanch •Stage II—partial-thickness skin loss . Partial thickness skin loss involving the epidermis or dermis or both. shallow crater, abrasion or blister •Stage III—full-thickness skin loss; not involving underlying fascia. Full thickness skin loss involving damage or necrosis of the subcutaneous tissue which may extend to fascia. Deep crater, may have undermining •Stage IV—full-thickness skin loss with extensive destruction. Full thickness skin loss with extensive destruction and tissue necrosis. Damage to muscle, bone & tendon, undermining may be present •Unstageable—base of ulcer covered by slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in wound bed.

Normal of Mood and Affect

Healthcare professionals describe affect in terms of: o Appropriateness o Rangeo Stability o Intensity o Congruence Normal range of mood is general stable

Manages Care and Delivery Models

Healthcare providers and agencies work together to provide care that uses limited resources -the goal is to decrease cost and increase patient satisfaction, in part by promoting health and delivering preventative services -Health maintenance organizations (HMOs) and preferred provider organizations (PPO) are both committed to managed care *Case Management* Coordination of patient care itilizing health and social services to meet the patient's needs *Patient Focused Care* healthcare that is focused on the expressed physical and emotional needs of the patient *Differentiated Practice* The nurse's educational preparation and skill set determine how to use the nurse *Shared Governance* nursing staff participate with administrative personnel in making, implementing, and evaluating patient care policies *Team Nursing* Individualized nursing care to a group of patients by a team led by a nurse

Prevention of pressure ulcers

Identify patients at risk and implement strategies to decrease risk Promote proper nutrition Maintain skin hygiene Avoid SKIN trauma provide supportive devices Prevention Goal •promote proper nutrition •Proper diet •High in protein •Enriched with vitamins A-B-D •Enrich with minerals as zinc-iron •Proper hydration - monitor patients weight and serum albumin -avoid hot water -minimal friction -apply moisturizer •avoid skin trauma Manage Tissue Load & Minimize shear and friction •Head Of Bed < 30 degrees -avoid side-lying position •Wrinkle free foundation to lie or sit •Use skin barriers •lotions/gels/long sleeves/soft socks •Proper positioning & transfer techniques (LIFT not drag) •lift sheet/trapeze •Prevent sustained pressure •frequent position change at least every 2 hours •written turning schedule •if possible change position 10-15 degrees every 15-30 minutes GOALS •provide supportive devices •Overlay mattress -foam/gel •Replacement mattress •Alternating air mattress •High/Low air loss mattress•Heel protection •4 P's (Pain, position, potty, perfusion)

Postmortem Care

Identify the pt. using double identifiers. Treat with respect. Check for any cultural or religious practices, minister requests, etc. Follow the hospital policy for care i.e. remove lines, tubes etc. if no autopsy, etc. Unless otherwise ordered, remove the pts. clothes, and other personal affects and secure and document contents. Close pt. eyes. Leave dentures in or insert. Close mouth. Place pt. supine, with wrists crossed palms down on abdomen or at the sides of the pt.or with a pillow beneath the head. Wash soiled or bloody areas only. Place in clean gown, comb hair, if possible, cover with clean sheet to neck. Place water proof pads under perineal area. Clean the pts. room. Offer for loved ones to view the pt. Describe how the pt. looks or how they may feel i.e. cold, etc .Allow for religious or cultural customs. Have fly. sign funeral home release, sign for personal affects, etc. After the significant others leave the room, obtain a shroud or postmortem pack, morgue stretcher. Loosely tie the crossed wrists and label shroud tags, attach to toe, wrists, and the outside of the shroud. Place the body onto morgue stretcher with blue pads under perineal area. Wrap the body with the shroud and tie around neck, around hips, and around ankles. Cover shrouded body with a sheet and transfer to morgue with funeral home release and death certificate.

Effects on Oxygenation of immobility

Immobility affects all three parts of respirations • Pulmonary ventilation or the inflow and outflow or air between the atmosphere and the alveoli • Diffusion of oxygen and carbon dioxide between the alveoli and pulmonary capillaries • Transport of oxygen and carbon dioxide via the blood to and from the cells • Oxygenation effects Decrease expansion of lungs • bed presses against chest and decreases chest movement • abdominal organ pushes against the diaphragm • muscle atrophy affects respiratory muscles Reduced gas exchange in alveoli • Blood and mucus pools in dependent areas of the lungs which are less effectively ventilated. • Coughing mechanism is impaired due to weakened muscles, inability to inhale and decreased ciliary movement. Therefore cannot expectorate mucus. • Oxygenation complications • Atelectasis- • collapse of lobe or entire lung. • Hypostatic Pnuemonia • pooled secretions provide an excellent media for bacterial growth Impairs oxygen and carbon dioxide exchange in the alveoli

How to use inclusive and neutral language

Instead of: "Do you have a wife/husband or boy/girlfriend?" Ask: "Do you have a partner?" or "Are you in a relationship?" "What do you call your partner?" Instead of "How may I help you sir?" use "How may I help you?" Familiarize commonly used terms and the diversity of identities within the transgender community, for example FTM and MTF

Principles of Wound Healing

Intact skin is the first line of defense against microorganisms. •Surgical asepsis is used in caring for a wound. •The body responds systematically to trauma of any of its parts. •An adequate blood supply is essential for normal body response to injury .•Normal healing is promoted when wound is free of foreign material. •The extent of damage and the person's state of health affect wound healing .•Response to wound is more effective if proper nutrition is maintained. Factors Effecting Wound Healing •Developmental Considerations (age) -children and healthy adults heal more rapidly •Circulation and oxygenation -adequate blood flow is essential •Nutritional status-healing requires adequate nutrition •Lifestyle •Medications/Health Status •Wound condition •Wound stress

Skin Integrity and factors affecting integrity

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. •Genetics •Age (New bornsand Elderly differences; inadequate sub Q tissue, Hi risk for deep tissue damage from shearing & pressure) •Underlying health •nutrition •Newborns and infants have thinner skin than adults. •Older adults begin to develop thinner, less elastic skin .•Chronic illness and their treatments. •Corticosteroid topical treatment •Medications can increase sensitivity to sunlight (antibiotics, chemotherapeutics, psychotropics)

Classifying Types of Wounds

Intentional or Unintentional Open or Closed Acute or Chronic Depth Superficial (leg abrasion) Partial Thickness

Standards of care

Joint commission American Nurses Association National League for Nursing

Isometric

Kegel exercise Muscles contract without moving the joint • Involves alternately tightening or tensing muscles, then relaxing, without moving body parts • Increase muscle mass, tone, and strength thus decreasing the potential for muscle wasting • Increased circulation to the involved muscle only

Pathologic conditions affecting urination.

Kidney Disease. Abnormal amounts of protein or blood cells may be present in the urine, or the kidneys may virtually stop producing urine altogether, a condition known as renal failure. Heart and circulatory disorders such as heart failure, shock, or hypertension can affect blood flow to the kidney. If abnormal amounts of fluid are lost through an-other route (e.g., vomiting or high fever), the kidneys retain water and urinary output falls. Processes that interfere with the flow of urine from the kidneys to the urethra affect urinary excretion.

Leadership and management

Leaders- individuals who use interpersonal skills to influence others to accomplish specific foals. Leaders can be formal or informal Formal Leaders- are selected by an organization and given official authority to make decisions and to act Informal Leaders- are not officially appointed to direct the activities of others, but are recognized by a group as a leader Managers- (In contrast to leadership management is always formal)- Individuals who hold an official position within an organization. Example- director, supervisor, manager, and administrative

Three stages of moral development

Level 1: Caring for oneself Level 2: Caring for others Level 3: Caring for self and others. "in the realization that just as inequality adversely affects both perspectives in an unequal relationship, so too violence is destructive for everyone involved."

The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of their disease processes. Which are the primary laboratory testing the nurse will assess prior to initiation of this type of therapy? Select all that apply.

Liver function tests Creatine clearance

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood • Early signs of hypoxia: Increased restlessness, anxiety and confusion. • Rapid pulse • Rapid, shallow respirations, dyspnea • Substernal or intercostal retractions • Nasal flaring • Fatigue • Cyanosis (Late sign)

Health Beliefs and Practices

Magico Religious- super natural forces, getting ill is God's will, magic can cause illness. Scientific or Biomedical- physical control, manipulated by humans. Illness caused by germs. Cured by antibiotics etc.. Holistic- nature maintains balance- off balance =illness Folk Medicine - belief and practices related to healing illnesses. Consultation and treatment take place in the community. It is important for the nurse to obtain information about folk or family healing practices that may have been used before or while the client used conventional medical treatment. Often clients are reluctant to disclose the use of home remedies to HCP for fear of being laughed at or rebuked.

catheter

Male Patient has to be in supine position while female patients need to be dorsal recumbent position -Insert catheter in makes about 7-9 inches -female is about 2-3 inches

Managing Patient care

Managed care is a healthcare delivery system that focused on decreasing costs and improving outcomes for groups of patients

GUIDELINES FOR CHANGING THE NEEDLE ON A SYRINGE

Medication is known irritant or stains the skin Multiple puncturing of rubber stopper of vial Needle becomes contaminated Anticoagulants as recommended by literature *Changing Needle on a Syringe* P—Prepare the injection P—Pull the plunger down C—Change the needle P—Push the plunger up

Factors Contributing to Hypertension

Modifiable Factors ■ High sodium intake ■ Low potassium, calcium, and magnesium intake ■ Obesity ■ Excess alcohol consumption ■ Insulin resistance ■ Low activity level ■ Hypothyroidism ■ Low vitamin D levels ■ Depression ■ Tobacco use Nonmodifiable Factors ■ Genetic factors ■ Age ■ Family history ■ Race

Lower Urinary Tract

bladder, urethra, pelvic floor

expiration (exhalation)

breathing out

Orthopnea

ability to breathe only in an upright position

apnea

absence of breathing

Nebulization

adds moisture or medications to inspired air by mixing particles of varying sizes with the air

Which of the following actions is most likely to protect the staff during the dressing change of an infected pressure ulcer?

1.Beginning antibiotic therapy before the dressing change *2.Using appropriate personal protective equipment* 3.Adhering to sterile technique during the intervention 4.Completing the dressing change in an effective, time-efficient manner

Infants

250-500 ml a day during first year. May urinate about 20 times a day. Has a specific gravity of 1.008, since newborns have immature kidneys, they are unable to concentrate urine very effectively.

Urgency

feeling the need to urinate immediately

Types of Wound Healing

first (primary) intention secondary intention tertiary intention

Parenteral Nutrition

giving nutrients through a catheter inserted into a vein like the subclavian vein Needs to be sterile TPN Total parenteral nutrition is a yellow solution that contains nutrients and no meds This is not a long term thing Needs to be check by XRAY To see placement Complication: can knick the tip of the lung causing it to collapse, this happens only during insertion, Air amylase can happen patient might sleep on the tube osmotic diuresis and dehydration sterile dressing technique needs to be used

Pressure Ulcer Hydrogel

glycerin or water based -jelly like sheet (granules or gel) nonadhesive •requires secondary occlusive dressing •liquefies necrotic tissue or slough •rehydrate wound bed •fill in dead space Øpressure ulcers with necrotic tissue or slough

Dysphagia

condition in which swallowing is difficult or painful can put thickeners in water to help to swallow Aging, stroke, cerebral palsy, ALS, diabetic neuropathy, head and neck cancer, trauma, surgical resections Complications = Silent aspiration (resulting in pneumonia) always have your suction ready to go so that if anything happens youre prepared crush meds they cost more and need care longer lung sounds are pretty bad like wheezing cuz stuff gets stuck in there *Airway*

Malpractice:

conduct deviating from standard of practice dictated by a profession •Nursing malpractice cases associated with liability risks of nursing, increasingly well-informed patients •Nurse must know regulations of healthcare providers, institutions, payment system, federal and state laws that pertain to healthcare •Strategies to Prevent Incidents of Professional Negligence •Continuing issue of medication errors -Must be clearly documented, discussed with patient •Other problematic situations-Communicating care concerns, key information about patient's condition -Ensuring that physicians' orders are clear (Always Read Back Orders that are Verbal) -Understanding how to use equipment -Providing appropriate mentoring, assessment, care plans for patients Accurate documentation and reporting provide information to support or refute allegations of malpractice -Nursing documentation serves as legal record of what occurred -Nurses should document defensively, be inclusive, not rely on their own or patient's memories of details of care

hemoptysis

coughing up blood

Enuresis

involuntary discharge of urine. The pelvic floor muscles are under voluntary control and are important in controlling urination (continence). These muscles can be weakened by pregnancy, childbirth, chronic constipation, decrease in estrogen (menopause). being overweight, aging. lack of general fitness.

diaphragmatic breathing

involves the contraction and re-laxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm's contraction and downward movement

Gout

is a common form of arthritisthat usually affects *one* joint at a time often the big toe joint. Repeated bouts of gout canlead to gouty arthritis. Considered a systemic disease (no cure) Uric Acid crystal deposits in joints and other body tissues and causes inflammation.

incentive spirometry

is a device that measures how deeply you can inhale (breathe in). It helps you take slow, deep breaths to expand and fill your lungs with air. This helps prevent lung problems, such as pneumonia. The incentive spirometer is made up of a breathing tube, an air chamber, and an indicator

Fecal Impaction

is a mass or collection of hardened feces in the folds of the rectum. Impaction results from prolonged retention and accumulation of fecal material. A client will experience diarrhea and no normal stool. Administration of medications such as anticholinergics and antihistamines will increase the client's risk in the development of fecal impaction. Laxatives or enemas are usually given to ensure removal of the barium

Altruism

is concern for the welfare and well-being of oth-ers. In practice, altruism is reflected in the nurse's con-cern for the welfare of patients, other nurses, and other healthcare providers.

Aphasia

is defined as a language disorder that results from damage to the brain. Expressive aphasia is the inability to name common objects or express simple ideas in words or writing. Receptive aphasia is the inability to understand written or spoken language. Global aphasia is the inability to express and understand language.

Oliguria

is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Although oliguria may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure

Exudate

is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. The nature and amount of exudate vary according to the tissue involved, the intensity and duration of the in-flammation, and the presence of microorganisms.

Meconium

is the first fecal material passed by the newborn, normally up to 24 hours after birth. It is black, tarry, odorless, and sticky. Transitional stools, which follow for about a week, are generally greenish yellow; they contain mucus and are loose.

Upper urinary tract

kidneys and ureters

A full liquid diet would include which foods?

milkshakes with no chunks gelatin popsicles ice cream NOT CREAMED POTATOES

Sublingual and Buccal Meds

need to be placed under the tongue (sublingual) in cheeks (buccal) these are strong meds and need to dissolve slowly in the mouth and not swallowed

Local Infection signs

oRedness oSwelling oInduration oEdema oWarmth oPainoLoss of function oExudate oSerous oFibrinous oPurulent (thick, opaque, black green discharge) not normal oHemorrhagic/ sanguineous

Systemic infection

oTemperature greater than 100.4 or less than 96.8 oPulse >90 oTachypnea oWBC >12 oMalaise oFatigue oFever oLeukocytosis oTachycardia

Insulin syringe

only use insulin syringes for insulin and never round off insulin to the next highest unit

Urinary incontinence (UI)

or involuntary leakage of urine or loss of bladder control, is a health symptom, not a disease. It is only normal in infants (more common in women). The four main types of UI are stress urinary incontinence (weak pelvic floor caused by laughing or any body movement), urge urinary incontinence, mixed urinary incontinence (both stress and urgency), and overflow incontinence. enlarged prostate is an example in men

Dysuria

painful urination caused by Urinary tract inflammation, infection, or injury Hesitancy, hematuria, pyuria (pus in the urine), and frequency

Values and personal values

personal beliefs about truths and worth of behaviors, thought, objects -Beliefs: an interpretation or conclusion that one accepts as true •Values also reflect beliefs based on a pattern of mental views established by prior experience-Individuals may hold beliefs based on own experience that differ from beliefs of a group to which they belong •Personal values developed through individual observation, experience -May be strongly influenced by social traditions and cultural, ethnic, religious norms experienced within the person's family, associated groups

Management Functions

planning- decision making and problem solving are inherent in planning organizing- identify the work of the organization, divide the labor, develop the chain in command, and assigning authority directing- the process if getting the organization's work done controlling- comparing actual results with projected results with projected results, similar to the evaluation step in the nursing process

Muscle atrophy

decrease in muscle mass caused by decreased muscle fiber contraction. As much as 20% loss after one week of bedrest, results in decreased strength and endurance.

hypoventilation

decreased rate or depth of air movement into the lungs

Metabolism

describes the processes of biochemical reactions occurring in the body's cells that are necessary to produce energy, repair cells, and maintain life."

Urinary control

develops at the age of 2-5 years

continuous positive airway pressure (CPAP)

device used to treat sleep apnea; includes a mask that fits over the sleeper's nose and mouth, which is connected to a pump that pumps air into the person's airways, forcing them to remain open

Dyspnea

difficulty breathing or shortness of breath (running)

micturition, voiding, urination

process of emptying the urinary bladder

Health Care Organizations

purposefully designed, structured social system developed for the delivery of health care services by specialized workforces to defined communities, populations, or markets All have a common purpose to provide a healthcare delivery service Each has a unique mission unique financial classification unique ownership *Health Care Organizations* Public Health Physician Office Ambulatory Care Centers Occupational Health Clinics Hospitals Subacute Care Facilities Extended (Long=Term) Care Facilities Retirement and Assisted Living Rehabilitation Centers Home Health Care Agencies Day Care Centers Rural Care Hospice Services Crisis Centers

Anuria

refers to a lack of urine production

bowel (fecal) incontinence

refers to the loss of voluntary ability to control fecal and gaseous discharges. Partial incontinence is the inability to control flatus or to prevent minor soiling. Major incontinence is the inability to control feces of normal consistency. Generally associated with impaired functioning of nerves, neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle.

Polyuria (diuresis)

refers to the production of abnormally large amounts of urine by the kidneys, often several liters more than the client's usual daily output. Polyuria can follow excessive fluid intake, a condition known as polydipsia, or may be associated with diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis. Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss.

Cheyne-Stokes respiration

rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea

Isotonic

running ,walking, swimming • Cause muscle contraction and change in muscle length • Enhance circulatory and respiratory function • Increase muscle mass, tone, and strength • Promote osteoblastic activity if weight bearing- combats osteoporosis

Mourning (MB):

the behavioral process where through which grief is eventually resolved or altered.

Cognition

the process of thought that embodies perception, attention, visual spatial cognition, language, learning, memory, and executive function with the higher order thinking skills of comprehension, insight, problem solving, reasoning, decision making, creativity, and metacognition Normal Cognition Perception (proprioceptive, orientation) Attention Memory (sensory, short-term, long-term) Communication and Social Cognition Motor Coordination (praxis) Executive Function Intellectual Function Adaptive Behavior Risk Factors Population at highest risk Personal behaviors Learning disabilities Intellectual Disabilities Dementia Health related conditions Assessment Prepare the patient Position and Observe the patient Assess language skills Assess level of orientation Assess memory Assess computation ability Assess emotions and mood Assess decision making ability

determinants of blood pressure

the pumping action of the heart: When the heart pumps weakly, less blood is pumped into arteries (lower CO), and the BP decreases. the peripheral vascular resistance PVR the resistance supplied by the vessels through which the blood flows: Peripheral resistance can increase BP, especially the diastolic pressure. Increased vasoconstriction raises the BP, whereas decreased vasocon-striction lowers the BP. blood volume: When the blood volume decreases (e.g., as a result of a hem-orrhage or dehydration), the BP decreases because of decreased fluid in the arteries. viscosity: BP is higher when the blood is highly viscous (thick), that is, when the proportion of red blood cells (RBCs) to blood plasma is high. This proportion is referred to as the hemato-crit. Viscosity increases markedly when the hematocrit is more than 60-65%

Tissue Integrity

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes Tissue integrity includes integumentary, mucus membrane, corneal, or subcutaneous tissues uninterrupted by wounds.

chest physiotherapy cpt

therapy used to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles; types include postural drainage, chest percussion, and vibration

TB syringe

used for any amount less than 1 ml that must be given in hundreths.

Perfusion assessments

• Interview: chief complaint, chest pain & type, genetic considerations. (Family history of high cholesterol, early-onset coronary artery disease, medications). • Cardiac rate and rhythm • Heart sounds

Isokinetic (resistive)

• Involves muscle contraction or tension against resistance. • Increase muscle strength. The person tenses against the resistance.

Planning (Urinary)

• Maintain or restore a normal voiding pattern. • Regain normal urine output. • Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem. • Perform toileting activities independently with or without assistive devices. • Contain urine with the appropriate device, catheter, ostomy appliances, or absorbent product. Planning for home Care -consider needs for teaching, assistance -assess client and family's resources -Referrals

Thrombus formation / Pulmonary embolus immobility

• Metabolic changes • Decreased metabolic rate • Anorexia • Calcium resorption (loss) from bones, increases calcium in the circulation, can lead to osteoporosis and kidney stones • Negative nitrogen balance caused by inability to metabolize glucose, so protein stores are broken down catabolism exceeds anabolism, causes loss of lean body mass and increase in fat, decreased muscle mass, weakness, poor wound healing

Primary Hypertension

• Persistently elevated systemic blood pressure • Develops through interaction between: -Overstimulation of alpha-, beta-adrenergic receptors - Altered function of renin-angiotensin- aldosterone system -Insulin resistance, hyperinsulinemia, endothelial function

General assessment Mobility

• Presence of pain with movement • changes in mobility or problems with balance • Presence of fatigue, shortness of breath, chest pain with movement • History of falls • Ability to complete activities of daily living and instrumental activities of daily living

if patient experiencing pain

v Do each exercise 3 times, at least twice a day v Older adults, not necessary to achieve full ROM, emphasize achieving sufficient ROM to carry out ADL's • Benefits of physical activity/exercise • Lower resting blood pressure and heart rate • Improve lipoprotein profile, C-reactive protein, and other coronary heart disease biomarkers • Enhance insulin sensitivity (prevent diabetes) • Weight management • Preserves bone mass and reduces the risk of falling (prevent osteoporosis) • Increase joint flexibility, and range of motion • Maintain and improve balance, agility, coordination • Benefits of physical activity/exercise • Prevention of and improvement in mild to moderate depressive disorders and anxiety • Enhances feeling of "energy" and well-being • Associated with a lower risk of cognitive decline and dementia Overall improves the quality of life of life for individuals Special considerations • Anyone over 35 years and sedentary should obtain medical consultation before starting an exercise program • Should start with a 5-10 minute warm-up that includes stretching and aerobic activity performed at a lower intensity • Should end with 5-10 minute cool down that also includes stretching • Wear appropriate clothing when exercising, drink adequate fluids, wait 1.5 to 2.5 hours after a meal to exercise • Stop if pain, pressure in the chest, dizziness, fainting or light-headedness

Range of motion (ROM) exercises

v active ROM—patient moves all joints through their ROM unassisted v passive ROM—patient unable to move independently and nurse moves each joint through its ROM v active-assistive or self-assisted ROM—some done active, some passive, patient may do passive exercises on affected side with unaffected side Active or/and passive ROM exercises to prevent complications of immobility • Should be done to point of resistance not beyond,

Clostridium difficile

which produces mucoid and foul-smelling diarrhea. Clients at the highest risk for the development of C. difficile include immunosuppressed individuals, clients on chemotherapy, and those who have recently used antimicrobial agents, usually fluoroquinolones. Older adults are at the greatest risk due to underlying disease(s) and greater exposure in hospitals and extended care facilities. Infection control against C. difficile infection includes hand hygiene, contact precautions, and cleaning of surfaces with a bleach solution

Sprain

• A sprain is an injury to a ligament, the strong bands of tissue that connect a bone to another at a joint. • DEGREES OF SPRAINS • First degree (mildest) - little tearing, pain or swelling; joint stability is good. • • Second degree - broadest range of damage, with moderate instability and moderate to severe pain and swelling. • • Third degree (most severe) - ligament is completely ruptured; joint is unstable; severe pain and swelling; other tissues are often damaged.

Strain

• A strain is damage to muscle fibers and to the other fibers that attach the muscle to the bone. Other names for a strain include "torn muscle," "muscle pull" and "ruptured tendon." • DEGREES OF STRAINS • • First degree (mildest) - little tissue tearing; mild tenderness; pain with full range of motion. • • Second degree - torn muscle or tendon tissues; painful, limited motion; possibly some swelling or depression at the spot of the injury. • • Third degree (most severe) - limited or no movement; pain will be severe at first, but may be painless after the initial injury

Aerobic

• An activity in which the amount of oxygen taken into the body is greater than or equal to the amount the body requires • Improves cardiovascular fitness, the more intense the activity the greater the workout for the cardiovascular system

• Nurse's role Pefusion

• Assess for medication use • Support client during test if necessary • Document procedures, monitor results • Fulfill orders in a timely fashion PLANNING Interventions - What are independent? • Assessment • Medication/s • Primary prevention • Intake/Output • Daily weights • Obtaining an ECG Evaluate • Head-to-toe • Level Of Conciousness • Urinary output • Shortness Of Breath • Skin color • Vital Signs • Edema

Etiology/Pathophysiology of Atherosclerosis

• Blood vessel damage causes an inflammatory response causing a fatty streak to appear on the lining of the artery. This leads to the formation of a fibrous plaque that protrudes into the vessel lumen leading to partial or complete obstruction of the blood flow. *Atherosclerosis*: A progressive disease characterized by plaque formation that affects midsized and large arteries. This is a form of arteriosclerosis

Nursing responsibilities Mobility

• Counsel patients to adopt and maintain regular physical activity • Can benefit from engaging in amounts of exercise less than recommended • Correct misconceptions • Does not qualify to supervise or plan intense exercise program • American heart association has excellent pamphlets on exercise programs

Diagnosing Urinary elimination

NANDA 2 General Diagnostic labels for urinary elimination • Impaired Urinary Elimination: dysfunction in urine elimination • Readiness for Enhanced Urinary Elimination: a pattern of urinary functions for meeting eliminatory needs, which can be strengthened. *specific* • Functional Urinary Incontinence—inability to reach toilet in time to avoid unintentional loss of urine • Overflow Urinary Incontinence—involuntary loss of urine associated with overdistention of the bladder • Reflex Urinary Incontinence—involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached • Stress Urinary Incontinence—sudden leakage of urine with activities that increase intra-abdominal pressure • Urge Urinary Incontinence—involuntary passage of urine occurring soon after a strong sense of urgency to void • Risk for Urge Urinary Incontinence—vulnerable to involuntary passage of urine occurring soon after a strong sensation or urgency to void, which may compromise health • Urinary Retention

ENTERAL

NASOGASTRIC GASTROSTOMY PEG DUODENOSTOMY JEJUNOSTOMY RECTAL TOPICAL TRANSDERMAL

BMI

Normal: 18.5-24.9 Overweight: 25-29.9 Obese I: 30-39.9 Morbidly Obese >40

Artificial Airways

Oral airway Ø Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Endotracheal and tracheal airways: Ø Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy Ø Long-term assistance, surgical incision made into trachea

• Secondary Hypertension

• Elevated blood pressure from identified cause • Kidney disease • Congenital • Endocrine disorders • Neurological disorders • Drug use Pregnancy

BICARBONATE (HCO3)

• Found in both ICF, ECF • Major body buffer • Regulates acid-base balance • Produced through metabolic processes 21-28 meq/lpao2C

Common Diagnostic Tests Perfusion

• Radiographic studies • Chest X-ray, MRI, CT, ultrasound • Echocardiogram ECHO • Cardiac catheterization (angiogram) • Stress testing Doppler

Benefits of bed rest

• Reduces the need of the body cells for oxygen because of reduced metabolism, secondary to reduced activity • Directs energy resources toward the healing process rather than toward activity • Reduces pain in some instances, thereby decreasing the need for analgesics • Relieve edema • Prevent labor or miscarriages

Etiology for other problems related to urinary elimination

• Risk for Infection if the client has urinary retention or under-goes an invasive procedure such as catheterization or cystoscopic examination. • Situational Low Self-Esteem .• Risk for Impaired Skin Integrity if the client is incontinent. Bed linens and clothes saturated with urine irritate and macerate the skin. • Toileting Self-Care Deficit • Risk for Deficient Fluid Volume or Excess Fluid Volume if the client has impaired urinary function associated with a disease process. • Disturbed Body Image • Deficient Knowledge • Risk for Caregiver Role Strain if the client is incontinent and being cared for by a family member for extended periods. • Risk for Social Isolation if the client is incontinent.

Venous Vasodilatation and Stasis immobility

• Skeletal muscles atrophy- • No longer assist in pumping blood back to the heart • Blood pools in the leg veins causing engorgement vasodilatation • Valves no longer work effectively to prevent backward flow of blood - results in dependant edema

Hypertension

• Systolic blood pressure ≥130 mm Hg or • Diastolic blood pressure ≥80 mm Hg or

immobility

• The inability to move about freely • Can be partial as with a broken limb or complete as with paralysis • The greater the extent and duration of immobility, the greater the consequences • Reasons for immobility • Severe pain • Impairment of the musculoskeletal or nervous system Generalized weakness • Psychosocial problems like depression • Infectious process

Urine output collection steps

• Wear clean gloves to prevent contact with microorganisms or blood in urine. • Ask the client to void in a clean urinal, bedpan, commode, or toilet collection device ("hat") • Instruct the client to keep urine separate from feces and to avoid putting toilet paper in the urine collection container. • Pour the voided urine into a calibrated container. • Hold the container at eye level, read the amount in the container. Containers usually have a measuring scale on the inside. • Record the amount on the fluid intake and output sheet, which may be at the bedside or in the bathroom. • Rinse the urine collection and measuring containers with cool water and store appropriately. • Remove gloves and perform hand hygiene. • Calculate and document the total output at the end of each shift and at the end of 24 h on the client's chart.

Contractures

• deformity of the joint Contributing factors • Fibrosis: increase in the amount of fibrous connective tissue • Ankylosis: fixation of joining structures whenever joints are not moved • Permanent shortening of flexor muscles because flexor muscles are stronger than extensor • Foot drop is one type of contracture

Dressings for Stage 3 with Infection and/ Exudates

•Alginates •Absorb exudates •Eliminate dead space •Hydrogels •Liquefy necrotic tissue •Fill in dead space Assess for complications & Sepsis

Nutritional Assessment

•Assessing •Nutritional Screening •Nursing History •Anthropometric Measurements •Calculating BMI •Patients at risk for nutritional problems •Physical examination •Laboratory values •Dysphagia difficulty swallowing

Debridement Removal of Necrotic Tissue

•Chemical collagenase enzyme agents •Autolytic body's own enzymes •Surgical /Sharp scalpel /scissors •Mechanical wet-to-dry dressings scrubbing Irrigation (use 35ml syringe with 19 g needle to deliver 8 psi)

Nursing Interventions -Stage 1 Erythema (non-blanching)

•Cleanse area •Use barrier cream / ointments (A&D, Aloe Vesta) •Protective dressings: transparent film (non-fragile skin) •May use hydrocolloids •Appropriate surfaces •Redistribute pressure •Frequent positioning

Good Samaritan Laws

•Encourage healthcare providers to help victims in an emergency •Designed to protect healthcare workers from potential liability when volunteering skills outside of employment contract •To be protected by law, nurse must adhere to standard of nursing care -Provide only care consistent with nurse's level of training, licensure -Having decided to render emergency care, nurse must follow through •Providing necessary care •Safely placing victim in care of someone who can provide appropriate care •§1731. Gratuitous service at scene of emergency; emergency care at hospitals; limitation of liability• A.(1) A physician, surgeon, or physician assistant licensed under the provisions of Chapter 15 of this Title, his professional medical corporation chartered under the provisions of R.S. 12:901 et seq., or his limited liability company, or a nurse licensed under the provisions of Chapter 11 of this Title who in good faith gratuitously renders emergency care or services at the scene of an emergency, to a person in need thereof shall not be liable for any civil damages as a result of any act or omission in rendering such care or services or as a result of any act or failure to act to provide or arrange for further medical treatment or care for the person involved in said emergency, unless the damage or injury was caused by willful or wanton misconduct or gross negligence.

Purposes of Patient Education

•Goal - assist individuals, families and communities to achieve the optimal level of health / produce a change .•Maintenance and promotion of health and illness prevention. •Restoration of health •Coping with impaired functioning

Phases of Wound Healing

•Inflammatory •Hemostasis (cessation of bleeding) •Phagocytosis •Proliferation •Maturation (remodeling) Complications of Wound Healing •Infection•Hemorrhage•Wound Disruption•dehiscence•evisceration Support Wound Healing •Maintain moist wound healing•Provide sufficient nutrition and hydration•Prevent wound infection•Proper positioning Goals of Wound Care •To P r e v e n t I n j u r y•To P r e v e n t C o m p l i c a t i o n s•To P r o m o t e H e a l i n g

Factors Affecting Nutrition

•Lifestyle •Economics •Medications and Therapy •Health •Alcohol Consumption •Advertising •Developmental Factors •Sex •Ethnicity and Culture•Beliefs About Food •Personal Preference •Religious Practice

Process for helping patient clarify values

•List alternatives •Examine possible consequences of choices •Freely choose a course of action •Feel good about the choice •Affirm the choice •Act on the choice •Act with a pattern -Nurse should help patient think each question through but not impose nurse's own values -*Nurse should rarely, if ever, offer an opinion even when patient asks for it*

Planning (Fecal Elimination)

•Maintain or restore normal bowel elimination pattern •Maintain or regain normal stool consistency •Prevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention and pain •Planning for home care Assess client's, family's ability to meet specific care needs for ongoing elimination issues

Implementing urinary

•Maintaining normal urinary elimination •Preventing urinary tract infections •Managing urinary incontinence •Managing urinary retention •Urinary catheterization *Nursing interventions for clients with indwelling catheters* -Encourage large amounts of fluid intake o Provide foods that create acidic urineo Give routine perineal care o Prevent contamination with feces in incontinent clients o Removing indwelling catheters Obtain receptacle for catheter; place client in supine position; remove catheter-securing device Insert syringe into injection port and withdraw fluid from balloon •Removing indwelling catheters •Clean intermittent self-catheterization

Basic Learning Principles

•Motivation - to learn if they are learning it for survival they are more motivated ----- ex. - learning to walk again •Mild anxiety can motivate learning but as anxiety increases the ability to pay attention or attend decreases. •The ABILITY to learn is affected by developmental capability and physical capacity. •ASSESS their level of knowledge, what the patient knows and what needs to be taught. •PHYSICAL CAPACITY- no need teach a patient how to transfer in a bed if they do not have upper body strength •Attributes of Learning

Patient Education

•Multifaceted, involving promoting, protecting, and maintaining health. •Involves teaching about reducing health risk factors, increasing a persons' level of wellness, and taking specific protective health measures. Standards for Patient Education •Nurse Practice Acts- nurses responsibility •Accreditation agencies set guidelines - TJC •Collaboration all health care professionals must participate in patient and family education to meet standards •EBP

Nurses must have

•Must provide high-quality care to all patients regardless of patient's morality/immorality -Awareness of own ethics -Thorough understanding of requirements nurse must follow under professional code of ethics -Understanding of reporting requirements in their state -Understanding of reporting procedures in place of employment

Evaluating Urinary

•Nurse collects data to evaluate the effectiveness of nursing activities. If desired outcomes not achieved, explore the reasons before modifying the care plan Client perception and understanding, access to toilet, ability to manipulate clothing, Kegel exercises Review schedule for voiding, fluid intake (including caffeine, etc.), diuretics Lighting, mobility aids, continence aids

Nursing Assessment for Tissue INtegrity

•Nurse-cannot delegate assessment •When AM care or anytime repositioning •How Inspect-skin folds, moist areas, and pressure point Remove antiembolistockings/braces/or other medical devices Palpate (temperature, moisture, turgor) •What to Look For? Color distribution Presence of edema Risk of breakdown Turgor Tattoos Piercings Disruption (i.e. lesions) Odors

Special Teaching Considerations

•Older AdultIncreased population of the older adult Physical and psychological changes •Cultural aspects of CareRapport, background, resources

Barriers to Learning

•Pain•Prognosis•Biorhythms•Emotion•Age•Culture/religion•Physical disability•Mental disability acute illness

several individuals are usually involved in ethical decision making

•Patient •Family •Other members of healthcare team •Sometimes a spiritual advisor or other trusted individual -Collaboration, communication, compromise are needed -Stress management also a valuable skill

Implementing Fecal Elimination

•Promoting regular defecation •Teaching about medications •Decreasing flatulence •Administering enemas •Digital removal of a fecal impaction •Bowel training programs •Bowel incontinence pouch Collect and contain large amounts of liquid feces To prevent skin breakdown and frequent linen changes To prevent damage to internal mucosa and rectal sphincter from insertion of large Foley catheter in rectum

Functions of the Skin

•Protection/ Immunological •Body temperature regulation •Psychosocial •Sensation •Storage and Synthesis ---Vitamin D production •Contorlof evaporation/ Water resistance•Absorption •Elimination

Facts about the Stages of D & D

•Pts. can move back and forth through the stages, possibly extending over a long period of time. • Also, some pts. can get stuck in a stage. • Unresolved grief can cause complications. •Remember that grief is essential for normal physical and emotional health.

Assessment wound drainage

•Serous •Sanguineous •Purulent Can be a combination: serosanguineous/purosanguineous

Measurement of wounds

•Size of wound•Depth of wound•Presence of undermining, tunneling or sinus tract

Medical Nutrition Therapy (MNT)

•Specific nutritional therapy used for treating illness, injury, or certain conditions. •Most effective with collaborative health care team and dietitian

Role of a Nurse Educator

•Teaching Role of the Nurse •Teaching the client is a major aspect of nursing practice and an important independent function. •The American Hospital Association's Patient's Bill of Rights mandates client education as a right of all clients. •State nurse practice acts include client teaching as a function of nursing, making this a legal and professional responsibility .•The Joint Commission on Accreditation of Healthcare Organization (JCAHO) expanded its standards of client education by nurses to include evidence that patients and their significant others understand what they have been taught. •This requirement means that providers must consider the literacy level, educational background, language skills, and culture of every patient during the education process.

Evaluating Fecal Elimination

•The goals established during planning phase are evaluated according to specific desired outcomes. •If outcomes are not achieved, nurse should explore the reasons. •Review fluid and diet, activity level, prescription medications, and other factors •Do client and family understand instructions? •Was sufficient support provided?

Learning Environment

•To promote an environment that is conducive to learning, consider the following•Number of participants•Privacy•Room temperature•Lighting•Noise

Nursing Interventions Treat Infection

•clean thoroughly -irrigate•use normal saline (no betadine / hydrogen peroxide) •wound culture (needle aspirate/punchbiopsy •antibiotic powder or ointment •silver impregnated products (Ag)

Nursing Interventions -Stage 2 Excoriated Skin Epidermal/Dermal

•cleanse area •protective dressing: moisture retaining transparent film or hydrocolloid to non-infected wound •protect surrounding skin before taping (skin gel, etc.)•frequent positioning •comfort measures •assess for necrosis & infection

Pressure Ulcers

•decubitus ulcers •pressure sores •bedsores •Injury to skin or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement. •Intact tissue requires only intermittent blood flow to maintain viability, limited periods of ischemia are well tolerated. •Pressure Ulcer VS Hyperemia Pressure Ulcersregulatory agencies •Because pressure ulcers are preventable, they are considered •never events •and not reimbursed by public and many private health insurers •--Stage III and IV are serious reportable events Pressure Ulcers Assessment •Location •Measurement •size/depth/undermining. (Longest part: L x W x D) •Color •Stage •Condition of wound margins •Integrity of surrounding skin •S/S infection (HIPER) warmth-swelling-pain-odor-exudateHeat-Induration(loss of function)-Pain-Edema-Redness

Pressure ulcer purpose of dressings

•dressings Purpose •Protect from mechanical injury •Protect from microbial invasion •Provide moist healing environment •Provide thermal insulation •Absorb drainage •Debride a wound •Prevent hemorrhage (with a pressure dressing) •Splint or immobilize a wound Many different types •Transparent film •Hydrocolloids •Hydrogels •Alginates Dressing choice depends on •Location/size/type •Amount of exudate •Debridement needed? •Infection present? •avoid transparent film on fragile skin •do use HYDROCOLLOID dressing on fragile skin and NON-INFECTED wound •HYDROGELS liquefy necrotic tissue or slough •AUTOLYTICS allow necrotic tissue to self digest with enzymes •ALGINATES absorb and eliminate dead space

Pressure Ulcr Alginates

•nonadherent sheet (powder/rope/beads/granules/paste)•conforms to wound surface•requires secondary dressing •absorbs 20 times weight in exudate •provides moist wound surface by interacting with exudate to form a gelatinous mass •eliminated dead space•supports debridement Ødeep wounds with largeamounts of exudate

Factors Affecting Blood Pressure

■ Age. At day 10, the average systolic pressure of newborns is 90 mmHg. This pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline some-what. In older adults, elasticity of the arteries is decreased—the arteries are more rigid and less yielding to the pressure of the blood. This produces an elevated systolic pressure. Because the walls no longer retract as flexibly with decreased pressure, the diastolic pressure may also be high. ■ Exercise. Physical activity increases the CO and BP; thus 20-30 minutes of rest following exercise is indicated before resting BP can be reliably assessed. ■ Stress. Stimulation of the SNS increases CO and vaso-constriction of the arterioles, thus increasing the BP. How-ever, severe pain can decrease BP greatly by inhibiting the vasomotor center and producing vasodilation. ■ Race. African American men over 35 years of age have higher BPs than Caucasian men of the same age. ■ Gender. After puberty, women usually have lower BPs than men of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher BPs than before. ■ Medications. Many medications, including caffeine, increase or decrease the BP. ■ Obesity. Both childhood and adult obesity predispose individuals to hypertension. ■ Diurnal variations. Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening. ■ Disease process. Any condition affecting CO, blood vol-ume, blood viscosity, and/or compliance of the arteries has a direct effect on BP.

Prinicples of management

Accountability- the ability and willingness to assume responsibility for one's actions and to accept the consequences if one's behaviot Responsibility- an obligation to meet objectives and perform tasks -Managing Resources -Enhancing employees performance -Building and managing teams - managing conflict -managing time

ADVANTAGES and Disadvantages OF PARENTERAL DRUG ADMINISTRATION

Accurately measure amount absorbed. Complete absorption Can be administered to a patient with altered level of consciousness (LOC) Medication is not affected by gastric disturbances Administered to patients with difficulty swallowing Administered to patients with vomiting/diarrhea, gastric suction, NPO Medication irritating to SC can be given IM as there are fewer pain receptors Larger volume of medication can be given IM IM route has faster rate of absorption than SC *disadvantages* Potential for infection (skin broken) Potential of damaging major nerves and blood vessels Pain/discomfort Sterile abscess (collection of undissolved medication) - caused by medication injected too fast. Hypertrophy - (thickening of skin) - caused by multiple injections Lipodystrophy - (atrophy of tissue) - caused by multiple injections in the same site. Periostitis - inflammation of periosteum (membrane covering bone) - caused by the needle hitting the bone during an IM injection.

MEDICATION ADMINISTRATION

Administer and document only those medications you prepare Check patient identification Remain with the patient Omitted medications Documentation Only persons actively receiving medical care can be given medications Medications brought by patient to hospital

Competency for Consent

Adult assumed to be competent if over 18, not declared legally incompetent, rendered temporarily incompetent -Adults declared legally incompetent are provided a legal guardian -A person may be rendered temporarily incompetent by Medication or Serious fall -May become incompetent gradually through dementia -If provider determines that patient is not competent for purposes of informed consent •Emergency doctrine may apply •Someone else may need to make healthcare decisions on patient's behalf- -Courts presume continuing competency unless healthcare facility can show that patient cannot understand consequences of his/her actions

Buccal/Sublingual

Advantages: Absorption is quick, Quick termination, First-Pass avoided, Can be self-administered, Economical Disadvantages: Unpalatable & Bitter drug, Irritation of oral mucosa, Large quantities not given, Few drugs are absorbed

Concepts related to managing care

Advocacy -Nurses protect hte rights of patients and defend patients from harm Clinical decision making -Analyzing assessment data to identify priorities of actions for best patient outcomes Communication -Among the collaborative team of healthcare providers to ensure the continuity of care Ethics -principles of altruism, autonomy, human dignity, integrity, and social justice influence decisions made in dispersing services/resources Healthcare Systems Coordinating services and allocating resources as a means of meeting multiple patient needs and keeping cost in check Teaching and Learning -Educating patients about their conditions and health management is essential for enabling them to maintain and avoid future complications

Patient Advocacy

Advocacy is generally defined as the act or process of sup-porting, defending, or assisting in another's cause. -Nurse advocates for patient on basis of patient's values, not nurse's own ethical or moral values -Nurse makes sure the patient is making an Informed Decision. It may not be possible to act on every patient request. Skilled nurse-advocates are able to explain the rationale for care limitations to the patient in plain language and also manage their own ability to cope with disappointing outcomes to prevent frustration and burnout.

Factors Affecting Respiratory Function

Age Environment Lifestyle Health status Medications Stress

Laboratory Values

Albumin gives long time view (over 21 days) norm is 3.5-5 g/dl pre-albumin shorter view like 2 days norm is 17-40 g/dl Hemoglobin 12-18 g/dl

ANXIETY

An alteration to the human condition of impending doom, either real or imagined, accompanied by autonomic responses that serve as a protective mechanism. Clinical Manifestations Sleep Disturbance Muscle Tension Irritability Inability to concentrate Fatigue Restlessness Assessment Observation o Physical Symptoms o Medical Hx o Family Hx o Emotional and Psychological o Social well being o Socioeconomic pressures o Home and work conditions Physical o Focused assessment on somatic complaints Implementation and Therapies Mild Anxiety o Manage stressors and modify behaviors Moderate Anxiety o Cognitive reframing o Physical exertion Severe Anxiety o Isolate distressed patient o Provide safe, quiet, protective environment Implementation and Therapies Mild Anxiety o Manage stressors and modify behaviors Moderate Anxiety o Cognitive reframing o Physical exertion Severe Anxiety o Isolate distressed patient o Provide safe, quiet, protective environment

Older Adults

An estimated 30% of nephrons are lost by age 80. Renal blood flow decreases because of vascular changes and a decrease in cardiac output. The ability to concentrate urine declines. Bladder muscle tone diminishes, causing increased frequency of urination and nocturia (awakening to urinate at night). Diminished bladder muscle tone and contractibility may lead to residual urine in the bladder after voiding, increasing the risk of bacterial growth and infection. Urinary incontinence may occur due to mobility problems or neurologic impairments.

Arterial blood pressure

Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. Because the blood moves in waves, two types of BP are measured. The *systolic blood pressure* is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave. *The diastolic blood pressure* is the pressure when the ventricles are at rest. Diastolic pres-sure is the lower pressure and is present at all times within the arteries. The difference between the diastolic and the systolic pressures is called the *pulse pressure*.

INJECTION PROCEDURE

Assess: Is the area free of infection or necrosis? Are local areas of bruising or abrasions evident? What is the location of underlying bones, nerves, and major blood vessels? What is the volume of the medication to be administered? Each site has different advantages and disadvantages. Failure to select injection sites by anatomical landmarks leads to tissue, bone, or nerve damage. Assess the muscle before giving the injection. Properly identify the site by PALPATING bony landmarks. Be aware of potential complications with each site. The site needs to be free of tenderness. Minimize discomfort. Cleanse skin in circular motionInject; leave needle in place for 5 to 10 seconds. If bleeding occurs hold manual pressure for 1-3 minutes without massaging

Maintenance and Promotion of Lung Expansion

Ambulation Positioning Ø Reduces pulmonary stasis, maintains ventilation & oxygenation Ø Incentive spirometry Ø Encourages voluntary deep breathing Promotion of Lung Expansion: Flow-oriented Incentive Spirometry: Continuous positive airway pressure (CPAP): Maintenance and Promotion of Oxygenation Oxygen therapy Ø To prevent or relieve hypoxia Ø Safety precautions Supply of oxygen Ø Tanks or wall-piped system Methods of oxygen delivery Ø Nasal Cannula Ø Simple Oxygen mask Ø Breather Mask Ø Nonrebreather Mask Venturi Face Mask Face Tent

nocturnal euresis

Bed-wetting, shouldnt be a concern until after child is 6 years old.

Nutrition for obesity

Collaborate with nutritionist •Create diet plan to create 500-1,000 kcal deficit •Low kcal, low fat, high in fiber •Very-low-calorie diet for client BMI > 30 Behavior Modification •Critical component •Food records •Eliminating cues that precipitate eating •Examine factors that affect eating behaviors •Social support, group programs successful Surgery •Bariatric surgery BMI > 40 kg/m2 •Restrictive/malabsorptive procedures •Bypass portion of small intestine •Rapid weight loss Restrictive procedures •Safer •Generally less effective in long term Overall through surgeries for obesity there are high risks

Collaborative Care for inflammation to keep tissue integrity

Collaboration with a nutritionist may benefit patients who are in a chronic inflammatory state. A nutritionist may advise on an anti-inflammatory diet that contains omega-3 fatty acids, antioxidant vitamins, and probiotics. A physical therapist can assist patients with building muscle strength and regain use of limbs that have been underused because of loss of function related to inflammation.

Conditions Affecting Transport Oxygenation

Conditions that decrease cardiac output, i.e., CHF, hypovolemia, affect tissue oxygenation and the body's ability to compensate for hypoxemia. Respiratory Distress S & S: Nasal flaring, cyanosis, chest tightness, Use of accessory muscles, numbness tingling in hands & feet, pursed lip breathing, on exhalation, coughing crowing, bark sound, wheezing, rattling heard in chest, impaired mentation, unconsciousness, dizziness, restlessness, anxiety, combativeness.

USDA Dietary Guidelines

Dietary Guidelines doesnt really give the amount of food or nutrition but gives you different diets and it updated every 5 years adults and children have about 2,000 calorie diet

Nursing interventions for Fluid Electrolytes

INDEPENDENT Monitor intake and output (can also be an order) Daily weights Engage patient in plan of care Provide patient education as indicated COLLABORATIVE INTERVENTIONS Intravenous management Monitoring fluid balance Blood transfusions Pharmacologic therapy •Electrolyte correction to restore balance •Diuretics •Dietary recommendations

Access to Health Care

High-quality health care beyond reach of many National Healthcare Disparities Report Uninsured No insurance at all Underinsured Insufficient coverage

blood urea nitrogen (BUN)

Hypo (down) dehydration (fvd) Kidney stones kideny disease chf heart attack Hyper (up) liver disease malnutrition FVE 10 - 20 mg/dL

Diagnosing Gout

Gout can only be diagnosed during a flare when a joint is hot, swollen, and painful and when a lab test finds uric acid crystals in the affected joint. So only during an acute attack

Gout signs and symptoms

Gout usually occurs in one joint at a time (usually the great toe). Gout can occur in other joints such as the other toe joints, ankles, elbows, hands, and knees .Pain (usually intense) Swelling Heat redness

Clinical Manifestations: Signs of Impending Death

I. Loss of Muscle Control II. Slowing of Circulation III. Changes in Respirations IV. Sensory Impairment Implementation: Health Promotion: Providing palliative care in acute and restorative settings, Providing hospice care, Using therapeutic communication, Providing psychosocial care, Managing symptoms. Implementation: Care After Death Federal and state laws apply to certain events after death, Documentation, Organ and tissue donation, Autopsy

The Standard of Care

Louisiana State Board of Nursing's rules §3701. & §3703. •Providing Competent Nursing Care •Legal Requirements for Mandatory Reporting •Informed Consent •Competency for consent

Regulating Electrolytes

Maintain fluid balance, Contribute to Acid-Base Regulation, Facilitate Enzyme reactions and Transmit neuromuscular reactions.

Hypoxemia

Reduced O2 levels in blood. Caused by conditions that impair diffusion at alveolar level. I.e., Pulmonary edema, atelectasis, or low hemoglobin levels. If severe, it results in hypoxia potentially causing cell injury or death.

Treatment for sprains and strains

P- Protect from further injury • R-rest • I-Ice • C-Compression E-Elevation

MOBILITY

PURPOSEFUL PHYSICAL MOVEMENT, INCLUDING GROSS SIMPLE MOVEMENTS, FINE COMPLEX MOVEMENTS, AND COORDINATION.

Activity-Exercise Pattern

Routine of exercise, activity, leisure, and recreation. Includes: 1) ADL's that require energy 2) Type, quality, and quantity of exercise including sports Physical activity: Any bodily movement produced by skeletal muscles that results in energy expenditure.

Five major components of growth and development theories:

Psychosocial (development of personality) Cognitive (learning to think and reason, birth to 15 years old) Moral (relating to right and wrong) Spiritual (perceptions about the meaning of life, faith) Biophysical (development of the physical body)

Comparison of Arterial and Venous Leg Ulcers

Signs and Symptoms • May be totally asymptomatic • Unilateral leg edema, measure calf circumference to determine changes • Redness, warmth, tenderness surrounding area of clot • Increased temperature, related to inflammation • If superficial may be firm, palpable, cordlike vein.

Cognitive

Thinks abstractly Develops ability to understand how an individual's actions effect or influence others Considers an infinite variety of causes and solutions when presented with a problem Develops ability to determine and rank possibilities

Informed Consent Exceptions

1. Minors: Parent or Guardian most of the time can give consent (same is true if adult person has mental capacity of child if someone has been appointed guardian) **** Some states all minors to consent for blood donation, substance abuse treatment, mental health treatment and reproductive concerns*** Minors who are married, pregnant, military or emancipated may give consent 2. Unconscious or Injured in way that would not allow for consent: Closest adult Relative may give consent. Life threatening Emergency: law generally agrees that consent is implied to provide necessary care for the emergent condition 3. Mental Illness( Judge has deemed incompetent) Refer to state statutes for specific rights

Factors Affecting the Pulse

■ Age. As age increases, the pulse rate gradually decreases overall. ■ Gender. After puberty, the average male patient's pulse rate is slightly lower than the average female patient's. ■ Exercise. The pulse rate normally increases with activity. The rate of increase in professional athletes is often less than in average individuals because of greater cardiac size, strength, and efficiency. ■ Fever. The pulse rate increases (a) in response to the lowered BP that results from peripheral vasodilation associated with elevated body temperature and (b) because of the increased metabolic rate. ■ Medications. Some medications decrease the pulse rate, and others increase it. For example, cardiotonics (e.g., digitalis preparations) lower the heart rate, whereas epi nephrine raises it. ■ Hypovolemia. Loss of blood from the vascular system normally increases pulse rate. In adults, the loss of circu lating volume results in an adjustment of the heart rate to increase BP as the body compensates for the lost blood volume. Adults can usually lose up to 10% of their nor mal circulating volume without adverse effects. ■ Stress. In response to stress, sympathetic nervous stimu lation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system. ■ Position changes. When an individual is sitting or stand-ing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in venous blood return to the heart and a subsequent reduc-tion in BP and increase in heart rate. ■ Pathology. Certain diseases, such as some heart condi-tions or conditions that impair oxygenation, can alter the resting pulse rate.

Patient's rights (including disabilities)

■ Personal rights, including the right to safety with people they know, including family, staff, and strangers. ■ The right to be respected and treated with dignity. ■ The right to have or not have a sexual relationship, includ-ing the right to permit or deny another person's touch. ■ The right to control their money and possessions, includ-ing items such as cigarettes and clothing. ■ The right to treatment in a place that respects their free-dom and includes a current, written treatment plan that the patient participated in creating. ■ The right to refuse or accept a suggested medication. In most states, psychiatric facilities cannot force patients to take medication except in an emergency. ■ The right to exercise these rights without punishment, withholding of treatment, loss of privileges, or physical/ emotional abuse. ■ The right to a living space that provides reasonable pro-tection from harm, including physical or emotional abuse and the use of overmedication or excessive restraint.

Enema

- Depending on policy there can be an order by a doctor or by nurse. -Lubricate about 5 cm (2 in.) of the rectal tube (some commer-cially prepared enema sets already have lubricated nozzles). • Run some solution through the connecting tubing of a large-volume enema set and the rectal tube to expel any air in the tubing, then close the clamp. Rationale: Air instilled into the rectum, although not harmful, causes unnecessary distention. *client may experience a feeling of fullness while the solution is being administered. Explain the need to hold the solution as long as possible.* 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Apply clean gloves. 4. Provide for client privacy. 5. Assist the adult client to a left lateral position, with the right leg as acutely flexed as possible ❶, with the linen-saver pad under the buttocks. Rationale: This position facilitates the flow of solution by gravity into the sigmoid and descending colon, which are on the left side. 6. Insert the enema tube. *tell the client to take a deep breath if resistance, never force it* • Place the enema tube in a disposable towel as you withdraw it. 8. Encourage the client to retain the enema. • Ask the client to remain lying down. • Request that the client retain the solution for 5 to 10 minutes for a cleansing enema or at least 30 minutes for a retention enema. 9. Assist the client to defecate. 10. Document

Culture Defined

Culture affects how people value, evaluate, and categorize life experiences. The members of a cultural group share values and ways of thinking and acting. These values and ways of thinking and acting are different from those of people who are outside the group Integrates patient's values and beliefs into plan of care. Even when a practice is different from what would be prescribed, the nurse should consider whether any harm is resulting from the practice, and take caution to *not judge different as wrong.* Develops self-awareness of nurse's own culture, attitudes, and beliefs Integrates patient's values and beliefs into plan of care .The nurse must keep in mind that a treatment strategy that is consistent with the client's beliefs may have a better chance of being successful.

What does food provide?

Homeostasis repair of tissues energy helps healing most importantly we need to consume water carbs lipids proteins are most essential

• Nursing interventions to prevent complications for immobility

Important to do thorough baseline assessment as soon as patient is immobilized so changes can be detected. 2. Turn at least every 2 hours 3. Ambulate client as soon as possible 4. 2000-3000 mL of fluid/day if not contraindicated 5. Have patient perform weight bearing exercises/resistive exercises v Push against footboard 6. Normal calcium diet, may encourage decreased oxalate diet: avoid nuts, soy, wheat germ, wheat, bran, spinach, tea, rhubarb, beets, most dried beans, chocolate, sweet potatoes 7. high fiber diet 8. Implement all measures that promote defecation and urination 9. Turn, cough, deep breathing every 2 hours v Splinting, controlled cough, huff cough 10. Proper body alignment at all times, loosen covers 11. Remove constrictive abdominal binders 12. Use discretion in use of narcotics and sedative 13. Leg exercises, ankle pumps and circles, make alphabet with feet, knee flexion 14. Respiratory toiletry, need doctor's order v Incentive spirometry v Percussion v Postural drainage 15. Teach to talk or sing when moving to avoid holding breath 16. Use overhead trapeze or legs when moving, not arms 17. No pillows behind the knee 18. Avoid use of knee gatch 19. Elevate legs 10 to 15 degrees 20. Encourage independence in activities of daily living 21. Involve patient in their own care 22. Antiembolic hose 23. Sequential compression device (SCD), plexi-pulse 24. Do not massage or rub legs 25. Plan nursing activities so the patient is able to talk and interact with staff 26. Provide daily newspaper 27. semi-private room if OK with patient 28. Administer stool softener or laxative if ordered 29. Administer anticoagulant (heparin, lovenox) if ordered 30. Implement measures to prevent UTI's 31. Encourage well balanced diet with adequate protein 32. Employ devices such as trochanter roll, positioning boots, and ankle-foot orthotic (AFO) devices 33. Elevate head of bed periodically, dangle before standing

llegal, Immoral, Unethical Activities of Professionals

Nurses have legal responsibility to intervene on behalf of patient if have reason to believe another professional is engaging in practice that is unethical, unsafe, substandard, or unprofessional- State nurse practice acts include sections regulating nurse's actions in this regard and reporting requirements -If the professional is not a nurse, the nurse should still intervene •Nurse must follow established reporting procedures for agency or facility -First step: notify nurse's own direct supervisor •Supervisor can assist nurse, facilitate reporting procedure •Supervisor is nurse's resource if immediate assistance is needed to stop unsafe practice before harm comes to patient

Oxygenation Assessment

Obtain subjective and objective data from physical assessment and health history. Observe for S & S of hypoxia: Increasing restlessness, irritability or unexplained sudden confusion, increased pulse and respiratory rate. Nursing History Assess for current respiratory problems, History of respiratory diseases and frequency of occurrence. Lifestyle Presence of cough Description of sputum Presence of chest pain Presence of risk factors Medication history Oxygenation Assessment Assess Nose: Symmetry, midline, no flaring, patent, pink, and moist. Assess: Resp. Rate: Counting 1 full minute, for bradypnea, tachypnea, apnea, Cheyne-Stokes respirations. Check quality, depth, & if regular, and effort, i.e., SOB, dyspnea, etc. Inspect Thoracic Cavity: Anterior to Posterior vs transverse diameter. 1 : 2 ratio WNL. Inspect the Muscles of Breathing/ Thoracic Wall: Symmetrical rise and fall movement inspected and done with one hand applied on each side of the chest. Trachea midline, eupnea, no use of accessory muscles. Skin and Nailbed Assessment: Normal color for race and ethnicity.Abnormal:If cyanotic in white or fair colored pts. Or gray colored in darker pigmented pts. And nailbeds > 180 degrees for clubbing GOALS Provide patent airway Increase tissue oxygenation Increase level of independence Increase tolerance for activity Implementation: Nursing Interventions Deep breathing exercises Positioning Smoking Cessation Monitoring for activity intolerance Promote secretion clearance Suctioning Implementation: Nursing Care Dyspnea: Airway maintenance: Breathing Exercises: Pursed-lip breathing: Diaphragmatic breathing: TCDB every 2 hrs. Keep airway patent with suctioning, etc. Hydrate with at least 2,000mL/day unless contraindicated. Humidification mobilizes secretions. Nebulization: Adds moisture to medications. Proper coughing: Huff cough: Chest physiotherapy or Postural Drainage: Can be used with percussion, postural drainage and vibrations. Evaluation Ask about Ø Degree of breathlessness Ø If distance ambulated without fatigue has increased Ø Rating the breathlessness from 0 to 10 Ø Which interventions reduce dyspnea? Ø Frequency of cough & sputum production Ø Observe respiratory rate before, during, & after any activity. Ø Assess any sputum produced. Ø Auscultate lung sounds for improvement in adventitious sounds.

Abnormal Skin Assessments

Primary skin lesions basic reaction of skin with a definite morphology -macule -papule -patch -plaque -nodule -wheal -tumor -hives -vesicle -cyst -bulla -pustule Secondary skin lesions develop during the evolutionary process of skin disease or created by scratching or infection -crust -scake -fissure -erosion -ulcer -scar -alphric scar -keloid -licherification

Percutaneous Endoscopic Gastrostomy

(PEG) tube. A tube placed through the skin directly into the stomach to assist with eating. This is when the patient cant take an NG tube patients can pull it out but nurses cannot put it back in They will need to go to the OR Not a sterile procedure

Which of the following statements best addresses the need to safely apply an enzyme débridement ointment?

*1."Enzyme ointments attach the deadtissue so healing can occur."* 2."Place the ointment on a tongue blade and gently spread it on the wound." 3."Apply the ointment, being careful to avoid contact with surrounding skin." 4."Cover the wound with a gauze dressing toensure contact with the ointment."

The priority intervention when a wound assessment suggests the presence of an infection is to:

*1.Notify the physician immediately.* 2.Draw blood for a white blood cell count. 3.Don treatment gloves to prevent contamination. 4.Measure the patient's temperature to confirm the infection.

Which of the following interventions can the nurse delegate to ancillary staff regarding the prevention of pressure ulcers on an elderly dependent patient?

*1.Repositioning the patient at least every 2 hours* 2.Assessing the patient's bony prominences every shift 3.Educating the family to the importance of healthy skin 4.Assisting the patient in the selection of high-protein foodsAssessing Wounds

Oxygenation in relation to inflammation

-Exposure to allergen or infection (bronchitis, pneumonia) results in abnormal inflammatory response resulting in airway edema, bronchoconstriction, and increased mucus production. Nursing implication—assess for coughing, wheezing, dyspnea, and chest tightness, cyanosis, changes in ABG, labored breathing, abnormal lung sounds, and inability to clear sputum. Anticipate-administration of epinephrine, bronchodilators, antihistamines, and anti-inflammatory medications, monitor oxygen saturation via pulse oximetry, administer oxygen.

4 types of nursing diagnosis

1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pat-tern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms. 2. Ahealth promotion diagnosis relates to clients' preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness for Enhanced Nutrition. 3. A risk nursing diagnosis is a clinical judgment that a prob-lem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibil-ity of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client's health status. 4. A syndrome diagnosis is assigned by a nurse's clinical judg-ment to describe a cluster of nursing diagnoses that have similar interventions

THIRD SPACING

A SHIFT OF FLUID FROM THE INTRAVASCULAR SPACE INTO AN AREA WHERE IT IS NOT AVAILABLE TO SUPPORT NORMAL PHYSIOLOGIC PROCESSES IS KNOWN AS THIRD SPACING Usually a serous cavity such as, joints, cerebrospinal, peritoneum and pleura.

A patient with chronic gout takes Uloric(febuxostat) and comes to the clinic reporting frequent severe headaches and a new gout flare. The patient is frustrated because the gout had been under good control. Which question by the nurse is most helpful?

A."What do you take for your headaches?"

Dietary Reference Intakes (DRIs)

Acceptable range of quantities of vitamins and minerals for each gender and age group

Implementation of Metabolism

Acute care Risk factors in acutely ill patient Advancing diets = Gradual progression of dietary intake or therapeutic diet to manage illness Promoting appetite Assisting with oral feedings When a patient needs help with eating, it is important to protect his or her safety, independence, and dignity. give small bites and time to chew promote independence and safety

Pharmaceutical Therapy for Gout

Acute gout pain:NSAID's indomethacin (Indocin), (ibuprofen), steroids, IV colchicine (Colcrys) and usually on oral medications for 4 to 7 days Chronic gout: vallopurinol (Zyloprim) Uloric(febuxostat) Krystexxa(pegloticase) Teaching Increase fluid intake, take meds after meals and with full glass of water Avoid diuretics and aspirin Avoid alcohol, organ meats, oily fish Weight loss

Pharmacologic Therapy for Obesity

Amphetamine, nonamphetamine appetite suppressants •Phentermine •Sibutramine (Meridia) •Orlistat (Xenical) OTC •Bulk-forming agents Exercise •Critical element •Under care of physician •Aerobic exercise 30-40 minutes 5 days each week

Diagnostic Tests for obesity

BMI divide weight (in kg) by height (in m2) •Anthropometry •Underwater weighing •Bioelectrical impedance •Waist circumference •Other tests •Thyroid profile •Serum glucose •Serum cholesterol •Lipid profile •ECG

Guidelines for communication with a person who is aphasic:

Communicate in a quiet environment Talk to the person in a normal tome, loudness, and intonation, do not use baby talk Use shorter, simple statements and questions, rephrase if the person does not understand Pause often when talking, give the person time to understand and respond Use gestures, facial expression, pointing, pictures to reinforce words Accept any form of communication from the person with aphasia Use "yes" and "no" questions

Disorders of Metabolism

Disorders of the structure and function of the endocrine gland alter normal hormone levels and the way that body tissues use those hormones. When hormone production increases or decreases, individuals experience alterations in health such as diabetes, obesity, osteoporosis, and glandular disorders.

Alternate Feeding Methods

Enteral Nutrition (goes directly into GI Tract) -NG Tube -G tube Cheapest way makes sure patients is getting all nutritional needs Complication: Aspirations, Abscess (coughing causes this), Pneumonia You have to shut the feeding tube off 15 mins earlier and then suction any foods out when bathing lay them flat down and turn off the feeding tube and turn it on once done keep their head up about 30 deg Every 4-6 hours nurses need to aspirate to see the residual, flush water right after, suctioning needs to be kept on bedside

COMPONENTS OF THE ASSESSMENT Fluid Electrolystes

H&P (HISTORY AND PHYSICAL): medication socioeconomic facotrs age lifestyle PHYSICAL ASSESSMENT OF THE PATIENT CLINICAL MEASUREMENTS (DAILY WEIGHT, VS, IS/OS) Intake Oral fluids Ice chips Liquid foods Foods that becomes liquid at room temperature Tube feedings Parenteral fluids, IV medications Output: Urine Emesis Liquid feces Tube drainage (gastric, intestinal) Wound drainage Drains Insensible? DIAGNOSTIC TESTS FVE (FLUID VOLUME EXCESS) The increase in total body water causes weight gain (greater than 5% of body weight) -circulatory overload causes manifestations such as: A full bounding pulse Jugular Vein Distention (JVD) cOUGH, Dyspnea, orthopnea crackles Ascites Peripheral edema or anasarca -Heart failure SERUM ELECTROLYTES -COMPLETE BLOOD COUNT -RADIOGRAPHIC STUDIES -PHYSICAL ASSESSMENT -NURSING ASSESSMENT

Corticosteroids for inflammation of infection (Mood/Affect and Safety

In relation to inflammation Corticosteriods prescribed can cause mood changes, euphoria, depression, or severe mental instability Safety In relation to inflammation. Use of corticosteroids affect the adrenal gland, abrupt stopped will cause adrenal insufficiency== Hypotension, tachycardia, etc.

Fluid Intake/Output

Intake 2.,500 ml/day at moderate activity and temperature Food Contributes Thirst Regulator in the hypothalamus Output 1,400-1,500 ml/day of urine (30-35ml an hour) Insensible loss through skin and lungs (spit) Feces Sweat

Concepts related to inflammation

Localized infection results in a limited inflammatory response that causes redness and tenderness at the affected site.

Pharmacology Therapy for Inflammation

NSAIDS (aspirin, Celebrex, ibuprofen, naproxen)-administer with food or milk. Contraindicated in patients with gastric ulcers or who are taking anticoagulants. Use cautiously in older adults because of their reduced kidney and liver function. not super safe Corticosteroids (prednisone, betamethasone, dexamethasone)-Contraindicated in patients with a systemic infection, systemic fungal infections, diabetes, live virus vaccines. Do not discontinue abruptly. Opioid analgesics (hydromorphone, fentanyl, morphine, oxycodone)-Take with food if GI upset occurs, reduce dose for renal impairment, monitor respiratory rate. Natural Therapies (Fish oil and omega-3)-They interact with anticoagulants, aspirin, and NSAIDs.

Magnesium

Normal levels 1.3-2.1 mEQ/L -Found in skeletal system ICF -Second Most abundant ICF CATION -Intracellular metabolism -Operated sodium potassium pump -Regulates cardiac, neuromuscular functions -relaxes muscles contractions

Prevention/Health Promotion for Metabolism

Nurses provide education and counseling to all patients to prevent disease and promote health. •Healthy People 2020 •"ChooseMyPlate.gov" •Food labels know how to read them •Diet and exercise •Food safety proper handling, clean hands, undercooked foods Exercise routine needs to be approved by doctors Healthy Eating• MyPlate.gov 1,600-2,800 calories •Nutrition Facts •Fresh Fruits & Vegetables

Gout triggers

Obesity Comorbid conditions such as congestive heart failure, hypertension, poor kidney function, and diabetes. Drinking alcohol (the higher the alcohol intake the higher the risk for gout) .Eating or drinking foods high in fructose .Diet high in purines (red meat, organ meats, anchovies, sardines, musse.ls, scallop, trout, and tuna).

Independent nursing interventions

are those the nurse is licensed to prescribe or delegate

serous exudate

consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells. An example is the fluid in a blister from a burn.

sanguineous exudate

consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in open wounds. Mixed types of exudates are often observed. A serosanguineous exudate consisting of both clear and blood-tinged drainage, is com-monly seen in surgical incisions. A purosanguineous discharge, con-sisting of pus and blood, is often seen in a new wound that is infected.

On admission to the clinic, the nurse notes a moderate amount of serous exudate leaking from the patient's wound. The nurse realizes that this fluid

contains the materials used by the body in the initial inflammatory response.

sensory alteration

is impaired reception, perception, or both, of one or more of the senses.Sensory alterations can be the problem (nursing diagnosis) itself such as Acute Confusion, Chronic Confusion, Impaired Memory, or Risk for Acute Confusion. Alterations may also cause a problem, for example, having impaired vision or hearing may justify the diagnosis Risk for Injury. Detecting sensory problems early helps prevent serious problems. Most newborns should be tested for hearing problems before leaving the hospital, if not they should be tested by one month of age .Periodic vision screening of all infants and children is recommended to detect congenital blindness, strabismus, and refractive errors.

purulent exudate

is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tis-sue debris, and dead and living bacteria. The process of pus formation is referred to as suppuration. Purulent exudates vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

"Although inflammation is always present with infection, inflammation often occurs in the absence of infection." Giddens

like a sprained ankle anything that has an itis is usually an inflammatory response

The five cardinal signs of inflammation

pain swelling redness heat impaired function of the part, if the injury is severe

Infection in relation to inflammation

pathogen triggers activation of inflammatory and immune responses. WBCs are attracted to pathogen with increased WBC production .Nursing implication---observe s/s of hyperthermia malaise, pain and discomfort, purulent drainage, and excess sputum production. Anticipate---blood test for WBC and differential, culture, and serum albumin; treatment includes possible antipyretics and anti-infectives.

Basic Metabolic Panel (BMP)

sodium Cl- BUN CO2 BUN K+ Cr Glucose HCO3

Obesity

state in which excess calories are stored as fat. 33% of adults; 17% of youth

Nursing Implications for inflammation immunity- allergic reaction

to observe for mentation, airway, allergies, hives, itching alterations in color, airway constriction, weak and rapid pulse, nausea, and dizziness. Anticipate-administration of epinephrine, oxygen, antihistamines, cortisone, beta-agonists, and analgesics, blood tests, x-rays to determine cause

Diet History

who shops for food who cooks cultural background allergies to food religious practices surrounding food socioeconomic status patients general knowledge on nutrition info on food preferences etc. physical ability to obtain food and eat it maybe ask the patient to fill out a food diary

Fluids and Electrolytes

• 60% of healthy adult's weight is water • Water necessary for normal cellular function • Medium for metabolic reactions • Transports nutrients, waste products • Acts as lubricant, insulator, shock absorber • Helps to regulate, maintain body temperature • DISTRIBUTION AND COMPOSITION OF BODY FLUIDS • ELECTROLYTES ARE CHARGED IONS CAPABLE OF CONDUCTING ELECTRICITY • HOMEOSTASIS DEPENDS ON MULTIPLE PHYSIOLOGICAL PROCESSES • IMBALANCE CAN RESULT FROM A VARIETY OF CONDITIONS • IMBALANCE CAN AFFECT CHRONIC AND ACUTE ILLNESSES • CHRONIC AND ACUTE ILLNESSES CAN CREATE IMBALANCE • REGULATING BODY FLUIDS, CONTINUED • MAINTAINING HOMEOSTASIS:

Nursing History: Health History for metabolism

•Diet History current weight and weight history health status age allergies to food and meds use of alchol or illegal drugs use of vitamin mineral and herbal supplements prescription or over the counter drugs dentures, mouth pain, difficulty chewing which foods might cause problems like gas or heartburns

Assessment for Obesity

•Health history •Risk factors, family history •Recent weight gain or loss •Perceptions of weight, health •Diet, food intake Physical examination •Vital signs, height, weight •Skinfold measurements Nursing diagnoses may include: •Imbalanced Nutrition: More Than Body Requirements •Chronic Low Self-Esteem •Noncompliance •Activity Intolerance Planning• Make sensible dietary choices •Follow exercise routine •Relate strategies to deal with hunger •Attend support group meetings •Demonstrate appropriate weight loss Implementation •Caring interventions •Encourage client to identify contributing factors •Establish realistic goals, objectives •Assess knowledge of balanced diet plans •Discuss behavior modification strategies •Monitor weight loss, BP, lab data •Encourage exercise•Assess current activity level, tolerance •With medical clearance, plan program •Promote weight loss Discuss ability, willingness to incorporate changes •Help identify behavior modification strategies •Have client establish strategies for "stress" eating Expected outcomes may include that client: •Identifies and understands factors contributing to weight loss •Understands and applies behavioral modification techniques to lose weight •Accomplishes desired weight loss •Incorporates physical activity into routines

Overnutrition/Obesity

Obesity excess of adipose tissue •Most prevalent preventable health problem in U.S. •Has serious physiology and psychological consequences •Associated with increased morbidity and mortality •35% adults in U.S. are obese •17% of children in U.S. are obese comorbidities Type 2 diabetes HTN Obstructive sleep apnea osteoarthritis heart diseases Complex systems regulate •Food intake •Energy storage •Energy expenditure •Appetite regulated by CNS, emotions •Hormones involved in regulating obesity: thyroid hormone, insulin, leptin. Risk Factors •Genetics: hereditary contributes 25 - 40% of risk for obesity •Physical inactivity: most important contributor •Environmental factors: contribute to increased food intake •Psychological factors: low self-esteem Gallstones •Several types of cancer •Osteoarthritis •Depression •Sleep disorders •Stress incontinence •Low back pain •Postoperative complications Clinical Manifestations, continued Many contributing factors •Treatment is complex •Ongoing process •Individualized program needed Morbid obesity •BMI > 40 kg/m2 or >200% of ideal body weight •Complications of Obesity •Significant risk factor for cardiovascular disease •60% have metabolic syndrome•Increases risk of insulin resistance and type 2 DM •Affects reproductive function

KIDNEYS

Primary regulator -> Renin-angiotensin-aldosterone system Antidiuretic hormone (ADH)- holding onto fluids, alcohol inhibits this hormone which then would make it a diuretic

DIETARY SOURCES OF KEY ELECTROLYTES

SODIUM - NUTS, CHIPS, BACON, ANCHOVIES, SOUPS CHLORIDE - OLIVES, TOMATOES, CELERY POTASSIUM - SWEET POTATOES, MELONS, RAISINS, BANANAS CALCIUM - MILK, YOGURT, BROCCOLI, TOFU MAGNESIUM - LEAFY GREEN VEGETABLES, WHOLE GRAINS, DRIED BEANS, LENTILS

Verification of Placement of Enteral Tubes

X-Ray is first to see if the tubes are in the GI Tract Check the PH needs to acidic

nursing diagnosis

a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community

Preventing Sensory Deprivation

1. Encourage the patient to use eyeglasses and hearing aids 2. Address the patient by name, touch the patient while speaking if this is not culturally offensive. 3. Communicate frequently with the patient and maintain meaningful interactions, discuss current events .4. Provide a telephone, radio and/or TV, clock, and calendar 5. Provide murals, pictures, sculptures, and wall hangings. Many libraries and museums will lend artwork free of charge, or a local school may provide are projects developed by their students. 6. Have family and friends bring freshly cut flowers and plants. 7. Consider having a resident pet such as fish, a cat, or a bird or make arrangements for pets to visit on a regular basis .8. Include different textured objects to feel such as a sheepskin pillow, silk scarf, soft blanket, or other inanimate object. 9. Increase tactile stimulation through physical care measures such as back massages, hair care, and foot soak. 10. Encourage social interaction through activity groups or visits by family and friends. 11. Encourage the use of crossword puzzles or games to stimulate mental function. 12. Encourage environment changes such as a walk through a mall, or for an immobilized patients, sitting near a window or at a place on the nursing unit where the patient can watch local traffic. 13. Encourage the use of self-stimulation techniques such as singing, humming, whistling, and reciting.

Additional interventions for promoting meaningful stimulation, establishing safe environments and improving communications for those patients with hearing impairment include:

1. If conductive hearing loss is due to excessive cerumen irrigation of the ear should be recommended. 2. Suggest modifying the environment such as amplifying the sound on telephones and televisions or changing to a lower-pitched, buzzer like sound on alarm clocks and doorbells. Lamps designed to turn on in response to sounds such as doorbells, burglar alarms, smoke detectors, and babies crying are also available. Other devices convert words over the telephone to a computer or printer. Some patients with severe hearing loss are able to hear music recorded in the low-frequency sound cycles and may be able to hear recorded music. 3. If patient reads lips: person lip-reading must see the speaker, the speaker's mouth, jaw and eyes must be clearly visible, use sentences rather than single words, give clues to the subject, if not understood restate the question another way, do not exaggerate mouth movements, sit at eye level with patient.

Assessing for Safety hazards in the hospital:

1. Is the call light within easy, safe reach? 2. Are intravenous (IV) poles on wheels and easy to move? 3. Are suction machines, IV pumps or drainage bags positioned so a patient can rise from a bed or chair easily? 4. Ask patient to read a label to determine if he or she is able to read the dosage and frequency.

. Which of the following statements shows the best understanding of the nursing actions appropriate for infection control regarding a surgical wound?

1."If it's a surgical wound, then it's always sterile technique. "2."It takes a physician's order to initially remove a surgical dressing." *3"The primary reason to assess a surgical wound is to monitor for infection."* 4."Monitoring the post-surgical patient's temperature is vital in detecting an infection"

Which of the following assessment observations would be most indicative of healthy wound healing?

1.Absence of eschar 2.Presence of slough *3.Presence of granulation* 4.Small wound size compared with original wound

Which of the following wounds is the best example of tertiary wound healing?

1.Cleft lip repair *2.Eviscerated hysterectomy incision* 3.Exploratory laparoscopy incision

Factors Affecting Sensory Function

1.Developmental Stage The diminishing of sensory perception may come with chronic disease or aging is generally gradual. Hearing loss is common in older adults. Approximately 50% of those over age 75 have hearing loss. 2. Culture Cultural deprivation or cultural care deprivation is a lack of culturally assistive, supportive, or facilitative acts. It is important for nurses to be aware and sensitive to what stimulation is culturally acceptable to a patient. 3. Stress People experiencing stress may find their senses already overloaded and thus seek to decrease sensory stimulation, may only want close support people to visit in hospital. Nurses should help decrease unnecessary stimuli such as noise. 4. Medications and IllnessNarcotics, antiepileptic agents, and sedatives can decrease awareness of stimuli. 5. Lifestyle and Personality Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed.

Which of the following characteristics is most likely that of a Stage 2 pressure ulcer?

1.Eschar *2.Blister* 3.Deep crater 4.Nonblanchable redness

Assessment For inflammation

1.Observe patient current condition (assess skin, scalp, eyes, presence or absence of discharge). 2.Assess signs and symptoms of fever, respiratory difficulty, and pain. Look at body language. 3.Conduct patient interview and obtain patient's medical history. Look for any NSAIDS they used for pains and aches. Did they have surgery? Body obese or not? Stress levels can also cause inflammatory responses so ask for that. Any nausea, bowel movement, elimination