HESI

planning for End-ofLife and advance directives

PSDA (patient self determination act) grants people the right to determine the medical care they want provided ( or not provided) if they become incapacitated this is done by completing an advance directive (AD) PSDA requires that a rep In every healthcare agency ask pt when admitted if they have written advance directives those without AD should be provided with info of the values of having an AD in place and given the opportunity to complete state required forms AD should be completed long before a medical crisis

when pt has limited ability to walk

assess his or her activity tolerance, tolerance to the upright position, strength, and presence of pain , coordination, and balance to determine the amount of assistance needed

implication for patient centered care

- develop an open, non restrictive attitude for assessing and encouragingg cultural practices to improve patients self concept understand that the relationship among self esteem, stress, and social support can facilitate the development of nursing strategies to promote effective coping in culturally diverse adolescents - ask pt what they think is important to help them feel better or gain stronger sense of self encourage culture identity and pride by individualizing self-care practices and offering treatment choices to meet pt self concept needs facilitate culturally sensitive health promotion activities that address at risk behaviors identified through evidence based practice (smoking, drinking, eating disorders, premature sex experiences, excessive video gaming)

patient teaching for low back problems

- matin a healthy body weight - maintain a neutral pelvic position when standing, place on foot on a low stool if standing for long periods - choose a seat with good Lowe back support, armrest, and swivel base place a pillow at the lumbar spine to maintain normal curvature keep knees and hip level -sleep in a side-lying position with knees and hips bent and a pillow between the knees for support -sleep on back with a lift under knees and legs or on back with 10 in high pillow under knees to flex hips and knees - use proper body mechanics when lifting heavy objects, bend at knees, not at waist, and stand up slowly while holding objects close to your body - participate in regular strength and flexibility training and low impact aerobic exercise - use local heat and cold application to relieve muscle tension

"The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe and effective delivery of the oxygen, the nurse avoids which of the following?" a. secure the oxygen tubing to the clients bottom sheet b. keeps the humidification jar filled with distilled water c. observe the clients nares frequently for skin breakdown d. checks the oxygen flow rate and physicians order every shift

a. secure the oxygen tubing to the clients bottom sheet

lifestyle changes for those with OSA

- sleep hygiene, alcohol moderation, smoking cessation, weight loss teach pt to elevate head of bed and use a side or prone position for sleep use pillows to prevent supine position most effective therapy = nasal continuous positive airway pressure (CPAP) this device is used at night, pt wears a mask over the nose, mask delivers room air at high pressure air pressure prevents airway collapse the CPAP device is portable and effective for OSA another treatment option: use of an oral appliance; these appliances advance the mandible or tongue to relieve pharyngeal obstruction in case of severe sleep apnea the tonsils, uvula, or parts of the soft palate are removed surgically, this success varies

educating older adults

1) schedule teaching sessions in midmorning (when energy levels are high several brief teachings on different days are more important than one lengthy session that might fatigue the patient 2) minimize the use of medical terminology and replace with lay terms when possible 3) allow additional time for the older adult to process new information by pausing after presenting each new concept or bit of information 4)link new knowledge or skill to clearly identifiable past experiences. reminiscing and storytelling help the older adult reconnect with lived experience and serve as a valuable strategy to facilitate learning 5) keep the content practical and relevant to the older adults daily activities, social structure and physical function emphasize safety and maintaining independence 6) help the older adult focus during each interaction by minimizing` distraction, limiting the message t a few (five or fewer) essential key points, and avoiding extraneous information 7)speak slowly, but not so slowly where the pt becomes distracted or bored face the pt when speaking, and sit at the same level as the pt 8) encourage the older adult to invite a family member or trusted friend to attend and actively participate in each teaching session evaluation - ensure understanding by teach back method - be sure the pt. is able to demonstrate and do psychomotor skills independently

third part of an AD - DNR

DNR = do not resuscitate this is an actual order from a physical or other authorized HCP who instructs that CPR not be attempted in the event of cardiac or respiratory arrest these are intended for those who have life limiting conditions such as terminal cancer by law, HCP must initiate CPR for a person who is not breathing or is pulseless unless that person has a DNR order issue with CPR It is a violent and often painful intervention to prevent peaceful death CPR is unsuccessful if pt has advanced disease and comorbidity, especially if pt is 65 or older. many pt and families do not understand the limitations of CPR and do not realize it was never intended to be performed on pt with end stage disease

parts of an AD

Durable power of attorney for health care (different than power of attorney for finances) designated for the person appointed to making medical decision in the event the the pt less decision making decision capacity synonyms are health care proxy, healthcare agent, surrogate decision maker

application to nursing practice

actively participate in the evaluation and selection of advance technologies also participate in the development of nursing policies and protocols used for medication administration implement agency policies when technology cannot be used ( during downtime or power outages) follow manufacturer guidelines for care of electronic equipment and report problems with technology immediately ~

Factors affecting blood pressure

age: with age, elasticity in arteries decreases, peripheral resistance increases, leading to higher BP gender: BP is usually lower in women than in men until menopause race: hypertension is more prevalent in African American men and women medication: oral contraceptives cause an increase in blood pressure in some women weight: blood pressure usually is higher in people who are obese circadian rhymes: BP is usually lower in the morning and rises during late afternoon head injury: increased intracranial pressure from head injury causes increased BP increase blood volume: increase fluid in the cardiovascular system increases bp food intakeL BP increases after eating emotions: anger, fear, and excitement cause BP to rise until the emotion passes pain: pain increases blood pressure

hypernatremia

aka water deficit it is a hypertonic solution, two general causes are 1) loss of relatively more water than salt or gain of more salt than water when interstitial fluid is hypertonic, water leaves cells by osmosis, and they shrivel signs and symptoms: cerebral dysfunction may be seen after successful fluid resuscitation if large amounts of hypertonic solutions were used. may also be caused by tube feedings, innapropriate fluid administration manifestations include thirst, dried, furry tongue; lethargy, confusion, and possible seizures sodium restriction may be applied to IV fluids and enteral or oral feedings until level return to safe limits

hyponatremia

aka water excess or water intoxication hypotonic solution more gain of water than salt or more loss of salt that water water enters the cells causing them to swell can cause the brain to swell can develop from excessive GI suctioning and diarrhea manifestations include: weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion to avoid this condition, offer the pt fluids other than water, such as juice or nutritional supplements to drink

A nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. The nurse includes which intervention in the plan to ensure accurate monitoring of the client's oxygenation status? a. notify the physicians immediately of O2 saturation less than 90 % b. instruct the client not to move the sensor c. tape the sensor lightly to the clients finger d. place the sensor on a finger below the blood pressure cuff

b. instruct the client not to move the sensor

`what to do if someone is shows signs of nearing death

be present with the person, listen, and be open to communication acceptable to ask gentle question such as " what are you seeing" or "how does that make you feel" having an open discussion with the family while describing what is occurring Amy provide further insight to the nurse as the HCP as well as promoting a sense of understanding and acceptance for the family

A postoperative client with no history of respiratory disease is still drowsy on arrival from the postanesthesia care unit. The client has an oxygen mask delivering 40% oxygen. The nurse attaches a pulse oximeter to the client and obtains a reading of 89%. The nurse determines that the client should be: a. given a dose of nelaxone (Narcan) b. aroused and nasotracheally suctioned c. woken and encouraged to deep breathe d. allowed to rest, with another measurement done in 1 hour

c woken and encouraged to deep breathe

recommended nutrient

calories: 30-35 kcal/day protein: 1.25 - 1.5 vitamin C: 1000 mg/day vitamin A 1600-2000 retinol equivalents per day zinc: 15-30 mg fluid: 30-35 mL, kg, day

nursing intervention for walking a pt

check environment to be sure that there are no obstacles in the pt path clear chairs, over-bed tables, wheelchairs out of the way establish a resting point in case activity tolerance is less than estimated or the pt becomes dizzy nurse stands on either side of the patient, and each hold one side of the gait belt if pt has hemiplegia or hemiparesis, stand on the pt affected side and support him or her with gait belt

respiratory etiquette as standard precaution

covering the mouth and nose with a tissue when sneezing or coughing and disposing tissue immediately washing hands right after wearing mask if infected, posting signs and education pt and staff regarding cough etiquette remain 3 ft away from another person

types of topical medication

creams or oils (lubrication) lotions (protection and soothe) powders ( for drying surface moisture and decreasing friction) ointment ( to provide prolonged contact with medication and to soften) transdermal patches (continuous medication administration for hours to day)

A registered nurse asks a nursing student to apply oxygen via nasal cannula at 4 L/min to a client having multiple premature ventricular contractions (PVCs). The registered nurse determines that the nursing student needs instructions about oxygen therapy if the nursing student: a. provides water-soluble lubricant to nares b. plans to tell the client and family about the reason for the oxygen c. humidifies the oxygen if the client complains of dry nose d. plans to tell the client to breathe through the nose only

d. plans to tell the client to breathe through the nose only

continuous positive airway pressure

delivered continuously during spontaneous breathing, thus preventing the patients airway pressure from falling to zero most commonly used for obstructive sleep apnea CPAP can be administered with tight-fitting mask or an ET or tracheal tube CPAP increases work of breathing because the pt must forcibly exhale against the CPAP, therefore it must be used with caution in patients with myocardial compromise

procedures for using sharp needles

discard needles in sharp containers use safety needles needless systems are preferred when their use is feasible

what NOT to do for Lower back problems

do not... -lean forward without bending knees -lift anything above level of elbows - stand unmoving for prolonged time -sleep on abdomen or on back or side with legs out straight - exercise without consulting HCP if having severe pain -exceed prescribed amount and type of exercise without consulting HCP -smoke or tobacco products

factors affecting pressure ulcer formation

external factors: shear, friction, moisture internal factors: nutrition, infection, age shear : force exerted against skin while the skim remains stationary and the bony structure moves ex: when head of the bed is raised friction: surface damage caused by skin rubbing against another surface that often results in an abrasion most at risk are elbow, heels moisture: increases risk for ulcer formation it softens skins and reduces the resistance to other physical factors such as pressure or shear it can come from... wound drainage, perspiration, and or fecal/urinary incontinence nutrition: severe protein deficiency, increases risk of the breakdown of soft tissue and alters fluid electrolyte imbalance low protein levels also cause edema or swelling, which contributes to problems with the transportation of oxygen and nutrients infection: infection and fever increases metabolic needs of the body, making the already hypoxic tissue more susceptible to ischemic injury fever also results in diaphoresis and increases skin moisture, which further causes skin breakdown tissue perfusion: those with PVD are at risk for poor tissue perfusion bc of poor circulation age: dermis becomes thinner in older adults , this makes skin paper thin and nearly transparent and increases risk for skin tearing older person skin is more vulnerable to pressure ,shear, and friction neonates and young children are also at higher risk for pressure ulcer and occurrence

osmolality imbalance

fluids in the body become hypertonic or hypotonic, which causes somatic shifts of water across cell membrane this is called hypernatremia or hyponatremia

practicing good hygiene

good hygiene is done 1) before and after a procedure 2) before applying and after removing gloves - when hands are visibly soiled, they must be washed. if hands are not visibly soiled, alcohol based hand sanitizer may be used -is there possible contact with C. Diff if so, use soap and water and rubbing during washing.

care of the dying patient

high level of caring compassion 1) gentle bathing if necessary 2) peri-care performed on regular basis unless symptoms or shortness of breath are intolerable 3) oral care is essential, keeping mouth moistened and lips to prevent dryness will promote comfort 4) turning and repositioning to prevent skin breakdown 5) decrease environmental stimuli while playing soothing music may promote a sense of peace and comfort 6) INSURE SYMPTOMS ARE CONTROLLED 7)frequent and attentive assessment to ongoing or new symptoms with prompt interventions will promote comfort and prevent any undue distress or suffering

reasons to apply medication on skin

hormone treatment application of narcotic analgesics administration of cardiac medication assistance with overcoming nicotine addiction treatment of pruritis provision of protective coating on the skin treatment or prevention of infection

a 74 yr old male returned to clinical unit following surgery for a hip replacement. You are having difficulty arousing him with either verbal or physical stimulation. His wife tell you to just let him sleep. His respiratory rate ranges from 8-10 breathes/min. what should you do?

if the patient respiratory rate falls below 8-10 breathes/min and the sedation level is 3 or greater, you should vigorously stimulate the patient and try to keep the patient awake if patient becomes overstated, administer oxygen in this situation, the opioid dose should be reduced

acute low back pain

lets 4 weeks or less causes by trauma or an activity that produces undue stresss (hyperflexion) ex: lifting, overusing back during yard work, sort injury, or sudden jolt in a motor vehicle accident symptoms: usually develop 24 hr later, shooting or stabbing pain, limited ROM, inability to stand up right

why are healthcare personnels more at risk for low back pain

lifting and moving pt, excessive bending or leaning forward, and frequent twisting can result in low back pain

risk factors for back pain

most common problem is lumbar reason bc it bears most of the body weight, most flexible Reginas of the spinal column, contains nerve roots that are at risk for injury, and has naturally poor biomechanics structures risk factors: lack of muscle tone, excess body weight, poor posture, cig smoking, pregnancy, prior compression fracture of the spine, spinal problems since birth, and family history of back pain

low back pain

musculoskeletal issue localized back pain- pt will feel soreness or discomfort when a specific area of the back is palpated diffuse pain - occurs over a large area and comes from deep tissue radicular pain- causes by irriation of a nerve route, usually pain moves along a nerve distribution ex: sciatica is an example of radicular pain referred pain - felt in the lower back but the source of the pain is another location (kindy abdomen)

health literacy

organize what you want to say so the most important points come first ex: when teaching about medication, start with purpose, the dose a patient is to take, and the time to take the medicine then info about side effects and what to report to the dr break complex information into understandable chunks use simple language, avoid jargons and defining technical terms ( use tablets instead of medication) use the active voice instead of passive voice active = "one of the nurses will give you a prescription before you go home passive = "the prescription for your medicine is being prepared by one of the nurses "

symptom management of the dying patient

pain medication ( sublingual drops or suppositories) supplemental oxygen may help a patient who is struggling to maintain oxygenation medication for nausea or vomiting use of alternative therapies such as guided imagery, massage, distraction techniques, and herbal therapies secretions can be controlled through medication to decrease oral and respiratory secretion, and suctioning if it does not cause the person distress

signs of patients who are experiencing nearing death awareness

patient might seem confused and report speaking to deceased persons such as parents or spouse description of spiritual beings and bright lights, with a sense of beauty and peace hand gestures, such as reaching or picking , or holding something unseen objects is common nurses shouldn't think pt is hallucinating or reacting to meds, end of life care personnels state this is common q

why are PT with OSA at risk for complication at hospital

patients with OSA (obstructive sleep apnea) are at risk for complication at hospital surgery and anesthesia disrupts normal sleep patterns, after surgery, pt reach deep levels of REM sleep. this sleep causes muscle relaxation that leads to OSA pt with OSA who are given opioid analgesics after surgery have an increased risk of developing airway obstruction bc the medication surpasses normal arousal mechanisms these pt often need ventilator support support in the post op period because of the increased risk of respiratory complication monster the pt airway, respiratory rate and depth, and breath sounds frequently after surgery

topical medication

placed on skin surface, on mucous membrane, or body cavities sites: eyes, ears, nose, rectum, vagina, and lungs clean skin before applying to remove body oils or dry skin, which can impair medication absorption gauze can be placed to prevent removal of medication by clothing gloves and applicators ares used to avoid absorption through the nurses skin during placement of topical medication inunction = absorption of medication through skin

lateral position

pt is supported on the right or left side with opposite arm, thigh, and knee flexed and resting on the bed place a pillow under the pt head to keep the head, neck, and spine aligned upper arm is flexed and supported with a pillow upper leg is flexed at the hip and knee and positioned on a small pillow pt who are obese or older are often not able to tolerate this position 30 degree lateral position is recommended to avoid pressure ulcers trouble points common in side lying position: - lateral flexion of the neck - spinal curves out of normal alignment -shoulder and hip joints internally rotates, adducted, or unsupported -lack of support for the feet -lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles -excessive lateral flexion of the spine if the pt has large hips and a pillow is no placed superior to the hips at the waist

factors influencing pressure ulcer formation and wound healing

pt who has undergone surgery and is well nourished still needs 1500 kcal day wound healing depends on protein , vitamins, and and trace mineral zinc and copper vitamin C is necessary for synthesis of collagen, vitamin A reduces negative effects of steroid s on wound healing

promoting safety in infants bed

reduce chance of suffocation by removing pillows, stuffed toys, or the end of loose blankets in cribs loose fitting plastic mattress covers are dangerous bc infants pull them over their faces and suffocate parents need tp place an infant on his or her back to prevent suffocation

transdermal patch nursing intervention

rotate placement application site ensure each site is free from hair, and not located over bony prominence note any redness, irritation, skin breakdown, do not apply a new patch to an area of skin irritation or breakdown never apply over pacemaker or implanted port always mark patch with initials, date, and time apply gentle pressure with palm of hand for 10 - 15 min do not massage the patch each new patch should be applied at the same time of day and on the days ordered evident based practice - if pt is in cardiac emergency, remove transdermal patch before defibrillation. many patches have aluminum backing that can cause second degree burn if removal is not possible, check pt after the event for patches and treat accordingly

vital signs

should be taken after the general survey. measurement of vital signs isomer accurate if completed before beginning positional changes or movements if there is a chance that the vital signs are skewed when first measures, recheck them alter during the rest of the exam pain is the 5th vital sign

promoting safety for those with confusion or falls

small night light helps a pt orient to the room environment before going to the bathroom bed set lower to the floor can lessen the chance of a person falling when first standing instruct pt to remove clutter and throw rugs from the path used to walk from bed to bathroom if a pt needs help to ambulate from bed to bathroom, place a small bell at the bedside to call fam members sleepwalkers are unaware of their surrounding and are slow to react do not startle sleep walkers ,instead gently wake them and lead them back to bed

nearing death awareness

special communication of the dying, which occurs when patients are approaching death or imminently dying thought to be a symbolic communication, perhaps asking permission to die or resolving past conflicts

documentating

standard precautions do not require documentation but patient and family education should be documented educated pt and staff regarding procedure to be performed on the patient

breathing exercises

techniques to improve ventilation and oxygenation the 3 basic techniques are deep breathing and coughing exercise, pursed lip breathing, and diaphragmatic breathing

second part of advance directive ; living will

this identifies what one would or wound not want if he or she were near death treatments that are discussed include CPR, artificial ventilation, and artificial nutrition or hydration

when to use standard precaution

use for all patient when contact with potentially infectious bodily materials such as - blood and bodily fluids (except perspiration) -secretion and excretions precautions must be used whether blood is visible or not - non intact skin (sores) -mucous membrane -other potentially infectious material

transdermal patch

used for extended period of time (12 hours - 7 days ) before applying a new patch, done gloves and remove old one keeping same old patch in place can cause an overdose of medication many patches are clear, which makes them difficult to see- carefully assess

Diaphragmatic breathing

useful for those with pulmonary disease, postoperative pt, and women in labor used to promote relaxation and provide pain control improves efficiency of breathing by decreasing air trapping and reducing WOB it is more difficult than others bc it requires pt to relax intercostal and accessory muscles while taking deep inspirations how to do it: pt places one hand flat below breastbone and other hand on flat abdomen ask him or her to inhale slowly, making the abdomen push out ( as diagram flattens, abdomen should extend out and hand should extend out) when pt exhales, abdomen goes in ( diaphragm ascends and pushes on lungs to help expel trapped air) first practice in supine position and then while sitting and standing (often used with pursed lip breathing)

skin application

wear gloves when applying lotions, paste, and ointments use sterile technique if pt has open wound skin encrustation and dead tissue harbor microorganism and block contain of medication with tissue to be treated make sure to clean skin thoroughly by washing the area gently with soap and water, soaking an involved site ,or locally deriding tissue lightly spread lotions and cream onto the surface of the skin, do not rub, but gently spread firmly into the skin dust a powder lightly to cover the affected area with a thin layer

nursing intervention for skin application

when taking a medication history or reconciling medication, specifically ask pt if they take any medication in the form of patches, topical creams, or any other route other than the oral route when applying a transdermal patch, ask the pt if he or she has a existing patch wear disposable gloves when removing and applying transdermal patches if dressing or patch is difficult to see, apply a noticeable level to the patch document the location on the pt body where the medication was placed on the MAR document removal of the patch or medication on the MAR fold sticky sides of the patch together and dispose of the patch in a child-proof container