Blueprint Exam #3
Why are some wounds left open after surgery?
-Wound is left open and heals from the edges inward and from the bottom up Extensive wound with tissue loss • Edges that cannot/should not be approximated • Wounds (NOT infected) are open and heal by granulation Infection? The contaminated wound is left open and closed after the infection is controlled
What are the 5 stages of Kubler Ross grief process
1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance
What is an appropriate urine output, per hour?) Why is this important?
30 ml per hr An output of less than 30 mL/hr indicates possible circulatory, blood volume, or renal alterations.
Postpartum Psychosis
A much rarer condition A very serious mental illness that can affect a new mother. The episode of psychosis usually begins within 1 to 3 months of delivery. Postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning Hallucinations Delusions Illogical thoughts Insomnia Refusing to eat Extreme feelings of anxiety and agitation Periods of delirium or mania Suicidal or homicidal thoughts
When is a depressive patient at risk for self-directed violence? Why
After starting antidepressants. The sudden change in energy typically means the client is more suicidal with more energy to follow through with suicide. The change in behavior and energy is especially seen after starting antidepressants such as selective serotonin reuptake inhibitors (SSRIs). Nurses must monitor the client at all times. This is a priority nursing assessment. Clients at risk for suicide may begin to give away cherished or valued possessions.
Describe differences from a clean surgical site vs. an infectious surgical site.
After the initial discharge of a bit of pus and blood, your wound should be clear. If the discharge continues through the wound healing process and begins to smell bad or have discoloration, it's probably a sign of infection. Infectious: Yellow pus or cloudy drainage. Odor coming from the wound. Fever, chills. Swelling Hot to touch. Redness. Pain or sore to touch.
Situational depression
An adjustment disorder is a type of mental disorder resulting from maladaptive, or unhealthy, responses to stressful or psychologically distressing life events. Generally begins 3 months after an event Typically last no more than 6 months This low level of adaptation then leads to the development of emotional or behavioral symptoms. Risk Factors: Any life-altering event Older adults Resilience factors: Capacity to respond to stressors Clinical Manifestations: Sleep disturbances Feelings of hopelessness, sadness, despair Loss of self-esteem Irritability Difficulty concentrating Behavioral Changes
Appendicitis interventions and eval
Appendicitis >inflammation of appendix Positioning (knees flexed) Children may not verbally complain of pain, but will cry, resist moving Promote psychosocial well-being, Relieve anxiety. Promote rest Provide emotional support for client, family Comprehensive education to reduce anxiety Encourage and answer questions. Provide effective client teaching Give instructions on reestablishing diet slowly Recognize manifestations that need treatment An appendectomy is a surgical procedure to remove the appendix and will be performed soon after confirmation of appendicitis since there is a high risk of perforation or rupture in appendicitis. Most common emergent abdominal surgery Administer analgesics as ordered, Assess effectiveness of medication 20-30 minutes after administration
Appendicitis Define
Appendicitis is inflammation of the appendix. It presents as pain in the lower right abdomen, nausea, vomiting, decreased appetite, fever, constipation/diarrhea and/or abdominal bloating. For diagnosis, a physical assessment of pain, blood test, and CT scan is used. Once confirmed by CT, an appendectomy is the next step. It is important to visually see the appendix before performing surgery. This will also confirm the appendix has not perforated or ruptured, requiring emergent surgery.
Different areas for an ostomy and what the stool will look like
Ascending: diarrhea Transverse : soft pudding poop Descending and sigmoid: formed stool
Discuss therapeutic interventions for depression
Ask open-ended questions about the client's feelings; (very important when working with clients who do not give eye contact and sit with head down, avoiding conversation with peers) Adopt emotionally neutral attitude while maintaining confidence that they will feel better Not trivializing client's feelings Be aware of personal feelings, mood Risk of emotional contagion Improve self-esteem Provide distraction from self-absorption. Involve client in recreational activities Dispel notion clients often has such as: "When I feel better, I will engage in activity." Recognize accomplishment Do not use flattery or excessive praise Be accepting of client's negative feelings Set limits on time spent discussing past failures Teach assertiveness techniques
What would the clinical manifestations be for a patient with peritonitis?
Belly pain or tenderness. Bloating or a feeling of fullness in the abdomen. Fever. Upset stomach and vomiting. Loss of appetite. Diarrhea. Reduced urine. Thirst Inflammation of the membrane lining the abdominal wall and covering the abdominal organs. Peritonitis is usually infectious and often life-threatening. It's caused by leakage or a hole in the intestines, such as from a burst appendix. Even if the fluid is sterile, inflammation can occur. Symptoms usually include pain, tenderness, rigid abdominal muscles, fever, nausea, and vomiting. Antibiotics are almost always needed, along with surgery or drainage. Peritonitis is a medical emergency that requires prompt medical attention, as it develops very rapidly. Upon rupture of the abdominal wall or abdominal organs, the peritoneum can become infected within 24 to 48 hours.
What are the differences between UC and Crohns?
Both conditions are autoimmune diseases (the body is attacking itself), so naturally signs & symptoms come & go during times of stress, smoking & sepsis (infection). US- pain LLQ Crohns- Pain in RLQ
List nursing interventions to decrease the chances of dehiscence.
Bracing your wound when coughing Avoiding staring when having a BW Preventing emesis :The action or process of vomiting would put pressure on the abdominal operative incision. The wound should be kept moist, not dry.
Anticipatory grieving
Caregivers of patients with chronic illness often begin to grieve long before the actual death Patients can also experience anticipatory grief at the end of their lives Terminally ill clients Appropriate for family to be tearful and sad
Major depression
Change in several aspects of individual's life Emotional state May describe feelings • Sadness • Discouragement • Hopelessness (no chance of improvement) May consist of single episode, may recur Anhedonia-inability to feel pleasure Changes in appetite Sleep disturbances FATIGUE, decreased energy, psychomotor retardation FEELINGS OF GUILT Worthlessness; Self-blame Restlessness SUICIDAL IDEATIONS
Depression: assessment and clinical manifestations
Characterized by sad, despondent mood or loss of interest in usual activities; Many symptoms associated with depression Lack of energy, psychomotor retardation or agitation Sleep disturbances (decline in the amount of sleep; difficulty falling asleep at night) Anxious distress; Anxiety Abnormal eating patterns Feelings of despair, guilt, hopelessness Risk factors History of abuse, neglect, loss Dysfunctional family relationships Personal or family history of mental illness, substance abuse Majority of depressed clients in mainstream settings
Chronic depression
Chronic depression for most days :At least 2 years No more than 2 months symptom free Symptoms tend to be less severe than those of MDD Childhood, adolescence, early adulthood
Hospice care goals?
Concept of care that provides compassion, concern, and support for persons in the last phases of a terminal disease *Live fully *Live comfortably *Die pain-free and with dignity Hospice care is underutilized Patients should be referred as soon as possible to facilitate care at the end of life Patients do not need to be actively dying Patients who have been dx with a terminal illness. Provide patients with dignified, pain free death. Mostly given inside the patients home
Explain each stage: Kubler-Ross
Denial may last minutes to months and be characterized by withdrawal. Anger may be focused in any number of directions: *The person who inflicted the hurt *At the world for letting it happen *At oneself even though nothing could have been done to stop an event from happening (car accident). Bargaining for more time or something other than the death Depression may be expressed in numbness, anger, or sadness. Admitting the reality of the loss results in a calmer phase known as acceptance.
Crohns disease interventions and eval
Eating a diet low in residue/fiber and high in protein will reduce diarrhea and increase absorption of nutrients. Cleansing the perineal area with a gentle cleanser and applying a skin barrier will prevent excoriation of skin from the frequent diarrhea. Encouraging the client to drink plenty of water will help replenish fluids lost by diarrhea.
What is a fistula, in which can it develop?
Fistulas are usually the result of trauma or surgery, but can also result from infection or inflammation. Crohn disease is an inflammation of the intestines caused by immune response to an infection. The lining of the intestine may ulcerate and form channels of infection, called fistulas.
Stage 3 Pressure Injury
Full-thickness loss The ulcer is deep, down through the dermis, with red base and often 'some' drainage May be able to see subcutaneous tissue (fat) May have undermining or tunnel formation
Stage 4 Pressure Injury
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. visible signs of tissue death • Undermining or tunneling more common • Exposure of bone increases risk of associated osteomyelitis
Unstageable Pressure Injury
Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough or eschar
What foods would you teach your patient with a colostomy to avoid?
Gas-forming foods include broccoli, cauliflower, mushrooms, onions, peas, and cabbage. These foods should be avoided by the client with a colostomy until tolerance to them is determined.
Nursing interventions to assist a suicidal patient?
Gather information "How does that make you feel?" "How does the patient 'feel?' "Do you have a plan?" 24/7 surveillance Remove dangers: Necklaces, rings, clothes, belts, Contract with the client: Patient will report suicide ideations to the nurse Use (and count) plastic utensils. No private room; keep door OPEN, at all times. Jump-proof and hang-proof bathrooms. Lock doors to non-patient areas. Monitor for and remove potentially harmful gifts. In patient's presence, assess belongings and search pts for harmful objects Ensure that patients do not bring or leave harmful objects
Grieving
Grief is the normal process of reacting to loss Grief occurs in response to real loss as well as what might have been. Psychologic responses include anger, guilt, anxiety, sadness, depression, and despair. Physiologic reactions include sleeping problems, changes in appetite, physical problems, and illness.
What is the last sense to leave the patient at the end of life?
Hearing is usually last sense to disappear
What instructions would you give to a diabetic patient with a lower leg arterial ulcer?
If your ulcer becomes infected, it should be cleaned and dressed as usual. You should also elevate your leg most of the time. properly applied compression therapy using increased pressure over the wound may lead to an improvement of the arterial flow and to complete healing. Examine feet (especially between the toes) and legs daily for any unusual changes in color or the development of sores. Quit smoking. ... Manage blood pressure, cholesterol, triglyceride and glucose levels. Ensure that footwear is properly fitted to avoid points of rubbing or pressure. Your doctor will try to restore blood circulation to the affected area. Treating the underlying cause with antibiotics can help reduce symptoms, but it won't heal the ulcer completely. Doctors may use surgery to restore blood flow to tissues and organs in addition to antibiotics.
What would you see in a patient who is showing improvement?
Improvement in depression may be present when clients state things such as: "I want to get out of bed, shower, eat and contact friends and family to visit with."
Appendicitis clinical manifestations
Initially dull periumbilical pain; anorexia, nausea, vomiting Clinical manifestations of perforation of the appendix includes symptoms of shock, including cool, clammy skin, hypotension, tachycardia. Another obvious symptom of perforation is a board-like abdomen. Persistent RLQ pain: McBurney's point (Periumbical area) Fever, localized tenderness, rigidity, muscle guarding Rebound tenderness on palpation Aggravated by sneezing, deep breath, coughing, moving, walking Lie still with right leg flexed Complications Perforation, peritonitis, abscess Chronic appendicitis
What are some nursing interventions to assist and talk with a depressive patient?
Instill hope! Explore previous achievements of success Encourage client to identify personal strengths Encourage client to believe in self Help client weigh, choose alternatives Explore problem-solving models with client Inform client of rights Help client identify resources Provide accurate information. Provide support, encouragement Help client in setting goals for self Help client clarify needs, wants with goals Discharge planning begins with first contact Foster effective communication Promote firmness, persistence so needs met Support family with referrals
Stage 1 Pressure Ulcer
Intact skin with localized area of non-blanchable erythema. Firm warm areas of skin from poor circulation • Spongy, reddened tissue from increased pressure • The skin remains intact, and the redness is not blanchable
Ulcerative Colitis US define
Involves colon; starts in rectum spreads to cecum Mucosal layer (innermost) Diarrhea Electrolyte loss—cannot absorb through inflamed tissue Protein loss in stool Pseudopolyps form—tongue-like projections into bowel Characterized by periods of symptomatic flares and remissions Granular appearance; inflammation of open sores
EOL: Respiratory & Sensory Manifestations
Irregular breathing that gradually slows Cheyne-Stokes respiration Inability to cough or clear secretions Grunting, gurgling, or noisy congested breathing ("death rattle") Hearing is usually last sense to disappear Decreased sensation Decreased perception of pain and touch Blurring of vision Blink reflex absent Patient appears to stare Eyelids remain half-open Decreased sense of taste and smell
Interventions for parents who have delivered a still born baby?
Listening The best support was someone who was just there for them and listened. Someone who cared and asked questions about how they could help, rather than acting as though they knew best how to deal with the situation Supporting the family Try not to assume that the parents are dealing with their grief together as a couple (if they are in a relationship). It is very common for parents to have different feelings at different times, one may want to talk and the other might not be able to yet, so they may need support in different ways. Sometimes they may seem to be quietly getting on with things and may even have returned to work, but it is important they have someone to support them too. If there are other children, try not to assume the parents would like them kept away or don't want to see the parents upset. It is important that children know it is ok to feel sad about what has happened. Offering practical help Remember that the mum will have given birth. Ask her how it was and remember that she will be recovering physically from the birth, as well as emotionally. She may not be able to lift heavy things, she may have stitches or be sore. You could ask what practical support the parents need. Maybe ask whether they would like you to stay, and if you do, keep checking that you are not over-staying. Be prepared to change plans quickly and leave if they need time alone. Don't throw things away Don't make assumptions about what should be kept or cleared away at home. For example, don't clear away baby equipment, clothes or toys. This may be something that the parents want to do later, and having the things around may actually be a comfort and reminder of the baby. Meeting the baby If you are family, or a very close friend, the parents may want you to come and meet the baby in the hours or days after the stillbirth. This may be the first time you have seen a baby that has died, which may be quite shocking or distressing for you. Remember that the parents only have the baby for a short, precious amount of time. Acknowledging the baby Most parents want people to acknowledge their baby's existence and the fact that they had a baby - try not to ignore what has happened Following the parent's lead There will be some parents who don't name their child, or who don't want to share their baby's name with colleagues or friends. They may only want to share those details with close family. Choosing your words carefully Many parents find certain sentiments and sayings unhelpful. Responses such as, 'You'll have another baby' can undermine their grief and belittle their sadness. They might not be ready, now or ever, for what may seem like encouraging, positive comments about their future.
Postpartum depression
Major depressive disorder with peripartum onset 80% of mothers have these feelings May begin during pregnancy or in first 2-4 weeks following delivery May or may not be accompanied by psychotic symptoms Feeling sad; crying a lot Exhaustion Sleeping a lot Eating too less or too much Unexplained aches, pain, or illness Irritability, anxiousness, anger Sudden mood changes Feeling 'out of control' Feelings of worthlessness, guilt,& hopelessness Preference for solitude; withdrawn Feeling disconnected with the baby
What are the clinical manifestations for patients at the end of life?
Metabolism is decreased Body gradually slows down until all function ends Respiration generally ceases first Heart stops beating within a few minutes
EOL: Integumentary, Urinary and Cardio
Mottling on hands, feet, arms, and legs Cold, clammy skin Cyanosis of nose, nail beds, knees "Waxlike" skin when very near death Gradual decrease in urinary output Incontinent of urine Unable to urinate Increased heart rate -Later slowing and weakening of pulse Irregular rhythm Decreased BP Delayed absorption of IM or SQ drugs
Do all people go through each stage the same way?
NO, not everyone will experience all stages of grief, and you may not go through them in order. Grief is based on your personal relationship to who or what was lost. Each person and relationship is different, which means that how we deal with each loss will be different as well.
Appendicitis: pain control. What does absence of pain indicate?
NOOOO masking the symptoms pain leaves? this indicates a rupture LET the doc know is the pain is relived--> rupture
Stoma assessment what it important to report to the HCP and why?
Observe for any potential common complications of a stoma, such as parastomal hernia (common with colostomies), prolapse, retraction, or infarction (whereby the stoma is turning jet black). Check the surrounding skin for any evidence of erythema, ulceration, or fistulation.
List nursing interventions for a patient with reddened heels.
Off loading or floating the heels with pillows Sheepskin protective padding devices Ambulation & repositing Nutritional Assessment Foam boots to prevent friction Braden Scale assessments
What are the clinical manifestations of a fistula?
Pain and swelling around the anus. Bloody or foul-smelling drainage (pus) from an opening around the anus. The pain may decrease after the fistula drains. Irritation of the skin around the anus from drainage Fistula formation Occur in 1/3 of pts; with Crohn's Sinus tracts penetrate through bowel Fistulas from colon to small intestine or stomach can results in bacterial overgrowth;
What foods will reduce odor in a colostomy?
Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Charcoal filters—deodorize and release flatus (even breath mints)
Stage 2 Pressure Injury
Partial-thickness (down to the dermis) opening in the skin with surrounding erythema from pressure Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. Wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum-filled blister. • Shallow open ulcer with red pink wound bed • Presents as an intact or ruptured serum-filled blister • Affected skin may be shiny or appear as a 'shallow ulcer'
EOL: Traditions for Catholics
Patients should be kept as free of pain as possible so that they may die comfortably and with dignity and in the place where they wish to die. Last rites cannot be performed on someone who has already died. does not believe in euthanasia or in taking away life-sustaining care to allow a life to end. We strive to create a balance between providing life-sustaining care and avoiding prolonging suffering. can be cremated, but their ashes should not be scattered at sea, and the urn should not be kept in the home
Complicated grieving
Persists, worsens over a period of > 6months Extreme distress Inability to function (i.e.; spouse losing spouse/dinner ritual) (i.e.: keeping things exactly as they were) Risk for suicide if longer than 6 months Complicated Grief Treatment (CGT) *Loss-restoration process *Combination with antidepressants
Postpartum define
Pregnancy is a time of great joy for many mothers, but great anxiety as well First few days after birth, mother may seem passive Food and sleep are priority needs Second or third day, new mother is ready to resume control But may experience anxiety Common after birth Has periods where she feels let down Finds pleasure in her new role Usually self-limiting as woman adjusts to her new role Resolves without treatment within a few days or weeks
What are actions to assist family in the grieving process r/t to manifestations
Priority interventions provide for patient to express feelings Bereavement and grief counseling are core components of patient- and family-centered palliative care. The grieving process takes time, energy, and work. The process of resolution in normal grief may take months to years. Grief counseling facilitates discussion of feelings and cultivates an environment for open expression of all feelings (anger, fear, guilt). Respect for privacy and desire to talk or not to talk is important. Honesty in answering questions and giving information is essential.
What are the goals for the patient at end of life?
Provide comfort and supportive care during dying process Improve quality of remaining life Help ensure a dignified death Provide emotional support to family Refers to the final phase of a patient's illness, when death is imminent Period of time from diagnosis of a terminal illness to actual death varies considerably, depending on the patient's diagnosis and extent of disease
EOL: Traditions for Native Americans
Provide social support in the dying and burial process through the tribe or clan of the individual. That same social support system sustains the bereaved after the disposal of the dead. The grief process includes the ceremony of the funeral, the burial, and the give-away ceremony. Although the body is often honored for up to 4 days, embalming fluids are not used
Why is resting the bowel important for a patient having an exacerbation of diarrhea?
REST THE BOWEL (NPO) Control inflammation Combat infection Correct malnutrition Alleviate stress Relieve symptoms Improve quality of life
Plan for a patient in the ER with appendicitis
Rapid diagnosis and treatment are important IV fluids & antibiotics initiated (priority) pain control is NOT Oral food and fluids withheld until diagnosis is confirmed: NPO DO NOT APPLY HEAT TO THE APPENDICITIS PATIENT'S ABDOMEN AS THIS COULD LEAD TO RUPTURE
EOL: Traditions for Jehovah Witness
Refuse a blood transfusion A Jehovah's Witness should agree to autopsy when required by law, but the next of kin may request that no organs be removed and that the body be treated with care. NO special rituals for the sick or the dying. You should make every reasonable effort to provide medical assistance and comfort. Spiritual care will be provided by local Witnesses
Clinical manifestations that may be experienced by family losing a loved one?
Sadness Anxiety Anger Confusion Sleep disturbances Loss of appetite Difficulty concentrating Psychologic responses include anger, guilt, anxiety, sadness, depression, and despair. Physiologic reactions include sleeping problems, changes in appetite, physical problems, and illness.
Empty an ostomy
Sit on or next to the toilet. Or stand in front of the toilet. Put a layer of toilet paper in the toilet bowl to keep stool from splashing. Pull your clothes away from the pouch. Hold the bottom of the pouch up. Open the Velcro closures or remove the clamp and set it aside. Slowly unroll the tail, or spout, over the toilet. Bend over the toilet to help prevent splashing Slide your fingers down the pouch to push out all the stool. Steps to cleaning the pouch: Wipe the inside and outside of the tail with toilet paper. This helps prevent any odor. Check both sides of the pouch for tears or holes. If you find any, put on a new pouch. If the pouch closes with a clamp, rinse the clamp if there is stool on it old the clamp open with the curved side, or hinge, toward your body. Lay the bar, or "knife," of the clamp flat on the tail of the pouch, about 1 inch from the bottom of the tail. Fold the tail up over the bar. Make sure the tail lies flat against the bar. Also make sure the whole width of the tail is held within the bar. If it isn't, the pouch may leak or smell. Hold the tail of the pouch firmly against the bar. Then close the clamp by bringing the hinge up to the bar. Press the two parts together until they lock. Wash your hands with clean, warm or cold running water for at least 20 seconds when you are done. Or use a hand sanitizer that is at least 60% alcohol. Handwashing is important if your hands are possibly soiled with stool.
EOL: GI and Musculoskeletal
Slowing of digestive tract and possible cessation of function Accumulation of gas Distention and nausea Loss of sphincter control Bowel movement may occur before imminent death or at the time of death Gradual loss of ability to move Trouble holding body posture and alignment Loss of facial muscle tone Sagging of jaw Difficulty speaking Loss of gag reflex Swallowing can become more difficult
Pre-op and post op care for appendicitis
Strong analgesics withheld preoperative because sudden disappearance of pain indicates perforation Administer IV fluids and antibiotic therapy: third-generation cephalosporin Prevent complications: Keep NPO Monitor VS Antiemetics General postop care Antibiotic therapy: repeated during surgery continued for at least 48 hours postoperative and if rupture occurred Early ambulation Advance diet as tolerated
Suicide define
Suicide: Intentional act of killing oneself by any means Suicidal ideation: Thinking about killing oneself Completed suicide: Suicide successfully resulting in death
Postpartum nursing interventions and eval
Symptoms difficult for family Difficulty understanding Worry, confusion Practical matters Running household Managing children Taking care of newborn Caring for the mother Emotional support Assistance in providing, obtaining care Identify community resources Referrals to public health nursing service Expected outcomes may include: Client's signs of depression are identified, receives prompt intervention Newborn is effectively cared for by father, other support persons until mother able to provide care Mother and newborn remain safe Newborn is successfully integrated into family unit
Activity (sexual) with an osotmy
Teach patient the effects from surgery Nerve or vascular disruption to genitalia Radiation, chemotherapy, fatigue, overall health Males—concern with erection and ejaculation May be temporary for 3 to 12 months Females—vaginal dryness and sensation Arousal and orgasm concerns; Pregnancy is possible Body-image—fear rejection Teach about alternatives for pouching/security
Berevement
The period of time following the death of a loved one Grief is experienced and mourning occurs
Discharge teaching for a patient with a colostomy
The plan should include teaching basic skills and providing information about how to manage the ostomy (ie, emptying and changing the pouch, how to order supplies, available manufacturers, dietary/fluid guidelines, potential complications, medications, and managing gas and odor), assisting with transitions in care
Crohns disease clinical manifestations
The principal manifestations of Crohn's disease are diarrhea and abdominal pain.
EOL: Traditions for Jewish
The shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden. For patients who are terminally ill, treatments that are not potentially curative may be refused, especially when harm may result. it's expected that every effort will be made to sustain and extend life. A person is allowed to refuse treatment if illnesses cannot be cured. The decision to accept hospice care is a personal one. Burial should happen as soon as possible after death. The coffin should be simple to show equality, and the burial ceremony takes place at a cemetery, not in a synagogue . Funeral services include prayers, psalms and a eulogy . Families must buy a gravestone so that the dead are not forgotten.
Assessment of skin around an ostomy?
The skin around your stoma should look just like the skin on the other side of your abdomen, or anywhere else on your body. The skin around the stoma should be intact without irritation, rash, or redness. A properly fitting skin barrier protects the skin from being irritated or damaged by the stoma drainage.
Assessment of a stoma: normal and abnormal
The stoma should be beefy red, moist, and shiny in appearance. The peristomal skin should stay meticulously clean to prevent skin breakdown around the stoma. When a stoma is first created, it will be swollen, but will shrink to the size it will stay within 4-6 weeks. The client should measure the stoma weekly and cut the wafer about 1/8th inch larger than the stoma.
Postpartum blues
Transient period of mild depression: 'baby blues' Affects 70-80% of new mothers Begins in the first week postpartum. Usually resolves within 10-14 days. Manifested by mood swings, anger, anorexia Difficulty sleeping, weepiness, feeling of letdown Evaluate for depression if symptoms persist Must be distinguished from postpartum depression or postpartum psychosis Assess woman for predisposing factors -Edinburgh Postnatal Depression Scale -Postpartum Depression Predictor Inventory Key feature is episodic tearfulness Without identifiable cause Emotional letdown that follows labor, birth • Physical discomfort typical in early postpartum period • Fatigue • Anxiety about caring for newborn at home • Depression during pregnancy or previous depression
Ulcerative Colitis manifestations
Usually has a gradual onset Flares/remissions BLOODY DIARRHEA—Hallmark Sign Mild— fewer than 4 stools/day Moderate—up to 10 stools/day Malaise, anemia, anorexia Severe - 10 to 20 stools/day Anemia, tachycardia, dehydration Weight loss Abdominal pain Fever Fatigue
What are verbal cues/ behavioral that a patient may want to commit suicide?
Verbal cues • "I just want to die" • "No one is going to miss me when I am gone." Actions : behavioral clues Giving away items that the patient values the most • Cutting wrists • Sloppy dressing Lethality Assessment: 24-72 hour hold We do NOT want patient to be a risk to themselves
What are dietary measures for a patient with inflammatory bowel disease?
Well-tolerated fiber sources include tender cooked vegetables, canned or cooked fruits, and starches like cooked cereals and whole wheat noodles and tortillas. Between flares, eat a wide variety of foods as tolerated. This includes fruits, vegetables, whole grains, lean protein, and low-fat and nonfat dairy products
Plans for suicide? What questions must the nurse ask to assess the means of suicide?
When they plan to do it? Where they plan to do it? How they plan to do it? Have they tried this before? • What will be used and what is available to the client? • Pills? Gun? Cords? Alcohol? Drugs?
Secondary intention healing
Wound is left open and heals from the edges inward and from the bottom up • Extensive wound with tissue loss • Edges that cannot/should not be approximated • Wounds (NOT infected) are open and heal by granulation • Wounds that occur from trauma, ulceration, and infection • Large amounts of exudate and wide, irregular wound margins with extensive tissue loss • Edges cannot be approximated • Results in more debris, cells, and exudate
What factors contribute to delayed wound healing
age, body type, chronic disease, immunosuppression, oxygenation, infection, nutritional status, radiation therapy, and vascular insufficiencies. Proper nutrition is vital to optimal healing. A wound is unable to heal properly if you lack the necessary nutrients for cell repair and growth.
Primary intention healing
is the best type of healing for abdominal surgery 3 Stages: Initial, Granulation, Maturation • Wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to from a mature scar • Tissue surfaces approximated with little or no loss • Closed surgical incision • Serous drainage
List risk factors for pressure ulcer formation.
• Advanced age • Loss of lean body mass • Generalized thinning of epidermis • Increased dryness • Diminished pain perception • Diminished venous, arterial flow • Incontinence • Bed or wheelchair bound • Recovering from spinal cord injuries • Anemia • Contractures • Diabetes mellitus • Elevated body temperature • Immobility • Impaired circulation • Incontinence • Low diastolic BP (<60 mm Hg) • Mental deterioration • Neurologic disorders • Obesity • Pain • Prolonged surgery • Vascular disease
Tertiary intention healing
• The contaminated wound is left open and closed after the infection is controlled • Occurs with an open ragged-edged wound with infection • Wound left open for 3-5 days then sometimes, are closed • Allows edema, infection to resolve, wound to drain • Also heals by granulation
