Exam 3- Units 11-14- Nursing 121

continent urinary diversion

Urinary storage in a leak proof pouch. Requires intermittent catheterization for emptying.

Adverse Drug Effects- 1. Acute

To sustain life.

nephrotoxic

capable of causing kidney damage.

Nocturia

excessive urination at night

incontinence

inability to control urination

enuresis

involuntary discharge of urine

Pressure Injury

localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.

Urinary Elimination- Implementation- 1. Promoting normal urination

maintain normal voiding habits, schedule, assist when pt first feel the urge to void, privacy, position, hygiene.

excudate

mass of cells and fluid that escape from blood vessels.

granulation tissue

new tissue, forms the foundation for scar tissue development, it is highly vascular, red and bleeds easily.

colostomy

permits formed feces in the colon to exit through the stoma.

fecal impaction

prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum.

Proteinuria

protein in the urine.

emesis

vomiting.

Pyuria

white blood cells in the urine.

creatinine

- A waste product produced by muscle. It is removed from the body by the kidneys, which filter almost all of it from the blood and release it into the urine. - Elevated levels signifies impaired kidney function or kidney disease. - Normal- 0.7- 1.4mg/dL

Administering via Inhalation

- Aerosol spray, mist, or powder via handheld inhalers- used for respiratory "rescue" and "maintenance" 1. Pressurized metered-dose inhalers (pMDIs)- Need sufficient hand strength for use. 2. Breath-actuated metered-dose inhalers (BAIs)- Release depends on strength of patient's breath. 3. Dry powder inhalers (DPIs)- Activated by patient's breath

Routes of Administration- Topical Medications

- Applied locally to skin- use gloves, tongue blade, or cotton- tipped applicator, clean skin first, and follow directions for each type of medication. Transdermal patches- remove old patch before applying new, document the location of the new patch, ask about patches during medication history, apply a label to the patch if difficult to see, document removal of the patch. - date it, initial it.

Obesity

- BMI of 30 or more. - at risk for numerous health problems. - resources for pts: 1. dietary guidelines for americans. 2. choose my plate.

Cultural and Genetic Considerations

- Cultural practices, religious beliefs/ restrictions. - Ethnicity influences response to certain medications. Ethnopharmacology- scientific study of ethnic groups and their use of drugs. Pharmacogenetics- the study of the role in the genome in drug response.

Energy balance and metabolic requirements

- The body needs energy to function. - Energy is produced by BMR- basal metabolic rate: the energy required to carry out the voluntary functions of the body at rest. Maintaining body temp, muscle tone, propelling food through GI system, inflating lungs, contracting heart muscles. - BMR counts for almost half of people most total energy requirement. - Larger muscle mass- higher BMR. - Determine caloric requirements. Normal: 1cal/kg/hr for men, 0.9cal/kg/hr for women.

Pharmacokinetics- 4. Half- life (t1/2)

- The time it takes for one half of the drug concentration to be eliminated. - Metabolism and elimination affect the half life of a drug. - The longer the half life, the longer it takes for a drug to be eliminated.

Nutrition- 2. Protein

- Vital component of every living cell, required for the formation of all body structures. - Found primarily in animals, can be high in saturated fats. - Will lack fiber, but promote tissue growth and wound healing.

Mixed Incontinence

- a diagnosis that indicates that there is urine loss with features of 2 or more types of incontinence.

Transient Incontinence

- appears suddenly and last for 6 months of less. - caused by treatable factors such as confusion secondary to acute illness, infection, and as a results of medical txs, like diuretics or IV administration.

Nursing considerations for enteral feedings- 1. Promote Safety- a) gastric residual

- check before each feeding or q4-6hrs during continuous feedings. High gastric residual 200-250ml> associated with high risk for aspiration. - Stop feedings if residual is >500ml in the abdomen.

Overflow Incontinence

- chronic retention of urine- the involuntary loss of urine associated with over distention and overflow of the bladder. - the signal to empty the bladder may be underactive or absent, the bladder fills and dribbling occurs. - it may be due to secondary effect of some drugs, fecal impaction or neurologic conditions.

Implementation- Elimination of feces- 4. Oral Intestinal Lavage

- cleanse the intestine of feces as a "bowel prep" prior to procedure or surgery. ex. GoLYTELY

Total Incontinence

- continuous or unpredictable loss of urine, resulting from surgery, trauma, or physical malformation.

Diagnosis studies- 4. Direct Visualization- Endoscopy

- direct visual examination of body organs or cavities. 1. esophagogastroduodenoscopy (EGD)- visualization of esophagus, stomach, and duodenum. 2. colonoscopy- large intestine (anus to the ileocecal valve) 3. sigmoidoscopy- sigmoid colon, the rectum, anal canal. 4. wireless capsule endoscopy- can swallow.

Layers of the skin- Epidermis

- distinct cell layers from deep to superficial. 1. stratum basale 2. stratum spinosum 3. stratum granulare 4. stratum corneum 5. stratum lucidum- inner most layer of stratum corneum- found on palms of hands and soles of feet. 90-95% of epithelial cells are ectodermally derived keratinocytes. 5-10% of epidermal cells are non-keratinocytes.

Nutritional Assessment- Dietary Intake Record

1. 24hr recall- what the pt consumed in the last 24hrs. Relies on pts accuracy for memory, and recalls what they've eaten and portion size. Not reliable. 2. Food diaries/calorie counts- requires documentation over a period of time. Gives overall picture of the nutritional intake. All food consumed in 3-7days. More accurate. Gives a better pic of the pts dietary history. 3. Food frequency record- general overview of nutritional consumption and ask questions of how often they eat something. 4. Diet history- includes all of the above, or portions of the above. Info about past and present food intake and habits.

Common Drugs that Require Blood Drug Levels

1. Antibiotics- Gentamycin, Tobramycin, Vancomysin. 2. Anticonvulsants- Phenobarbital, Phenonytoin. 3. Cardiovascular Drugs- Digoxin, Lidocaine, Procainamide, Quinidine. 4. Respiratory Drug- Theophylline. 5. Antirejection Drug- Cyclosporine. Monitor highly protein bound drugs, very narrow TI drugs, and extensive first pass effect drugs.

Implementation- Laxatives

1. Bulk forming: psyllium (Metamucil) 2. Stool softener: docusate sodium (Colace) 3. Stimulant: bisacodyl (Dulcolax) and senna (Ex-Lax, Senokot) 4. Emollient: mineral oil 5. Saline- osmotics: magnesium hydroxide (MOM)

The "Rights" of Medication Administration- 11. Right to refuse

1. Determine the reason for refusal and document, inform prescribing practitioner. 2. explain the risk for not taking the meds, reinforce the importance of taking the meds.

Types of Catheters

1. External- "texas catheter", condom catheter- not invasive. ex. bedtime. 2. Intermittent- "straight catheter"- insert catheter- used to drain the bladder for shorter periods, short term use. 3. Indwelling catheters- "foley", "retention"- have balloons, stay in- continuous drainage, does not slip out of bladder 4. Suprapubic- insert surgically above the pubic area, long term urinary drainage.

Urinary Elimination- National Patient Safety Goals from Joint Commission

1. Health care associated infections- Goal 7: prevent infection reduce the risk of healthcare associated infections. 2. catheter- associated urinary tract infection (CAUTI)- most frequent type of healthcare associated infection (HAI) and represents as much as 80% of HAIs in hospital.

Nutritional Assessment- Anthropometric Data

1. Obtain pts baseline height and weight upon admission and then using the same scale at the same time each day, before breakfast and after voiding. 2. weight pt daily, weekly, monthly. 3. assess for changed in weight. 4. BMI- preferred method to determine pts healthy weight. Provides estimation about relative risk for disease such as heart disease, diabetes, hypertension. Based on pts weight (lbs)/ height2 (in)x 703. - underweight <18.5 - normal 18.5- 24.9 - obesity >30 - extreme obesity >40 - BMI not accurate for athletes, edema pts or dehydration, elderly or anyone with loss of muscle mass.

The "Rights" of Medication Administration- 5. Right route

1. PO- assess ability to swallow, stay with patient until meds are swallowed, know what meds can be crushed and mixed, do not mix with large amount of food/ fluid. 2. use aseptic techniques when administering meds, sterile techniques with parenteral routes.

Other mechanisms of action

1. Some drug actions are not linked to receptor but are connected directly with cell function. 2. Such as changing the membrane excitability or stability of a nerve or muscle, or causing a defect in cellular state that leads to cell starvation and death. 3. Enzyme interaction- may inhibit or enhance the action of specific enzymes.

Urinary Elimination- Implementation- 5. Urinary Retention

1. absence of urine output for several hours. 2. retention overflow due to urethral obstruction- increase prostate, uterine prolapse, alteration in motor or sensory innervations of bladder, and medication side effects. 3. do bedside scanner to see if absence or overflow or urine.

Gastrointestinal Tract

1. absorb fluid and nutrients- any problems with the GI you will have fluid imbalance, lose fluids and electrolytes since we make about 8L/ day. 2. prepare food for absorption- through small intestines, get electrolytes from food we eat. 3. provide temporary storage of feces- colon is temporary storage for feces. 4. fluid balance 5. receives secretions from organs like gallbladder and pancreas- we make 800ml of bile a day.

Controlled Substances- Nursing Responsabilities

1. account for all controlled substances. 2. keep records of required information. 3. countersign all discarded or wasted medications. 4. ensure that records and medications on hand match. 5. only authorized staff have access. 6. keep locked.

Anatomy of the skin - Facts

1. accounts for 15% if total body weight. 2. largest organ in the body- since its an organ, its prone to failure- skin will fail at the end of life. 3. protects from external insults. 4. skin pathologies include- inflammatory disorders, mechanical and thermal injuries, infectious diseases, benign and malignant tumors

Layers of the skin- Subcutaneous

1. adipose tissue- fatty tissue. 2. helps in thermoregulation. 3. insulates- underlying body parts, bone and muscles. 4. storage of energy due to fat layer. 5. protection from mechanical injuries.

The "Rights" of Medication Administration- 4. Right time

1. administer at specified time, military time. 2. administer half hour before or after the scheduled time- if the administration interval is greater than 2 hours. 3. know if medication needs to be administered with food, before meals. 4. may adjust schedule as appropriate to fit patients schedule, tolerance, or preference. 5. check for scheduled procedures or tests that contraindicate administration of mediations. 6. antibiotics and some cardiovascular drugs- administer at even intervals- bid- q 12hrs, tid- q 8hrs.

Factors that effect urination

1. age- young and old. 2. food and fluid intake- increase in food and fluid intake will increase urine, high salt diet= more concentrated urine, food like asparagus, alcohol will cause diuresis- urinate more frequently. 3. psychological factors- not having privacy to void. 4. activity and muscle tone- pts with foley catheters will cause bladder muscle to never stretch. 5. pathologic conditions- benign prostatic hyperplasia: enlarged prostate will affect outlet of urine. 6. medications- furosemide: will cause diuresis. 7. environmental factors- if pt unable to get to the bathroom cuz its far, will cause incontinence.

Factors that Affect Wound Healing

1. age- young heal quicker than older pts 2. sun 3. nutrition status- large wound that is draining alot, losing alot of protein- tell them to increase their protein, meats, fish, pb. 4. hydration- increase fluid intake. 5. soaps- some can be very drying on the skin. 6. edema- manage edema on LE, control drainage and how fast wound heals. 7. medications- some can cause wound, hydroxyurea affect wound healing. 8. smoking- vasoconstriction 9. pt compliance.

Factor affecting bowel elimination

1. age- young kids dont have ability to be continent. older adults everything slows down. 2. daily pattern- gastrocolic reflex will cause propulsive movements in the large intestines after eating. 3. food and fluid- having less than 6-8cups of water will cause stool to be harden, different foods will make stool have diff. characteristics. 4. activity and muscle tone- have pt walk if have constipation. 5. lifestyle- a person's daily schedule, occupation, and leisure activities contribute to a habit of defecating at regular times or to an irregular pattern. 6. psychological variables- anxiety has a direct effect on GI motility and diarrhea accompanies high anxiety. 7. pathologic conditions- c.diff will cause diarrhea, crohn's disease, infections, gallbladder removal. 8. medications 9. diagnostic studies- barium will affect bowel elimination. 10. surgery and anesthesia- post surgery pt won't have bowel sounds due to meds that slow down GI juices to prevent aspirations.

Factors affecting drug action

1. age. 2. weight. 3. gender. 4. pathology- medical conditions. 5. cultural and genetic factors. 6. psychological factors. 7. environment. 8. timing of administration. 9. food.

Wound

1. an injury to the body that typically involves laceration or breaking of a membrane (skin) and usually damages underlying tissues. ex. violence, accident, surgery. 2. an injury to living tissue caused by a cut, blow or other impact, typically one in which the skin is cut or broken.

Medication Errors

1. any preventable event that may cause or lead to inappropriate medication use or harm to a patient. 2. report all medication errors. 3. patient safety to top priority when an error occurs. 4. documentation is required. 5. the nurse is responsible for preparing a written occurrence or incident report, an accurate, factual description of what occurred and what was done. 6. medication administration is a process, errors occur when medication are ordered, transcribed, dispended, administered, and monitored.

Contraindications of Heat in Skin

1. areas of active bleeding. 2. acute local inflammation. 3. over a large area/ for a prolonged period of time if pt has cardiovascular disease or diabetes.

Effects of medications on stool

1. aspirin, anticoagulants- pink to red to black stool- indicated that may have cause bleeding along tract. 2. iron salts- contain sulfate, black stool and cause stool to be harden. 3. antacids- white discoloration/ speckling in stool. 4. antibiotics- green-gray color. 5. action on GI smooth muscle- slows the action of the smooth muscle. - opium (paregoric) - diphenoxylate and atropine (lomotil) - loperamide (imodium)

Colostomy Care

1. assess new stoma color and appearance q8. 2. cleanse skin and apply skin barrier. 3. mild edema and bleeding are normal. 4. moderate to severe edema and bleedings are not normal. 5. record volume, color, and consistency of stool 6. teach ostomy self care.

Three Checks

1. at the time of contact with the drug, bottle or container. 2. after retrieval from the drawer and compared with the CMAR/ MAR before pouring the drug from a multi- dose container or before taking it out of packaging. 3. after pouring or before discarding the packaging and before giving the medication to the patient.

Distribution influenced by

1. blood flow- decrease blood flow in the body, there's decrease distribution of the drug to the body. 2. protein- binding effect- once drugs are on the system, it has the affinity to attach to protein. ex. albumin. When drug attaches to albumin the drug is not free, becomes inactive. Drugs that are free are going to be active, and be able to reach target cell and attach to receptors so it can cause an effect/ outcome. ex. pt who is malnourished will have less albumin, so there will be more free drugs, so there is a chance of higher drug toxicity- due to more active, free drugs. 3. affinity to body tissues- some medications will bind to body tissues like tetracycline has the affinity to attach to calcium salts so they are deposited into the bones and teeth. Bisphosphonate drugs given for osteoporosis or bone metastasis, will be deposit into the skeletal system and takes years for meds to be release in to the circulation. 4. Blood brain barrier allows lipid soluble drugs to work like inotropic drugs or psych drugs. Placental barriers also allows lipid soluble or water soluble drugs to go through.

Diagnostic studies- 3. Occult blood

1. blood that is hidden in the specimen or cannot be seen on gross examination, detect presence of microscopic blood. 2. hematest, or guaiac 3. black stool- upper GI bleed 4. bright red stool- lower GI bleed 5. certain foods can yield false- positive results.

Bowel Elimination- Assessment- Health History

1. bowel elimination pattern 2. recent change to bowel pattern. 3. aids to elimination. 4. problems with bowel elimination. 5. usual character of stool- form and consistency. 6. diet and fluid history. 7. illness, medical, surgical history affecting GI tract 8. presence of artificial orifices

The "Rights" of Medication Administration- 3. Right dose

1. calculate dose correctly. 2. within dose guidelines. 3. patient's physical status- age, renal function.

Warning signs of colon cancer

1. change in the bowel elimination pattern. 2. blood in the stool- check hbg and hct levels. 3. rectal or abdominal pain. 4. change in the character of the stool- thin stool 5. sensation of incomplete emptying after bowel movement.

Routes of Administration- Nasogastric and Gastrostomy Tubes

1. check for proper placement. 2. liquid, dissolved powder or crushed tablet. 3. do not crush enteric- coated or time- released drugs. 4. always flush tube 30-60ml and mix with 15-30ml.

Drug Classifications- Drug names

1. chemical- provides the exact description of medication's composition. 2. genetic- the manufacturer who first develops the drug assigns the name, and it is then listen in the US Pharmacopeia. First letter lower case. 3. trade- aka brand or proprietary name, this is the name under which a manufacturer markets the medication. First letter uppercase. - Genetic and trade have the same active ingredient, but differ by some fillers or other ingredients.

Nursing Considerations for Wound Care

1. clean not sterile use clean technique when changing the dressing. 2. cleanse with normal saline or other appropriate wound cleanser. 3. apply correct dressing 4. control edema- assess pt/family readiness to learn wound care, provide teaching/education on wound dressing, how often to change, how to correctly apply products, when to notify PMG or wound care MD, importance of follow up visits.

Types of Diets

1. clear liquids- should be able to see through it, lacks protein and essential nutrients, for diagnostic testing, before and after surgery, short term only. 2. full liquid- progressing from clear, can be creamy soup, ice cream, jello. 3. pureed- after oral surgery with difficulty swallowing and chewing, lacks fiber, can be mashed potatoes. 4. mechanical soft- soft foods that tear apart easily, lack fiber.

Urine specimen results- Characteristics

1. color- pale, yellow, straw colored, amber. shouldnt be red, pink, or dark. 2. odor- aromatic. shouldnt be foul smelling or ketones. 3. turbidity- clear or translucent. 4. ph- 4.6-8 5. specific gravity- 1.015-1.025. Bigger number indicates more stuff in urine= more concentrated, pt dehydrated, need fluids. 6. constituents- organic: urea, uric acid, creatinine, inorganic: ammonia, sodium, chloride, potassium, calcium, phosphorus, traced of iron, sulfur.

Aquathermia Pads

1. commonly used in health care facilities for health problems like back pain, muscle spasms, thrombophlebitis, and mild inflammation. 2. safer than heating pad but must be checked carefully.

Layers of the skin- Dermis

1. compressible, elastic connective tissue. 2. supports and protects the epidermis. 3. fibroblasts are the fundamental cells- important for wound healing. 4. contains collage- important for wound healing. - where the red cells live and flatten out as you age.

Fibrin sealants

1. comprised of two substances found naturally in the human body. 1. fibrinogen- a protein and 2. thrombin- an enzyme that acts on the fibrogen to create a fibrin clot. 2. stops bleeding and glues together epidermal surfaces, allows for wound closure with minimal drainage and scarring.

Food affecting bowel elimination

1. constipating foods- cheese, lean meat, eggs, pasta. 2. food with laxative effect- fruits, vegetables, bran, chocolate, alcohol, coffee. 3. gas producing foods- onions, cabbage, beans, cauliflower.

Nursing Diagnosis- Bowel Elimination

1. constipation r/t decreased fiber in diet. 2. constipation r/t decreased physical activity. 3. diarrhea r/t intestinal infection- such as c.diff.

Urinary Elimination- Assessment- Diagnostic Procedures

1. cystoscopy 2. intravenous pyelogram (IVP) 3. renal/ bladder ultrasound 4. computerized axial tomography 5. retrograde pyelogram 1+4 should ask pt if allergic to iodine.

Phases of wound healing- 4. Maturation/ Remodeling

1. day 21 to 2 years after the wound is closed. 2. develop scar formation. 3. unbroken skin 100% develop tensile strength, if you get wound and closes the area is at 80%, puts pt at greater risk of developing an ulcer in the same area, specially if they have uncontrolled edema due to poor circulation. 4. if wound continues over and over in the same spot, the wound won't heal cuz scar tissue isn't as vascular as unbroken skin.

Phases of wound healing- 3. Proliferation

1. day 4- 21, about 2-3wks. 2. fibroblast, collagen will come in, and will fill wound from bottom up till it reaches the top and then cells will come across- hypergranulation will occur formation of new skin tissue. 3. physician or apn will debrit the hypergranulation or burn it with silver nitrate- to get a level surface, cuz cells won't climb the mountain. 3. re-establish skin function, and closure of wound at the end of proliferation.

Complications of enteral feedings

1. dehydration- due to high concentrations of glucose and proteins in the tube feedings. 2. aspiration- due to alot of fluid/food in stomach, so do small frequent feedings, avoid oversedation of pts and check residuals. 3. diarrhea- change delivery set q12-24hrs, open system should be hang for 8hrs to minimize bacterial growth. Refrigerate open system and discard after 24hrs. 4. constipation- decrease fiber in diet, mobility and motility in the stomach, decrease free water and gastric mobility. 5. infection- assess for enteral stoma sites peg or j tubes, signs and symptoms for infection- red, drainage, clear NG tube and assess daily. 6. delayed gastric emptying- due to decreased mobility.

Other Factors that Affect Wound Healing

1. desiccation- dehydration. 2. maceration- softening and breaking down of skin due to overhydration. 3. trauma- repeated trauma to a wound area will result in delayed healing. 4. edema- vascular issues make sure there is a consult. 5. infection. 6. excessive bleeding- non-stop bleeding after holding pressure, will result in large clots. 7. necrosis- death of tissue 8. biofilm- layer of bacteria on wound, happens within 24hrs, appears on top of wound, need to remove it by debriefing, impedes wound healing.

Pharmacokinetics- Factors affecting bioavailability

1. drug form- tabler or liquid. 2. route of administration- IV or oral. 3. blood flow to area of absorption- area that is highly vascular will have better absorption of the drug. 4. body surface area- intestines have greater surface area than the stomach. 5. GI mucosa and motility- hyperactive bowel movements, drug will go straight through the large intestines to rectum, it will not retain. 6. food and other drugs- food can enhance or temper with absorption. 7. pH- drugs will be better absorb in acidic environment, like aspirin. 8. lipid solubility of a medication- fat soluble, water soluble, or lipid soluble medications are better absorbed in the mucosa b/c of fatty layers.

Nutrition- Oxygen

1. edema- albumin. decrease albumin= decreased oncotic pressure and lead to edema and overhydration. 2. HGB- iron- require for hgb. decrease iron= anemia and decrease in oxygen carrying capabilities. Transferrin- transfers iron to the blood. decrease transferrin levels impaired hbg production. Infection and malignancy can decrease levels and hbg production.

Implementation for incontinence- 1. Nocturia, Frequency and Urgency

1. ensure easy access to the bathroom or commode. 2. discourage fluid intake and alcohol use at bedtime. 3. evaluate medication regimen. 4. use a night light. 5. use clothing that is easily removed for voiding. 6. keep assistive ambulatory devices available. 7. assess for UTI.

The "Rights" of Medication Administration- 10. Right response/ evaluation

1. evaluate therapeutic effect, what was the patient's response, was the medication effective. 2. evaluate for side effects, adverse reaction. 3. document.

Implementation- Elimination of feces- 5. Digital Removal of Stool

1. fecal impaction. 2. requires order. 3. may cause irritation of rectal mucosa and bleeding. 4. can stimulate vagus nerve, resulting in a slowed heart rate.

Medication Legislation and Standards

1. federal regulations- food and drug administration (FDA). 2. state and local regulation of medication. 3. health care institutions and medication laws. 4. medication regulations and nursing practice- Nurse practice acts. Mainly to protect the patient.

Stage 4 Pressure Injury

1. full thickness skin and tissue loss. 2. exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. 3. slough/ eschar visible.

Stage 3 Pressure Injury

1. full thickness skin loss. 2. adipose fat is visible in the ulcer and granulation tissue and epibole- rolled wound edges are present. 3. slough/ eschar visible.

National Patient Safety Goals

1. identify patients correctly. 2. improve staff communications. 3. use medication safely. 4. use alarm safely. 5. prevent infection. 6. identify patient safety risks. 7. prevent mistakes in surgery.

Contraindications of Cold in Skin

1. if the injury site is edematous. 2. in the presence of neuropathy. 3. if the pt is shivering. 4. if the pt has impaired circulation.

Correct Dressing for Wound Care

1. if wound bed is dry- moisten it with Hydrogel, non-adherent dressing. 2. if the wound bed is too wet-dry it- Alginates, foams. 3. if the wound is infected- use a silver product, Hydrofera blue, or Cadexomer Iodine. 4. if the wound is large may need to use negative pressure wound therapy to assist in granulation.

Alteration in nutrition: Less than body requirements

1. illness. 2. age. 3. decreased appetite 4. reduced social contact. 5. tooth loss. 6. medications. 7. self care deficits.

Nursing diagnosis- Urinary Function as the Etiology

1. impaired skin integrity r/t urinary incontinence. 2. disturbed body image r/t urinary diversion- ostomy.

Nursing Diagnosis- Urinary Functioning as the Problem

1. impaired urinary elimination r/t UTI. 2. functional urinary incontinence r/t altered environmental factor. 3. stress urinary incontinence r/t weak pelvic muscle.

Types of healing- 3. Tertiary Closure

1. infected surgical wound- left open with local wound care until wound is clean and can be surgically closed. 2. pt on iv antibiotics. 3. leave open for a week or 2 and then try to close it.

Urinary Incontinence

1. involuntary leakage of urine. 2. more prevalent in women. 3. age related changes. 4. use of absorbent products. 5. self concept diminished.

Practices to Avoid with Catheters

1. irrigation of catheter- unless its ordered. 2. disconnecting catheter from the drainage tubing. 3. allowing drainage bag to overfill. 4. using the same collection container for more than one pt. 5. placing drainage bag or tubing on the floor.

Pharmacokinetics- 4. Elimination/ excretion

1. kidneys- urine. BUN/ creatinine, creatinine clearance. 2. liver- bile. 3. bowel- feces. 4. lungs- breath. 5. exocrine glands- saliva, sweat, breast milk.

Phases of wound healing- 2. Inflammatory

1. last 1-4 days. 2. phagocytosis by macrophages, fibroblasts- helps reconnect and regrow enter wound to assist in granulation formation. 3. wound area will be red, but when you push on it, its going to blanch- turn white and then pink again- not sign of infection. subsides as wound progresses into the healing process.

Wound Assessing and Documentation

1. location 2. measurements- length x width x depth, tunneling or undermining. 3. drainage- describe color; clear, serous, serosanguineous, sanguineous, purulent, green. 4. describe the wound bed- red, granular, yellow, slough, eschar, epithelial. 5. describe the peri-wound- dry, moist, macerated, violaceous, rash, erythema. 6. describe any odor. 7. document pain pre and post dressing change.

Diagnostic studies- 1. Stool collection

1. medical aseptic technique. 2. pt may need specific instructions. 3. usually, 1in of formed stool or 15-30ml of liquid stool is sufficient. 4. include visible blood, mucus, pus. 5. no barium or enema solution. 6. label and transport specimens accordingly.

Stage 1 Pressure Injury

1. non- blanchable erythema of intact skin. 2. may appear differently in darkly pigmented skin.

Pressure injury risk factors- Intrinsic

1. nutritional status 2. build 3. age 4. sensory impairment 5. incontinence 6. infection 7. reduced mobility 8. circulatory disorders 9. dehydration 10. mental status 11. neurological disease.

Types of tubes- Small bore nasogastric tubes

1. nutritional support, short term <4wks, from nose to stomach. 2. increases the pts risk for aspiration, due to being thin and narrow, may curl up, pts head elevated, and make sure gag reflex. 3. do not use on pts with nasal injuries and those unable to have head elevated. 4. verify placement with xray, mark at the nose, measure it and document. 5. aspirate ph- volume of fluid withdrawn frim tybe at q4 intervals during feeding, ph should be <5.5 in the gastric secretions but meds will alter that. 6. use multiple methods for verifying placement.

Unstageable Pressure Injury

1. obscured full thickness skin and tissue loss. 2. the extend of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

Phases of wound healing- 1. Hemostasis

1. occurs immediately after initial injury. 2. clotting, release of growth factors, platelets arrive and release cytokines to aid in recruiting of macrophages- which will eat bacteria and clean wound.

Implementation- Elimination of feces- 2. Retention Enemas

1. oil retention enemas- lubricate the stool and intestinal mucosa, making defecation easier. About 150-200ml of soln is administered to adults. 2. carminative enemas- help to expel flatus from the rectum and provide relief from gaseous distention. Common soln include the milk and molasses enema and the magnesium sulfate- glycerin-water (MGW) enema. 3. medicated enemas- provide medications that are absorbed through the rectal mucosa. 4. anthelmintic enemas- destroy intestinal parasites.

The "Rights" of Medication Administration- 2. Right drug

1. order sheets, prescription pad, computerized order system, TO, VO 2. MD, DDS, DPM, APRN. 3. verify medications on MAR or eMAR against the original written order.

Nutrition- Rest and activity/ Safety

1. pain- affect willingness to prepare and eat meals. Opioids can decrease gastric mobility can lead to constipation. Minimize pain and risk associated with pain med. they're receiving. 2. weakness. 3. confusion/ dementia- impact nutrition. 4. swallowing difficulty- impact nutrition.

Stage 2 Pressure Injury

1. partial thickness skin loss with exposed dermis. 2. wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.

Assessing therapeutic drug monitoring

1. patient response and tolerance to drug given- assessment pre and post administration. 2. plasma drug concentrations- certain drugs that have low safety profile. 3. serum levels- therapeutic range. Ex. Digoxin level, phenytoin level. 4. peak and trough levels.

Treatment Options for incontinence- 1. Behavioral Techniques

1. pelvic floor muscle training exercises (PFMT) and kegel exercises. 2. biofeedback- measuring devices that can help the pt become aware of when pelvic floor muscles are contracting. 3. electrical stimulation- electrodes are placed in the vagina or rectum that then stimulates nearby muscles to contact. 4. timed voiding or bladder training- pt keeps track of when voiding and leaking occurs to enable oneself to plant when to void, with increasing length of voiding intervals, involves biofeed and muscle training.

Nursing Assessment for pressure injuries

1. previous history of ulcers or pressure injuries. 2. previous treatment, timeline for healing. 3. changes to skin. 4. slow to heal or non-healing ulcers. 5. bruising. 6. rashes. 7. decreased sensation. 8. incontinence. 9. mobility

Routes of Administration- Inhalation

1. produce local effects such as bronchodilation. 2. some medications create serious systemic side effects. 3. spacers- enhances delivery of medications. 4. nebulizer (aerosol) changes a liquid medication into fine mist. 5. semi or high fowler's position. 6. oral care important, steroids can cause thrush.

Negative Pressure Wound Therapy (NPWT)

1. promotes granulation tissue formation via fibroblast stimulation. 2. removes excess drainage. 3. decreases bacteria load in wound. 4. dressings are changed 3x's weekly.

Nursing Diagnosis for Skin

1. risk for impaired skin integrity 2. risk for infection 3. acute or chronic pain 4. disturbed body image 5. impaired tissue integrity 6. ineffective tissue perfusion 7. imbalanced nutrition: less than body requirements

Collection of urine specimen

1. routine urinalysis- at least 10ml. 2. clean catch- midstream urine. 3. sterile specimen. 4. urine specimen from a device. 5. 24hr urine specimen. 6. point of care urine testing. Urine C & S- at least 5ml

Age related changes affecting bowel elimination

1. slowing of GI motility with increased stomach-emptying time- at risk for constipation, might need to eat smaller meals 2. decreased muscle tone/ incontinence- perineal, need muscle to evacuate stool. 3. weakening of intestinal walls with greater incidence of diverticulitis- little pockets within the colon that stool and bacteria get stuck in there and get inflamed and get fever.

Selected Therapeutic Diets

1. sodium restricted diet- pts with hypertension, heart failure, liver and renal disease. 2. renal diet- restrict protein, sodium, potassium, and fluids. Pts with chronic/ acute kidney problems. 3. fat restricted diet- cardiac diet, reduce intake of saturated fats. Pts with cholecystitis, cardiovascular disease and to help prevent arteriosclerosis. 4. NPO- nothing by mouth. Before and after surgery till bowel movements. Pts with severe nausea and vomiting or unable to chew and swallow, short period of time only.

Types of healing- 1. Primary Closure

1. surgical repair- wound edges are approximated and closed with sutures, staples, or steri-strips. aka primary intention- surgical incision.

Types of Debridement

1. surgical- either in the OR or bedside . 2. mechanical- wet to dry, pulse irrigation or whirlpool 3. chemical- enzymatic- santyl 4. autolytic- medi- honey, antimicrobial 5. biotherapy- larval therapy

diphenoxylate with atropine

1. therapeutic classification- antidiarrheals. 2. mechanism of action- inhibits excessive GI motility, related to opioid analgesics, atropine added to discourage abuse. decreased GI motility with subsequent decrease in diarrhea. 3. adverse reaction- dizziness, constipation, blurred vision, tachycardia, epigastric distress, urinary retention, flushing. 4. nursing implication- assess the frequency and consistency of stools and bowel sounds, assess pts fluid and electrolyte balance and skin turgor for dehydration. 5. education- instruct pt to take as prescribed, may cause drowsiness, advise pt that frequent mouth rinses, good oral hygiene may relieve dry mouth, avoid alcohol, instruct HCP if diarrhea pepsist, fever, abdominal pain, palpitations.

promethazine

1. therapeutic classification- antiemetics, antihistamines, sedative/ hypnotics. 2. mechanism of action- blocks the effects of histamine. Has inhibitory effects on the chemoreceptors trigger zone in the medulla. Alters the effects of dopamine in the CNS. relief of symptoms of histamine excess usually in allergic conditions, diminished nausea and vomiting. sedation. 3. adverse reactions- neuroleptic malignant syndrome, confusion, disorientation, sedation, extrapyramidal reactions. 4. nursing implications- monitor for development of neuroleptic malignant syndrome, monitor BP, pulse, RR, extrapyramidal side effects, assess for fall risk. 5. education- may cause drowsiness, caution pt to avoid driving, advice pt that frequent mouth rinses and good oral hygiene may decrease dry mouth, advice pt to change positions slowly to minimize orthostatic hypertension, and instruct pt to notify HCP for sore throat, fever, jaundice, or uncontrolled movements.me

metoclopramide

1. therapeutic classification- antiemetics. 2. mechanism of action- blocks dopamine receptors in chemoreceptors trigger zone of the CNS. decreased nausea and vomiting, decreased symptoms of gastric stasis, easier passage of NG tube into small bowel. 3. adverse reactions- drowsiness, extrapyramidal reactions, restlessness. 4. nursing implications- assess for nausea, vomiting, abdominal distention and bowel sounds before and after administration, assess for extrapyramidal side effects, monitor for neuroleptic malignant syndrome, monitor for tardive dyskinesia and assess for signs of depression. 5. education- instruct pt to take as directed, may cause drowsiness, avoid use of alcohol, inform pt of risk of extrapyramidal symptoms, tardive dyskinesia, and neuroleptic syndrome.

ondansetran

1. therapeutic classification- antiemetics. 2. mechanism of action- blocks the effects of serotonin at 5-HT3 receptor sites located in vagal nerve terminals and the chemoreceptor trigger zone in CNS. decreased incidence and severity of nausea and vomiting following chemotherapy or surgery. 3. adverse reactions- serotonin syndrome, headache, dizziness, drowsiness, constipation, diarrhea, torsade de pointes, abdominal pain, dry mouth, extrapyramidal reactions. 4. nursing implications- monitor ECG in pts with hypokalemia, hypomagnesemia, HF, bradyarrhythmias, monitor for signs and symptoms of serotonin syndrome, assess for rash, may cause stevens-johnson syndrome or toxic epidermal necrolysis. 5. education- instruct pt to take as directed, to notify health care professional if symptoms of irregular heart beat, serotonin syndrome, or involuntary movement of eyes, face or limbs.

megestrol acetate

1. therapeutic classification- antineoplastics, hormones. 2. mechanism of action- effect may result from inhibition if pituitary function. regression of tumor, increased appetite and weight gain in pts with AIDS. 3. adverse reactions- thromboembolism, edema, alopecia. 4. nursing implications- assess for swelling, pain, or tenderness in legs. 5. education- instruct pt to take as directed, to report any unusual vaginal bleeding or signs of deep vein thrombophlebitis, and discuss possibilities of hair loss.

bisacodyl

1. therapeutic classification- laxatives 2. mechanism of action- stimulates peristalsis, alters fluid and electrolyte transport, producing fluid accumulation in the colon. evacuation of the colon. 3. adverse reaction- abdominal cramp, nausea, diarrhea, rectal burning, hypokalemia, muscle weakness 4. nursing implication- assess pt for abdominal distention, presence of bowel sounds and usual pattern of bowel function, assess color, consistency, and amount of stool produced. 5. education- prolonged therapy may cause electrolyte imbalance and dependence, advice pt to increase fluid intake to at least 1500-2000ml/day to prevent dehydration, use other forms of bowel regulation, avoid straining with pts with cardiac disease due to valsalva maneuver, do not use if constipation is accompanied by abdominal pain, fever, nausea or vomiting.

psyllium

1. therapeutic classification- laxatives. 2. mechanism of action- combines with water in the intestinal contents to form an emollient gel or viscous solution that promotes peristalsis and reduces transit time. relief and prevention of constipation. 3. adverse reaction- bronchospasm, cramps, intestinal or esophageal obstruction, nausea, vomiting. 4. nursing implication- assess pt for abdominal distention, presence of bowel sounds, and usual pattern of bowel function, assess color, consistency, and amount of stool produced, may cause elevated blood glucose levels with prolonged use. 5. education- encourage other forms of bowel regulation, may be used for long term management of chronic constipation, avoid straining with pts with cardiac disease, do not use if abdominal pain, nausea, vomiting, or fever is present.

docusate sodium

1. therapeutic classification- laxatives. 2. mechanism of action- promotes incorporation of water into stool, resulting in softer fecal mass, may promote electrolyte and water secretion into the colon. softening and passage of stool. 3. adverse reaction- throat irritation, mild cramps, diarrhea, rashes. 4. nursing implication- asses for abdominal distention, presence of bowel sounds, and usual pattern of bowel function, assess color, consistency, and amount of stool produced. 5. education- should be used for short term therapy, long term may cause electrolyte imbalance and dependence, use other forms of bowel regulation, pts with cardiac disease should avoid straining, do not use when abdominal pain, nausea, vomiting or fever is present, don't take within 2hr of other laxatives.

magnesium hydroxide

1. therapeutic classification- mineral and electrolyte replacement/ supplements, laxatives 2. mechanism of action- essential for the activity of many enzymes, important role in neurotransmission and muscular excitability, osmotically active in GI tract, drawing water in the lumen and causing peristalsis. replacement in deficiency states and evacuation of the colon. 3. adverse reaction- diarrhea, flushing and sweating. 4. nursing implication- assess for heartburn and indigestion as well as location, duration, character, and precipitating factors of gastric pain. 5. education- advice pt not to take meds within 2hr of taking other meds. advice HCP if taking antacids for more than 2wk, if symptoms of gastric bleeding occur.

bethanechol chloride

1. therapeutic classification- urinary tract stimulant. 2. mechanism of action- stimulates cholinergic receptors, contraction of the urinary bladder, decreased bladder capacity, increased frequency of ureteral peristaltic waves, increased tone and peristalsis in the GI tract, increased pressure in the lower esophageal sphincter, increased gastric secretions. bladder emptying. 3. adverse reactions- abdominal discomfort, diarrhea, nausea, salivation, flushing, sweating, heart block, syncope/ cardiac arrest. 4. nursing implications- monitor BP, pulse and respirations before administration and for at least 1hr after subcut administration, monitor intake and output ratios, palpate abdomen for bladder distention, notify HCP if drug fails to relieve conditions, and catheterization may be ordered to assess postvoid residual. 5. education- instruct pt to take med as directed, caution pt to change positions slowly to minimize orthostatic hypotension. advice pt to report abdominal discomfort, salivation, sweating, or flushing.

Nursing Interventions for skin

1. turn and position q2, elevate heels, skin assessment qshift, upon transfering to another unit/ or when condition changes. 2. make sure pt has the correct mattress, alternating pressure, low air loss or a specialty bed, make sure all tubing is free. 3. incontinence management, encourage pt to shift weight q30min when seated in chair if possible. 4. keep HOB at 30 degree unless eating or contraindicated. 5. nutritional risk assessment- add dietary supplements, encourage increase protein intake unless contraindicated. 6. braden score.

Other risk factors for pressure injury

1. use medical devices- cpap/ bipap 2. medical conditions such as diabetes mellitus, multi- system trauma, vascular conditions, steroid therapy, history of previous ulcers, cancer. 3. end of life skin change-

Clean Technique/ Medical Asepsis for Skin

1. used on wounds that are chronic or contaminated. 2. use clean gloves. 3. cleanse from the least to the most contaminated.

Support of body parts/wounds- Montgomery Straps

1. used to secure dressings without removing and reapplying tape. 2. acts like a girdle to secure the wound. 3. use a protective dressing underneath the straps to protect the skin. ex. Hydrocolloid.

Braden Scale

1. validated assessment tool used to quantify a pts degree of risk for developing a pressure ulcer. 2. the lower the total score, the higher the risk for pressure ulcer development. 3. pt are at risk for developing pressure ulcers if the total score is less than 17. 4. high risk of 1, low risk of 3 or 4. 5. parameters include sensory perception, moisture, activity, mobility, nutrition, and friction and shear. 6. pt need to be assessed on a regular basis.

Therapeutic Benefits of Cold in Skin

1. vasoconstriction. 2. local anesthesia. 3. reduced cell metabolism 4. increased blood viscosity. 5. decreased muscle tension. 6. used on sprains, strains, fractures, muscle spasms, minor burns, arthritis.

Therapeutic Benefits of Heat in Skin

1. vasodilation. 2. reduced blood viscosity. 3. reduced muscle tension. 4. increased tissue metabolism 5. increased capillary permeability. 6. used on infiltrated IV sites, arthritis, muscle strain, lower back pain.

Stool characteristics

1. volume- variable. 2. color- brown. 3. odor- pungent, affected by food, c. diff. 4. consistency- soft, semi-solid, and formed. 5. shape- about 1in in diameter, tubular shape. 6. constituents- waste residues of digestion, bile, intestinal secretions, bacteria, calcium, and phosphates.

Care of Patients with Indwelling Catheters

1. wash hands, clean perineal area, cleanse catheter from meatus outward, use mild soap and water or perineal cleanser. 2. adequate fluid intake, encourage pt activity. 3. note and record amount and character of urine q8hrs, maintain closed system. 4. teach pt personal hygiene, and report any signs and symptoms of infection. 5. keep collecting bag lower than the bladder at all times, and remove catheter at the earliest time possible.

Types of healing- 2. Secondary Closure

1. wound edges are not approximated, heal by granulation and contraction of wound- secondary intention- healing of open wound, from the base upward by laying down new tissue. ex. lower extremity wounds, some pressure injuries, burns.

Diagnosis studies- 5. Indirect Visualization

1. xray (abdomen)- upper GI series swallow barium, lower GI series enema barium, abdominal xray. 2. ultrasound 3. ct scan with or without contrast 4. magnetic resonance imaging (MRI)

tolterodine tartrate

1.therapeutic classification- urinary tract antispasmodics. 2. mechanism of action- acts as a competitive muscarinic receptor antagonist resulting in inhibition of cholinergically mediated bladder contraction. decreased urinary frequency, urgency, and urge incontinence. 3. adverse reactions- headache, dizziness, dry mouth, blurred vision, stevens johnson syndrome, anaphylaxis, angioedema. 4. nursing implications- monitor for signs and symptoms of anaphylaxis and angioedema, assess rash, may cause stevens johnson syndrome or toxic epidermal necrolysis. 5. education- instruct to take as directed, may cause dizziness, avoid driving, and notify HCP if rash or signs and symptoms of anaphylaxis or angioedema.

oxybutynin chloride

1.therapeutic classification- urinary tract antispasmodics. 2. mechanism of action- inhibits the action of acetylcholine at postganglionic receptors, has direct spasmolytic action on smooth muscle, including smooth muscle lining the GU tract, w.o affecting vascular smooth muscle. increased bladder capacity, delayed desire to void, decreased urge incontinence, urinary urgency, and frequency. 3. adverse reactions- dizziness, drowsiness, constipation, dry mouth, nausea. 4. nursing implications- monitor voiding pattern and intake and output ratios, and assess abdomen for bladder distention. Cystoscopy performed to diagnose type of bladder dysfunction. 5. education- instruct to take as directed, may cause drowsiness or blurred vision, avoid alcohol, frequent rising of mouth, good oral hygiene to decrease dry mouth, overheating may occur, notify HCP if signs of angioedema or anaphylaxis occur.

The "Rights" of Medication Administration- 1. Right client or patient

2 forms of ID.

bolus

A term used to describe food after it has been chewed and mixed with saliva.

Nutrition- 6. water

- essential nutrient, necessary for substances to be broken down and used by our bodies. - need 2-3L a day, 50-60% of our total body weight.

Reflex Incontinence

- experience emptying of the bladder without the sensation of the need to void r/t to spinal cord injuries.

Nutrition- 7. fiber

- huge impact on elimination. - found in grain, vegetables, fruits and promotes normal bowel function. - helps make waste materials, through colon faster which reduces colon exposure to potential carcinegious, reduces colon cancer, prevents constipation, hemorrhages, diverticulitis disease. - recommend 20-35g/day fiber intake.

Nutrition- 5. minerals

- inorganic elements found in all body fluids and tissues.

Maintenance Dose

The dose of drug that maintains or keeps the drug in the therapeutic range.

Adverse Drug Effects- 5. Substitutive/ replacement/ supplemental

Replace substance to maintain normal function. Ex. insulin.

Urinary Elimination- Patient Outcomes and Planning

The patient will: 1. produce urine output about equal to fluid intake. 2. maintain fluid and electrolyte balance. 3. empty bladder completely at regular intervals. 4. report ease of voiding. 5. maintain skin integrity.

Pharmacokinetics- Bioavailability

The percentage of the administered drug dose that reaches the systemic circulation/ bloodstream. Oral route- <100% Intravenous route- 100%, will elicit a reaction immediately.

Pharmacokinetics- 3. Metabolism- biotransformation

The process by which drugs are converted to a form that is usually more easily removed from the body. - Liver is primary site of drug metabolism. - Hepatic microsomal enzyme system/ P-450 system- group of enzymes that degrade/ breakdown, detoxify, inactivate drugs. - Prodrugs- has no pharmacologic activity unless they are first metabolized to their active form. - Lungs, kidneys, and intestines metabolize drugs too.

Pharmacokinetics- 2. Distribution

The process by which the drug becomes available to body fluids and body tissues.

Adverse Drug Effects- 3. Palliative

To make the patient comfortable, relieve pain.

Adverse Drug Effects- 9. Side effects

Unintended, secondary effects.

Adverse Drug Effects- 11. Idiosyncratic reaction

Unpredictable, peculiar to individual, not known.

Nursing considerations for enteral feedings- 3. Monitor for complications

Use sterile water for flushing and medication administrations. Water and flushing system should be changed every 24hrs to minimize bacterial growth.

Drug Classifications- Therapeutic Classification

Usefulness of the drug.

Phases of drug action- 1. Pharmaceutics

When a tablet goes through disintegration- into small particles and dissolution- into liquid form

Kidney Function

1 waste product removal- from ingesting and taking meds. 2. fluid and electrolyte balance. 3. hormone secretions- erythropoietin, renin, calcium and phosphate regulation, prostaglandin and prostacyclin.

Pharmacokinetics- 1. Absorption

Process of drug absorption. a. passive- diffusion of drug absorption goes from higher to lower concentration. b. active- drug requires a carrier, enzyme, or protein to get across the membrane. c. pinocytosis- drug is engulfed or membrane encapsulates the drug to cross the membrane.

Assistance with feedings- 2. patients with dysphagia

Provide 30min rest up prior to meals. Sit upright in chair, don't rush them or force feedings. Need thick liquids, easier to swallow. Alternate solid and liquids. Inspect oral cavity for pocketing of food. Assess for signs of aspiration- coughing, choking and change in voice.

Drug Interactions- 6. Drug Incompatibility

Can some drugs be mix together or separate in the IV.

Elimination- Nausea and Vomiting

Causes- medications, surgery, infection, illness. Intervention- identify the cause, administer meds ordered, monitor pt for therapeutic response, assess for side effect of medication and provide education.

Assistance with feedings- 1. patients with dementia

Change in environment in which meals occur. Create homelike environment. Observe formal rituals. Avoid clutter and distractions. Serve same place, same time, closely supervise meal times. Assess food temp to prevent injury.

Drug Interactions- 3. Antagonistic

Combine drugs alter the overall sum effect or negate each other. Results in an effect less than that of each drug alone.

Loading Dose

Comparatively large dose given at the beginning of treatment to rapidly obtain the therapeutic effect of a drug.

Drug Plasma Concentration and Therapeutic Response

Concentration of medication in target tissue is often impossible to measure, so it must be measured in plasma.

Possible causes of medication errors

Distractions, lack of knowledge, memory lapses, overworked staff, transcription, dispensing, inadequate monitoring, lack of standardization, equipment failures, inadequate patient history, poor communication, violation of the rights of medication administration, increase in number of drugs available.

Receptor Theory- Antagonist Drugs

Drug prevents the endogenous substance from acting. ex. betablocker- blocks beta1 adrenergic receptors.

Receptor Theory- Agonist Drugs

Drug that produces the same type of response as the endogenous substance. ex. epinephrine- stimulates alpha adrenergic receptors.

Receptor Theory

Drugs act by forming a chemical bond with specific receptor sites. The better the fit, the better the response.

Nonspecific Drugs

Drugs that act at a receptor and affect all anatomic sites of location.

Nonselective Drugs

Drugs that act at different receptors, like Alpha1, Beta1, Beta2.

Drug Interactions- 2. Synergistics

Drugs with different sites or MOA, results in a greater effects when taken together. One drug potentiates the other.

Drug Interactions- 1. Additive

Drugs with similar pharmacological action, results in an increase in overall effect. ex. aspirin and codeine.

Therapeutic Index (TI)

Estimates the margin of safety of a drug by using a ratio that measures the effective dose (ED) and lethal dose (LD). Low therapeutic index- Narrow margin of safety: greater danger for toxicity. High therapeutic index- Wide margin of safety: less danger of producing toxic effects. Therapeutic range- between the minimum effective concentration and minimum toxic concentration. Always read the recommended dose for the drug.

The "Rights" of Medication Administration- 7. Right assessment

Gather necessary information prior to administration- HR, BP, blood glucose, LOC, ability to swallow.

Adverse Drug Effects- 12. Drug tolerance

Getting used to effect of drugs, might need higher dose.

Elimination- Enteral Feedings

Indications- if pt is unable to meet nutritional needs through oral intake of an adequate diet.

Medication administration- Keys to accuracy

1. Avoid distractions and follow the same routine. 2. Administer only medications you prepare, and never leave prepared medications unattended. 3. Document medications immediately after administration. 4. Use clinical judgment in determining the best time to administer prn medications. 5. When preparing medications, check the medication container label against the medication administration record (MAR) three times.

The "Rights" of Medication Administration- 6. Right reason

Know the indication for administering the medication.

Nutritional Assessment- Biochemical Data

Laboratory tests which measures blood and urine levels of nutrients for biochemical functions, that are depended on adequate supply of nutrients and they can detect nutrition problems in early stages.

Parenteral Nutrition- 1. PPN- Peripheral Parenteral Nutrition

Less concentrated nutrient solution. Can administer through peripheral IV. Isotonic solution and contains low concentrations of dextrose and amino acids.

purulent drainage

Made up of WBC's liquified dead tissue debris and both dead and live bacteria. Thick, often musty or foul odor and varies in color.

Adverse Drug Effects- 4. Supportive/ maintenance

Maintain the integrity of body functions.

Drug Classifications- Pharmacologic Classification

Mechanism of action.

autonomic bladder

bladder no longer controlled by the brain because of injury or disease; void by reflex only

glycogenolysis

breakdown of glycogen to glucose.

fistula

abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another.

Anuria

absence of urine

micturition or void

act of passing urine.

ileostomy

allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma.

TPN/ PN

1. Use electronic infusion device to administer. 2. Check VS q4, including temp. 3. It is high in dextrose solution and can lead to infection. 4. Monitor blood glucose levels. 5. Use aseptic technique when changing tubing or dressings. 6. Monitor pts weight, if increased more than 1lb/day or more than 3lbs/week, will indicate fluid retention. 7. Assess electrolyte levels, serum albumin, and prealbumin levels.

Urinary Elimination- Physical Assessment

1. bladder- we can do scan. 2. urethra orifice- inspect for any signs of inflammation, discharge or foul odor. 3. skin integrity and hydration- if pt has incontinence, make sure they dont have skin breakdown or rashes, measure hydration by skin turgor, color, texture, and compare weights. 4. kidneys in the retroperitoneal- flank tenderness= inflammation, pain at costovertebral angle on percussion= kidney infection.

Support of body parts/wounds- Binder and Splints

1. create pressure over a body part. 2. immobilize a body part. 3. support a wound. 4. reduce or prevent edema. 5. secure a splint. 6. secure dressings.

Common Nursing Dx Related to Drug Therapy

1. deficiency knowledge regarding new drug treatment regimen with insulin r/t lack of information. 2. anxiety r/t new drug treatment regimen. 3. noncompliance to medication regimen r/t misunderstanding of information. 4. noncompliance to medications r/t undesirable side effects of medicine.

Older Adults- Physiologic Changes

1. gastrointestinal. 2. cardiac and circulatory. 3. hepatic. 4. renal.

Administration of a tap water enema

1. identify the pt. 2. generously lubricate end of the rectal tube 2 to 3 inches. 3. introduce solution slowly over a period of 5-10min. 4. encourage the pt to hold the solution until the urge to defecate is strong, usually in about 5-15 minutes.

Routes of Administration- Parenteral Route

1. injection into body tissues. 2. invasive procedures that requires aseptic techniques. 3. risk of infection. 4. skills needed for each type of injection. 5. effects develop rapidly, depending on the rate of medication absorption. 4 major sites of injection- subcutaneous (Sub-Q), intramuscular (IM), intravenous (IV), intradermal (ID).

Deep Tissue Pressure Injury (DTPI)

1. intact or non-intact with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. 2. epidermal separation revealing a dark wound red or blood filled blister. 3. pain and temperature change often precede skin color changes.

Therapeutic Drug Monitoring

1. measurements of blood drug levels to determine effective drug dosages and to prevent toxicity. 2. to identify noncompliant patients. 3. helpful in patients who take other medicines that may affect the drug levels or act in a synergistic or antagonistic manner with the drug to be tested. 4. helpful in prescribing medicines that have a very narrow therapeutic margin (index).

Routes of Administration- Oral Route

1. most commonly used- easiest and most desirable route. 2. given by mouth and swallowed with fluid. 3. have slower onset of action. 4. aspiration precautions. 5. can be solid, liquid, sublingual, buccal.

Bowel Elimination- Assessment- Physical Assessment

1. mouth- inspection of teeth, gums, tongue. 2. abdomen- inspection, auscultation, percussion, palpation. 3. anus and rectum- inspection for lesions, ulcers, hemorrhoids- abnormally distended rectal veins, fissures- linear break on the margin of the anus, inflammation.

Types of Wound Drains

1. placed in surgical wounds to drain off excess fluid. 2. connected to wall suction, canister or self-suction. 3. need to note type, amount of drainage. 4. deflate to maintain suction. 5. keep secured.

Older Adults- Behavioral and economic factors

1. polypharmacy. 2. self- prescribing of medications. 3. OTC medications. 4. misuse of medications. 5. noncompliance.

Pressure injury risk factors- Extrinsic

1. pressure 2. shear- when one layer of tissue slides over another layer. 3. friction- occurs when two surfaces rub against reach other. 4. restricted mobility 5. moisture 6. surgery 7. poor moving and handling 8. medication 9. inappropriate positioning 10. poor hygiene 11. inappropriate clothing. 12. ischemia- deficiency of blood in a particular area.

Anatomy of the skin

1. pressure injuries are a preventable negative outcome for a pt. 2. if they come in without a pressure ulcer they should leave without a pressure ulcer. 3. epidermis- outer layer 4. dermis 5. subcutaneous layer- contains fat

Patient Outcomes for normal bowel elimination

1. pt has a soft, formed bowel movement every 1-2days without discomfort. 2. pt will consume 25gms of fiber/ day 3. pt will demonstrate label reading. 4. pt modify any factors that contribute to current bowel movements.

Goals and outcomes for skin

1. pt will experience no skin breakdown during hospital stay. 2. pt's wound will have a 20% increase in granulation tissue in 7 days. 3. pt will increase caloric intake by 10% in 5 days.

Routes of Administration- Suppositories

1. rectal or vaginal. 2. capillaries in the rectal area promote local or systemic absorption. 3. lubricate suppositories. 4. let patient remain on his/ her side for 5min after insertion. 5. vaginal- lithotomy position, provide patient with sanitary pad.

Nursing Implications- Legal Liability: Nurses

1. responsible for their action even when there is a written medication order. 2. along with physicians and pharmacist, participate in the system to maintain medication safety. 3. a nurse is the LAST STOP in the system. 4. responsible to ensure that the "rights" of medication administration are executed. 5. responsible for assessing patients condition in relation to the use of the ordered medication. 6. must have knowledge of the effects and potential effects of every drug administered. 7. take measures to protect the patients from safety hazards that may expected from a medications effects.

Criteria for Insertion of Catheters

1. retention- use a bladder scan first. 2. strict urine output or 24hr urine collection required and the pt is unable to use urinal or bedpan or is incontinent. 3. obtaining a specimen when the pt cannot void. 4. surgery. 5. open sacral ulcers. 6. physical trauma/ unstable spine. 7. terminal illness/ comfort measures.

Nurses Rights

1. the right to complete and clear order. 2. the right to have correct drug, route and dose dispensed. 3. the right to have access to information. 4. the right to have policies to guide safe drug administration. 5. the right to administer drugs safely and to identify systems problems. 6. the right to stop, think and be vigilant when administering medications.

Urgency

feeling the need to urinate immediately

Types of tubes- gastrostomy and jejunostomy

for long term nutritional support, surgically implanted.

glycogenesis

formation of glycogen from glucose

Glycosuria

glucose in the urine

Urinary Elimination- Implementation- 4. Assisting with toileting

help pt get bedpan, or urinal when feeling urge to void.

Suppression

holding back or restraining

serous drainage

clear, serous portion of the blood and from serous membrane, clear and watery.

sanguineous drainage

consists of large number of red blood cells and looks like blood. bright-red sanguineous drainage is indicative of fresh bleeding, darker drainage indicates older bleeding.

Urinary Elimination- Implementation- 2. Promoting fluid intake

if pt can drink then have them drink. its good for kidneys.

Retention

inability to empty the bladder

Polyuria

increased volume of urine voided.

Enuresis

involuntary emptying of the urine at night.

Dribbling

involuntary leakage of small amounts, as of urine from the urethra

fecal incontinence

involuntary or inappropriate passing of stool or flatus

Gluconeogenesis

metabolic process by which organisms produce sugars for catabolic reactions from non-carbohydrate precursors.

serosanguineous drainage

mixture of serum and red blood cells, it is light pink to blood tinged.

Dysuria

painful urination.

Dehiscence

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

bacteriuria

presence of bacteria in the urine

eschar

dead tissue that appears as dry, black, leathery tissue.

sloughing

dead tissue, presents as moist, yellow, stringy tissue

epithelialization

epithelial cells migrate to the wound bed.

Evisceration

protrusion of viscera through an incision

Hematuria

red blood cells in the urine.

Sutures

removed when the wound has developed enough tensile strength to hold the wound edges together during healing.

anthropometry

scientific study of the measurements and proportions of the human body.

Implementation- 2. incontinence

teach kegel exercises.

lipogenesis

the metabolic formation of fat.

cutaneous ureterostomy

the ureters are directed through the abdominal wall and attached to an opening in the skin.

cheilosis

ulceration of the lips.

ileal conduit

urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall.

postvoid residual (PVR)

urine that remains in the bladder after the act of micturition; a synonym for residual urine.

Frequency

voiding more frequently than every 3hrs

Valsalva maneuver

when a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decrease blood flow to the atria and ventricles, lowering cardiac output.

Nursing considerations for enteral feedings- 2. Provide comfort

Administer oral care frequently q2-4hrs to prevent drying of tissues and to relieve thirst. Keep nares clea if NG tube. Use lubrication after cleaning around nares.

Adverse Drug Effects- 10. Allergic reaction

Antigen- antibody reaction. Can be local or systemic- anaphylaxis.

Adverse Drug Effects- 8. Adverse Drug Events

Any undesirable occurrence related to administering or failing to administer a prescribed medication. Preventable, medication errors, administration, dispensing, monitoring, prescribing.

Urinary Elimination- Health history

Ask specific questions. 1. patterns of urination, frequency, volume. 2. recent changes? 3. aids to elimination? 4. present or past urinary problems? 5. presence of urinary diversion?

The "Rights" of Medication Administration- 9. Right to education

Accurate and thorough information about the meds, therapeutic purpose, expected results, side effects, lab monitoring required.

BUN- blood urea nitrogen

Another indicator of kidney function. Urea is a metabolic byproduct which can buildup if kidney function is impaired. The BUN/creatinine ratio provides more precise information about kidney function. BUN increased also associated with dehydration. Normal- 10-20mg/dL

Adverse Drug Effects- 13. Toxic effects

Can cause serious harm or death. Cumulative effect- when taking more of the drug that its been excreted, it can cause toxicity. Antidote- counteracts effect of drug. ex. narcan.

Oliguria

Decreased urine output

Drug Interactions- 5. Drug- induced photosensitivity

Drugs that cause a skin reaction when exposed to sunlight.

Adverse Drug Effects- 7. Adverse Drug Reaction

May or may not be preventable, may occur in normal therapeutic use, mild or severe. Side effects of the drug.

Urinary Elimination- Implementation- 3. Strengthening muscle tone

Pelvic floor muscle training (PFMT) and kegel exercises.

Adverse Drug Effects- 6. Prophylactic/ empiric

Prevent illness/ based on clinical probabilities.

Adverse Drug Effects- 2. Curative

Prevent progression of a disease/ condition and treatment of chronic illness.

Nursing considerations for enteral feedings- 1. Promote Safety- c) prevent infection

- perform hand hygiene prior to setting up tube feeds. - maintain aseptic techniques when changing both open/close feeding systems. - assess pts stoma if has G or J tube, should be clean every shift. If pt has NG tube, provide care around the nares b/c it can lead to a sinus infection.

Stress Incontinence

- Occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities. - Childbirth, menopause, obesity, or straining from chronic constipation can also result in urine loss. The leakage usually does not occur when the person is supine.

Pharmacokinetics- First- pass effect or hepatic first pass

- Oral route- mechanism whereby drugs are absorbed across the intestinal wall and enter the hepatic portal circulation. - A large number of oral drugs are rendered inactive by hepatic metabolic reactions; most of the dose would be destroyed, bioavailability not 100%. ex. Lidocaine, Nitroglycerines, Coumadin/ warfarin.

Nutrition- 4. vitamins

- required for metabolism, water soluble vitamins like vitamin C and B are excreted in urine, so much take daily unlike fat soluble vitamins A, D, E, and K.

Nutrition- 3. fats

- saturated fats tend to increase serum cholesterol so minimize in diet.

Implementation- Bowel Incontinence

- the inability of the anal sphincter to control the discharge of fecal and gaseous material. 1. provide comfort- provide hand hygiene care, keep skin dry and clean. 2. indwelling rectal tube. 3. fecal incontinence device. 4. evaluate for possible fecal impaction.

Triglycerides

- the predominant form of fat in food and the major storage form of fat in the body. - <150 mg/dL

Functional Incontinence

- urine loss caused by the inability to reach the toilet b/c of environmental barriers, physical limitations, loss of memory or disorientation.

Sterile Technique for Skin

- used for procedures that require: 1. intentional perforation of skin. 2. skin integrity broken due to trauma, surgical incisions, burns. 3. insertion of catheters or surgical instruments into sterile body cavities.

The "Rights" of Medication Administration- 8. Right documentation

1. MAR, eMAR, drug, dose, route, injection site, if applicable, time, date, nurses initial/ signature. 2. patients response- pain relief, unexpected response. 3. do not document prior to administration.

Drug Interactions- 4. Drug- food

1. Mevacor/ lovastatin: antihyperlipidemic- must be taken with food. 2. grapefruit juice- interactions with antihyperlipidemic, antihypertensive, antidepressant- decreases the metabolism of drugs and increased effect. 3. tetracycline- take 1hr AC (before meals), or 2hrs PC (after meals), should not be taken with dairy products.

Urinary Elimination- Assessment of Urine

- Intake and output (I&O)- no need for order. 24 hourly 1ml/kg/hr or about 1 to 2 liters in a day. - Hourly= 40-80ml, at least 30ml. - Anuria= 50ml in 24hrs- kidneys shut down. - Oliguria= <400ml in 24hrs- half nephrons are shutting down, on way to kidney failure. - Polyuria= >50ml/kg in 24hrs- diabetic pts, cant stop urinating. - Measure in pts with edema, right after surgery, with foley catheters, getting iv fluids, renal failure and chf.

Plasma Drug Concentration- Peak Level

- Is the highest plasma concentration of drug at a specific time after the drug is administered. - Indicates the rate of absorption. Oral- 1-3hrs after drug administration. Intramuscular- 1hr after administration. Intravenous (IV)- 10-30min.

Plasma Drug Concentration- Trough Level

- Is the lowest plasma concentration of a drug and measures the rate at which the drug is eliminated. - Indicates the rate of elimination. - Levels are usually obtained shortly before the next scheduled dose, or 30min before given next medication.

Routes of Administration- Instillation

- Liquid medications administered as drops, ointment or sprays. - eyedrops, eye ointment, ear drops, nose drops and sprays.

Biochemical Data- 5. BUN

- Normal 10-20g/dL. - blood urea nitrogen- breaks down product of amino acids. - Increased in periods of starvation or high protein intake or severe dehydration.

Implementation- 3. UTI

- lots of education to prevent UTI. 1. shower, dont bathe. 2. void before and after intercourse. 3. dont use baby powder.

Biochemical Data- 3. Prealbumin

- normal 23-43 g/dL. - Indicates short term nutritional status. Will tell you daily changes in pts protein status. - Decreased= protein depletion, malnutrition.

Phases of drug action- 3. Pharmacodynamics

- Effect of drug on cellular physiology, biochemistry. - The drug's mechanism of action. - Drug response- primary effect: desirable effect and secondary effect: undesirable, usually side effects.

Phases of drug action- 2. Pharmacokinetics

4 processes. 1. absorption 2. distribution 3. metabolism- biotransformation 4. excretion- elimination

Nutrition- 1. carbohydrates

- Easiest to produce and store, least expensive source of calories. - Simple carbs lack fiber, increase blood sugar, nutrient poor. - Complex carbs like vegetables include fiber and aid in digestion and bowel elimination. Helps maintain steady blood glucose levels. - Coordinate with income.

Creatinine clearance

- Estimates the rate of filtration by kidneys- glomerular filtration rate (GFR)- the rate is produced urine. - Normal- 88-135ml/min.

Nutrition- Psychosocial

- Food is affected by our culture, ethnicity, and our background. - What pts like to eat and how they prepare meals should be part of nutritional assessment. - Surgery and illness has effect on nutritional status. - Fear and depression can kill appetite.

Biochemical Data- 1. Hemoglobin/ Hematocrit

- Hemoglobin normal levels 12-18g/dL. Decreased= anemia. - Hematocrit normal levels 40-50%. Decreased= anemia. - If pt dehydrated hematocrit will increased, if overhydrated hematocrit will decreased.

Biochemical Data- 4. Transferrin

- Normal 240- 480mg/ dL. - Acts as an iron protein transport. May not be best indicator for nutritional status. - Decreased= anemia, protein deficiency.

Biochemical Data- 6. Creatinine

- Normal <1 - Directly proportional to pts body mass. - Decreased= reduction of severe malnutrition, reduction in total body mass. - Increased= dehydration.

Implementation- Elimination of feces- 1. Cleansing Enema

- introduction of a solution in the large intestine to remove feces. 1. hypotonic: tap water and isotonic: normal saline solution- large volume enemas about 500-1000ml, rapid colonic emptying. 2. hypertonic solution- available commercially, smaller volumes about 70-130ml, draw water out of the interstitial space into the colon.

Urge Incontinence

- involuntary loss of urine that occurs soon after feeling an urgent need to void. Loss of urine before getting to the toilet and an inability to suppress the need to urinate.

Nursing considerations for enteral feedings- 1. Promote Safety- b) prevent aspiration

- keep head of bed elevated at 30-45 degree angles at all times during enteral feedings and for 1hr afterward to prevent reflux and aspiration. - stop feeding if repositioning pt or laying them flat in bed.

Biochemical Data- 2. Serum albumin

- normal levels 3.5-5.5 g/dL. - Greater indicator of pts nutritional status. - Decreased with malnutrition- prolonged protein depletion, malabsorption. - Overhydration decreased levels. - Dehydration increased levels.

Diagnostic studies- 2. Stool culture

1. Indicated for suspected infection such as c.diff, ecoli, bacteria, virus, fungi, or parasites 2. obtain specimen before initiation of anti-infective therapy.

Parenteral Nutrition- 1. TPN- Total Parenteral Nutrition

Highly concentrated, hypertonic nutrient solution. Administer through central venous access device due to hypertonic osmolarity. Provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals and trace elements. Order daily for pt based on current lab values to meet pts nutritional needs. Can promote tissue and wound healing, and provides chance to heal and reduces activity of gallbladder, pancreas, and SI.