final exam

CHF patient teaching

●Take your medicines, even if you feel well - The medicines your doctor prescribes can help you feel better and live longer. But they will work only if you take them as your doctor tells you to. ●Watch for changes in your symptoms and follow an action plan - An action plan is a list of instructions on what to do if your symptoms change. To use an action plan, you must watch your symptoms closely and weigh yourself every day (see next bullet). If your symptoms get worse or if you gain weight suddenly, you must take action (figure 2 and figure 3). Keep your action plan somewhere handy, such as on your refrigerator, so that you can always check it to see what you should do. ●Call your doctor or nurse if you gain weight suddenly - Weigh yourself every morning after you urinate but before you eat breakfast. Wear roughly the same amount of clothing every time. And make sure to write down your weight every day on a calendar. Call your doctor or nurse if your weight goes up by 2 or more pounds (1 kilogram) in 1 day, or 4 or more pounds (2 kilograms) in 1 week. When you have heart failure, sudden weight gain is a sign that your body could be holding on to too much fluid. You might need a change in your medicines. ●Cut down on salt - Try not to add salt at the table or when you cook. Also, avoid foods that come in boxes and cans, unless their labels say they are low in sodium. The best choices for food are fresh or fresh frozen foods, and foods you prepare yourself (table 1). Ask your doctor how much salt you should have. Your doctor might also tell you to limit the amount of fluids you drink. ●Lose weight, if you are overweight - If you are overweight, your heart has to work extra hard to keep up with your body's needs. ●Stop smoking - Smoking worsens heart failure and increases the chance that you will have a heart attack or die. ●Limit alcohol - If you are a woman, do not have more than 1 drink a day. If you are a man, do not have more than 2. ●Be active - Ask your doctor what activities are safe for you. Your doctor will let you know if activities such as walking or biking on most days of the week can help reduce your symptoms. But do not exercise if your symptoms are bothering you a lot. ●Check with your doctor before taking any new medicines or supplements - Some over-the-counter and prescription medicines, "natural" remedies, and supplements are not good for people with heart failure. For example, medicines such as ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve) can make heart failure worse.

➢On-going

➢As needed, continuing to monitor

Psychological Stages of Dying Dr. Elisabeth Kubler-Ross: Five "Stages of Dying & Grief"

Denial Anger Bargaining Depression Acceptance

Left side heart failure powerpoint

Increased intra-cardiac pressure Distention of the left ventricles Pulmonary edema/congestion Coughing Shortness of breath Dyspnea Frothy pink sputum LEFT SIDED = LUNGS

Factors Affecting Grief

No two people experience grief the same way Young to Middle Adults, Older Adults Significance of the loss Support system Unresolved conflict Circumstances of the loss Previous loss Spiritual/cultural beliefs and practices Timeliness of death Developmental stage of the bereaved Factors can affect grieving: everyone is different, and the time period to grieve is different Significance of the loss: • The meaning the person has attached to the person or object lost will be different for each person • The more attachment to the relationship or object, the more difficult is the grieving Support System: • The amount of support for the bereaved: people with more emotional and psychosocial support typically have less complicated grief Unresolved Conflict: Conflict existing at the time of death: A conflict left unresolved may cause prolonged grief Circumstances of the loss: If circumstances of the loss leave the bereaved feeling guilty or responsible, healing process may be impeded Previous loss: • If the person has sustained more than one loss in a short period of time, the grieving process can become more complicated Spiritual/cultural beliefs and practices: • Spirituality and religious beliefs can help or hinder the grieving process • Most cultures engage in rituals (e.g., funerals) that help the bereaved begin the grieving process by openly expressing their emotions and pain • Some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings Timeliness of death: • May be a sense of unfairness and loss of the person's potential • Loss of a child more difficult than loss of an older adult Developmental stage of the bereaved: • Developmental stages are an important factor in grieving • Grief can affect the healthy development of life stages, and in turn, the person's stage of development can affect the grieving process • Young to Middle Adults are able to understand death because they have experienced losses • Perceive as a normal part of living • Older Adults: Experience many different types of losses. ex: Family, Friends, Physical loss, and preparing for their own death

It is important to establish rapport, trust & respect prior to beginning assessment data collection

Perform assessment with awareness to possible cultural modifications or variations needed Ask open-ended questions can provide information about client's culture, beliefs, values and expectations that may impact or influence care Use a professional medical interpreter or translator if needed. ask patients what matters most to them in their illness and treatment Identify evidence-based interventions that are supportive of client & culture Goals & S.M.A.R.T outcomes culturally sensitive Collaborate with the client to validate the goals Encourage practices that could be helpful and discourage those that may cause harm Information about cultural values, beliefs, and practices help identify interventions that will support these practices Incorporate these interventions into care

Right Sided Heart Failure Power Point

Systemic venous congestion Peripheral edema Jugular venous distention Ascites Hepatic congestion Peripheral edema

Types of Grief

Uncomplicated Complicated Chronic Masked Delayed Disenfranchised Anticipatory

What factors affect or disrupt sleep?

↓ Melatonin Depression Anxiety & Stress Menopause Nocturia Illnesses Medications Pain or discomfort Foods Exercise Smoking & Alcohol Environmental

What is ASKED?How can nurses become culturally competent? Five components of cultural competence, using the mnemonic:

"A S K E D" Awareness Skills Knowledge Encounters Desire

PVD peripheral vascular disease intervention

"Bad blood flow to my legs" help clients elevate legs

Ace Inhibitors

"PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension

Malignant hyperthermia nursing considerations

"Some Hot Dude Better Give Iced Fluids Fast!" (Hot dude = hyperthermia):Stop triggering agentsHyperventilate/ Hundred percent oxygenDantrolene (2.5mg/kg)BicarbonateGlucose and insulinIV Fluids and cooling blanketFluid output monitoring/ Furosemide/ Fast heart [tachycardia] Airway and respiration Circulation Temperature control Malignant hyperthermia- hypercarbia, tachypnea, tachycardia, PVC's, labile BP, cyanosis, mottling, muscular rigidity. Increased Temp is late sign. POTENTIALLY FATAL (next few slides) Fluid and electrolyte balance Neurological functions To assess a patient's post-operative condition, apply critical thinking while relying on information from the pre-operative nursing assessment, knowledge regarding the surgical procedure performed, and events occurring during surgery. •Certain anesthetic agents cause respiratory depression. One of your greatest concerns is airway obstruction. •The patient is at risk for cardiovascular complications resulting from actual or potential blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory regulating mechanisms and ischemia. •The OR and recovery room environments are extremely cool. The patient's anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. •In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Despite the name, an elevated temperature occurs late. Increased expired carbon dioxide is one of the first signs. •Because of the surgical patient's risk for fluid and electrolyte abnormalities, assess hydration status and monitor for signs of electrolyte alterations. •As anesthetic agents begin to metabolize, the patient's reflexes return, muscle strength is regained, and a normal level of orientation returns.

Boykin and Schoenherr -

"caring" respect for persons as caring individuals and respect what matters to them.

Leininger's-

"culture' a nurse must understand different cultures, in order to function effectively.

Roach's-

"five c's" compassion, competence, confidence, conscience, and commitment.

Watson-

"human caring" care of the mind, body, and soul. *harmony*

· Secondary data

"second hand" Ex: from the medical record or another caregiver/NAP reports patient's heart rate was high

Maslow's hierarchy of needs-

#1 priority physiological (breathing, food, sleep, homeostasis) Safety, love/belonging, esteem and self-actualization.

Prostate problems

#43 BPH dribbling, retention, frequent urination, urgency to go, difficulty voiding

Hypotonic Intravenous solutions

(1L of half normal saline)

Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk ModelTM

(A score of 5 or greater = High Risk) TOTAL SCORE

Defining Characteristics

(AKA "SYMPTOMS") Defining Characteristics AKA "SYMPTOMS" Defining characteristics are also known as "Symptoms"

Know the patient's usual range of vital signs

(ALWAYS COMPARE TO BASELINE VITAL SIGNS AND TRENDS)

Diuretics such as Spironolactone can cause

(Aldactone) is potassium sparing!! Which means it can cause Hyperkalemia!!

hyperthyroidism

(an increase in the thyroid hormone thyroxine) increases the BMR. Clients with hyperthyroidism often complain of feeling warm even when in a cool environment.

#26 know pneumothorax

(collaspe lungs ) no breath sound on the side; treatment is chest tube.

(Increase BMR=heat production)

(decrease BMR= heat loss)

#7 Hypokalemia, Hyperkalmia reasons for high potassium

(fluids that are over and under can change the value)

#11 Barriers to culture in care

(language, ones own bias, stereotype) *ethnocentrism- culture barrier *when one believes ones culture is superior, better than others.

#12 What type of questions should be asked in a culture assessment?

(open ended questions)

#33 Adjunct:

(pair ) relaxation music distraction, biofeedback, therapy, massage

#36 Know PCA-

(patient controlled analgesia pump) Ask patient if its working if patient feeling less pain.

#13 What is the preffered alternative treatment?

(patients point of view what are their thoughts regarding their health and illness)

#45 C-diff

(remember alcohol is a no go) precautions wash hands

Civility What causes incivility?

(rude, disrespectful behavior) Stress of school, work, financial, and balancing home life. Consequences? It can lead to cheating, exhaustion, and burnout. Examples: side conversations, being late to class, gossiping, bullying, not staying on topic. (not fair to other students learning).

Diabetic foot care

(select all) change shoes frequently, wash feet with soap and water -Nailcare: Podiatrist, cut nail straight across. -Wear Clean Cotton Socks/Closed Shoes -Do not soak feet or wear ointments Clean w/ soap and warm water, clean socks everyday, cut toe nails straight across, keep feet dry, no powder or lotion b/t toes , wear shoes , inspect feet daily, no gardners use mirror!!

Etiology

(set of causes)

Oxygenation #21 pulmonary ventilation and respiration

(the exchange of oxygen and carbon dioxide)

slough

(v.) to cast off, discard; to get rid of something objectionable or unnecessary; to plod through as if through mud; (n.) a mire; a state of depression

beta blocker nursing considerations

* Take with meals *Check vital signs prior to administration * Do not administer if SBP <100 and HR <60 * For diabetic patients; blocks normal signs of hypoglycemia (sweating, tachycardia); monitor blood glucose * Teach patient to check pulse before each dose; withhold if pulse <60 bpm * Do not discontinue abruptly without consulting physician d/t risk of myocardium excitability

Opioid side effects

* respiratory depression * sedation * nausea/vomiting * urinary retention * blurred vision * sexual dysfunction * constipation * pruritius

#8 electrolyte can effect cardiac status

*if you look up electrolytes does to each system it makes it easier*

#27 implementation & evaluation What are the purpose of each? Can they be delegated?

*power point if patient is not stable nurse can't implement* Can't delegate nursing eval or care plan Determine if interventions were successful that's why we evaluate To know the progress of goals and outcomes check if goal were met or not. *planning & intervention always pt specific patient is unique and individual.

Nursing Interventions for aspiring

+ Nursing Intervention Use in caution in patients at risk for bleeding Platelet aggregation will not return to normal for at least 5 days once drug in stopped

Edema Rating Scale

+1 (minimal) to +4 (deep depression lasting 2 to three minutes) "pitting"

malignant hyperthermia treatment

- Activate EMS and discontinue all volatile inhalation anesthetics substituting 100% O2 - Dantrolene - must be reconstituted • Administer 2.5 mg/kg bolus rapidly up to 10mg/kg until signs are controlled - Administer bicarbonate in order to correct the metabolic acidosis (1-2mEq/kg) - Active cooling with cold IV saline 15mL/kg every 15 minutes x 3 - Treat hyperkalemia with hyperventilation and IV glucose and insulin. Consider calcium chloride (2-5mg/kg) if hyperkalemia is life threatening. - Diuretics for myoglobinuria - ICU observation for 24hours because MH may recur. - Continue dantrolene administration 1mg/kg every 4-6 hours.

Diabetic neuropathy treatment

- Strict monitoring of blood glucose levels - PT for: pain, foot care, overall fitness - Drugs

Stress incontinence

- cough dribble

Diuretic side effects

- decrease in Ca++ (except thiazides), Cl, K, Mg, Na - metabolic alkalosis (loops) - ototoxicity (loops) - hyperuricemia - hyperglycemia - hyperlipidemia - photosensitivity dehydration, orthostatic hypotension, hypokalemia, hyponatremia, hypomagnesemia with loop and thiazide diuretic, potential for hyperkalemia with spironolactone (Aldactone)

#25 Interventions for patient with congestive cough

- meds fluid (encourage fluid s needs to thin secretion maybe IV humidifier Contraindicated to increase fluid with patients with renal issues, Strict I&O and also in pneumonia? Not a lot of fluids are recommended

respiratory acidosis/alkalosis

-Caused by failure of respiratory system to perform pH-balancing role -Single most important indicator is blood PCO2

Aspirin (mechanism, use, toxicity)

-Mechanism: irreversibly inhibits cyclooxygenase (both COX-1 and COX-2) via acetylation, which synthesis of TXA2 and prostaglandins. bleeding time. No effect on PT, PTT. A type of NSAID. -Use: low dose (< 300 mg/day): platelet aggregation. Intermediate dose (300-2400 mg/day): antipyretic and analgesic. High dose (2400-4000 mg/day): anti-inflammatory. -Toxicity: gastric ulceration, tinnitus (CN VIII). Chronic use can lead to acute renal failure, interstitial nephritis, GI bleeding. Risk of Reye syndrome in children treated with aspirin for viral infection. Causes respiratory alkalosis early, but transitions to mixed metabolic acidosis-respiratory alkalosis.

normal cardiac cycle 1

-P wave is depolarization of the atria -QRS complex is depolarization of ventricles -T wave is repolarization of ventricles

Sleep #17 What is sleep? #18 what do we do in sleep assessment

-ask questions to patient

High Fowler's Position

-client lies supine with head of bed elevated approx 90 degrees, and knees may or may not be elevated -position promotes lung expansion by lowering the diaphragm and used for clients experiencing severe dyspnea

Fowlers

-religion

Intermittent

-the patients temp returns to normal at least once every 24 hours without pharmacological intervention. Ex: sepsis, abscesses ·

pulse quality rate

0=absent/ unable to palpate 1= weak/ thready/barely felt 2=normal/easily palpated 3=full and bounding

smell and see

1 &2 I, II

2 & 3-PART NURSING DIAGNOSES Basic 2 or 3 part statement:

1-problem (diagnostic label) There are words that have been added to some NANDA label to give additional meaning e.g. Altered, impaired, decrease, ineffective, acute, chronic, knowledge deficit, ineffective breathing pattern. 2- Etiology: (related factors and risk factor) identifies one or more probable causes of the health problem. 3 Defining characteristic Are cluster of sign symptoms that indicate the presence of a particular diagnostic label.

Valves and point of maximal impulse (PMI)

1. Aortic 2. Pulmonic 3. Erb's point 4. Tricupsid 5. Mitral (all pigs eat too much)

Identify the steps of the nursing process:

1. Assessment- gathering objective (measurable) and subjective (how patient feels) data in order, to draw conclusions about a patients health status. Ex: vital signs 2. Diagnosis- identify clients health needs, reflects the clients responses to actual or potential health problems. Ex: risk for impaired urinary elimination aeb (as evidence by) urinary incontinence. 3. Planning- a care plan is written or electronic document containing detailed instruction for a client's nursing care. Ex: patient will be on a 2-hour toileting schedule. 4. Implementation- action phase, carry out or delegate action to another member of the health care team. 5. Evaluation- nurse determines whether the desired outcomes have been achieved and judge whether your actions have successfully treated or prevented the clients health problems. *Can be revised at any step of the nursing process*

Documenting and reporting What is the purpose of documentation?

1. Communication between providers, educational tool, legal documentation of care, quality improvement, research, and reimbursement.

Describe the purpose of a health assessment: Different types of health assessments:

1. Comprehensive physical assessment- Health history interview, complete head to toe exam. 2. Focused physical assessment- Particular problem, topic, body part, or functional ability rather than overall health status. 3. System-specific assessment- Limited to one body system. Ex: lungs, peripheral circulation. 4. Ongoing assessment- Performed as needed, after the initial database is completed.

Older adult Identify and compare developmental theories of older adult:

1. Cumming and henry (disengagement)- aging is inevitable. Decrease interaction between others in social system due to mandatory retirement, chronic illness, and loss of spouse/relative/friends. 2. Activity- staying active for as long as you can to enjoy highest life satisfaction (traveling, hobbies, volunteering) 3. Erikson's- ego integrity versus despair acceptance- that one's life has meaning, and death is part of the continuum of life. 4. Havighurts developmental- decrease physical strength and income, retirement, loss of spouse, establish adapting social roles/physical living arrangements

Analyze factors that influence the communication process.

1. Environment- quiet, private, free of unpleasant smells, and at a comfortable temperature. 2. Developmental variations- physical and cognitive development, language, and level of education. 3. Gender- woman- tend to communicate forming connections and establishing relationships. Men- focus on goals, tasks, and maintaining independence.

Digoxin mechanism of action

1. Inhibits sodium/potassium pump, thereby increasing intracellular calcium levels 2. Positive inotropic effect, increases cardiac output 3. Decreases chronotropy and dromotropy; slows AV conduction

right sided heart failure

1. Jungular Vein Distention 2. Ascending Dependent Edema 3. Weight Gain 4. Hepatomegaly (Liver Enlargement)

Diabetic Labs

1. Large Ketones (DKA) 2. Accu Check; finger stick glucose (less than 80 or more than 110) is low or high blood sugar

Use MORAL model to come up with alternative solutions

1. M= Massage the dilemma 2. O= outline the options 3. R= resolve the dilemma 4. A= act by applying the chosen option L=look back and evaluate

Common HAIS (hospital acquired infections)

1. MRSA- lives on skin and in nose, skin to skin contact. 2. VRE- lives in intestines and female genital tract, contact with contaminated person or surface to portal of entry. 3. CDIFF- severe diarrhea, lives in GI tract, occurs after antibiotic use or contact with contaminated area or stools. *wash hands with soap/water, clean room with bleach and avoid alcohol-based products.

Prolonged immobilization causes physiological changes in almost every body system, along with psychological changes:

1. Muscle and bones- loss of muscle strength, joint stiffness, can lead to contractures, osteoporosis. 2. Lungs- at risk for pneumonia, aspiration due to decrease strength to effectively cough/expectorate secretions diminishes. 3. Heart- edema, hypotension, thrombosis, increased workload of the heart and decrease mobility. Active skeletal muscle in legs help pump blood back to the heart.

Describe factors that attribute to stress and disrupt health:

1. Physical disease-disrupts our lives in many ways and can reduce our ability to perform our life roles effectively or to engage in activities we once enjoyed. Ex: diagnosed with breast cancer. 2. Injury- usually something sudden. 3. Mental illness- anxiety, depression. 4. Pain- can affect a person's quality of life. 5. Impending death 6. Compete demands- people ignore health issues because the competing demands are too great. Ex: taking care of a loved one, that person may feel an overwhelming burden.

Left sided heart failure

1. Pnea, SOB 2. Crackles 3. Oliguria 4. Frothy Sputum 5. Displaced Apical Pulse (Hypertrophy)

Therapeutic relationship:

1. Pre-interaction phase- gather information before meeting with the patient. 2. Orientation- meeting the patient, establishing rapport and trust. 3. Working- nurse communicate bulk of the conversation, clarifies feelings and concerns. 4. Termination- conclusion of relationship.

Nutrition Distinguish the individual components of nutrition and the effects on maintaining homeostasis:

1. Protein- builds and repairs cells, fights infection and heals cuts · Meat, fish, poultry, beans, eggs, milk, cheese 2. Carbs- supply energy, supply fiber to help food move through the digestive tract · Breads, cereals, rice, pasta, fruits, vegetables 3. Water- carries other nutrients throughout the body, carries waste out of the body, regulates temperature · All foods and beverages 4. Vitamins- support immune system, necessary for metabolism, preventing a particular deficiency disease · Vitamin A- night and color vision, cellular growth, maintaining skin and mucous membranes (green leafy vegetables, egg yolk, liver, egg yolk) · Vitamin D-regulates blood calcium levels, resorption of calcium in bone( fortified milk, sunlight exposure, fish) · Vitamin E- antioxidant, protects red blood cells and muscle tissue cells (vegetable oils, nuts, milk, eggs, muscle meat) · Vitamin K- synthesis of clotting factors, bone development( green leafy vegetables) · Vitamin C- collagen synthesis, iron absorption, immune function, cementing substance for capillary walls (citrus fruits, tomatoes, potatoes, green vegetables, cauliflower) 5. Lipids- fats give you energy, and help the body absorb certain vitamins. Not all fats are good for you. · Saturated and trans-fats are found in processed food, margarine, butter, cookies · Monounsaturated= canola, olive, avocados, peanut butter polyunsaturated= soybean, fatty fish, seeds, corn are both good fats 6. Minerals- assist in fluid regulation, nerve impulse transmission, and energy production; they are essential to the health of bones and blood and help rid the body of by-products of metabolism · Calcium (Ca)-bone and teeth formation, blood clotting, nerve conduction, muscle contraction, cellular metabolism, heart action · Magnesium (Mg)- aids thyroid hormone secretion, maintains normal basal metabolic rate, activates enzymes for carbohydrate and protein metabolism, nerve and muscle function, cardiac function · Potassium (K)- intracellular fluid control, acid-base balance, nerve transmission, glycogen formation, blood pressure regulation · Sodium (Na) - water balance, acid-base balance, muscle action, convulsion

Differentiate between standard, contact, droplet, and airborne precautions:

1. Standard- hand hygiene, use of PPE, safe injection practices 2. Contact-gloves/gown Ex: MRSA,VRE, CDIFF 3. Droplet- mask/gown/gloves. Ex: flu, rubella, cold 4. Airborne- gown/gloves/n95 respirator mask. Ex: measles, TB, fungal infections. Negative pressure room 6-12 exchanges. PPE removal: gloves, googles, gown, mask

Identify factors that influence vital signs:

1. Temperature: · Developmental level- elderly=difficulty maintaining body heat due to slower metabolism, decreased vasomotor control, and loss of subcutaneous tissue · Gender-woman body temp varies due to menopause, ovulation, and menstrual cycle · Exercise- increases metabolism, hard work or strenuous activity can increase body core temperature · Emotions/stress- stimulate the sympathetic nervous system causing production of epinephrine and norepinephrine that trigger an increase metabolic rate · Fever- temp above persons usual range of normal · Heat exhaustion/stroke

Braden scale categories

1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction/shear

shrug and stick your tongue right out

11, 12 XI, XII

cranial nerves

12 pairs of nerves that carry messages to and from the brain

· Normal (eupnea)-

12 to 20 breaths

Prehypertension-

120-139/80-89 obtained with two readings, 6 mins apart while sitting. Encourage lifestyle changes, recheck in 1 yr. or sooner

Stage 1 hypertension-

140-159/90-99 on two or more separate occasions. Encourage lifestyle modifications, follow up with primary in 1-2 months, thiazide-type diuretic may be given

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk

Get up and go-

1=normal, 5= severely abnormal a score over 3 means risk for falls

Anticoagulants/antiplatelets

2 RNs have to verify dose Warfarin PT Heparin PTT Lovexox none

normal cardiac cycle

2 atria contract while the 2 ventricles relax, 2 ventricles contract while the 2 atria relax

HCO3 normal range

22-26 mEq/L

pupils large and small

3 III

and look around

3, 4, 6, I, II, III

PCO2 normal range

35-45 mmHg

Fowler's position

45-60

clench your teeth

5 VI

· Normal pulse rate is

60-100 and the most accurate reading is apical

smile and hear

7, & 8 VII VIII

pH normal range

7.35-7.45

then say a-h-h

9 IX

Bradypnea-

<10 breaths

Bradycardia-

<60 bpm ·

· Fever occurs in three phases: initial

=period where temp is rising second phase=temp meets max point third phase=temp returns to normal

Tachycardia- ·

>100 bpm

Stage 2 hypertension-

>160/>100 encourage lifestyle modification, refer for care within 1 week, or immediately if warranted. Most pts will be given a two-drug combination therapy thiazide-type diuretic with ACE inhibitor

Tachypnea

>24 breaths

Integrated Plans of Care (IPOCs)

A combined charting and care plan form Maps out on a daily basis, from admission to discharge Client outcomes, interventions, and treatments for a specific diagnosis or condition Laboratory work, diagnostic testing, medications, and therapies included in the pathway

Stage III Pressure Ulcer (Stage 3)

A deep crater characterized by full- thickness skin loss with damage or necrosis of subcutaneous tissue. May extend down to, but not through, underlying fascia. Undermining (deeper-level damage under boggy superficial layers) of adjacent tissue may be present. Bone/tendon is not visible or directly palpable. Some stage III pressure ulcers can be extremely deep when located in an area with significant adipose layers.

congestive heart failure (CHF)

A disorder in which the heart loses part of its ability to effectively pump blood, usually as a result of damage to the heart muscle and usually resulting in a backup of fluid into the lungs.

respiratory acidosis

A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.

Dunn's Health Grid

A grid that plots a person's health-illness continuum against environmental conditions

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.

Contusion (bruise)

A large patch of capillary bleeding into tissues. Color is red-blue or purple immediately after or within 24hrs >blue to purple>blue-green> yellow >brown-disappearing. Bruise in dark skinned is deep dark purple. Pressure on bruise does not cause it to blanch : a closed discolored wound caused by blunt trauma, a bruise

SVR (systemic vascular resistance) what does it do

A measure of the amount of resistance which the vascular bed offers to the flow of blood.

SVR (systemic vascular resistance)

A measure of the amount of resistance which the vascular bed offers to the flow of blood. Best indicator of left sided afterload 800-1200

Holistic Nursing Care

A modern type of nursing care that allows the nurse to examine the entire person and their world to include but not limited to cultural beliefs, fears, and physiological needs.Florence Nightingale, is considered to be the founder of Holistic Nursing.

Stridor:

A piercing, high-pitched sound heard primarily during inspiration ***ALWAYS concerning and may be life threatening!

The Geriatric Depression Scale (GDS)

A score > 5 points is suggestive of depression. A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment.

Nursing Process

A systematic problem-solving process of critical thinking that guides nursing actions.

Hemoglobin A1c

A test that measures the level of hemoglobin A1c in the blood as a means of determining the average blood sugar concentrations for the preceding two to three months. 4-6% good glucose control.

Maslow's Hierarchy of Basic Human Needs

A theory that believes lower-level needs must be met prior to higher needs.

Prevention

A type of nursing that focuses on the avoidance of disease, infection, and other co-morbidities.

How to reduce errors and safe enteral nutrition use ALERT mnemonic: ·

A=aseptic technique · L=label enteral equipment · E=elevate head of bed · R=right pt, formula, tube · T=trace all lines and tubing back to the patient *Administer feedings at room temperature, and be sure to check the expiration date of any feedings before starting an infusion,

Why would you use an ARB versus an ACE inhibitor? What is a MAJOR side effect of ACE inhibitors, and what life threatening side effect may occur with ACE inhibitors?

ARBs cause less cough than ACE inhibitors, and patients are less likely to discontinue ARBs because of adverse effects. ACE inhibitors should be used in patients with hypertension because they reduce all-cause mortality, whereas ARBs do not. With Ace inhibitors constant cough, when patients can't tolerate they are switched to ARBs due to the side effects of ACE inhibitors. With cardiac meds potassium is affected

EDEMA

Abnormal accumulation of fluid in interstitial spaces of tissues.

metabolic acidosis

Abnormal condition of high hydrogen ion concentration in the extracellular fluid caused by either a primary increase in hydrogen ions or a decrease in bicarbonate.

dysrhythmia/arrhythmia

Abnormal heart rhythm

Hyperthermia

Abnormally high body temperature

Hypoglycemia things to know

Abnormally low blood glucose level (below 70 mg/dL) Mild cases can be treated with diet—higher intake of protein and lower intake of carbohydrates—to prevent rebound postprandial hypoglycemia Treatment "Cold and clammy.... Need some candy, hot and dry sugars high" 15 grams of CHO , recheck in 15 minutes 15-15-15 rule 15 grams, recheck in 15 minutes if still low, give another 15 grams of CHO ASSESS patient Awake -> if can take po give food (candy, orange juice with sugar in it) NPO with an IV-> give IV D50W (NOTE D50W not D5W) NPO without IV access IM glucagon

Apnea—

Absence of breathing. Respiratory arrest re- quires immediate cardiopulmonary resuscitation.

Discuss the concepts and process of pharmacokinetics ·

Absorption- route of administration "movement" of the drug into the bloodstream. · Distribution- transportation of a drug in body fluids to various tissues and organs of the body, the rate of distribution depends on adequate local blood flow in the target area (site where drug effects occurs) ex: shock(vasoconstriction) decreases circulation · Metabolism- once a medication reaches its site of action, it is metabolized (changed into the inactive form) in preparation got excretion. Which takes place in the liver. if liver function is impaired (liver disease or aging) then, it'll eliminate more slow and toxic levels may accumulate · Excretion- drug continues to act in body until its excreted

Interventions:

Acetaminophen (Tylenol) or ibuprofen (Motrin) Though, a fever up to 102.2F can be beneficial because it enhances the immune response to fight off infection. However, you want to keep the patient comfortable and from allowing fever to get dangerously high. Avoid making the patient shiver because it produces heat, which can increase temp. Cooling blankets, cloth-covered ice packs to groin, neck, or axillae, alcohol/tepid baths, and fluids.

#37 Know aspirin and tynennol Used for- What are their cautions-

Acetaminophen-very toxic to the liver 4,000 in 24hrs *be aware of other medication combined with acetaminophen, may have more doses on acetaminophen and then it becomes too much (overdose)

acid-base imbalances and causes

Acid-base balance depends on balanced chemical reactions Acid-base balance is maintained by chemical buffering, pulmonary and renal mechanisms Disruption of the acid-base balance has a profound effect on overall health ABG's: ▪ An acid-base balance is determined by arterial blood gases Metabolic --> change in HCO3 (bicarbonate) ◦ Metabolic acidosis◦ Metabolic alkalosis Respiratory --> changes in PCO2 (carbon dioxide) ◦ Respiratory acidosis Respiratory alkalosis

LABS to determine ABG

Acidity pH (Hydrogen ion) H+ determine acidity. Respiratory imbalance PaCo2 Metabolic imbalance HCo3

Acid-Base Imbalances

Acidosis ▪ Serum pH below 7.35 ▪ H+ increases above normal ▪ Respiratory cause: retention of CO2 ▪ Metabolic cause: loss of bicarbonate Alkalosis ▪ Serum pH above 7.45 ▪ H+ decreases below normal ▪ Respiratory cause: eliminating "blowing off" CO2 ▪ Metabolic cause: increase in bicarbonate Three mechanisms maintain acid-base balance:▪ chemical buffers▪ (lungs) respiratory control of carbon dioxide (CO2)▪ (kidneys) renal regulation of bicarbonate (HCO3-)Buffer systems are an acid-base homeostatic mechanism to maintain pH

Contusion treatment

Acute - RICE (rest, ice, compress, elevate) for first 24 hours in minor, 48 hours in major. Heat and ultrasound used. Ultrasound promotes muscle adhesion (myogenisis). make sure passive range of motion is performed after therapy.

electrolyte metabolic acidosis CLINICAL MANIFESTATIONS

Acute: Increased pulse and respiratory rate Headache, dizziness Confusion, decreased level of consciousness (LOC) Muscle twitching Chronic: Weakness Headache

What is Evaluation? What is purpose of evaluation in the nursing process? Can Implementation & Evaluation be delegated?

After preparing care plan; it is time to act: Nursing actions are done by nurses or delegated to others During implementation, both the nursing orders on care plan and medical orders are coordinated and carried out Delegation is the process of directing another person to perform a task or activity & includes supervision Delegation = transferring responsibility while retaining accountability for activity outcome Why or why not? Knowledge and Skills Promote Client Participation and Adherence Collaborating and Coordinating Care Delegation and Supervision Delegating Is Not the Same as Assigning You Cannot Delegate Nursing Care Decisions Use NAPs Appropriately Right task Right circumstance Right person Right direction/communication Right supervision Evaluation: After all nursing interventions/actions have been completed; evaluation to determine if client goals and expected outcomes have been met Nursing process beings again if client has shown no improvement or goals were not met Evaluation: Cannot delegate!!! overlaps with asessment step=both involve data collection data is collected after interventions are to evaluate whether client goals were achieved or not achieved outcomes stated in planning stage are used as criteria for evaluation during implementation client responses are evaluated in order to make changes in activity if necessaryHow do nurses choose and determine what nursing interventions are to be implemented? occurs throughout the nursing process to determine any modifications needed and does not ONLY need to be done at the end. Modifications may be made any where throughout the nursing process.

What are risk factors for the older adult?

Age: • an older adults' skin is less elastic, thinner, drier, has reduced collagen, areas of hyperpigmentation and is more prone to injury Mobility status: • increased pressure, shearing, and friction can lead to skin breakdown

asthma

Airway inflammation and obstruction: Allergic inflammatory airway reactions such as

Partially compensated

All 3 values will be abnormal.

Lactated ringers

Also known as LR, Ringers lactate, or RL) as isotonic crystalloid that contains sodium chloride and sodium lactate in sterile water-great for burn victims avoided with patients with liver disease.

approaches to coping with stressors

Altering the stressor, adapting to the stressor, and avoiding the stressor.

Anesthesia concerns

Anesthesia concerns: O Use caution for aspiration (rapid sequence induction, RSI) O Be aware that halothane hepatitis is a possibility due to increased fatty infiltrates in the liver O Assess your airway O Calculate drug dose on ideal rather than actual body weight O Regional anesthesia may be difficult due to obscured bony landmarks-osteoarthritis O Monitor ABGs O Mechanical ventilation with high tidal volumes O Prone to nerve stretch injuries due to difficulty in positioning; watch brachial plexus O Need to wake up quickly; extubate awake - sleep apnea

Preoperative time out

Anesthesiologist, nurse and patient verify patient , sight (must be marked by surgeon if laterality) procedure, consent signed and witnesses, surgeon in building, room is ready The above must be done prior to giving patient any mind altering medications.

Aspirin

Antiplatelet Prevent platelet adhesion to the site of adhesion Heart attacks and strokes Ex: Aspirin, Plavix The 1st line of pharmacologic intervention in the treatment of angina. Indications Reduces atherosclerotic events in patients with documented atherosclerosis by recent CVA, MI or Peripheral artery disease (PAD). Reduces atherosclerotic events in patients with ACS (acute coronary syndrome)

3 Defining characteristic

Are cluster of sign symptoms that indicate the presence of a particular diagnostic label.

respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

#30 ABCDE

Ask Believe Choose right med Deliver intervention timely manner Empower pt, they have control.

Barriers to the therapeutic communication:

Asking too many questions, closed ended questions, asking why, changing the subject, failing to listen, failing to probe, expressing disapproval, offering advice, giving false reassurance, and using patronizing language.

Define tort, assault, battery, and libel

Assault- threatening a patient with harm · Battery- physical contact is made without their consent · Assault and Battery- is both · Libel-written/published form of defamation of character · Quasi-intentional tort- defamation of character · Intentional tort- action taken by one person with the intent to harm another person · Unintentional tort- negligence

Describe appropriate steps to take when communicating a medication error

Assess patients vital signs/physical status, report to HCP and nurse manager

The 5 steps of the nursing process

Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE)

RN's May not Delegate

Assessments Diagnoses Planning Delegation of Nursing diagnoses Per the ANA: The RN may NOT delegate nursing diagnosis to UAP!!

➢System-specific

Attention to one body system

Physical activity and mobility Describe how to maintain and use proper body mechanics:

Avoid sitting in same position for a lengthy time don't lock knees when standing upright Keep stomach muscles tight to support back don't slump when you sit stand with wide stance do not bend forward at the waist, bend down with knees active range of motion use assistive devices to decrease risk of injury

Nurses must be familiar with nursing professional organization guidelines (BORN, ANA, NLN etc)

BORN (Board of registration in nursing) ANA (America Nurses Association) NLN (National League of Nursing)

Prehypertension

BP reading of 120 to 139 mm Hg systolic or 80 to 89 diastolic mm Hg Obtained with two readings, taken 6 min apart, with the client sitting (JNC 7, 2003)

Diagnosing Diabetes

Based on serum glucose level (Fasting plasma glucose, casual plasma glucose, oral glucose tolerance test)

Intraoperative Care

Begins when the patient enters the surgical suite & ends at the time of transfer to the postanesthesia recovery area.

Beta blocker mechanism of action

Block sympathetic activation of Beta adranergic receptors, leading to decreased heart rate and contractility by lowering the resting membrane potential and increasing the threshold for an action potential, making SA node pacemaker cells more less excitable. This decrease in HR and SV leads to decreased cardiac output and decreased blood pressure. Reduce renin secretion and Angiotensin II levels, also lowering blood pressure.

body image

Body Image: the way individuals perceive their appearance, size, and body structure or function Body Image can be influenced by: • Ideal, Perceived, and Actual Body Image • Appearance and Function Gradual Versus Sudden Body Changes Health • Body image: ones own mental image and attitude related to physical self (ones own body), including physical appearance and physical functioning • People do not always see their own bodies as objectively as others see them • Both cognitive understanding and sensory input influence body image • Cognitive understanding is influenced by family, social, ethnic, and cultural norms; education,

Beta blocker side effects

Bradycardia, hypotension, fatigue, and weakness

(hypothyroidism)

By contrast, when the thyroxine level is low less heat is produced, and clients commonly report feeling cold.

ACE inhibitor mechanism of action

By inhibiting ACE, ACE inhibitors prevent Angiotensin I conversion to Angiotensin II, which inhibits vasoconstriction, aldosterone secretion, and Sodium retention, decreasing blood pressure.

Administrating medications Distinguish among various nomenclature systems for naming and classifying drugs ·

By usage- why the drug is used ex: ibuprofen can be an analgesic, inflammatory, and an antipyretic agent · By body system- where the drug works ex: can act on more than one body system. Valium can be used for anxiety or helps the intestinal system · By chemical or pharmacological class- what the drug is made of · Brand name, official name, nonprescription, over the counter, chemical name, and genetic name

Critical thinking and its relevancy to nursing?

By using critical thinking skills will help you to prioritize your patients needs. For example, a patient who is having trouble breathing versus a patient who is complaining of a headache. You would help the patient with breathing problems first. *Maslow law*

Indication: Edema

CHF PVD Kidney Disease Low albumin levels Rate and Rhythm

uncompensated

CO2 or HCO3 normal

Standardization communication strategies:

CUS- used to raise safety concerns. C= I am concerned, U= I am uncomfortable, I think this is a safety issue. Check back- used to clarify information. Repeat back order. Briefing/debriefing- to go over patients care plan/review and give feedback.

Calcium Channel Blockers

Calcium calms the heart. Ending in dipine, zem, amil. Nifedipine, Diltiazem, Verapamil. Dipine-helps the blood pressure to decline. Zem like Cardizem, is kind of like Zen yoga. (its so calming to the blood vessels and the heart that it results in the blood pressure to drop. Low B/P and heart rate.

Identify hygiene care for cognitively impaired patient:

Can give towel or bag bath instead. Bag bath= 10 cloths basin and water= incontinence

*Remember PACET*

Cannot delegate Nursing Process (PLANNING) Cannot delegate (ASSESSMENT) "you can delegate secondary assessments (vitals) *but if unsure go back and do it* (Cant delegate First Assessment diligent assessment) Cannot delegate (COLLABORATION) "social worker dietary services etc" Cannot delegate (Education/ Evaluation) LPN can reinforce but can't educate primary "Educate patient well enough decrease patient well enough decrease patient complications after discharge Cannot delegate (EVALUATION) LPN can jot down vital signs and pain scale but they cannot (EVALUATE VITALS OR ANYTHING) Cannot delegate (TEACHING)

Digoxin (Lanoxin)

Cardiac glycoside gives a deep contraction also known as increase contractility and also slows the heart rate down also known as negative chrono tropic Chrono means time so negative times means less beats per minute Remember D for Digoxin is D for deeper contraction. (dig Jackson) because it digs for that deeper contraction. Digoxin toxicity can occur in the presence of hypokalemia

Nursing Interventions for Common Sensory Alterations (cont'd) Impaired hearing

Care of a hearing aid Closed-caption television Regular inspection of ear canals Teach techniques to improve communication. Promote safety. Assess for social isolation.

metabolic alkalosis causes

Causes: hypovolemia, hypokalemia, hypochloremia DDx: -Volume contracted (saline responsive, urine Cl<10): Vomiting, diarrhea, NG suction, diuretics -Normal or expanded volume (saline unresponsive, urine Cl>10): primary hyperaldosteronism (Conn's), secondary hyperaldosteronism (CHF, cirrhosis, nephrotic syndrome, Cushing's, Barter's, Licorice, ectopic ACTH) -Other: milk-alkali syndrome, citrate, nonparathyroid hypercalcemia Treatment -Saline responsive: fluid and acetazolamide -Saline resistant: replace K and spironolactone (aldosterone antagonist)

Calcium Channel Blocker Nursing Considerations

Change positions slowly especially with elderly to prevent orthostatic changes Measure I&O closely and fluids due to potential for edema. Monitor liver and kidney function (metabolize by the liver, excreted by the kidneys) Obtain BP and heart rate before administering hold typically if SBP <90 HR <60

#24 Respiration change in older adult -physiological-lungs in older adult What happens to the lungs and chest?

Chest elasticity decreases Barrel chest Lung expansion spirometer Asthmatic -peak flow Know how to position patient who have breathing problems (semi fowlers 45 degree for pt. Who are having difficulty )

Admission Database

Chief complaint or reason for admission Physical assessment data Vital signs Allergy information Current medications ADL status and discharge planning information/needs Data about client support system and contact information

Nutritional assessment: ·

Collect a dietary history-includes; cultural factors, basic eating habits, preferences · 24-hour recall- client writes down everything they ate in a day · Food frequency questionnaire- used to find out how many times per day, week, or month a particular food group is eaten · Food record- diary of measured and weighed food eaten within a 3-day period

Common Hearing Deficits

Common Hearing Deficits Conduction deafness - results when one of the structures that transmits vibrations is affected. May be temporary or permanent caused by an infection of the middle ear, a punctured tympanic membrane, or arthritis of the auditory bones. Hearing aid may be helpful. Nerve deafness- damage to the cranial nerve VIII or the receptors of the cochlear. May result from ototoxic medications such as Gentamycin or viral infections. Chronic exposure to loud noise may also lead to nerve and receptor impairment. Presbycusis-progressive sensorineural loss associated with aging. Results from deterioration of the hair cells in the cochlear. Central deafness- results from damage to the auditory areas in the temporal lobes. Tumor, trauma, meningitis, or CVA in the temporal lobe may cause this. Tinnitus- ringing in the ears. Most comes from damage to the microscopic endings of the nerve in the inner ear. Impacted cerumen- earwax becomes tightly packed in the air canal. May experience a feeling of fullness or pain, decreased hearing , or tinnitus Otosclerosis-hardening of the bones of the middle ear. Leads to poor sound transmission to the inner ear. Otitis Media- middle ear infection. Common childhood illness that may be caused by bacteria or viruses.

What are common sleep disorders? What are the signs and symptoms?

Common Sleep Disorders • The inability to fall asleep, remain asleep & go back to sleep • Transient (Acute) or Chronic Sleep Deprivation : a result of prolonged sleep disturbances Causes: • Illness, Depression, • Side effects of medications • (Ex: Steroids, Bronchodilators) • Substance abuse • Anxiety/Stress, Menopause • Drinking caffeine, smoking • Watching TV in bed Signs & Symptoms: • Sleepy, Fatigue • Poor concentration, Irritable Common Sleep Disorders Sleep Apnea: periodic interruption in breathing during sleep Type: Obstructive sleep apnea: "OSA' caused by airway occlusion DX: Sleep studies where EKG, O2 sat. levels, and EEG are monitored Treatment depends on type of apnea 2 MAJOR RISK FACTORS ARE OBESITY AND HYPERTENSION!! Others are smoking, Alcohol, Family Hx, Heart Failure and Diabetes OTHER CAUSES ARE: Structural like Polyps, Deviated Septum, Large Necks, Enlarged Tonsils

Nursing Considerations

Communication Develop alternative methods of communication when interacting with clients with aphasia, or who speak another language, or who have difficulty hearing. Communication boards, a magic slate, pictures, or writing may be helpful. You might also hang a message board in the room and ask family members to post photos, cards, or notes. Computers are useful if the patient has one; and texting might also be used.

Describe IV site assessment, potential complications of IV therapy and steps of treatment.

Complications of Intravenous Therapy Complications at the IV site include infiltration, extravasation, infection, thrombus, and thrombophlebitis. Inserting an IV catheter breaks the body's first line of defense (the skin) and provides a portal of entry for microorganisms. In addition, trauma roughens the vein wall and predisposes the person to platelet clumping and thrombus formation. Minimize this effect by swiftly piercing the skin and anchoring the catheter and tubing to reduce tissue trauma. Systemic complications occur less frequently than do local complications but may be life threatening. They include fluid volume excess, sepsis, and embolus. Table 38-8 describes potential complications of IV ther- apy. For more information on managing infiltration and extravasation

• Nursing Diagnosis: Caregiver Role Strain

Components of Self-concept: Personal/Self- Identity View of oneself as a unique person, different & separate from all • The internal sense of individuality ~ "Oneself" • Relatively constant and consistent • Identity • Learn from Parents/Role models Gender Identity

Medication Administration Records

Comprehensive list of all ordered medications Provides information on client's medication allergies Documents scheduled/routine, prn, STAT, or omitted doses Additional explanation may be required for nonroutine or omitted medications.

CUS-

Concerned, uncomfortable, and safety.

Respiratory Alkalosis CLINICAL MANIFESTATIONS

Confusion, difficulty focusing Headache Tingling Palpitations Tremors

Theoretical-

Consists of information, facts, and evidence- based theories. For example: a nurse knows that drinking cold water before taking a temperature, can decrease the reading. Therefore, the nurse asks questions to find out when the last time they took a sip.

Decrease workload of the heart

Conversely, a decrease in heart rate or stroke volume can decrease cardiac output. What factors regulate increases and decreases in cardiac output? Factors affect cardiac output by changing heart rate and stroke volume. Primary factors include blood volume reflexes, autonomic innervation, and hormones.

Assessment finding for acid base imbalance

Correlate clients' fluid balance and creatinine levels with kidney function Correlate assessment findings with clients' diagnosisDo they match? Or pointing in a different direction? Double-check implications and adverse effects of all client medicationsIndividualized interventions are aimed at correcting the underlying disorder that led to imbalance Nursing care focuses on preventing imbalances Interventions Nurses can help restore the balance by targeting interventions to the specific acid-base disorder Monitor laboratory data Monitor vital signsMonitor respiratory status Monitor kidney functionDietary teachingOral electrolyte supplementsLimiting or facilitating oral fluid intakeParenteral replacement of fluids and/or electrolytes

Concept of Acid-Base Balance

Critical to homeostasis and optimal cell function Hydrogen ion (H+) determine the acidity of body fluids Measured as pHIncrease H+ pH falls acidityDecrease H+ pH rises acidityNormal range of pH of body fluids 7.35-7.45

Culture & Ethnicity What does culture consist of?

Cultures consist of common beliefs and practices. culture is what people in a group have in common and it changes over time.

How to approach someone who is being uncivil by using DESC: (rude nurse/rushes handoff)

D= Describe Ex: I know you're in a hurry and understand your upset but, I'm not getting enough information to do my job effectively. E= Explain Ex: Rushing through report can have an impact on the patient's care. S= State Ex: I know we're both concerned so, can I have more information to give her the best care possible. C= Consequence Missed information can compromise her health. Importance of speaking up: staying silent can increase stress, impair job performance and ultimately jeopardize patient care. Always think: if I don't speak up, what could happen to the patient. Six standards of a healthy work environment: skilled communication, true collaboration, effective decision making, making appropriate staffing, meaningful recognition, and authentic leadership. Ways to promote civility. Be on time, respect one another, be prepared for class, turn cell phones off, and training/education on civility.

Table 17-1 ➤ Theories of Grief. A Comparison STAGES

DESCRIPTION George Engel (1961)—Three Stages of Grief Shock and disbelief : Initial phase.The sufferer denies the loss in an attempt to protect himself against the shock of reality. Developing awareness of the loss The sufferer experiences painful feelings of sadness, guilt, shame, helplessness, hopelessness, loss, and emptiness.The person may lose interest in usual activities and experience impaired work performance. She may also experience loss of appetite, sleep disturbances, and even physical symptoms of pain or other discomfort. Restitution and recovery : The final phase, which is prolonged and gradual.The person carries on the work of mourning and overcomes the trauma of the loss, and a state of health and well-being is reestablished. John Bowlby (1982)—Phases of Grief Shock and numbness Initial stage, in which the person experiences disorientation and feelings of helplessness Yearning and searching The grieving person yearns to be reconnected with the deceased and searches for connections Disorganization and despair The permanence of the loss becomes real.The person feels the pain and emotions of grief to their fullest and feels there is no hope of reconnection. Reorganization Adjusting to life without the deceased (or lost object); developing new coping skills Theresa Rando (1984, 1986, 1993, 2000)—Three Processes of Grieving Avoidance Includes shock, disbelief, denial, anger, and bargaining Confrontation The person actually begins to face the loss; a very emotional and upsetting time, when the person feels the grief most acutely Accommodation The person begins to live with the loss, feel better, and resume some routine activities William Worden (2002)—Four Tasks of grieving (or object) Accepting the reality of the loss Realizing that the loved one is gone. In the hours and days after a significant loss, the grieving person typically feels numb and unable to accept the fact of the loss.This numbness is thought to be a helpful form of denial, which allows the person to "take in" only what the psyche is capable of handling at that time. So, the task of realizing the loved one or object is gone may take several days or, in the case of a sudden death, weeks. Working through the pain and grief Feelings and emotions that surface are intense and can change rapidly. This makes the person feel "out of control." People in this stage may say they feel as if they are "going crazy." This is usually the longest phase for two reasons. First, because none of us likes to be in pain; we become expert at finding ways not to feel it.We overeat, overmedicate, overwork, and drink to excess to avoid feeling the pain, and we thereby prolong the process of grief. Second, caring people do not like to see their loved ones in pain, so they make attempts to remove the pain (e.g., by distraction) rather than letting the person experience it. Like avoidance, this well-meaning behavior also prolongs the process. Adjusting to the environment in which the deceased is missing Adjusting to the environment without the deceased. This may mean performing alone activities and tasks, such as going for walks or shopping, that were once shared. Or it may include taking on roles and responsibilities that the deceased previously held. Such experiences can be extremely sad, frustrating and challenging, or very rewarding. However, once the person has established the new pattern, he or she typically feels satisfaction and increased self-esteem. Emotionally relocating the deceased and moving on with life Investing emotional energy. Initially all energy is focused on the deceased: thinking about the person, talking about him/her, reliving memories, and so on. It is nearly impossible to think of anything else. Concentration is difficult, so the grieving person finds it hard to engage in activities such as reading.When the person's energy begins to flow toward others or to different or former interests (e.g., working, socializing), the healing process is in progress

Beta blockers mechanism of action

Decrease contractions of the myocardium and decrease the speed of conduction through the atrioventricular (AV) node. This can result in a significant decrease in heart rate, and the patient should let the physician know if his heart rate falls below 60.

Examine physical, cognitive, and, psychosocial changes occurring in the older adult years.

Decrease hearing/vision appetite tooth loss (edentulism) functional limitations No physical activity (secondary lifestyle) thirst short-term memory depression *dementia is not apart of the aging process

Calcium Channel Blockers mechanism of action

Decreases peripheral vascular resistance (SVR) by blocking calcium entry into smooth muscle Cause coronary artery vasodilation Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance Reduce the workload of the heart Result: decreased myocardial oxygen demand

Verbal:

Deliver messages that the patient can understand and consider age, knowledge, cultural differences, and language. Consider timing and assess the patient first for physiological needs (pain, hunger, bathroom). A distracted patient will not receive the message as you intended it. Provide privacy and ask if they want visitors in the room. *nonverbal communication must match your spoken words. Ex: telling a patient their wound looks good but, your face says otherwise*

Kardex® or Client Care Summary

Demographic data Medical diagnoses Allergies Diet/activity orders Safety precautions IV therapy orders Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests A summary of medications ordered Special instructions such as preferred intensity of care or isolation orders

#35 nursing interventions for pain medications

Depending on patient health state, respiratory status, may need oxygen or fluid

Psychological effects of immobility:

Depression anxiety hostility constipation sleep disturbances change in ability to perform self-care activities

Promoting asepsis and preventing infection

Describe the links in the chain of infectious process: 1. Agent- bacteria, viruses, parasites (germs) 2. Reservoir- where germs live (people, animals, food) 3. Portal of exit- how germs get out (vomit, saliva, cuts in skin, incontinence) 4. Mode of transmission- how germs get around (contact=hands, droplet=sneeze) 5. Portal of entry- how germs get in (mouth, cuts in skin, eyes) 6. Susceptible host- who is vulnerable to get sick

Promoting safety Discuss development and individual factors that create safety risk:

Developmental: infant/toddler=drowning, choking. Preschool= car accidents, drowning. Adolescent= car accident, homicide, alcohol use (risky behavior) School aged= sports injury, car accident. Adults= overdose, work related injuries, lifestyle. Older adult= falls, burns Individual: lifestyle, cognitive awareness, loss of senses, impaired mobility, language barrier, hearing/speech impairment, physical and emotional well-being (depression)

Hypertension

Diagnosed when BP is persistently higher than normal. Diagnosed when BP is >140 mm Hg systolic or>90 mm Hg diastolic on two or more separate occasions.

The three part nursing statement

Diagnostic label Etiology (set of causes)

Describe the purpose of a health assessment: nursing diagnoses

Diagnostic label NANDA taxonomy Doenges' Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales

Benzodiazepines

Diazepam Lorazepam Side effects of both Ativan and Valium, aside from potential addiction, include drowsiness, fatigue, depression, unsteadiness, and memory problems.

Digoxin antidote

Digoxin immune Fab (Digibind)

Implementation

Direct care (interventions) (Assisting with activities of daily living or physical care techniques such as teaching "patient education" controlling for adverse reactions, preventive measures) Treatments performed when interacting with patients such as med administration, (IV) infusion etc. Counseling during time of grief Indirect care (away from the client on their behalf) (advocacy delegating supervising) evaluating the work of others. Reassessment of client condition should happen on ongoing basis!!

The Role and functions of nurses

Direct care provider, communicator, client/family educator, client advocate, counselor, change agent, leader, manager, case manager and research consumer.

vasodilator mechanism of action

Directly vasodilate arterial vascular smooth muscle, decreasing total peripheral resistance and thus decreasing total blood pressure.

Source-oriented system

Disciplines document in separate sections of the chart Contains a variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) Data scattered; may lead to fragmentation Source-oriented records Advantage: You can easily find the care provided by each discipline. Disadvantage: Data may be fragmented and scattered throughout the patient's record. You need to review all sections of the chart to fully understand the client's condition and care. It is especially difficult with source-oriented records to track the treatments and client outcomes associated with a particular problem.

Crackles:

Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds

Diuretics: What do they do?

Diureses the body dehydrates the body decreases blood pressure (most End in ide think body is dried) and drop blood pressure. (CAREFUL NOT TO CONFUSE ISOSORBIDE NITRATE USE FOR CHEST PAIN!) dehydrates the body decreases blood pressure (most End in ide think body is dried) and drop blood pressure. (CAREFUL NOT TO CONFUSE ISOSORBIDE NITRATE USE FOR CHEST PAIN!)

Metabolic Alkalosis CLINICAL MANIFESTATIONS

Dizziness Tingling of extremities Hypertonic muscles Decreased respiratory rate and depth

Vasodilator Side Effects

Dizziness, headache, profound hypotension, cyanide toxicity, thiocyanate poisoning Chest pain. Heart palpitations (fluttering or pounding heartbeat) Rapid heartbeat. Fluid retention. Nausea or vomiting. Dizziness. Headache. Flushing.

Down syndrome nursing interventions

Down syndrome can result in a broad range of mild, moderate, or severe cogni- tive and physical delays. Each patient is** unique** in his or her abilities and limita- tions, and care should be tailored to indi- vidual needs. ******When providing care for a patient with Down syndrome, tailor care to the patient's developmental age rather than his or her actual age.**** Talk to the patient's caregivers and ask questions so you can understand where your patient is developmentally. Down syndrome may or may not affect the patient cognitively. Develop a picture of your patient's needs by discussing home life and baseline functionality with the patient and his or her caregiver. Just as it's vital to include caregivers, it's vital not to exclude patients; they have much to offer no matter their developmental age.

About Drawing Up Two Insulins into One Syringe

Drawing short acting insulin into the syringe first prevents the possibility of accidentally injecting some of the longer-acting insulin into the shorter-acting vial, leading to potential for hypoglycemia later than anticipated.

Explain why resistance to infections a concern in healthcare is:

Due to excessive use/overuse of antibiotics many organisms have built up such a resistance that it's difficult to use one that will combat the infection. Concerns- new strains that aren't resistant to antibiotics will cause sepsis. higher level drugs are more costly.

Explain how critical thinking relates to the nursing process?

During an assessment the nurse uses critical thinking to gather information on a problem and recognizes the need for more information. For example, implementation and evaluation the nurse uses critical thinking skills to visualize potential solutions to a problem and explores advantages/disadvantages/consequences of each potential action.

Diuretic uses

Edema with CHF Pulmonary Edema Hypertension Conditions that cause hyperkalemia Renal Disease (Loop) HTN, HF, renal insufficiency/ acute renal failure.

Diabetic teaching. Education

Education for Type 2 diabetes i.e. lose 5-7% of body weight reduce fat and calories signs and symptoms of hypo/hyperglycemia Foot care, potential complications (High BP, renal failure, difficulty healing etc.) Disease process Diet and exercise recommendations Self-administration of insulin or oral drugs Potential complications Monitor for therapeutic response Decrease in blood glucose levels to the level prescribed by physician Measure hemoglobin A1C to monitor long-term compliance with diet and drug therapy Monitor for hypoglycemia and hyperglycemia

Betablockers

End in LOL ex. atenoLOL They block beats from the heart. It slows the heart rate down kind of pumping the brakes on the heart. Beta Blockers, Block the beats like pumping the brakes, so we slow the heart rate down. Decreases workload of the heart, decreased heart rate, B/P, and decreased contractility. Must be used with caution in those with history of HF. They have excessive activation of SNS which will worsen CHF over time. B Blockers very effective to manage this complication

preoperative care

Ensuring informed consent signed and attached to chart, all lab tests, chest xray and EKG have been completed, perform skin and bowel prep, NPO, administer pre-op meds such as sedation and antibiotics, removing dentures, jewelry, and nail polish

How to take care disable

Environment should be safe and allow the older adult to maintain as much inde- pendence as possible. Is the home setting conducive to allowing the older adult to perform both activities of daily living (bath- ing, feeding, dressing) and instrumental activities of daily living (cleaning, laundry, cooking, shopping)? If your patient needs additional assistance, what support systems can be initiated? Is the older adult safe in the neighbor- hood? Is there ample street lighting? How about curbs and streets? If an individual has decreased visual acuity, impaired depth per- ception, and decreased tactile sensation, poor lighting, uneven sidewalks, and high curbs could lead to falls and possible fractures and other injuries. Teach your older patients to be aware of their surroundings.Nursing process should be used each time you care for an older patient. Remember the older adult may experience both normal and abnormal sensory changes. Your as- sessment, plan, nursing diagnosis, interven- tions, and evaluation may help improve your patient's quality of life. It's never too late to teach health promotion activities.

Older adults (Erikson)

Erikson believed that much of life is preparing for the middle adulthood stage and the last stage involves much reflection. As older adults, some can look back with a feeling of integrity — that is, contentment and fulfillment, having led a meaningful life and valuable contribution to society.

Major life shifts can occur during this stage. For example, children leave the household, careers can change, and so on. Some may struggle with finding purpose. Significant relationships are those within the family, workplace, local church and other communities. 8. LATE ADULT: 55 OR 65 TO DEATH Integrity vs. Despair - Wisdom

Erikson believed that much of life is preparing for the middle adulthood stage and the last stage involves much reflection. As older adults, some can look back with a feeling of integrity — that is, contentment and fulfillment, having led a meaningful life and valuable contribution to society. Others may have a sense of despair during this stage, reflecting upon their experiences and failures. They may fear death as they struggle to find a purpose to their lives, wondering "What was the point of life? Was it worth it?"

A1C testing frequency

Every three months

Describe the purpose of a health assessment: Monitor status of previously identified problem

Ex: patient is already begun treatment for hypertension. Today's exam will go over lab results to further explore the status of their hypertension.

Describe the purpose of a health assessment:Screen for health problems

Ex: regular checkups can identify health problems at early stages.

Periwound

Examine the skin surrounding the wound. Skin discoloration may indicate a hematoma or additional injury to the surrounding tissue. Look for maceration, un- dermining, crepitus, blistering, erythema, and epiboly, slough, and eschar.

Differentiate between the signs, symptoms and interventions; including pharmacological for: Asthma, COPD, Pneumothorax

Example: decreased air flow and increased difficulty in breathing • chronic obstructive pulmonary disease (COPD) describes progressive lung diseases characterized by shortness of breath/breathlessness: emphysema, chronic bronchitis, refractory asthma (non-reversible) Airway inflammation and obstruction: Allergic inflammatory airway reactions such as asthma Abnormalities in: Pulmonary System Inhibit inflation of lungs such as pneumothorax, absence of breath sounds on side of pneumothorax

Isometric

Exercise that involves tightening the muscle without moving body parts.

expected pre-op outcomes

Expected pre-op patient outcomes Relief of anxiety, evidenced when the patient: • discusses concerns related to types of anesthesia and induction• verbalizes an understanding of the preanesthetic medication and general anesthesia• discusses last-minute concerns• discusses financial concerns, when appropriate• requests a visit with a spiritual advisor, when appropriate• relaxes quietly after being visited by healthcare team members. Decreased fear, evidenced when the patient: • discusses fears with healthcare professionals or a spiritual advisor,or both• verbalizes an understanding of any expected bodily changes, including the expected duration of bodily changes. Understanding of the surgical intervention, evidenced when the patient: • participates in pre-op preparation• demonstrates and describes exercises she's expected to perform postoperatively• reviews information about post-op care• accepts preanesthetic medication, if prescribed• remains in bed once premedicated• relaxes during transportation to the OR or unit• discusses post-op expectations. No evidence of pre-op complicationsPost op pain management article

considerations (how loud do you speak, what side of the patient do you speak on etc.)

Face the hearing-impaired person directly, on the same level and in good light whenever possible. ...

interpersonal-

Face to face conversation Ex: patient assessment, communication with other healthcare members, delegate to naps, group and public speaking.

Nonverbal:

Facial expressions, posture and gait will clue to persons attitude, emotions, physical well- being and self-concept. Ex: slow, shuffling gait may signify someone who is ill, has pain, is depressed, or has poor self-esteem. Also, someone who is depressed may lack the energy for hygiene and grooming. Gestures are a good indicator of the feeling tone behind the conversation. Ex: Patient says, "I'm okay" but, they have a broad grin and raised arms. Touch- convey affection, caring, concern, and encouragement.

Recognize normal sexual development in the middle/older adult that may impact sexual health

Factors influencing Sexuality Culture Religion Lifestyle: • Family • Socioeconomic status, • Employmentfactors • Interpersonal relationships Sexual knowledge Self-Esteem Health & Illness • Surgeries • Mental Health • Medications • STI's • Sexual dysfunction • Hormonal changes • Hypoactive sexual desire • Sexual Abuse *Age is not a factor! Factors can influence our attitudes toward sexuality, sexual behaviors, and intimate relationships Culture: • influences ideas about gender role, identity, sexual expression, social responsibilities • determines what is acceptable and what is not Religion:

What risk factors impact pulmonary function in young to older adult?

Factors that influence Pulmonary Function Developmental stage: Young, middle & older adults Environment • Stress • Allergic reactions • Air quality • Altitude Temperature & Humidity Developmental stage: Developmental factors have less effect on function in young/middle adults than in the older adult • Young, middle & older adults: • unhealthy practices such as smoking, lack of exercise • changes in respiratory system begin in middle age & increase in older adulthood; increase significance when person experiences stressors such as infection, surgery, anesthesia, etc. • Number of cells & organ efficiency decline with age Environment: Stress, allergic reactions, altitude, and temperature affect oxygenation • Stress: • stress response suppresses immune system & inflammatory response, increases potential for blood clot, infections; resulting in increased risk for pulmonary embolism, infections (especially respiratory) • Allergic reactions: • hay fever & asthma; allergic reactions increase swollen membranes, nasal fluid & congestion • asthma occurs in bronchioles=causes bronchoconstriction, edema, spasms that increase breathing difficulty & ineffectiveness, can be life threatening, significant amount of asthma in adults made worse by workplace environment Factors that influence Pulmonary Function Developmental stage: Young, middle & older adults Environment • Stress • Allergic reactions • Air quality • Altitude • Temperature & Humidity • Pulmonary allergens include things such as dust, pollen, mold, tobacco smoke, animal dander, etc. • Air quality: • Respiratory problems triggered by air pollution interfere with oxygenation, clients with existing respiratory or cardiac disease, can become unable to function • Altitude: • higher altitudes lead to decrease in oxygen levels & diffusion (impaired gas exchange) can result in hypoxemia & hypoxia • Temperature & Humidity: • Extreme temps cause body to expend additional energy=increasing amount of oxygen body uses • Hot or cold air can dry or irritate airways leading to bronchospasm which decreases airway size; results in shortness of breath especially in older clients with conditions such as asthma or COPD

1. Explain disciplinary actions for unacceptable nursing decisions ·

False imprisonment- restraining a patient without proper legal authorization or sedative medications · Fraud- false documentation · Invasion of privacy- violating a patients right to be left alone · Negligence- failure to act in a reasonable and prudent (careful) manner · Malpractice- failure of a professional person to act in a reasonable and prudent manner. Malpractice lawsuit may occur when such actions cause injury or death · Felonies- involve crimes punishable by more than 1 year in jail (murder, rape/sexual assault, stealing drugs, and equipment) person may also lose their professional license · Misdemeanor- compared with felony, is a minor charge. Less than 1 year in jail (assault and battery, petty theft) may also lose professional license

Diagnosing diabetes test

Fasting glucose >126mg/dL Random glucose > 200mg/dL with S/S Glucose tolerance test > greater than 200mL/dL after 2 hour A1C 6.5% or greater

Describe interventions for alterations in vital signs and how they affect homeostasis:

Fever(pyrexia) over 100F · Hyperpyrexia is fever about 105.8F, without intervention can be dangerous · Fever occurs in three phases: initial=period where temp is rising second phase=temp meets max point third phase=temp returns to normal

Apply nursing interventions designed to promote exercise:

Find what motivates your patient/enjoyable activities set personal goals, simple/realistic Reward your patient to recognize and appreciate success Include variety and activities to keep the patient from feeling bored Provide encouragement, praise support from spouse, family members and friends

FACT Documentation

Flow sheets individualize specific services Assessment with baseline data Concise progress notes Timely entries

extreme hyperglycemia signs and symptoms

Flu like symptoms (n/v, diarrhea, aches) Symptoms of hyperglycemia Blood glucose > 300mg/dL Electrolyte imbalance DEHYDRATION - RIGHT!!! Fruity breath Coma Death

Occurrence Reports

Formal record of unusual occurrence or accident Not a part of patient's health record Quality improvement

Hyperglycemia S/S

Fruity odor, headache, N/V, abd. pain, Rapid Pulse frequent urination, deep rapid labored respirations, thirst, hunger, dry mucous membranes, weakness, malaise, rapid, weak pulse, hypotension, soft eyeballs Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope "hot and dry sugar is high"

Diuretic medications

Furosemide Lasix- most potent Bumetanide (bumex) most potent Hydrochlorathiazide (HCTZ) mod. Potency Spironolactone (Aldactone) mild potency K+ sparing

Digoxin toxicity

GI effects (anorexia, n/v, abdominal pain), CNS effects (fatigue, weakness, diplopia, blurred vision, yellow-green or white halos around objects)

*Mandatory waging on warts*

HPV- plantar, oral, and flat warts. Immunotherapy freezes warts. Pt teaching: don't scratch can spread, don't use other peoples personal items, wear sandals at gym/swimming pool. Don't forget the impat warts has on a personal perception of physical attractiveness, self-image and overall comfort level. Give words of encouragement and offer support. Warts resolve on its own if person has normal functioning immune system

Calcium Channel Blocker Uses

HTN, angina, controlling rapid heart rate in SVT or atrial fibrilation.

*Mandatory TJ article*

Hand off communication is important in the safety of the patients care. Inadequate information during handoff report can cause potential harm to a patient. For example, information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed. Factors handoff communication fails: no health care provider training, language barriers, cultural/ethical considerations, and nonexistent documentation. Adverse events: wrong site surgery, delay in treatment, falls, and medication errors. Tools to improve hand off report are SBAR and IPASS (illness, patient summary, action list, situation awareness, synthesis). Put patients safety first*

Metabolic Acidosis CLINICAL MANIFESTATIONS

Headache Confusion, drowsiness Weakness Peripheral vasodilatation Nausea and vomiting Kussmaul's breathing (rapid and deep) Frequently associated with hyperkalemia

Comprehensive physical assessment

Health history interview, complete head to toe exam.

Health and wellness Describe the models and concepts of health and illness from holistic approach:

Health-illness continuum is personal and dynamic because health changes over the course of time. 10= excellent health 1= gravely ill. An individual moves up and down. Dunn's health not only follows the health illness continuum but, also considers individuals environment. For example, a patient with multiple chronic diseases but, has a great support system would be protected poor health. Neuman's continuum is said to have varying levels of energy at various stages of life. More energy generated than expanded= wellness, more energy expanded than generated= illness.

What increases or decreases the workload of the heart? How does this effect oxygen requirements? What impact does this have on a stressed (ischemic) heart?

Heart rate, contractility, and ventricular-wall tension are the three factors that determine myocardial oxygen demand. An increase in any of these variables requires the body to adapt to sustain adequate oxygen supply to the heart. A mismatch between myocardial oxygen supply and demand can result in myocardial ischemia or infarct.

Stridor breathing-

High pitched sound that is heard without a stethoscope with someone who has an obstructed airway. May be life threatening*

Wheeze:

High-pitched continuous musical sounds, usually heard on expiration

Bowel #44 how to know if had a bowel obstruction

Hyper-bowel sounds Hypo bowel sounds Constipation

Hypercalcemia,

Hypercalcemia (Ca++) • ̃Serum Ca > 10.5mEq/L • ̃Causes: prolonged immobilization, thiazide diuretics, excess calcium supplementation • Signs & symptoms: muscle weakness, kidney stones, anorexia, nausea, vomiting, bradycardia • ̃Treatment: depends on cause; encourage fluids, medication, IV therapy, monitor I&O, limit calcium-rich foods

hyperglycemia things to know

Hyperglycemia in Diabetes ◼Blood glucose >160mg/dL Causes: Overeating Illness Stress Not enough medication Steroids (such as for asthma, inflammation etc.) 3 P's (do you remember them?) Fatigue Blurred vision Prone to infection Abdominal pain Headache Ketosis/acidosis Frequent yeast infection

Hypernatremia,

Hypernatremia (Na+) • Serum Na+> 145mEq/L • ̃Results from: excessive sodium intake, water deprivation,profuse sweating, hypertonic tube feeding • ̃Water shifts from cells to ECF • ̃Signs/Symptoms: thirst, dry mouth, increased temp, confusion, lethargy Treatment: IV therapy, diet, increase fluids Interventions: Hypernatremia: • Monitor I&O. • Monitor sodium level • Monitor vital signs and level of consciousness • Restrict sodium in the diet • Monitor weight • Administer IV solutions that do not contain sodium • Teach client to avoid high sodium foods: canned soup, processed food, etc. • Clients at risk for hypernatremia: Example: elderly (decreased thirst mechanism), client's receiving: tube feedings, certain medications. Seizures, coma or death may result if hypernatremia not treated

Differentiate lab values, causes, signs and nursing interventions for: Hypocalcemia Hypercalcemia,

Hypocalcemia Hypocalcemia (Ca++) • ̃Serum Ca2+ <8.5 mq/dl • ̃Cause: from low intake, vitamin d deficienty, diuretics, parathyroid disorders, renal failure, thyroid surgery • ̃Signs & symptoms: muscle cramps, cardiac irritability, EKG changes, positive Chvostek's & Trousseau's sign • Treatment: diet, IV therapy, supplements Chvostek's sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve: tap facial nerve in front of ear= facial spasm • Trousseau's sign: Carpal spasm occurs when the upper arm is compressed, as by a tourniquet or a blood pressure cuff due to increased neuromuscular excitability Hypercalcemia, Hypercalcemia (Ca++) • ̃Serum Ca > 10.5mEq/L • ̃Causes: prolonged immobilization, thiazide diuretics, excess calcium supplementation • Signs & symptoms: muscle weakness, kidney stones, anorexia, nausea, vomiting, bradycardia • ̃Treatment: depends on cause; encourage fluids, medication, IV therapy, monitor I&O, limit calcium-rich foods

Hypokalemia,

Hypokalemia (K+) • ̃Serum level < 3.5mEq/L • ̃Results from decreased intake, anorexia, bulimia, loss via vomiting, gastric suction, potassium depleting diuretics, steroids • L ̃ife threatening-all body systems affected • ̃Signs & symptoms: fatigue, muscle weakness, leg cramps, decreased GI motility, cardiac arrhythmias ̃Treatment: diet high in K+, supplements, IV therapy (diluted) & administered slowly, monitor level, po supplement Interventions: • Monitor I&O • Monitor potassium level • If the client is taking digoxin, monitor pulse and observe for toxicity • Ensure kidneys are functioning prior to IV K+ administration

Nitrate side effects

Hypotension Headache (Nitroglycerin)Use with caution with patients with volume depletion or hypotension Monitor VS closely Headache. Dizziness. Lightheadedness.Nausea. Flushing. Burning and tingling under the tongue. Low blood pressure.

#2 Know your IV and sites

If IV site is super warm & red tenderness & swelling- it can be an infection or *phlebitis- also called vein inflammation) Stop IV and remove. Treat with warm compress or antibiotic if infection is suspected.

Respiratory Alkalosis INTERVENTIONS

If caused by anxiety, encourage the patient to relax and breathe slowly. For other causes: Identify and treat the underlying disorder.

What does cloudy insulin mean?

If regular insulin becomes cloudy, throw it away, says the ADA. It has lost its effectiveness, and won't keep your blood sugar from getting too high. If your insulinis a mix of regular and NPH or ultralente insulins, you may be getting NPH or ultralente in the bottle of regular insulin. This, too, will make it cloudy.

#32 post op patient,

If they are in pain provide med (with dr. order) Distract them talk to them Assess pain 30-60 min and document Asses to look for adverse effect respiratory depression and if medication was effective or not

Things to remember about wounds***

If you are observing the following** Eschar and slough- necrotic yellowish tissue purulent serous drainage- signs of infection serous- clear liquid serous sanguineous- light pinkish, red to pink with plasma blood cells Sanguineous- active bleeding (fresh bleeding) Serous or sanguinous drainage (or a combination of the two) is normal, while seropurulent or purulent drainage is often a sign of infection. ..

Hearing - impact on daily life, hearing aids, major causes of hearing loss, nursing

Impaired hearing: Hearing deficits may result from injury or disease in structures of the ear, the nerves, or the brain (Box 30-3). Inability to hear decreases the ability to communicate and thus hampers social interaction. It may interfere with a patient's ability to understand instructions from healthcare professionals and create a safety hazard due to inability to hear warnings. Be careful when speaking to someone with hearing loss...........many times they will just smile rather than disclose they cannot hear you. Speak slowly and distinctly. Auditory Stimulation To stimulate hearing, help the patient with a hearing aid to apply it whenever she is not sleeping. Check that the hearing aid has working batteries and the sound is set at the appropriate level. When possible, move the patient to a quiet area to avoid background noise when communicating (book)

Taste/smell- what impact will this have on nutrition? What would you as the nurse investigate to assess why a pt is eating less? What about smell - fire (stove left on, electrical problem).

Impaired smell: When the sense of smell is lost (anosmia), food does not taste the same. Patients who are unable to smell food lose their appetite, and nutritional deficits may result. Permanent anosmia may develop after cranial nerve damage, a tumor, or atherosclerosis.

Nursing Interventions for Common Sensory Alterations sight

Impaired vision Attend to glasses. Provide sufficient light. Protect eyes in sunlight. Provide magnifying lens/large-print books. Evaluate Ability to perform ADLs Ability to remain safe in the environment Need for assistance seeing eye dog

sight changes in aging

Impaired vision: Visual deficits may result from trauma or disease of the eye, microvascular problems, or CNS disorders. Common causes of visual deficits include age- related changes, refractive errors, orbital trauma, cataracts, glaucoma, diabetic or hypertensive retinopathy, macular degeneration, or loss of visual fields after a stroke. Changes in vision affect all aspects of daily living and may severely limit mobility and interaction. Visual Stimulation For visual stimulation, help the pa- tient with glasses to apply them whenever she is not sleep- ing. Make sure eyeglasses are clean and in good repair. This will allow the patient to receive available stimuli. Put artwork on the walls, furnish colorful pajamas and robes, and place pictures or flowers where the patient can see them. Unless the patient objects, open curtains during the daytime to allow sunlight to enter the room. Avoid keep- ing the patient in a dark room, except to promote sleep.

What does this step of the nursing process involve?

Implementation involves some preparation Check Your Knowledge and Abilities Organize Your Work Establish Feedback Points Prepare Supplies and Equipment Prepare the Patient Critical thinking & nursing knowledge are important in the implementation "doing" phase of nursing Check Your Knowledge and Abilities: • review care plan, reflect critically on nursing & medical orders before beginning implementation of intervention/nursing activity • clarify any questions or orders that are unclear, incorrect or inappropriate • Are you qualified to carry out order? Organize your work: • make a time-sequenced work plan (worksheet) to prioritize client care and work efficiently • think of interventions you can perform at the same time while with each client • such as: performed a skin assessment while giving a bed bath • *For a worksheet you can print and use in clinical: Go to Student Resources: Chapter 7,Tables, Boxes, Figures: ESG Figure 7-1, Worksheet for Organizing Nursing Care, on DavisPlus. Establish feedback points: • carrying out a nursing order may not be exactly how it is written=be ready to alter activity/intervetion according to client's response • feedback=how client is responding to activity, done before intervention is complete • identify points during interventions where you can pause for feedback. • example: during range of motion exercised; plan to assess for pain, activity intolerance • feedback is not always verbal; may be a change in vital signs, skin color, or level of 15 consciousness

Teach client and family pressure ulcer prevention

Importance of adequate nutrition Characteristics of healthy skin Appearance of skin that has experienced pressure Skin care and hygiene Techniques for turning and positioning Importance of frequent position changes Use of pressure-redistributing devices

Language barrier can involve foreign languages, dialects •

In healthcare, a barrier from terminology and abbreviations that clients do not understand

Below are commonly used frequencies. However, one recent study suggests that low-risk patients might be allowed to rest instead of waking them up for routine vital signs during the night (Jordan, Yoder, Yuen, et al., 2013)

In the hospital: once every 4 to 8 hours In the home health setting: at each visit In the clinic: at each visit In skilled nursing facilities, also known as convalescent hospitals: weekly to monthly Also, agency policies usually require that nurses monitor and record vital signs regularly. The frequency varies by setting. The optimal frequency for assessing vital signs depends on the patient's condition and the events taking place (Schulman & Staul, 2010). It is up to the nurse to decide whether vital signs need to be monitored more frequently than the primary care provider has prescribed. Initially, you will measure VS to establish the patient's baseline.

Types of Health Assessments ➢Comprehensive

Includes health history & Head-to-toe assessment

Cardiac Glycosides mechanism of action

Increase myocardial contractility Change electrical conduction properties of the heart Decrease rate of electrical conduction Prolong the refractory period Area between SA node and AV node

Cumulative-

Increased response to repeated dose of a drug (opioids)

What increases the workload of the heart?

Increased workload causes increased oxygen demand and the potential for inadequate oxygen delivery to the heart, which may result in damage or death of heart muscle cells. ... Increased diastolic BP = increased workload to open the aortic valve = increased oxygen demand.

Describe nursing interventions that are culturally competent

Individualized nursing activities are important for clients from different cultural and ethnic groups Clients may have unique needs Support and encourage client to modify behaviors and to adopt new, different, and beneficial health behaviors, while still respecting cultural values and beliefs Identify educational methods that are most appropriate for client's needs (e.g., translated materials) Make community referrals as necessary

Apply nursing interventions to prevent safety hazards in the home environment:

Install fire/co detectors child proof home never take more frequent/larger doses of meds Lock cleaning supplies fire escape plan

Four important ways to describe fever: ·

Intermittent-the patients temp returns to normal at least once every 24 hours without pharmacological intervention. Ex: sepsis, abscesses · Remittent- the patients temp doesn't return to normal, although it varies a few degrees in either direction. Ex: viral respiratory tract · Constant(sustained)- the patients temp remains above normal with minimal variations(less than 1F) these fevers may be caused by drugs · Relapsing (recurrent)- consists of one or more episodes of fever, each as long as several days, with one or more days of normal temperature between episodes. Ex: fungal infections

Nursing philosophy

International council of nurse- collaborative care of individuals of all ages, families, groups, and communities for the sick or well in all settings. American nurse association- both art, science, heart, and mind. Nightingale- clean, well-ventilated, and quiet environment is essential for recovery. QSEN- teamwork and collaboration, evidenced based practice, patient centered care, informatics, safety and quality improvement. 6 skills all nurses must have before graduating. Primary care- wellness and prevention. Ex: Dr appts, immunizations Secondary care- emphasis on treatment of illness, disease or injury. Ex: specialist, cancer treatment, surgery, outpatient centers Tertiary care- long term care or hospice. Maslow's hierarchy of needs- #1 priority physiological (breathing, food, sleep, homeostasis) Safety, love/belonging, esteem and self-actualization. Standardization communication strategies: CUS- used to raise safety concerns. C= I am concerned, U= I am uncomfortable, I think this is a safety issue. Check back- used to clarify information. Repeat back order. Briefing/debriefing- to go over patients care plan/review and give feedback.

Mental Status Assessment of Older Adults: The Mini-Cog TM

Interpretation of Results: 0-2: Positive screen for dementia 3-5: Negative screen for dementia

Expected lab values (Creating your own chart can be helpful

Interpreting ABG's Examine the pHIs it acidotic, alkalotic, or normal? ▪ Normal blood pH 7.35 to 7.45▪ If blood pH falls below 7.35, it is acidic▪ If blood pH rises above 7.45, it is alkalotic If the pH is between 7.35 and 7.45, then it is normal If the pH is low (<7.35), then the blood is acidic.If the pH is high (>7.45), then it is alkaloticNeutral pH is 7.4 In looking at a clients pH level you can determine: If pH > 7.45: client is alkaloticIf pH < 7.35, client is acidoticIf pH is 7.35-7.45, client has normal pH Check carbon dioxide (PCO2) Is there too little or too much? ▪Normal is 35-45 mmHg ▪PC02 below 35 is alkalotic ▪PC02 above 45 is acidotic PaCO2 levels will determine if changes are due to respiratory system or metabolic If PCO2 is 35 to 45 mm Hg, then cause for the abnormal pH is not respiratoryIf PCO2 is <35 mm Hg: respiratory alkalosis; decreased acid in the bloodIf PCO2 is >45 mm Hg: respiratory acidosis; increased acid in the blood Bicarbonate level (HCO3) Is there too little or too much? ▪Normal is 22 -26 mEq/L ▪HCO3 Below 22 acidosis ▪HCO3 Above 26 alkalosis If HCO3 is 22 to 26 mEq/L: cause for the abnormal pH is not metabolic If HCO3 is <22 mEq/L: metabolic acidosis; not enough base in the blood If HCO3 is >26 mEq/L: metabolic alkalosis; too much base in the blood Look at PaO2 and SaO2If below normal:this is evidence of hypoxia Hypoxemia: lowered blood oxygen content Example of ABG that indicate hypoxia pH 7.32, PCO2 48, PO2 72 pH 7.34, PCO2 46, PO2 79

Apply nursing interventions that enhance emotional comfort of clients and families.

Interventions Involve family members in caring for the client Make sure everyone knows the plan Listen and be alert to nonverbal cues Encourage and accept expressions of feelings Reassure it is not wrong to feel anger or relief Continue to communicate, even in case of coma Examine own barriers to end-of-life communication Interventions Encourage questions Explore coping mechanisms Encourage visit to chapel or to talk with clergy Provide follow-up for referrals as needed Remind family and significant others to take care of themselves Teach what to expect and provide reassurance Ask directly if family wants to be present at time of death At the moment of death, do not intrude

What nursing interventions promote optimal lung expansion?

Interventions/Implementation Administering Respiratory Medications Promoting Optimal Respiratory Function • Immunizations/prevent URI's • Support Smoking Cessation • Position for Maximum ventilation: 45 degrees semi-fowlers position • Incentive spirometry Aspiration precaution Specific nursing interventions for clients include health promotion, prevention, and treatment Monitor oxygenation and ventilation with pulse oximetry, capnography, Administer respiratory medications: • Used to improve respiratory function • Examples: bronchodilators, anti-inflammatory agents, corticosteroids, cough suppressants, expectorants, decongestants Immunizations/prevent URI's: • encourage immunizations for flu & pneumonia • encourage hand hygiene • avoid exposure if possible • Infections may be viral or bacterial • Teach clients: viral infections usually last 10-21 days, self-limiting • However, can lead to other respiratory diseases in older adults with other illness • Take full course of prescribed antibiotics for bacterial infection, even if symptoms are no longer present Smoking cessation is important in preventing and treating all respiratory problems • Box 36-1 highlights of smoking cessation • Box 36-4 The 5A's for Treating Tobacco Dependence Interventions/Implementation Administering Respiratory Medications Promoting Optimal Respiratory Function • Immunizations/prevent URI's • Support Smoking Cessation • Position for Maximum ventilation: 45 degrees semi-fowlers position • Incentive spirometry • Aspiration precautions Positioning: • 45 degree semi-fowlers position best • elevated position allows maximum lung expansion • 1st priority when client experiencing breathing difficulty Incentive spirometry: • Designed to encourage clients to take deep breaths • Client encouraged to reach for goal-directed volume of air • For clients at risk for developing atelectasis or pneumonia: post op, prolonged bedrest, history of respiratory problems Aspiration precautions: • For clients with decreased level of consciousness, diminished gag or cough reflex, difficulty swallowing • Suction setup kept available for routine or emergency use • Aspiration prevention requires knowledge of positioning client, enteral or oral feedings, medication administration

Communication Discuss the elements of the communication process:

Intrapersonal- self talk interpersonal- Face to face conversation Ex: patient assessment, communication with other healthcare members, delegate to naps, group and public speaking. List the characteristics of verbal and non-verbal communication: Verbal: Deliver messages that the patient can understand and consider age, knowledge, cultural differences, and language. Consider timing and assess the patient first for physiological needs (pain, hunger, bathroom). A distracted patient will not receive the message as you intended it. Provide privacy and ask if they want visitors in the room. *nonverbal communication must match your spoken words. Ex: telling a patient their wound looks good but, your face says otherwise* Nonverbal: Facial expressions, posture and gait will clue to persons attitude, emotions, physical well- being and self-concept. Ex: slow, shuffling gait may signify someone who is ill, has pain, is depressed, or has poor self-esteem. Also, someone who is depressed may lack the energy for hygiene and grooming. Gestures are a good indicator of the feeling tone behind the conversation. Ex: Patient says, "I'm okay" but, they have a broad grin and raised arms. Touch- convey affection, caring, concern, and encouragement.

*Mandatory fall article*

Intrinsic- recent surgery, decreased mobility, confusion, delirium Extrinsic- environment, drainage tubes, Iv lines, catheters Nurses job to assess patients for falls. If a fall occurs, its nurses job to help prevent it from happening again. Interventions: hourly rounds, fall bracelets, sticker for door, specific colored slipper socks and educating patient/family. *Need to know contributing factors about how to prevent falls. Biological, behavioral and environmental risk. Use of screening tools and interventions.

Identify possible causes/risk factors for pressure ulcers & skin integrity issues

Intrinsicfactors• Immobility• Impaired sensation • Malnourishment• Aging• Fever • Extrinsicfactors • Friction • Shearing• Moisture• Compression

*Mandatory art of effective communication article*

Introduce yourself be aware of body language know your pts current/past medical history Don't interrupt clarify the problem know your pts test results/ treatment plan Use understandable language know your pts social history be sensitive about age Be culturally competent Let the patient ask questions

Stage IV Pressure Ulcer (stage 4)

Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. Exposed bone/tendon is visible or directly palpable. Slough or eschar may be present. Undermining and sinus tracts (blind tracts underneath the epidermis) are common. The depth of a stage IV pressure ulcer varies by location.They can be shallow on the bridge of the nose, ear, occiput, and malleolus because these areas do not have subcutaneous tissue. Stage IV ulcers can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule). Often require a full year to heal. Even once healed, the site remains at risk for future injury because the scar is not as strong as the original tissue

Stage II Pressure Ulcer

Involves partial-thickness loss of dermis. Stage II pressure ulcers are open but shallow and with a red pink wound bed. There is no slough. May also be an intact or open/ruptured serum- filled blister; or a shiny or dry shallow ulcer without slough or bruising. Do not use this stage to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. Do not mistake moisture- associated skin damage or fungal infections for Stage II pressure ulcer. Stage II ulcers do not involve sloughing or bruising

Fluid & Electrolytes Differentiate between isotonic, hypotonic & hypertonic solutions.

Isotonic fluids remain in the intravascular compartment Isotonic solutions are used: to increase the EXTRACELLULAR fluid volume due to blood loss, surgery, dehydration, fluid loss that has been loss extracellularly.

Know common side effects (hint most cause hypotension and decreased heart rate), mechanism of action (calcium channel blocker, vasodilator), risk for falls etc.

It's already on the medications explanation above, but most can cause orthostatic hypotension. Can cause low pulse that's why you hold if pulse is <60 and b/p <90

Digoxin toxicity

K+ predisposes the patient to Dig toxicity Mg++ predisposes the patient to Dig toxicity ????WHAT IS THE ANTIDOTE FOR DIG TOXICITY? Nursing Interventions Monitor rhythm Prolonging of PR ST wave depression from baseline AVblock Assess apical pulse before administration, hold & call MD for HR < 60. Call monitor tech immediately before beginning IV push, administer IV Dig slowly over 5 min or longer. (Signs and symptoms of toxicity) Adverse effects relate to therapeutic range for Digoxin is 0.5-2. ng/mL Monitor Digoxin levels as well as Potassium levels DIG TOXICITY: N/V/D BRADYCARDIA Digoxin toxicity can occur in the presence of hypokalemia Antidote: Digoxin immune Fab (Digibind)

#42 pyelonephritis

Kidney infection pain on back (flanks) assess by pain on flank and temperature.

Cultural/spirituality of caring?

Know patient cultural norms for caring practices also, regarding end of life care. Ask patient about culture or family member. Spirituality is very personal so, put your views aside and support patient. *All patients are unique*

#4 Different labs

Know the ranges to help determine if client has problems *

Apply nursing interventions to prevent safety hazards in a health care agency:

Know who is at risk for falls bed low ¼ inch side rails call light within reach Non-skin slippersnight lightsfloor cleanfree of clutterkeep table/phone within

Caring What are the five components?

Knowing= placing yourself in your patients shoes. Being with= actively listening to your patients needs Doing for= doing what the patient would do for themselves. Enabling= supporting patient with life changes. Maintaining belief= have faith the patient will get through their difficult time.

Stertor:

Labored breathing that produces a snoring sound

Client factors that affect therapeutic communication:

Language barrier, impaired cognitive skills (dementia), sensory perceptual alterations (hearing/vision), physiological barriers (loose fitting dentures, respiratory problems, cleft palate)

Measure the residual volume of the aspirate.

Large amount=greater risk for aspiration

#48 constipation relief:

Laxatives, stool softener, enema, fluids, warm fluids, move arround (unless contraindicated) dietary fiber.

System-specific assessment-

Limited to one body system. 1. Ex: lungs, peripheral circulation.

Fluid and Electrolytes levels to remember

Little maggie is 1.5-2.5 years old(mg) she ate 3.5-5 bananas (k+) and drunk 8.5 to 10.5 oz of milk (ca+) and then she took 135-145 hr nap after swimming in the ocean (Na+)

Examine the health benefits in promoting exercise:

Live longer* lower risk for: heart disease, stroke, type 2 diabetes, hypertension, colon/breast cancer, hyperlipidemia, depression, promotes weight loss, improves strength/balance and muscle tone, decrease risk in falls, improves memory and mental clarify.

Stage I Pressure Ulcer

Localized area of intact skin with nonblanchable redness, usually over a bony prominence. The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue. Discoloration will remain for >30 minutes after pressure is relieved. Dark skin may not have visible blanching; its color may differ from that of the surrounding area. Therefore, stage I may be difficult to detect.

Identify types of grief and variables that may influence the way a person experiences or responds to grief.

Loss & Grief Loss: Undesired change or removal of a valued object, person, or situation. (ex: Actual, Perceived, Physical, Psychological....) Whenever there is change, there is loss Experience many changes throughout life, also experience much loss Grief: The physical, psychological, and spiritual responses to a loss Mourning: action associated with grief Bereavement: mourning and adjustment time following a loss • Loss can be defined as the undesired change or removal of a valued object, person, or situation. • Grief is the physical, psychological, and spiritual responses to a loss. There is no single, correct way to grieve, nor do people move neatly from one stage or step of grief to the next • Grieving is a fluid, ongoing process • There is constant movement among stages, including recurrences of phases the bereaved person thought were resolved • Mourning consists of actions associated with grief (e.g., crying, wearing black clothing): processes are normal and natural responses to a loss Bereavement: the mourning and adjustment time after a loss

Touch - Decreased perception (i.e. Diabetic neuropathy) impacts perception of temperature and pain. Safety concerns with decreased touch perception, right? -> Priority is to minimize injury while maintaining safety and independence in the older patient's environment. What patient teaching?

Loss of tactile sensitivity can be caused by a cerebrovascular accident (stroke), brain or spinal tumor or injury, or peripheral nerve damage caused by diabetes, Guillain-Barré syndrome, or chronic alcoholism Touch is crucial to growth and development. It provides pleasure, warns us of injury, and transmits information about the external environment. The dermis of the skin contains receptors for the cutaneous sensations of light touch, pressure, heat, cold, and pain. I Interventions for Tactile Deficits Patients with peripheral vascular disease, spinal cord injury, diabetes, cerebrovascular accident, trauma, or fractures are at risk for diminished tactile sensation. They may not notice a cut or wound in an area with lim- ited sensation. For institutionalized patients, inspect the affected area daily and teach the patient to continue this practice at home. Look for open areas, cuts, abrasions, or areas of erythema. Any of these findings requires ca

partially compensated metabolic acidosis

Low pH Low PaCO2 Low HCO3

Rhonchi:

Low-pitched continuous sounds caused by secretions in the large airways

#22 Nursing assessment

Lung sounds o2 sat breathing pattern Capillary refill *how they breath -trouble breathing ? Are they using accessory muscles May have difficulty speaking May come uppon patient who need immediate intervention *must know*

metabolic acidosis compensation

METABOLIC ACIDOSIS Compensation: Respiration by Hyperventilation eliminating pCO2 Deep Rapid Kussmaul Resp

metabolic alkalosis compensation

METABOLIC ALKALOSIS Compensation: Respiratory Hypoventilation with Slow shallow breathing, retaining CO2

MEWS score

MEWS of 0 is an ideal score, representing a low risk of a preventable life-threatening emergency. The higher the MEWS, the more concerned you should be about the stability of the patient. MEWS can help the early identification of patients at risk for hemodynamic decline or respiratory compromise. Although the MEWS should never replace a clinical assessment, it can be utilized to effectively identify subtle trends, such as sepsis, alcohol and drug withdrawal, worsening congestive heart failure, thrombotic events, cardiac arrhythmias, excessive sedation, and airway compromising events.

Malignant hyperthermia - signs and symptoms, treatment, nursing considerations

Malignant hyperthermia (MH) is a potentially fatal, inherited disorder usually associated with the administration of certain general anesthetics and/or the drug succinylcholine. The disorder is due to an acceleration of metabolism in skeletal muscle. There is mounting evidence that some patients will also develop MH with exercise and/or on exposure to hot environments. Without proper and prompt treatment with dantrolene sodium, mortality is extremely high. The signs of MH include muscle rigidity, rapid heart rate, high body temperature, muscle breakdown and increased acid content. Immediate treatment with the drug dantrolene usually reverses the signs of MH. The underlying defect is abnormally increased levels of cell calcium in the skeletal muscle. Remember "Some Hot Dude Better Give Iced Fluids Fast!" (Hot dude = hyperthermia):Stop triggering agentsHyperventilate/ Hundred percent oxygenDantrolene (2.5mg/kg)BicarbonateGlucose and insulinIV Fluids and cooling blanketFluid output monitoring/ Furosemide/ Fast heart [tachycardia] Airway and respiration Circulation Temperature control Malignant hyperthermia- hypercarbia, tachypnea, tachycardia, PVC's, labile BP, cyanosis, mottling, muscular rigidity. Increased Temp is late sign. POTENTIALLY FATAL (next few slides) Fluid and electrolyte balance Neurological functions To assess a patient's post-operative condition, apply critical thinking while relying on information from the pre-operative nursing assessment, knowledge regarding the surgical procedure performed, and events occurring during surgery. •Certain anesthetic agents cause respiratory depression. One of your greatest concerns is airway obstruction. •The patient is at risk for cardiovascular complications resulting from actual or potential blood loss from the surgical site, side effects of anesthesia, electrolyte imbalances, and depression of normal circulatory regulating mechanisms and ischemia. •The OR and recovery room environments are extremely cool. The patient's anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. •In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Despite the name, an elevated temperature occurs late. Increased expired carbon dioxide is one of the first signs. •Because of the surgical patient's risk for fluid and electrolyte abnormalities, assess hydration status and monitor for signs of electrolyte alterations. •As anesthetic agents begin to metabolize, the patient's reflexes return, muscle strength is regained, and a normal level of orientation returns.

Informatics What is informatics?

Managing and processing information necessary to make decisions. Which includes four components: data, information, knowledge and wisdom.

Interventions that may be used to promote wellness and stress management

Massage, guided imagery, music, therapeutic touch, journaling, active listening, art, and meditation.

Systolic =

Maximum peak pressure during ventricular contraction

electrolyte metabolic acidosis

May be caused by conditions or medications that impair gas exchange at the alveolar-capillary membrane, depressed respiratory rate and depth, or injury to the respiratory center in the brain.

Metabolic Alkalosis

May be caused by excessive acid loss due to vomiting or gastric suction, use of potassium- wasting diuretics, hypokalemia, excess bicarbonate intake, or hyperaldosteronism.

Respiratory Alkalosis

May be caused by hyperventilation resulting from anxiety, fever, sepsis, thyrotoxicosis, lesion in the respiratory center in the brain, or excessive ventilation with a mechanical ventilator.

Metabolic Acidosis

May be caused by retained acids in the blood resulting from renal impairment, poorly controlled diabetes mellitus, or starvation. Conditions that decrease bicarbonate, such as excessive GI loss, will also trigger metabolic acidosis. May be caused by excessive intake of acids, which may occur with aspirin poisoning, or by prolonged infusion of chloride-containing IV fluids.

Sedation medications how does it affect us

Medications Many of the medications people take cause either sleeplessness or excessive grogginess and sedation. Medications to induce sleep (i.e., hypnotics) tend to increase the amount of sleep while decreasing the quality. Zolpidem tartrate (Ambien) promotes normal REM sleep and appears to influence sleep quality less than do other hypnotics. Amphetamines, tranquiliz- ers, and antidepressants reduce the amount of REM sleep; barbiturates, in addition, interfere with NREM sleep. Opioids, such as morphine, suppress REM sleep and cause frequent awakening. Beta blockers are reported to cause sleep disorders and nightmares.

Diabetic Neuropathies

Microvascular disease of chronic DM. Peripheral nerve damage, decreased nerve GF, ischemia

Diastolic =

Minimal pressure during ventricular relaxation

What nursing interventions promote airway management & cough enhancement?

Mobilizing secretions: • Coughing promotes deep inhalation & forceful expulsion of secretions • Teach client deep breathing, coughing exercises • Encourage fluids & maintain hydration; assists in thinning of secretions, increases & enhances cough & expectoration secretions • Supplement oral intake by intravenous fluid if client cannot ingest adequate amounts of fluid Humidify inhaled air; with humidification devices or nebulizers Teach Deep Breathing and Coughing Deep breathing promotes ventilation and gas exchange. Coughing after deep breathing mobilizes secretions, which keeps airways and alveoli open and provides greater surface area for gas exchange. This intervention is important, for example, in treating pneumonia and preventing stasis pneumonia postoperatively. For information about teaching patients to deep-breathe, Alter this procedure for patients with chronic lung disease. Have the patient exhale through pursed lips and cough throughout expiration in several short bursts to avoid high expiratory pressures, which collapse dis- eased airways.

#3 Nurse intervention for fluid status

Monitor I&O Vitals, *weight changes in persons fluid status*

Tools to use to address for falls:

Morse scale- history of falls, secondary diagnosis ambulatory aid, IV, gait, mental status. higher number means intervention. Get up and go- 1=normal, 5= severely abnormal a score over 3 means risk for falls Stratify- includes transfer, mobility, history, vision, agitation, and toileting. *Mandatory fall article* Intrinsic- recent surgery, decreased mobility, confusion, delirium Extrinsic- environment, drainage tubes, Iv lines, catheters Nurses job to assess patients for falls. If a fall occurs, its nurses job to help prevent it from happening again. Interventions: hourly rounds, fall bracelets, sticker for door, specific colored slipper socks and educating patient/family. *Need to know contributing factors about how to prevent falls. Biological, behavioral and environmental risk. Use of screening tools and interventions.

MDRO

Multi-Drug Resistance Organism

1. The Heart:

Murmurs unusual sound heard between heartbeats. Whooshing or swishing noise. May be a sign of a more serious heart condition.

Intermediate-Acting Insulin:

NPH (Humulin N, Novolin N)

Special diets:

NPO- means no food or fluid, May be ordered before surgery or an invasive procedure to limit the risk of aspiration · Clear liquids-provides fluids to prevent dehydration and supplies simple carbs to help meet energy needs. Includes: water, tea, broth, popsicles, gelatin · Full liquids- contains all liquids included in clear plus, food items that are liquid at room temperature. Includes: soups, milk, milk shakes, puddings, custards, yogurt · Mechanical soft- the diet of choice for people with chewing difficulties resulting from missing teeth, jaw problems, or extensive fatigue. Includes: soft vegetables and fruits, chopped/ground meat, breads, eggs, pastries · Pureed diet- is a blended diet. Thickener is added to drinks

treatment for opioid overdose

Naloxone (Narcan)

Common Types of Charting

Narrative PIE SOAP(IER) Focus Charting by exception (CBE) FACT system Electronic entry format

drawing up insulin

Nicole Richie RN (air into NPH, air into Regular, draw up Regular, Draw up NPH)

DKA pathophysiology

No insulin (Type I) Hyperglycemic (blood sugars > 260 sometimes as high as 1400+ Cells starving Fat breaks down Byproduct of fact breakdown = ketones Ketones are acidic, blood is acidic (this can't be good right?) DKA happens rapidly, within 24 hoursIV fluids to replace lost fluid and dilute blood glucose level IV insulin drip to reverse the cause of the acidosis] IV electrolytes necessary for the heart, muscle and nerves. Electrolytes are unbalanced due to lack of insulin and hyperomosolarity of blood DKA prevention GOOD DIABETES CONTROL

Postop care - how do you avoid complications? Pneumonia, DVT, PE, infection, bowel function falls,etc.

No surprise right? #1 Concern is Respiratory AIRWAY -> Monitor for gag reflex, cough and deep breathe, maintain the airway!!! ***REMEMBER HEARING IS LAST SENSE TO GO AND FIRST TO COME BACK!!!

Benzodiazepines vs Nonbenzodiazepines which one would you take?

Nonbenzodiazepines These sedative/hypnotics have short -life, which means that they are eliminated from the body quickly and do not cause daytime sleepi- ness. They are also selective, meaning that they target specific receptors that are thought to be associated with sleep rather than depressing the entire central nervous system. Benzodiazepines This class of sedative/hypnotics is the first-line treatment for insomnia, and includes both long-acting and short-acting drugs. Long-acting medica- tions linger in the body and potentially cause daytime drowsiness. Many benzodiazepines were originally Nonbenzodiazepine drugs are much more selective than the older benzodiazepine anxiolytics, producing effective relief of anxiety/panic with little or nosedation, anterograde amnesia, or anticonvulsant effects, and are thus potentially more precise than older, anti-anxiety drugs

A1C levels

Normal: below 5.7% Prediabetes: 5.7 to 6.4% Diabetes: 6.5% or above : really effects the periodontium and overall health negatively

Hand washing

Number one way that nurses can prevent HAIs.

Identify nursing interventions that may assist clients in reaching optimal sexual health

Nursing Interventions: Sexuality • Nursing interventions for patients with sexual concerns focus on supporting patients' needs for intimacy and sexual activity • Patients often feel overwhelmed and hopeless about returning to the previous level of sexual functioning • Patients need time to adapt to physical and psychosocial changes that affect their sexuality and sexual health Ask open ended question with a lead in statement helps to put the person at ease Interventions depend on the condition of the patient: • may include giving correct information, exercises, improving communication between partners, referral to specialists Nursing Implementation: Older Adult Sexuality & Sexual Health Develop a therapeutic and trusting relationship Reassure Plan care with the client Correct any misinformation Encourage strategies to enhance sexuality & sexual health Encourage client to discuss concerns or changes living situation lifestyle loss of loved one new interests health concerns Encourage routine screening: mammograms, pap smears, etc. Nursing interventions involve teaching about sexual health and self-care, counseling for altered sexual functioning

Digoxin - nursing implications,

Nursing implications) Nursing Interventions Monitor renal function studies: Renal impairment leads to decrease excretion of Digoxin: Dig toxicity (altered color perception, see yellow-green halos around visual images, or feel weak or dizzy. Notify MD immediately if you notice any of these changes) Nausea, vomiting, diarrhea, headache, halo Monitor electrolyte levels:

COPD & ASTHMA #23 know sign and symptoms

Nursing interventions Specific meds and effect Constriction- bronchodialator Asthma- short acting bronchoditlate Long term- take daily Steroidal med- long acting give to? (google)

Identify nursing interventions that prevent impaired skin integrity:

Nursing interventions: • should be based on the individual risk factors, as well as the total score of braden scale.

Summarize interventions that prevent infection:

Nutrition- protein( wound healing) vitamin/ minerals, water. Ex: patient with fever and increased secretions of mucus will need additional water. Hygiene- crucial for maintaining intact skin, a primary defense. Showering decreases bacteria count on skin. Rest/sleep- renew bod and mind, conserve strength Exercise/activity Stress reduction- increased stress= increase for disease. Immunizations- can protect against several infectious diseases

Analyze changes in physiological and psychosocial function associated with mobility and immobility:

Obesity- leads to other health problems Older adults- harder to start/maintain exercise problem Lifestyle- not making time to exercise Stress- leads to fatigue Environmental- weather, bad neighborhood, support system Disease and abnormalities- can negatively affect body alignment, balance, coordination, and joint mobility. Fracture/trauma/sprain/stroke/spine injury Disease of other body systems ex: respiratory shortness of breath

Restraint=

Obtain a consent form, unless of an emergency, quick release, ensure restraints don't impair circulation/integrity, check skin every 30 mins, release every 2 hours, re-order every 24 hours. Restraints never resolve the underlying problem, address reason behind behavior is key to calming the patient.

What respiratory changes occur in the older adult?

Older Adult: Factors that influence Pulmonary function & Impact gas exchange • Reduce lung expansion • Reduced alveolar elasticity • Difficulty expelling mucous or foreign material • Diminished ability to increase ventilation • Declining immune response • Gastroesophageal reflux disease (GERD) Chemoreceptors slowed Older adults experience changes that can affect pulmonary function • Reduce lung expansion & less alveolar inflation occurs especially in lung bases as lungs have decreased ability to recoil, alveoli lose elasticity • Difficulty expelling mucous or foreign material: cough reflex is less effective, mucus is drier, decreased cilia in airways • Diminished ability to increase ventilation due to decrease in diaphragm strength, exhalation less efficient • Declining immune response seen with decrease in cell-mediated immunity, inflammatory response & T-cell activity • Gastroesophageal reflux disease is more common, creating increased risk for aspiration of stomach contents into lungs, resulting in inflammatory response • Chemoreceptors that control breathing are slow to respond to increase need for oxygen or rising levels of carbon dioxide=hypoxemia risk increases when respiratory problems occur

How to put on and take off PPE

On: Gown, mask, goggles, gloves Off: gloves goggles, gown,mask

PPE (personal protective equipment) order

On: Gown, mask, goggles, gloves Off: gloves goggles, gown,mask

Rapid-Acting Insulin Times

Onset: 15 minutesPeak: 1 hourDuration: 3 "15 minutes feels like an hour during 3 rapid responses."

Intermediate-Acting Insulin times

Onset: 2 hours Peak: 8 hours Duration: 16 hours "Nurses Play Hero to (2) eight 16 year olds."

Long-Acting Insulin times

Onset: 2 hours Peak: NONE Duration: 24 hours "The two long nursing shifts never peaked but lasted 24 hours."

Short-Acting Insulin times

Onset: 30 minutes Peak: 2 hours Duration: 8 hours "Short-staffed nurses went from 30 patient to (2) 8 patients."

Rapid Insulin when to give

Onset: 5-15 min, 30-60min Peak: 45-90 min, 2-4hrs Give within 15 min of meal Lispro and aspart, zinc suspension

Problem oriented system

Organized around client problems Four components: database, problem list, plan of care, and progress notes Promotes greater collaboration The POR system has several advantages: Problem oriented: database, problem list, plan of care, and progress notes First, there is a common problem list that includes input from all disciplines. Second, it is easy to monitor the patient's progress because each problem is readily identified in the notes. Third, each discipline has ready access to the findings of the other members of the health team. This may encourage greater collaboration. The POR system requires a cooperative spirit among health providers as well as diligence in maintaining a current database and problem list.

#19 What are interventions for sleep and rest?

Orient them on sleep routine based on their specific need and schedule -dr orders for med melatonin

PLISSIT model

P - Permission LI - Limited Information SS - Specific Suggestions IT - Intensive Therapy

Serosanguineous

Pale, red, watery: mixture of clear and red fluid commonly seen in new wounds

Stage II pressure ulcer

Partial-thickness superficial, skin loss, abrasion, blister, or shallow crater

Focused physical assessment-

Particular problem, topic, body part, or functional ability rather than overall health status.

QSEN (Quality and Safety Education for Nurses)

Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics

What do patients with disabilities experience

Patients with TBI or ABI may experience reduced memory retention, comprehension variances, and cognitive dysfunction.

Sensory Impairment.

Patients with sensory impairment are at increased risk for injury related to use of heat and cold ther- apy because they may not perceive temperature changes, burns, or ischemia. Arterial Ulcers occur when there is a non-pressure-re- lated blockage of arterial blood to an area (e.g., by a clot or stenosis of the arterioles), causing ischemia and tissue necrosis. This type of wound usually occurs over the lower leg, ankle, or bony areas of the foot. The wound bed tends to be dry and pale, with little drainage. Arte- rial ulcers are usually very painful, especially at night.

Distinguish the physiological and psychological effects of death and dying on clients and families.

Physiological Stages of Dying 1-3 Months Before: Person withdraws from people & world Sleep increases Appetite decreases Difficult to digest food Prefer liquids Anorexia & Ketosis 1-2 Weeks Before: BP decreases; TPR fluctuates Skin color changes: yellowish pallor & extreme pallor of extremities Perspiration increases Apnea Congestion causes a rattling sound/nonproductive cough 1 to 3 months prior to death: • the dying person begins to withdraw from the world and people • Anorexia which results in ketosis: (body breaks down fat & proteins for energy): can be protective because this diminishes pain and sense of well-being increases 1 to 2 weeks prior to death: A host of physical changes indicates the body is beginning to lose its ability to maintain itself Physiological Stages of Dying Days to Hours Before: Surge of energy Mental clarity Appetite increases Desire to talk with family members As Death Approaches: Dehydration & difficulty swallowing = decreases blood volume Endorphins released = decreases pain Decreased gag reflex Secretions in bronchi & oropharanx Initially, apnea 10-30 sec. "Death Rattle" Cheyne-Stokes Respirations Days to hours prior to death: Often a surge of energy brings mental clarity and a desire to eat and talk with family members As Death approaches: • Dehydration is thought to not cause distress because dehydration stimulates endorphins to be released (produces an opiod affect in the brain and decreases pain) • Mucous membranes/lips dry & cracked • Initially respirations are shallow, rigid or irregular with apnea lasting 10-30 seconds • Will progress to more severe apnea • Congestion from secretions: "Death Rattle" can be loud • Cheyne-Stokes Respirations: a cyclic pattern of apnea 10-60 sec, then increase in rate & depth, then slow & shallow; repeats again with apnea Physiological Stages of Dying Final Hours: Restless/Agitated Either increase in energy/coherence OR Less communication/quiet Withdrawn Fatigue Moments Before: No response to touch/sound Cannot be awakened Long-spaced breaths Breathing stops Heart stops In the final hours of life, clients may become restless and agitated • response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues • near to the time of death, some clients unexpectedly become more coherent and energized for a time, others become less communicative, quiet, and withdrawn Moments prior to death: • client does not respond to touch or sound and cannot be awakened • short series of long-spaced breaths before breathing ceases entirely and the heart stops beating • eyes may be open but unseeing muscles relax/face droop Psychological Stages of Dying Dr. Elisabeth Kubler-Ross: Five "Stages of Dying & Grief" Denial Anger Bargaining Depression Acceptance

Nursing adpie STEP 3: PLANNING-CONT

Planning has 2 parts: 1. Prioritize nursing dx and develop patient outcomes ABC's (airway, breathing, circulation) Maslow's hierarchy 2. Plan and prioritize interventions. Identify what should be done first This step will be discussed further in Week 7 STEP 3: PLANNING-CONT. Planning needs to be pt specific so before you start; stop and consider Ethical Considerations

Pain Assessment for Older Adults

Please rate your pain from 0 to 10 with 0 indicating no pain and 10 representing the worst possible pain: _______

Post op complications

Post-op complications Respiratory* Respiratory depression Airway: Obstruction Airway: Spasms Aspiration Pneumonia Cardiovascular* Thrombi/emboli Hypervolemia: Fluid volume excess Hypovolemia: Fluid volume deficit Shock Complex dysrhythmias Tachycardia Bradycardia Thermoregulation Neurological Acute temperature alterations Altered mental status Pain Peripheral nerve trauma Gastrointestinal (GI) Nausea/vomiting Constipation Ascites Paralytic ileus Genitourinary Urinary retention Urinary tract infection Integumentary Infection Wound dehiscence Evisceration Decubiti Musculoskeletal Decreased range of motion Activity intolerance *Highest priority assessment.

Pre-op teaching and preparation. What would you ask the patient during your preop check (i..e.NPO, meds etc)

Preparing the client physically Assess NPO status Prepare skin: surgical scrub Bowel preparation Facilitate an empty bladder Administer preoperative medications Apply antiembolism stockings (TEDS) What About NPO? NPO for 2 hours prior to surgery No formula, solids, or milk for 6 hours No fatty foods, meats, fried foods for 8 hours **May take am meds with sip of water with MD order (cardiac

What nursing interventions help determine change in client's fluid status?

Prevent further fluid loss • ̃Oral rehydration therapy:offer fluids frequently, keep fluids at bedside • I ̃V therapy: IV fluids, parenteral fluid replacement • ̃Medications: depends on the cause Example: • Vomiting:giveantiemetics • Diarrhea: give antidiarrheal • Monitor status: Cardiovascular, Respiratory, Renal, Gastointestional • Monitor electrolytes • MONITOR WEIGHT Monitor I & O

Nursing interventions that prevent skin integrity

Prevention: prevention is the most important nursing intervention. Meticulous skin care and moisture control Adequate nutrition: increased protein Frequent repositioning: every 2 hours Therapeutic mattresses Client/familyteaching

Maslows hierchy

Priority 5 Personal goals (least important) Priority 4 Self esteem (not as important as:) Priority 3 Love and belonging (not as important as:) Priority 2 Safety and security (not as important as:) Priority 1 (physiologic needs) (main priority) Highest priority ABCs Maslow hierarchy of need constant changing patients might get better on one thing and move up the pyramid or change.

PES format (in nursing diagnosis)

Problem, etiology, signs and symptoms. Problem: from NANDA label (north american nursing diagnosis association) Etiology: starts with the phrase "related to..." Signs and symptoms: "as evidenced by" or "as manifested by."

Thermoregulation

Process of maintaining an internal temperature within a tolerable range.

Apply nursing interventions related to the physiological, cognitive, and, psychosocial changes:

Promote rest/sleep educate appropriate med use/routine provide support Establish therapeutic communication alter communication for client needs (hearing) Offer spiritual/religious assistance education for client/caregivers promote safety

Facilitating hygiene Explain how personal hygiene relates to health and well-being:

Promotes comfort decrease infection/disease improve self-image

#20 if patient is lacking sleep and had a busy day what would you do?

Provide frequent rest period when working with patient Try to do as much as possible in one session to let the patient have rest with no interruption. Avoid certain foods and alcohol Find out what sleep pattern are at home.

Respiratory Acidosis interventions

Provide pulmonary hygiene. Institute measures to improve gas exchange, such as chest physiotherapy, bronchodilators, antibiotics possible. Provide supplemental oxygen. Maintain hydration

purulent exudate

Pus: indicates a bacterial infection • thick, often malodorous yellow pus, drainage seen in infected wounds commonly caused by infection from (pus-forming) bacteria, such as streptococci or staphylococci may take on blue-green color if bacterium Pseudomonas aeruginosa is present

different types of insulin and what insulin falls into each category.

Rapid-acting (fastest) Short-acting Intermediate (medium acting) Long (longest) Remember the phrase to help you remember which ones are the fastest and longest: Ready (rapid), Set (short), Inject (intermediate), Love (long)!

Nursing Documentation Forms: Nursing Admission Assessment

Record of baseline data from which to monitor change Helps forecast future needs

Flow Sheets

Record routine aspects of care (hygiene, turning). Document assessments, usually organized according to body systems. Track client response to care (wound care, pain, IV fluids). Use graphic records to record vital signs. Record intake and output.

Side effect of anesthesia/analgesia Opiod side effects , treatment for opiod overdose

Recovery From Anesthesia The first postoperative phase is often known as the postanesthesia phase or the immediate postoperative phase. This phase begins when the client is transferred from the operating table to a bed (or gurney) for transport to the PACU. During this phase, the client is at high risk for respiratory and cardiovascular compromise. As a precaution, the anesthetist and the circulating nurse accompany the client and attend to her needs during transport to the PACU. They are also responsible for giving a comprehensive report to the PACU nurse. The PACU, located near the OR, is typically an open unit that allows nurses to observe clients easily. PACU nurses have specialized education and experience in car- ing for postoperative clients. Commonly, nurses working in the PACU have experience in critical care. The PACU nurse receives a comprehensive report from the anesthesia provider and circulating nurse (see Box 39-4): (Wilkinson's, p.1045) Airway—The patient is able to maintain a patent airway independently and to deep-breathe, cough, and expectorate secretions. Level of consciousness—The patient is conscious and easily reoriented. Often patients will drift off to sleep between arousals; however, they easily reorient and are generally aware of circumstances and surroundings. Vital signs—Vital signs are stable and within an acceptable range.The blood pressure may be markedly different from that taken during the immediate preoperative measures, because BP is often elevated preoperatively.This can also be caused by anxiety, pain, and not administering routine BP medications because of NPO status.The patient may require medication to control pain or BP before he can be discharged from the PACU. Mobility and sensation—The patient is able to move all extremities that he could move preoperatively.The patient regains movement and sensation once spinal or epidural anesthesia has worn off. Fluid balance (I&O)—The patient is urinating at least 30 mL/hr and is in relative fluid balance. Consider blood loss, urine output, gastric drainage, and emesis when calculating fluid balance. Dressings and drains—Dressings are dry and intact, or wound drainage is considered appropriate for the procedure.The patient should have no overt signs of excessive blood or fluid loss before he is transferred to the surgical unit. An unconscious client is usually positioned on his side to help maintain an open airway.This decreases the likelihood of as- pirating mucus or saliva by allowing it to drain out instead of back into the throat. Elevating the superior arm on a pillow allows for good chest expansion so the patient can breathe deeply and ex- pand the lungs fully. NIC: Postanesthesia Care. The only postoperative in- tervention from NIC's Perioperative Care category is Postanesthesia Care. Postanesthesia Care encom- passes the preceding assessments and adds measures such as providing for safety and administering oxy- gen. Many patients arrive in the PACU with an artifi- cial airway or endotracheal tube in place. The client re- mains in the PACU until the PACU nurse determines that he has recovered from the effects of anesthesia (Box 39-5) and is able to maintain his own airway. She then removes the airway and transfers the patient to the surgical unit.

Apply nursing interventions with clients who have impaired hearing, speech, or cognition:

Reduce environmental distractions, approach the patient directly/talk face to face, and always make sure they can understand what you are trying to communicate.

vasoconstriction

Reduces blood flow and heat transfer by decreasing the diameter of superficial blood vessels.

Short acting insulin

Regular (Humulin R, Novolin R)

systems involved in compensation

Renal mechanism can compensate for respiratory acidosis by producing HC03 Acid-Base Imbalance: Compensation Compensatory changes occur to restore normal pH and homeostasis Changes in respirations occur within minutes of change in pH Renal response takes longer to restore pHPH normal--> disorder is fully compensated Ph & one component (HCO3 or PCO2) start to move toward normal; other component is abnormal--> partially compensated Respiratory system compensates for metabolic disturbanceMetabolic (Renal) mechanisms compensate for respiratory disturbance Compensation reflected in ABG's

Enteral feeding:

Required when a patient has a functioning gastrointestinal (GI) tract but cannot get enough nutrients by mouth and becomes at risk for malnutrition · Patients who had trauma, burn, severe malnutrition, neurological disorders that affect swallowing (ex: stroke,) cancer · Formulas- bolus= given several times a day, usually during mealtimes. Continuous= drips small amounts of formula through the tube over several hours or all the time · Tubes- Nasogastric= goes through your nose or mouth, past your stomach to the small intestine up to days or weeks. Gastrostomy= needed for months or more, surgery is required; where a tube is placed in the stomach through a cut in the belly

C. difficile

Requires the use of hand soap and water rather than alcohol-based hand rubs.

Table 38-7 ➤ Acid-Base Imbalances electrolyte metabolic acidosis

Respiratory Acidosis May be caused by conditions or medications that impair gas exchange at the alveolar-capillary membrane, depressed respiratory rate and depth, or injury to the respiratory center in the brain Acute: Increased pulse and respiratory rate Headache, dizziness Confusion, decreased level of consciousness (LOC) Muscle twitching Chronic: Weakness Headache Provide pulmonary hygiene. Institute measures to improve gas exchange, such as chest physiotherapy, bronchodilators, antibiotics possible. Provide supplemental oxygen. Maintain hydration. Respiratory Alkalosis May be caused by hyperventilation resulting from anxiety, fever, sepsis, thyrotoxicosis, lesion in the respiratory center in the brain, or excessive ventilation with a mechanical ventilator. Confusion, difficulty focusing Headache Tingling Palpitations Tremors If caused by anxiety,

#34 opioid precaution fall risk

Respiratory assess for the 1st 24 hrs 1 hr to 2 hrs (review lectures ) Narcan, nalaxon,-reverse side effects.

#49 post op vomiting

Risk factors- dehydration Lungs- aspiration to prevent put an NG tube for suction aspirate and check Ph Know stomach 5.5 or less Above ph of 5.5 like 6 or 7 is lungs *verify tube placement before using*

Fulmer SPICES tool

S: Sleep disorders. P: Problems with eating or feeding. I: Incontinence. C: Confusion E: Evidence of falls. S: Skin breakdown.

Tools for older adult assessment: Spices

S= sleep disturbances P= problems with eating or feeding I= incontinence C= confusion E= evidence of falls S= skin breakdown

Techniques to enhance communication:

SBAR- used when communicating with a Doctor. Situation, background, assessment, and recommendation. Ex: your concerns, patients health history, what you seen and how to help the patient. CUS- Concerned, uncomfortable, and safety. Open-ended questions- which gives the patient a chance to respond, without using yes or no.

SCIP

SCIP-INF 6 requires proper hair removal at the surgical site. SCIP-INF 1 recommends that a pro- phylactic antibiotic be received within 1 hour SCIP-INF 2 addresses prophylactic antibi- otic selection for surgical patients. SCIP-INF 4 addresses cardiac patients specifically and recommends a controlled 6 a.m. postoperative serum glucose level. SCIP- CARD-2 states that patients taking a beta-blocker before arrival receive a beta- blocker during the perioperative period. The last area to improve surgical outcomes centers on VTE SCIP- VTE-1 directs that surgery patients have recommended VTE prophylaxis. SCIP-VTE-2 stipulates that patients receive VTE prophylaxis within 24 hours before surgery to 24 hours after surgery.

SCIP Core Measures

SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf- 4 SCIP-Inf-6 SCIP-Inf-9 SCIP-Inf-10 SCIP-Card-2 SCIP-VTE-1 SCIP-VTE-2 Prophylactic antibiotic received within 1 hour before surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery end time ( 48 hours for cardiac surgery) Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose Surgery patients with appropriate hair removal Urinary catheter removed on postoperative day 1 or postoperative day 2 with day of surgery being day 0 Surgery patients with perioperative temperature management Surgery patients on beta-blocker therapy before arrival receive a beta-blocker during the periopera- tive period Surgery patients with recommended VTE prophylaxis ordered Surgery patients who received appropriate VTE prophylaxis within 24 hours before surgery to 24 hours after surgery

Sleep What is sleep? How is a sleep assessment performed?

SLEEP: • a cyclic occurring state • decreased motor activity & perception • adequate amounts of sleep & rest promote health restores the body

gait belt/transfer belt

Safety equipment that should be placed on patients when transferring and ambulating.

Predicting Pressure Injury Risk

Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk, ≤ 9 indicate very high risk. The Epworth Sleepiness Scale (ESS)

Assessing Nutrition in Older Adults

Scores of 12-14 are considered normal nutritional status; 8-11 indicate at risk of malnutrition; 0-7 indicate malnutrition.

Hyperkalemia Hyperkalemia (K+)

Serum level >5 mEq/L Cause: excessive intake, major trauma, burns, renal failure, potassium sparing diuretics Signs & symptoms: muscle weakness, cardiac dysrhythmias, flacid paralysis, tall T waves on ECG Treatment: monitor I&O, monitor potassium level, caution about potassium rich food , IV therapy, medications

Sexual orientation vs. sexual concept

Sexual identity and sexual behavior are closely related to sexual orientation, but they are distinguished, with identity referring to an individual's conception ofthemselves, behavior referring to actual sexual acts performed by the individual, and sexual orientation referring to romantic or sexual attractions toward person of the opposite sex or gender

Florence Nightingale:

She described the work of nursing as putting patients in the best condition for nature to act upon them, emphasizing touch and kindness along with the healing influences of fresh air, sunlight, warmth, quiet, and cleanliness. Nightingale thought of people as multidimensional and as a part of their environment. ***First nursing theorist, she is making a come back and is now considered to have been WAY ahead of her time.

Jean Watson:

She developed a theory of nursing that identified caring as the primary focus of nursing. She described "authentic presencing," which facilitates the "caring moment" between the nurse and the patient.

Martha Rogers:

She felt that the environmental energy field is in constant and meaningful interaction with the human energy field. Nurses exert influence on these energy fields to effect change in health status.

Margaret Newman:

She identified disease as disequilibrium, which stimulates the person toward growth and regaining wholeness. From a holistic perspective, disease is an inevitable part of the human condition and is necessary and beneficial for growth, adaptation, and maturation.

Long and Short-Term Goals

Short-term goals: Achieved in a few hours or days Used in clinical so that you may have the ability to evaluate your pt outcomes at the end of the clinical day Long-term goals: Occurring over a week-month or more

Stage I Pressure Injury

Skin intact; Erythema; Does NOT blanch

What interventions promote sleep and rest?

Sleep history Schedule nursing care Darken room/ Light Control room temp Keep noise to a minimum Create a restful environment Good body alignment Pillows/Support pads/Foot boards Promote sleep and rest: Promote comfort & safety Promote bedtime rituals Herbal- OTC Melatonin Valerian root Chamomile tea Free Sleep Apps: Sleep Cycle, NatureSpace, To bed

#28 Pain Pain assess pain why? Some patient can't tell you

Some patient are nonverbal Pain is what patient says it is know the intensity, location, duration alleviating factors

Identify factors influencing personal and cultural hygiene practices across lifespan:

Some people prefer a shower or bath time of shower morning/evening Some cultures may consider bathing, deodorant, brushing teeth necessary. Where, some cultures may only bathe once a week. Preference of male or female should be considered.

Describe physical hazards and nursing interventions to prevent injury:

Some restraints are necessary review meds (some alter mental status or balance) Modify environment frequent assessment always find ways to communicate

*SMART GOALS* GOALS MUST BE SMART

Specific Measurable Attainable Realistic Timely SPECIFIC- Is it individualized? Is the wording clear for all to understand what is expected? MEASURABLE -What is the standard so that a pt's response may be measured against it? ACHIEVABLE- with all aspects considered REALISTIC - Can it be reached? Does it apply to the pt? Does it make sense? TIMELY - When should it happen? What is the expected time frame? Developing smart goals Statement should be what pt will do and always start with "Client will" or "Patient will." - NOT "nurse will." It is about the pt, not the nurse. Remember it states to "Specify Time Frame" and therefore must be included in the Goal! Listed outcomes should be used as a guide or example but may not be specific or "SMART" enough for your patient!!! You can develop SMART outcomes with your pt that are not in the Nursing Diagnosis Handbook

Compare and contrast concepts of religion and spirituality and the impact on homeostasis.

Spirituality and religion are related, yet are two distinct and different concepts Religion: • tells you what to believe, and what values are essential • provides a code of conduct that integrates those beliefs and values into everyday life Spirituality: • the day-to- day, moment-by-moment journey in life and living • lifelong process of growth (which may involve joy and/or struggle); a constant process of taking in "truth" and then adding individual insight to arrive at a way of perceiving and acting in the world ➢ Many life events that prompt spiritual growth are fulfilling and joyful, but growth often results from painful life events that cause great internal upheaval, struggle, and challenge Religion Serves as a "roadmap" that defines: Beliefs Values Code of conduct and ethics A tradition or system of worship that provides: Rituals Answers Norms

Standardized Language

Standardized nursing terminology helps to make nursing care and its effects on patients more visible NANDA International (NANDA-I) Nursing Interventions Classifications (NIC) Nursing Outcomes Classification (NOC) The ANA (2010) has recommended documentation systems use ANA-recognized terminology (e.g., NANDA-I, NIC, NOC). Standardized terminologies allow researchers to retrieve nursing data for aggregation and analysis. Through the use of standardized languages in nursing documentation, a standard for evidence-based nursing care delivery has now been established.

What nursing respiratory assessments require immediate intervention?

Stridor: high pitch, wheezing sound, heard without auscultation, airflow is disrupted by blockage, requires immediate intervention Partial airway obstruction can easily become complete airway obstruction. Therefore, the patient with stridor needs immediate care. Apnea—Absence of breathing. Respiratory arrest re- quires immediate cardiopulmonary resuscitation.

Surgical Consents - who does them, what do they include, who signs them, what if pt is sedated prior to consent?

THE CONSENT IS THE RESPONSIBILITY OF THE SURGEON -> THE SURGEON MUST GIVE THE PATIENT THE NECESSARY INFORMATION INCLUDING THE RISKS AND BENEFITS, AND 2) DETERMINE THE PATIENT'S COMPETENCE TO MAKE AN INFORMED DECISION ABOUT THE SURGERY. ***THE NURSE IS RESPONSIBLE FOR MAKING SURE THE CONSENT FORM IS SIGNED AND WITNESSED. •It is the surgeon's responsibility to explain the procedure to the patient and obtain an informed consent. •Preoperative teaching covers a myriad of subjects. This can begin up to 1 week before the scheduled procedure. •Preoperative teaching includes:•Postoperative exercises designed to prevent complications •Tours/directions of hospital waiting room, surgical suite, postanesthesia care unit (PACU), and other hospital rooms •Anticipated postoperative intravenous (IV) lines, patient-controlled analgesia (PCA), nasogastric (NG) tube, pumps, drains, ventilator, etc. •Questions and answers from patient and family •Determination of pain level and ways to alleviate pain

Katz Index of Independence in Activities of Daily Living (ADL)

TOTAL POINTS = ______ 6 = High (patient independent) 0 = Low (patient very dependent)

Techniques of Physical Examination Four major skills used:

Techniques of Physical Examination Four major skills used: Inspection Palpation Percussion Auscultation BUT...when assessing the abdomen Do in THIS order 1st. Inspection 2nd. Auscultation BEFORE PERCUSSION & PALPATION WHY?? (To avoid altering bowel sounds)

Components of nursing diagnosis

The 2 part statement - Problem statements or diagnostic label Etiology The diagnostic label and etiology are linked by the term related to (RT)

Don't skip the scip

The SCIP initiative targets complications that account for a significant portion of preventable morbidity as well as cost. One of the goals of the SCIP guidelines was a 25% reduction in the incidence of surgical site infections from implementation through 2010.

What are barriers to culturally competent care: bias, ethnocentrism, racism, stereotyping?

The ability to provide culturally competent care may be hampered by various barriers • Self-knowledge and critical thinking are essential in helping identify, manage and remove barriers • Lack of knowledge about cultural values, beliefs, and behaviors can cause misinterpretation of a client's behaviors • Emotional responses such as fear and distrust; communicate with clients effectively • Ethnocentrism is a barrier due to the tendency to think one's own group is superior • Cultural stereotypes: unsubstantiated belief people of a certain group are alike in certain respects; may be positive or negative • Prejudice: negative attitudes toward others based on faulty, rigid stereotypes about race, gender, sexual orientation, etc. • Discrimination refers to the behavioral manifestations of that prejudice • Racism is a form of prejudice and discrimination based on the belief that race is the principal determining factor of traits and capabilities • Sexism is the assumption that members of one sex are superior to those of the other sex • Language barrier can involve foreign languages, dialects • In healthcare, a barrier from terminology and abbreviations that clients do not understand

how to maintain skin integrity

The condition of the skin reflects overall nutritional status Adequate intake of protein, cholesterol, calories, fluids, Vitamin C and minerals are essential to maintaining skin integrity Adequate protein levels maintain the skin, repair minor defects, and preserve intravascular volume As protein levels decline from excess loss or inadequate intake, minor defects cannot be repaired, fluid leaks from the vascular compartment of dependent areas, and edema (excess fluid in the tissues) develops Edema decreases skin elasticity and interferes with the diffusion of oxygen to the cells Skin becomes prone to breakdown Cholesterol: • Low cholesterol levels predispose patients to skin breakdown and inhibits wound healing Calorie Intake: Inadequate calorie intake = the body uses proteins for energy not for building and maintenance functions When undernutrition is prolonged, client experiences weight loss, loss of subcutaneous tissue, and muscle atrophy Predisposing skin to pressure ulcers Vitamin C, zinc, and copper: • are involved in collagen formation, and deficiencies of either may impair healing Hydration: Dehydrated as well as edematous skin are prone to injury, especially when exposed to pressure, shearing, friction, and moisture ***Dehydration = poor turgor*** Diminished Sensation: Clients with diminished sensation are less able to sense pressure or a wound, Injury may go unnoticed and untreated Client may not shift position to relieve pressure over bony prominencesExample:Clients with peripheral vascular disease (PVD), spinal cord injury, diabetes, cerebrovascular accident (CVA), trauma, or fractures often have diminished tactile senseClients are therefore more prone and have increased risk for skin breakdown, impaired skin integrity Infection makes skin more vulnerable to breakdown and impedes healing of wounds Infection from wounds can gain access to the systemic circulation Lifestyle: Tanning: • exposes the skin to ultraviolet radiation, thereby increasing the risk for skin cancer, as well as drying the skin Bathing: frequent bathing and use of soap, may lead to drying, which jeopardizes skin infrequent cleansing of the skin contributes to inadequate removal of microbes on the skin, which can infect a wound or lesion Smoking: compromises oxygen supply to the tissues, skin more prone to breakdown and delaying wound healing also interferes with vitamin C absorption, which is needed for collagen formationBody piercings and tattoos: present a risk for infection and scarring complications, which occur in about 20% of piercings, include local infections, sepsis, endocarditis, hepatitis, and toxic shock syndrome Some examples of factors: immoblity, thin skin, medication reaction, diminished circulation

Opioid effectiveness

The effectiveness of opioids for pain relief can vary depending on individual differences in metabolism. Some patients metabolize opioids poorly; others very rapidly. Body mass alone is not the sole factor for ap- propriate opioid dosing (D'Arcy, 2008b; Patanwala, Edwards, Stolz, et al., 2012), even though existing opi- oid regimens tend to be based on lean body mass. Chronic pain is relatively resistant to effective long- term, opioid analgesia. Although opioids are shown to be effective for certain types of pain, their usefulness is not appreciable in improving physical function with the activities of daily living. Additionally, chronic use of opioids can invoke other hazards, including overdose, physical dependence, and sedation/cognitive impair- ment (Hooten, Timming, Belgrade, et al., 2013).

Mandatory article pain relief The CAM can

The four main types of CAM are: I body-based therapies (heat and cold, acupuncture, and massage) I cognitive-behavioral approaches (relax- ation, guided imagery, and biofeedback) I energy medicine (Reiki and therapeutic touch) I nutritional approaches that incorporate the use of herbs and vitamin supplements. When these techniques are used in con- junction with standard medicine, they're called complementary. When they're used in place of standard medical practice, they're called alternative. Another term applied to these therapies is integrative, which indicates a more combined approach to using both standard medicine and CAM therapies.

what do you do if insulin is cloudy

The only insulin that's cloudy is intermediate insulin

PTSD (Post Traumatic Stress Disorder) nursing interventions

The patient may have posttraumatic stress disorder (PTSD) due to his or her injury and be fearful when approached. Explain each action, procedure, interven- tion, or medication before you touch the patient. Speak clearly and distinctly, and make eye contact. Monitor your tone of voice and speaking volume when discuss- ing care and asking the patient about needs and comprehension. Frequent repetition may be required because memory loss is common. These patients may have either expres- sive or receptive dysphasia; if the patient is unable to communicate, verbally ask him or her to squeeze your hand as a yes or no response to questions. ******The key is to establish and maintain an open dialogue in any manner possible with the patient.*****

cardiac output

The volume of blood ejected from the left side of the heart in one minute. stroke volume x heart rate

Differentiate between practical, theoretical, self, and ethical knowledge. How does it impact the nursing process?

Theoretical- Consists of information, facts, and evidence- based theories. For example: a nurse knows that drinking cold water before taking a temperature, can decrease the reading. Therefore, the nurse asks questions to find out when the last time they took a sip. Practical- knowing what to do and how to do it. For example: giving an injection or meds. Self-knowledge- why did I do that and how did I come up with that? For example: a nurse values the "tough it out" response to pain but, puts that aside because she knows pain is individual and personal. Ethical-knowledge- right or wrong. nurse serves as a patient advocate. Ex: Staying late to make sure a patient gets their new medication.

1-problem (diagnostic label)

There are words that have been added to some NANDA label to give additional meaning e.g. Altered, impaired, decrease, ineffective, acute, chronic, knowledge deficit, ineffective breathing pattern.

codeine, hydrocodone (Vicodin), morphine, hydromorphone (Dilaudid), fentanyl, methadone, and oxycodone

These are excellent medications for breakthrough pain—pain that "breaks through" relief provided by long-acting analgesics. Breakthrough analgesia refers to a rescue or extra dose. Drugs used for breakthrough pain should have a rapid onset and short duration. There is no maximum daily dose limit and no "ceil- ing" to the level of analgesia from mu agonists. You can steadily increase the dose to relieve pain.

TBI (traumatic brain injury) or ABI nursing interventions

These patients may benefit from individualized reminders, such as written lists, notes, or electronic alarms, to cue them to perform certain tasks, such as when to take medica- tions or check their blood glucose. Assist the patient in overcoming barriers that inhibit his or her independence and utilize the support of the patient's caregiver when possible.

How can nurses provide culturally competent care?

To be culturally competent, one needs cultural: awareness, skills, knowledge, encounters, and desire • Cultural competence is a developmental process • Understand ones own cultural values and practices • Learn about the cultural groups • Study nursing theories and principles pertaining to culture

➢Focused

To obtain data on an identified actual, potential problem, body part (Ex: fractured leg)

Metabolic Acidosis INTERVENTIONS

Treatment is directed at correcting the underlying problem. Bicarbonate may be ordered.

Metabolic Alkalosis INTERVENTIONS

Treatment is directed at correcting the underlying problem. Treatment often includes administration of NaCl-rich fluids.

What are the side effects of the following medications to consider?

Tricyclic antidepressant, Drowsiness. Blurred vision. Constipation. Dry mouth. Drop in blood pressure when moving from sitting to standing, which can cause lightheadedness. Urine retention.

Extreme hyperglycemia

Type I Diabetic Ketoacidosis (DKA) Causes: High blood sugar in type I diabetes Stress Illness

Aspirin Use Cautiously

Use Cautiously in: history of GI bleeding or ulcer disease; Chronic alcohol use/ abuse; Severe hepatic or renal disease; Adverse Reactions/Side Effects EENT: tinnitus. GI: GI BLEEDING, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting. Hemat: anemia, hemolysis. Derm: rash, urticaria. Misc: allergic reactions including ANAPHYLAXIS and LARYNGEAL EDEMA. ● Prolongs bleeding time for 4-7 days and, in large doses, may cause prolonged prothrombin time. Monitor hematocrit periodically in prolonged high-dose therapy to assess for GI blood loss.

Evisceration treatment (Abs); exposed organs

Use most sterile saline keep warm occlusive dressing DO NOT REPLACE

1. Strategies to minimize liability in nursing practice

Use nursing process and follow professional standards of care · Void medication and treatment errors · Report and document · Obtain informed consent · Maintain patient safety · Provide education and counseling · Delegate according to guidelines

Describe the purpose of a health assessment: Obtain baseline data-

Used to compare if a patients status changes.

Beta blocker uses

Uses: HTN, HF, Acute MI, CAD, Ventricular dysrhythmias.

Universal protocol "time out"

VITAL INFORMATION - CONSENTS AND "TIME OUT" CONSENT FORMS MUST BE SIGNED *****THE CONSENT IS THE RESPONSIBILITY OF THE SURGEON -> THE SURGEON MUST GIVE THE PATIENT THE NECESSARY INFORMATION INCLUDING THE RISKS AND BENEFITS, AND 2) DETERMINE THE PATIENT'S COMPETENCE TO MAKE AN INFORMED DECISION ABOUT THE SURGERY. ***THE NURSE IS RESPONSIBLE FOR MAKING SURE THE CONSENT FORM IS SIGNED AND WITNESSED. MUST HAVE A "TIME OUT" PRIOR TO THE START OF SURGERY SILENCE IN THE ROOM - RIGHT PT, RIGHT PROCEDURE, RIGHT SIDE, ANTIBIOTIC THERAPY ETC. TJC instituted National Patient Safety Goals (2011) Three principles 1) all documents and results of labs and diagnostic studies are available and that the type of surgery is consistent with the patient's expectations 2) marking the operative site with indelible ink to mark left and right distinction, exact site, and levels of the spine 3) a "time out" just before the procedure for final verification of the correct patient, site, procedure , and implants if any. The patient or representative participate in the entire process

Nitrate mechanism of action

Vasodilate by increasing NO in vascular smooth muscle thereby increasing cGMP and smooth muscle relaxation. Dilate veins >> arteries. Reduces preload

Decrease workload of the heart caused by

Vasodilators - widen the blood vessels and reduce your heart's workload. Calcium channel blockers - lower blood pressure and slow your heart rate, helping to reduce your heart's workload. Diuretics or "water pills"- remove extra fluid from your body which helps to improve symptoms like swollen legs.

Oxygenation What are pulmonary ventilation & pulmonary respiration?

Ventilation: movement of air into and out of the lungs via breathing • Inhalation Exhalation Respiration: exchange of respiratory gases in the lungs & body tissues • External respiration Internal respiration

Pulmonary System Functions

Ventilation: movement of air into and out of the lungs via breathing • Inhalation • Exhalation Respiration: exchange of respiratory gases in the lungs & body tissues • External respiration • Internal respiration Perfusion: • ability of cardiovascular system to pump oxygenated blood to tissues & return deoxygenated blood to the lungs

List the characteristics of verbal and non-verbal communication:

Verbal: Deliver messages that the patient can understand and consider age, knowledge, cultural differences, and language. Consider timing and assess the patient first for physiological needs (pain, hunger, bathroom). A distracted patient will not receive the message as you intended it. Provide privacy and ask if they want visitors in the room. *nonverbal communication must match your spoken words. Ex: telling a patient their wound looks good but, your face says otherwise* Nonverbal: Facial expressions, posture and gait will clue to persons attitude, emotions, physical well- being and self-concept. Ex: slow, shuffling gait may signify someone who is ill, has pain, is depressed, or has poor self-esteem. Also, someone who is depressed may lack the energy for hygiene and grooming. Gestures are a good indicator of the feeling tone behind the conversation. Ex: Patient says, "I'm okay" but, they have a broad grin and raised arms. Touch- convey affection, caring, concern, and encouragement.

Risks for infection

Very young, the very old, tobacco and substance abuse, a break down in skin:surgical, bug bite, etc., recent illness or injury, chronic illness(es), undergoing an invasive procedure, taking medications that weaken the immune response, and increased exposure.

Who are the caring theorists?

Watson- "human caring" care of the mind, body, and soul. *harmony* Leininger's- "culture' a nurse must understand different cultures, in order to function effectively. Roach's- "five c's" compassion, competence, confidence, conscience, and commitment. Boykin and Schoenherr - "caring" respect for persons as caring individuals and respect what matters to them. Benner and Wrubel- caring creates possibility, uniqueness of individual, and helps patient face their illness. Cultural/spirituality of caring? Know patient cultural norms for caring practices also, regarding end of life care. Ask patient about culture or family member. Spirituality is very personal so, put your views aside and support patient. *All patients are unique*

Alteration in pulse: ·

When intervals between beats vary enough to be noticeable , the rhythm is abnormal (dysrhythmia). An irregular heart rhythm can be very serious and may require additional assessment by electrocardiogram (ECG), a procedure that traces the electrical pattern of the heart. · Intervention- closely monitor VS, activity tolerance, collect and assess lab data, help determine cause of dysrhythmia, and administer antidysrhythmic medications

appropriate body mechanics

Wide base of support and lower center of gravity, face the direction of movement, use arms and legs, avoid lifting: roll, turn or pivot when able.

and see if you can swallow

X

Braden Scale remember

You're high* your not at risk think age you can take care of yourself moderate risk you're a teen 13 10-12 you want to act grown high risk low scores at high risk! you're a kid 9

Young and middle adult Identify and compare developmental theories of young and middle adults: Havighurst-

Young adult- choosing mate/moving in, rearing children, managing home, occupation Middle adult- physiological changes, reaching satisfactory at job, adult leisure activities

Erikson's-

Young adult- intimacy vs isolation (develop commitment w/work and relationships) Middle adult- generativity vs stagnation (guiding next generation)

Identify factors that place individuals at most risk for infection:

Young and the old weak immune system break in skin illness/injury Tobacco use substance abuse multiple sex partners environmental factors Medications chronic diseases

Examine physical, cognitive, and psychosocial changes occurring in the adult years:

Young- physical (healthiest age, growth complete, childbearing) cognitive- (can agree to disagree) Psychosocial- (independent, career, relationships) Middle- physical (gray hair/andropause, menopause, decreased muscle tone/skin moisture) cognitive-(memory intact but, reaction time begins to diminish) Psychosocial-career/peal retirement planning, family transitions like empty nest/caring for aging parents)

3. Planning-

a care plan is written or electronic document containing detailed instruction for a client's nursing care. Ex: patient will be on a 2-hour toileting schedule.

macular degeneration (MD)

a gradually progressive condition in which the macula at the center of the retina is damaged, resulting in the loss of central vision

#39 erythropoietin-

a hormone produced by the kidney that helps with the formation of red blood cells.

Hematoma—

a localized mass of blood outside the blood vessel. Causes Nicking the vein during an unsuccessful insertion, discontinuing an IV line without holding pressure over the site, or applying a tourniquet too tightly above a previously attempted venipuncture site Signs and Symptoms Ecchymosis, localized mass, discomfort. Nursing Response Be gentle with venipuncture technique. Apply pressure when discontinuing an IV.

compensated acidosis

a pH value between 7.35-7.40= normal ph

self-identity

a person's sense of who he or she is and of where he or she fits in the social structure

Idiosyncratic-

abnormal response to a medication "extreme sensitivity" ·

Hypothermia

abnormally low body temperature Core temperature below normal (<95°F or 35°C) Associated with extended exposure to cold (e.g., extreme weather, immersion in cold water, or lack of shelter and clothing)

4. Implementation-

action phase, carry out or delegate action to another member of the health care team.

Intentional tort-

action taken by one person with the intent to harm another person

Katz index-

activities of daily living

Factors that impact activity and exercise?

age, physical ability, lifestyle, experience, support, education, environment, pain, and culture

1. Cumming and henry (disengagement)-

aging is inevitable. Decrease interaction between others in social system due to mandatory retirement, chronic illness, and loss of spouse/relative/friends.

Magnesium (Mg)-

aids thyroid hormone secretion, maintains normal basal metabolic rate, activates enzymes for carbohydrate and protein metabolism, nerve and muscle function, cardiac function

9% normal saline

also known as NS 0.9 Nacl or NSS- most common for Iv fluids because it works for most hydrated needs due to vomiting, diarrhea hermorrage or even shock use with caution or avoided patients with cardiac or renal failure.

Half-life-

amount of time it takes for half of the drug to be removed from the body. Ex: Ambien would take 11 hours (2 hours x 5.5) to be eliminated

sexual orientation

an enduring sexual attraction toward members of either one's own sex (homosexual orientation) or the other sex (heterosexual orientation)

ischemia

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

Vitamin E-

antioxidant, protects red blood cells and muscle tissue cells (vegetable oils, nuts, milk, eggs, muscle meat)

Mental illness-

anxiety, depression.

All Pigs Eat Too Much

aortic, pulmonic, erb's point, tricuspid, mitral

Agonist-antagonists

are another group of opioids. They stimulate some opioid receptors but block others. Agonist-antagonists are rarely used, but are appropri- ate for moderate to severe acute pain. This group of drugs includes mixed agonist-antagonists, such as pentazocine (Talwin) and nalbuphine (Nubain), and partial agonists, such as buprenorphine (Buprenex). Agonist-antagonists should not be given to patients taking mu agonists (e.g., morphine) because they may act as antagonists at the mu receptor sites and reduce or reverse the analgesia from the mu agonist.

Saturated and trans-fats

are found in processed food, margarine, butter, cookies

Adverse reaction-

are harmful, unintended, usually unpredictable reactions to the drug administered at the normal dosage ·

Enteral feedings

are preferred over parental nutrition because they maintain peristalsis and have lower incidence of infection. The risks are: if enteral formula is aspirated into the lungs, it can lead to infection, pneumonia, and abscess formation.

· Primary effect

are the reason the drug was prescribed.

Side effects-

are unintended, often predictable, physiological effects of medication to which patients usually adapt

Young/middle adult

ask woman if they perform monthly breast exams, or over 40 had mammogram done (earlier if history of BC in family). Ask men If they perform monthly testicular exams.

If tube migrated into lungs=

aspirate would be pale yellow and cloudy with a pH of 7.0 or higher. ·

Side effect of anesthesia? - What can aspiration cause?

aspiration, airway

Diuretic nursing considerations

assess hydration monitor for hypokalemia question potassium supplements with SPIRONOLACTONE!! (can cause hyperkalemia) Change positions slowly to prevent orthostatic changes. Obtain blood pressure before administering hold typically if BP is <90. Monitor sodium levels and K+ levels closely as well as GFR and creatine. Aldactone ace inhibitor can cause resultant hyperkalemia. If on Aldactone make sure to not use potassium based salt substitutes or foods rich in K+.

Explain the adaptations needed during the health assessment for clients of various ages:Older adult

assess the client's support system and ability to perform activities of daily living. Observe client's energy level and provide periods of rest. Hearing/vision may be impaired so, make sure to obtain feedback that they can see/hear you adequately. Use SPICES (sleep disorders, problems with eating, incontinence, confusion, evidence of falls and skin breakdown) during health assessment.

6. Minerals-

assist in fluid regulation, nerve impulse transmission, and energy production; they are essential to the health of bones and blood and help rid the body of by-products of metabolism

Ayurveda

attributes health to balance between three forces: creation (kapha), preservation (pitta), and destruction (vata). Imbalance between these forcesleads to illness and disease. Humans have a physical and psychological constitution made up of those three forces. This constitution is known as a dosha. The ideal dosha is vata-kapha-pitta in equal proportions. Imbalances may be caused by age; lifestyle; diet; too much or too little physical exertion; the seasons; or inadequate protection from weather, chemicals, or germs.

Describe the links in the chain of infectious process: 1. Agent-

bacteria, viruses, parasites (germs)

unstageable pressure ulcer

base of ulcer covered by slough and/or eschar in the wound bed.

Planning-

based on the assessment and diagnosis, the nurse sets measurable and achievable short- or long-term goals for the patient that might include moving from bed to chair at least 3x a day; maintaining adequate nutrition by eating smaller, frequent meals; resolving conflict through counseling; or managing paint through adequate medication

Components of self-concept

body image, role performance, personal identity, self-esteem

Formulas-

bolus= given several times a day, usually during mealtimes. Continuous= drips small amounts of formula through the tube over several hours or all the time

Calcium (Ca)-

bone and teeth formation, blood clotting, nerve conduction, muscle contraction, cellular metabolism, heart action

American nurse association-

both art, science, heart, and mind.

Protein-

builds and repairs cells, fights infection and heals cuts · Meat, fish, poultry, beans, eggs, milk, cheese

Pain-

can affect a person's quality of life.

Digoxin side effects

can do the opposite and can cause hypokalemia with toxicity. Dizziness.Changes in mood and mental alertness, including confusion, depression and lost interest in usual activities.Anxiety. Nausea, vomiting and diarrhea. Headache.Rash. Growth or enlargement of breast tissue in men (gynecomastia) Weakness.

Disease and abnormalities-

can negatively affect body alignment, balance, coordination, and joint mobility. Fracture/trauma/sprain/stroke/spine injury Disease of other body systems ex: respiratory shortness of breath

Monounsaturated=

canola, olive, avocados, peanut butter

• Internal Respirations:

capillary-tissue gas exchange: occurs in organs & tissues; oxygen diffuses from blood to tissue cells; carbon dioxide diffuses into blood, returned to lungs & exhaled

Postoperative care

care provided following surgery

Benner and Wrubel-

caring creates possibility, uniqueness of individual, and helps patient face their illness.

Pulse locations

carotid, brachial, radial, emoral, popliteal, posterior tibial, (inner ankle) dorsalis pedis (top of foot)

3. Water-

carries other nutrients throughout the body, carries waste out of the body, regulates temperature · All foods and beverages

· Charting by exception

chart only significant findings

#40 kidney issues assess

check hormone may show up in the hematocrit blood draw

Nightingale-

clean, well-ventilated, and quiet environment is essential for recovery.

Diagnosis=

clear diagnosis aids communication among team members NOT a medical diagnosis such as asthma myocardial infarction nurses have international standardize language for communicating clinical judgment. (NANDA) Diagnosis can be: Actual, Risk, possible, Wellness Concept maping =critical thinking

serous exudate

clear, like plasma clean wounds typically drain serous exudate watery in consistency and contains very little cellular matter consists of serum, the straw-colored fluid that separates out of blood when a clot is formed

· Kardex client summary med dx, allergies, diet/activity orders, safety precautions

client summary med dx, allergies, diet/activity orders, safety precautions

24-hour recall-

client writes down everything they ate in a day

cataract

clouding of the lens of the eye

International council of nurse-

collaborative care of individuals of all ages, families, groups, and communities for the sick or well in all settings.

Vitamin C-

collagen synthesis, iron absorption, immune function, cementing substance for capillary walls (citrus fruits, tomatoes, potatoes, green vegetables, cauliflower)

· Misdemeanor-

compared with felony, is a minor charge. Less than 1 year in jail (assault and battery, petty theft) may also lose professional license

CPOE-

computerized physician order entry helps prevent errors in reading and transcribing orders. Due to via computer instead of handwriting. ·

Therapeutic level-

concentration of a drug in the blood serum that produces the desired effect without toxicity. ·

Peak action-

concentration of medication is highest in the blood

· Altruism-

concerns for welfare and well-being of others "pt. advocacy

4. Termination-

conclusion of relationship

Deontology-

considers action to be right or wrong regardless of its consequences ex: right of self determination

Relapsing (recurrent)-

consists of one or more episodes of fever, each as long as several days, with one or more days of normal temperature between episodes. Ex: fungal infections

Full liquids-

contains all liquids included in clear plus, food items that are liquid at room temperature. Includes: soups, milk, milk shakes, puddings, custards, yogurt

IOM-

core competency for all healthcare professionals

Stabismus

cross-eyed

#16 nursing interventions-

culture competent based on patient (interpreter if needed ) show client respect make adaptation for their culture.

4. Havighurts developmental-

decrease physical strength and income, retirement, loss of spouse, establish adapting social roles/physical living arrangements

Kussmaul's-

deep, rapid breathing pace throughout its duration ex: late-stage diabetic ketoacidosis( blow off excess CO2)

Quasi-intentional tort-

defamation of character ·

Example: decreased air flow and increased difficulty in breathing • chronic obstructive pulmonary disease (COPD)

describes progressive lung diseases characterized by shortness of breath/breathlessness: emphysema, chronic bronchitis, refractory asthma (non-reversible)

Food record-

diary of measured and weighed food eaten within a 3-day period

1. Physical disease-

disrupts our lives in many ways and can reduce our ability to perform our life roles effectively or to engage in activities we once enjoyed. Ex: diagnosed with breast cancer.

Nonmaleficence-

do no harm and prevent harm

Beneficence-

doing and promoting good

Excretion-

drug continues to act in body until its excreted

Cardiac Glycosides

drugs used to improve heart output by increasing the muscular contraction One of the oldest groups of cardiac drugs No longer first line drug Beneficial effect on failing heart and help to control atrial fibrillation and flutter Positive Inotropics Drugs Increase the heart's pumping action (contractility) and slow down the electrical conduction of the heart. Slowing of HR Decrease velocity through AV node Digitalis

Fidelity-

duty to keep promises, faithfulness ex: going back to check effectiveness of pain medication

Veracity-

duty to tell the truth

With temperature No single number can be considered "normal," because body temperature varies among individuals as a result of differences in metabolism.

each person's temperature fluctuates with age, exercise, and environ- mental conditions. However, the body does function optimally within a narrow temperature range. normal internal temperature, called the core temperature (Think earths core its inside "internal")

After-

effectiveness of drug, side effects, signs of toxicity/adverse reactions

3. Erikson's-

ego integrity versus despair acceptance- that one's life has meaning, and death is part of the continuum of life.

compensated acidosis or alkalosis

either the kidneys compensate for pH imbalances of respiratory origin, or the respiratory system compensates for pH imbalances of metabolic origin

· EHR-

electronic health record used integrate all patient information in a secure way. Includes: allergy history, lab results, and other prescriptions. Can detect dosing errors(sound a-like drugs) or potential problems

Pyrexia (fever)

elevated body temperature

metabolic alkalosis

elevation of HCO3- usually caused by an excessive loss of metabolic acids

· EMTALA-

emergency medical active law act is the right to seek treatment regardless of pay

Therapeutic communication:

empathy, respect, genuine (honest), concreteness (makes sense) and confrontation (clarifying)

Secondary care-

emphasis on treatment of illness, disease or injury. Ex: specialist, cancer treatment, surgery, outpatient centers

Extrinsic-

environment, drainage tubes, Iv lines, catheters Nurses job to assess patients for falls. If a fall occurs, its nurses job to help prevent it from happening again.

Respiration:

exchange of respiratory gases in the lungs & body tissues • External respiration Internal respiration Respiration: exchange of oxygen & carbon dioxide; both external & internal respiration with adequate peripheral circulation is necessary for tissue oxygenation • External respirations: alveolar-capillary gas exchange; occurs in lungs; oxygen diffuses into blood, carbon dioxide diffuse out of blood

Glasgow coma scale-

eye opening response, verbal response, and motor response. Best score is 15, comatose < 8, totally unresponsive 3

Malpractice-

failure of a professional person to act in a reasonable and prudent manner. Malpractice lawsuit may occur when such actions cause injury or death

Negligence-

failure to act in a reasonable and prudent (careful) manner

Fraud-

false documentation

hyperopia

farsightedness

Presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

5. Lipids-

fats give you energy, and help the body absorb certain vitamins. Not all fats are good for you.

· Short term goal=

few hrs. or days/ long term goal= week, month, or months

· Fact

flowsheet, assessment, concise, and timely

Hypotonic

fluids pull body water out of the intravascular compartment Hypotonic Fluids IV • Osmolality is less than that of serum (less than 250 mOsm/L) • Pull water from intravascular to interstitial fluid & cells • Treats cellular dehydration • Used for conditions such as hyperglycemia Examples of hypotonic fluids • 0.45 % NaCl (⁄2 normal saline) • ̃0.33 % NaCl • ̃0.2% NaCl ̃D5W- Isotonic in the bag but becomes hypotonic in the body Important: Watch out for depleting the circulatory system of fluid since you are trying to push extracellular fluid into the cell to re-hydrate it. Never give hypotonic solutions to patient who are at risk for increased cranial pressure (can cause fluid to shift to brain tissue), extensive burns, trauma (already hypovolemic) etc. because you can deplete their fluid volume.

Isotonic

fluids remain in the intravascular compartment

· Occurrence (incident) report

formal record of an unusual occurrence or accident

A stage III pressure ulcer is characterized by:

full-thickness skin loss with tissue necrosis or damage to muscle or bone. possible visible subcutaneous fat

Pre-interaction phase-

gather information before meeting with the patient.

1. Assessment-

gathering objective (measurable) and subjective (how patient feels) data in order, to draw conclusions about a patients health status. Ex: vital signs

Factors that may impact a person's perception of health.

genetic makeup, gender, age and developmental stage, nutrition, sleep and rest, meaningful work, lifestyle choices, personal relationships, culture, religion and spirituality, environmental factors, finances

Long acting insulin

glargine (Lantus) detemir (Levemir)

PPE removal:

gloves, googles, gown, mask

2. Contact-

gloves/gown Ex: MRSA,VRE, CDIFF

Tubes- Nasogastric=

goes through your nose or mouth, past your stomach to the small intestine up to days or weeks.

Airborne-

gown/gloves/n95 respirator mask. Ex: measles, TB, fungal infections. Negative pressure room 6-12 exchanges.

Cheyne-stokes-

gradual increase then decrease, followed by apnea ex: brain stem injury, congestive heart failure ·

Utilitarianism-

greatest positive benefit, good results, usefulness

Grief can be categorized in several ways, most of which have to do with timing and intensity Uncomplicated: •

grief is the natural response to a loss • bereaved person experiences feelings, behaviors, and cognitions expected in light of culture, relationship to the lost person or object • emotions are intense but gradually diminish over time (several months to several years)

· FACCO

guideline for quality documentation and reporting. Factual, accurate, complete, current, and organized.

1. Standard-

hand hygiene, use of PPE, safe injection practices

Older adults-

harder to start/maintain exercise problem

Understand PLISST assessment model

he PLISSIT model was developed as a guideline to address/assess sexuality in a matter-of-fact manner The first three PLISSIT steps have been successfully adapted to address sexual knowledge deficits • Permission to discuss sexuality issues • Limited Information related to sexual health problems being experienced • Specific Suggestions only when the nurse is clear about the problem • Intensive Therapy referral to professional with advanced training if necessary

hyperglycemia

high blood sugar

Stridor:

high pitch, wheezing sound, heard without auscultation, airflow is disrupted by blockage, requires immediate intervention Partial airway obstruction can easily become complete airway obstruction. Therefore, the patient with stridor needs immediate care.

· Focus charting

highlights clients problems, concerns, and strengths in three columns

Morse scale-

history of falls, secondary diagnosis ambulatory aid, IV, gait, mental status. higher number means intervention.

Digoxin Nursing Considerations

hold med if apical pulse is less than 60 prior to doing Check if potassium levels are in range hold is less than 3.5 (risk for dig toxicity) Monitor for digoxin toxicity over 2.0 (vision changes n/v dizziness fatigue) hold med if apical pulse is less than 60 prior to doing Check if potassium levels are in range hold is less than 3.5 (risk for dig toxicity) Monitor for digoxin toxicity over 2.0 (vision changes n/v dizziness fatigue) Watch out for Hypokalemia and visual disturbances, fatigue, arrhythmias and anorexia. Remember to check labs for digitalis and potassium levels. Get a baseline of vital signs and a full minute of apical pulse. Digoxin has the power to control cardiac output and ventricular response in atrial fibrillation.

Interventions:

hourly rounds, fall bracelets, sticker for door, specific colored slipper socks and educating patient/family. *Need to know contributing factors about how to prevent falls. Biological, behavioral and environmental risk. Use of screening tools and interventions.

Mode of transmission-

how germs get around (contact=hands, droplet=sneeze)

5. Portal of entry-

how germs get in (mouth, cuts in skin, eyes)

3. Portal of exit-

how germs get out (vomit, saliva, cuts in skin, incontinence)

self-esteem

how much you value, respect, and feel confident about yourself

#51 Health literacy

how patient understands health info about their care and health to make inform decisions.

Ace Inhibitors Common Side Effects

hypotension, Dry cough, Dizziness, Angioedema (life threatening) Laryngeal swelling that can cause asphyxia, Facial swelling also concerning precursor and a clinical red flag.

Heart in older adults

hypotension- cardiac functions decline due to medications because the heart does not pump as well

Durable power attorney-

identifies a person who will make healthcare decisions in the event the patient is unable to do so (surrogate decision maker/health care proxy) ·

2- Etiology: (related factors and risk factor)

identifies one or more probable causes of the health problem.

2. Diagnosis-

identify clients health needs, reflects the clients responses to actual or potential health problems. Ex: risk for impaired urinary elimination aeb (as evidence by) urinary incontinence.

Allergic-

immune system identifies a medication as a foreign substance that should be destroyed; can be minor ·

Benefits of activity and exercise.

improved cardiovascular health, respiratory health, musculoskeletal health, mental health, GI health, Immune health, endocrine health, urinary health, nervous system health and overall health

Stratify-

includes transfer, mobility, history, vision, agitation, and toileting.

Verbal order

includes, time, date, written text, providers name, your signature. HCP has 24 hours to countersign it

Collect a dietary history-

includes; cultural factors, basic eating habits, preferences ·

Glaucoma

increased intraocular pressure results in damage to the retina and optic nerve with loss of vision a group of diseases

· Telephone order (TO)

increased risk for errors, use read back method

Developmental:

infant/toddler=drowning, choking. Preschool= car accidents, drowning. Adolescent= car accident, homicide, alcohol use (risky behavior) School aged= sports injury, car accident. Adults= overdose, work related injuries, lifestyle. Older adult= falls, burns

Phlebitis—

inflammation of the vein Causes May be due to mechanical irritation, infusion of solutions that are irritating to the vessel, or sepsis. Dextrose solutions, potassium chloride, antibiotics, and vitamin C are associated with a higher risk of phlebitis. Trauma to the vessel, compression of the line by client movement, or a low flow rate Signs and Symptoms Redness, pain, and warmth at the site, local swelling, palpable cord along the vein, sluggish infusion rate, and elevated temperature Slowed or stopped infusion, localized warmth at the site, inability to restart flow of IV Nursing Response Discontinue the IV infusion and restart in a new location. Initially, apply cold compresses to the site if the site is warm and tender.Thereafter, use warm compresses. Assess for circulatory impairment. Consult the primary care provider if there is streaking or erythema along the vein or a palpable cord. Prevention measures: Use the smallest catheter practical (usually 22-gauge or 24-gauge thin-walled catheter). Use polyurethane catheters instead of Teflon. Stabilize and secure the catheter to minimize movement in the vein. Rotate the site at least every 96 hours.

· Objective data

information that we can gather with our five senses. It is either a measurement or an observation Ex: vital signs, ambulation description, wound appearance, urine output, skin color

Potassium (K)-

intracellular fluid control, acid-base balance, nerve transmission, glycogen formation, blood pressure regulation

Felonies-

involve crimes punishable by more than 1 year in jail (murder, rape/sexual assault, stealing drugs, and equipment) person may also lose their professional license

#46 black stool causes -

iron supplements GI problems but always look at meds and diagnoses to assess

Astigmatism

irregular curvature of lens or cornea causing blurred vision

ethnocentrism

is a barrier due to the tendency to think one's own group is superior

Pureed diet-

is a blended diet. Thickener is added to drinks

Peripheral vascular disease (PVD)

is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm. This can happen in your arteries or veins. PVD typically causes pain and fatigue, often in your legs, and especially during exercise.

• Racism

is a form of prejudice and discrimination based on the belief that race is the principal determining factor of traits and capabilities

*trousseau signs of latent tenting

is a medical sign with pt with Low calcium very important assessment altered labs is specifically calcium *constrict risk* know nerves (google)

Modality

is a method of treating a disorder (e.g., therapeutic touch, antibiotics). Complementary modality is a treatment that is used together with traditional medical care.

Sexual identity

is a person's perception of his or her gender, gender identity, gender role, and sexual orientation•

Orthostatic or postural hypotension

is a sudden drop in BP on moving from a lying to a sitting or standing position. ****SAFETY CONCERNS FOR FALLS!!!!

1. Dress, Grooming, and Hygiene-

is affected by physical and emotional well-being. An unkept appearance may reflect chronic pain, fatigue, depression, or low self-esteem.

Assault and Battery-

is both

Hyperpyrexia

is fever about 105.8F, without intervention can be dangerous

· Subjective data

is gathered from the patient telling you something that you cannot use your five senses to measure. Ex: pain is subjective because the patient is telling you what their pain is. Pt reports being dizzy or fell down the stairs.

Evaluation

is one of the most important step required with critical thinking to asses if what you're doing is helping the patient. If progress is not being made find out why and revise the care plan.

· Ongoing assessment

is performed as needed, at any time after the initial database is completed

Health-illness continuum

is personal and dynamic because health changes over the course of time. 10= excellent health 1= gravely ill. An individual moves up and down.

Neuman's continuum

is said to have varying levels of energy at various stages of life. More energy generated than expanded= wellness, more energy expanded than generated= illness.

Primary data

is subjective and objective data obtained from the client

Sexism

is the assumption that members of one sex are superior to those of the other sex •

Nursing Process (2) Describe and distinguish the first three phases of the nursing process: Assessment

is the first step and is used to identify current and future patient needs. Includes: physiological, psychological, sociocultural, spiritual, economics, and lifestyle. For example, hospitalized patient in pain includes not only physical causes and manifestations of pain, but the response and inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain medication.

Convection

is the transfer of heat through currents of air or water. Nurses use this principle to intentionally effect changes in a patient's body temperature.

Evisceration nursing implications

is total separation of the layers of a wound with internal viscera protruding through the incision (Fig. 35-7). (This rare complication is a surgical emer- gency. Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bacteria. Have the patient stay in bed with knees bent to minimize strain on the incision.)***** Do not put a binder on the patient. Notify the surgeon and ready the patient for surgery (see Chapter 39 for pe- rioperative care).

secondary effect

is unintended/nontherapeutic(adverse effect) ·

Alternative modality

is used instead of traditional medical care. CAM encompass a range of philosophies, approaches, and therapies that the conventional healthcare system does not commonly use, accept, understand, study, or make available. Although a number of CAM treatments are holistic, many are narrowly focused.

Dehiscence

is usually associated with abdominal wounds. Patients often report feeling a "pop" or tear, especially with sudden straining from coughing, vomit- ing, or changing positions in bed. Usually there is an im- mediate increase in serosanguineous drainage. *****Nursing interventions include maintaining bedrest with the head of the bed elevated at 20° and the knees flexed. To pre- vent evisceration, a binder may be applied. The provider should be notified of the dehiscence to examine the wound***

D5W (5% dextrose in water)

isotonic carb sugar that contains glucose sugar are use for a diabetic patient NPO avoided with patients with cardiac and renal failure Risk for increase inter-cranial pressure lead to fluid overload

Practical-

knowing what to do and how to do it. For example: giving an injection or meds.

Stretor-

labored breathing that produces a snoring sound. Ex: mouth breathing, death rattle

Stress-

leads to fatigue

Obesity-

leads to other health problems

Anaphylactic-

life threatening allergic reaction and occurs immediately ·

Individual:

lifestyle, cognitive awareness, loss of senses, impaired mobility, language barrier, hearing/speech impairment, physical and emotional well-being (depression)

Rapid Insulin

lispro, aspart, glulisine

Auscultation

listening to sounds within the body · Diaphragm- Listens for high-pitched sounds that occur in heart, lungs, and abdomen. · Bell- Listens for low-pitched sounds , such as extra heart sounds (murmurs) or turbulent blood flow, known as bruits.

2. VRE-

lives in intestines and female genital tract, contact with contaminated person or surface to portal of entry.

1. MRSA-

lives on skin and in nose, skin to skin contact.

Chronic illness-

long period of time, usually 6 months or more, often a lifetime. Ex: aids, diabetes, hypertension.

Tertiary care-

long term care or hospice.

myocardial ischemia

loss of blood supply to heart muscle tissue of myocardium due to occlusion of coronary artery; may cause angina pectoris or myocardial infarction

impending death

loss of muscle tone slowing of the circulation changes in respiration sensory impairment

hypotension

low blood pressure Systolic blood pressure <100 mm Hg; some clients normally have low BP; ask if client is light-headed or dizzy.

Hypoglycemia

low blood sugar

prone position

lying on abdomen, facing downward

Trendelenburg position

lying on back with body tilted so that the head is lower than the feet

dorsal recumbent

lying on back with legs bent and feet flat

supine position

lying on back, facing upward

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

treatment for dehiscence

maintain bedrest, head of the bed elevated at 20°, the knees flexed, notify the provider

#47 constipation and opioid use-

make clients constipated intervention & goals be able to go to the br and have normal bm.

3. Droplet-

mask/gown/gloves. Ex: flu, rubella, cold

NPO-

means no food or fluid, May be ordered before surgery or an invasive procedure to limit the risk of aspiration

Check for placement for nasogastric: ·

measure pH (acidity) of the aspirate and inspecting color, character, and volume. Gastric fluid=clear, odorless, and green with a pH of 5.0 less. · If tube migrated into lungs=aspirate would be pale yellow and cloudy with a pH of 7.0 or higher. · Measure the residual volume of the aspirate. Large amount=greater risk for aspiration

· Before-

measure vital signs, assess pts general condition is appropriate for medication, know the medication your given and biological factors that affect drug metabolism

2. Orientation-

meeting the patient, establishing rapport and trust.

Article sensory changes

memory jogger Remember to make SENSE of sensory changes in your older adult patients. • Safety should be maintained at all times. • Environment should allow the older adult to maintain as much independence as possible. • Nursing process should be used each time you care for an older patient. • Stigmas associated with aging can be dan- gerous; remember to treat each older patient as an individual with unique needs. • Etiology of a condition that the older adult believes is "normal" may be detected during your nursing assessment; remember to listen carefully to the history given to you by your older patient.

Mini cog-

mental status

While-

mental status, coordination, ability to self-administer, swallowing ·

Five elements of communication are:

message, sender, channel, receiver, and feedback.

opioid treatment

methadone tapering or medication detox.

sanguineous drainage

mixture of serum and red blood cells Sanguineous: bloody drainage deep wounds or wounds in highly vascular areas indicates damage to capillaries fresh bleeding produces bright red drainage, whereas older, dried blood is a dark, red-brown

Kolbergs-

moral

Ventilation:

movement of air into and out of the lungs via breathing • Inhalation Exhalation Ventilation: movement of air, cycles of breathing • Inhalation: expansion of chest cavity & lungs, diaphragm & intercostal muscles contracts; drawing in air • Exhalation: diaphragm & intercostal muscles relax, air flows out of lungs; requires no energy or effort • Adequate ventilation is essential to oxygenation of blood, organs & tissues

· Drug incompatibility-

multiple drugs are mixed together, causing a chemical deterioration of one of both drugs

Digoxin signs of toxicity

nausea , vomiting, headache, premature ventricular contractions, diarrhea,confusion, drowsiness, blurred vision or visual disturbances in which lights appear brighter than usual or have halos around them

Hypoglycemia S/S

nausea, nervousness, & irritability, sweatinesss w/ pale skin.diaphoresis, pale cool skin, irritability, normal/shallow respirations, tachycardia and palpitations, strange or unusual respirations. slurred speeech, headache and blurred vision, decreasing loc, seizures leading to coma, change in emotional behavior,difficulty thinking. "cold and clammy need some candy'

Myopia

nearsightedness

Gastrostomy=

needed for months or more, surgery is required; where a tube is placed in the stomach through a cut in the belly

Prejudice:

negative attitudes toward others based on faulty, rigid stereotypes about race, gender, sexual orientation, etc. •

Unintentional tort-

negligence

Vitamin A-

night and color vision, cellular growth, maintaining skin and mucous membranes (green leafy vegetables, egg yolk, liver, egg yolk)

bowel sounds

normal 5-15 seconds (5-30 min) absent 0 after 5 min hypo-active (<5/min.) hyper-active (>30/min) document bs in each quadrant

Lifestyle-

not making time to exercise

Dunn's health

not only follows the health illness continuum but, also considers individuals environment. For example, a patient with multiple chronic diseases but, has a great support system would be protected poor health.

. Working-

nurse communicate bulk of the conversation, clarifies feelings and concerns. .

5. Evaluation-

nurse determines whether the desired outcomes have been achieved and judge whether your actions have successfully treated or prevented the clients health problems. *Can be revised at any step of the nursing process*

Diagnosis-

nurses clinical judgement about the clients response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within family, or has the potential to cause complications. For example, respiratory infection is potential hazards to an immobilized patient.

Justice-

obligation to be fair

Assessment=

observation+ interview+ physical examination (collect, organize validate, and record data) Subjective data is reported but not objectively measurable. (cant see it patients verbal description of health) (symptoms and represent things a client tells you) (collected during health history) Objective Measurable (Temperature, blood pressure, weight) (often referred to as signs) (signs can be measured seen heard or felt. Often collected in a physical exam) Critical thinking to correctly interpret data: Clear, precise, and consistent? Begin clustering cues and formulating inferences while you asses the client recognize patterns and trends in the data. Come to a conclusion and move to

Ace Inhibitors interventions:

obtain B/P before administering hold if B/P is <90 Change positions slowly especially with elderly to prevent orthostatic changes. Monitor for decreased WBC count, hyperkalemia as well as liver function and creatine (metabolized by the liver excreted by the kidneys.)

Hypoxemia

occurs if blood is not adequately oxygenated in the alveoli

Acute illness-

occurs suddenly and lasts for a limited time. Ex: cold, flu, surgery, hospitalization

myocardial ischemia happens?

occurs when blood flow to your heart is reduced, preventing the heart muscle from receiving enough oxygen. The reduced blood flow is usually the result of a partial or complete blockage of your heart's arteries (coronary arteries).

Trough level-

occurs when the drug is at its lowest concentration, right before the next dose is due

Hypoventilation-

occurs when the rate and depth of respirations decrease, and CO2 is retained ex: COPD, general anesthesia, respiratory failure

Cognitively challenged (articles also) Mandatory Articles Making SENSE

of sensory changes in older adults Learn how these changes affect older patients to ensure they remain safe in your care and independent in their communities. As a nurse, you play an essential role in discriminat- ing between normal and abnormal sensory changes. Y our assessment and subsequent interventions may mean the difference for keeping older adults safe and independent in their environment.

measure pH (acidity)

of the aspirate and inspecting color, character, and volume. Gastric fluid=clear, odorless, and green with a pH of 5.0 less. ·

Metabolism-

once a medication reaches its site of action, it is metabolized (changed into the inactive form) in preparation got excretion. Which takes place in the liver. if liver function is impaired (liver disease or aging) then, it'll eliminate more slow and toxic levels may accumulate ·

Antagonistic-

one drug interferes with the actions of another and decreases the resultant drug effect-that is, the combined effect is less than that of one drug given alone

· Problem-oriented record

organized around the clients problems. Four components= database, problem list, plan of care, and progress notes.

· IPOC maps

out day by day like clients goals, outcomes, interventions, treatments etc.

Fever(pyrexia)

over 100F

uncompensated respiratory acidosis

pH = ↓ PaCO2 = ↑ HCO3 = ↔

compensated

pH is normal

Stage IV Ulcer

partial-thickness skin loss involving the dermis or epidermis. Exposed bone or tendon or muscle

Compete demands-

people ignore health issues because the competing demands are too great. Ex: taking care of a loved one, that person may feel an overwhelming burden.

Duration-

period of time in which the medication has a pharmacological effect (before metabolism/excretion) if serum level of medication falls below the minimum effective concentration, then the drug is not effective during that time. Drug levels peak level, toxicity occurs ·

Calcium Channel Blocker side effects

peripheral edema, hypotension, constipation.

Battery-

physical contact is made without their consent

Factors that disrupt health.

physical disease, injury, mental illness, pain, loss, impending death, competing demands, the unknown. imbalance isolation

#50 Ostonomy stoma -

pink moist stoma Blue stoma- circulation issue (immediate emergent problem )

CHF treatment

place patient upright unless they are not comfortable in this position

Abnormalities in: Pulmonary System Inhibit inflation of lungs such as pneumothorax, absence of breath sounds on side of

pneumothorax

PMI

point of maximal impulse, the apical pulse, which is where the impulse of the left ventricle is felt more strongly; 5th intercostal space at the mid clavicular line on the left side

Health issues:

poor vision, orthostatic hypotension, dizziness, age greater than 80

Living will-

prepared by an alert and oriented(competent) individual that gives direction to others about the person's wishes regarding life-prolonging treatments if the person becomes unable to do so

Patients with an autism spectrum disorder

present a challenge for nurses. Many children and adults with autism spectrum disorders have difficulty com- municating with words that they're becom- ing frustrated, anxious, or uncomfortable. They may begin humming, pacing, or yell- ing. Consult with the patient's family or caregiver to find out what historically has worked to calm the patient down. Common nonpharmacologic interven- tions, such as decreasing environmental stimuli by reducing noise and distractions (such as the TV), can often greatly reduce the patient's anxiety. Having the family provide familiar items may also reduce anxiety. It's best to have the same health- care provider care for the patient during each visit because patients with autism spectrum disorders do better with com- fortable routines, and familiar faces and places. Ask patient what they prefer

Falls:

prevalent 65 years older. Causes: slippery floors, stairs, rubs, low toilet, high bed & pets. Prevention: nonskid shoes, tidy clothes, proper lightening, grab bars/rails, no scatter rugs

· Pie

problem, intervention and evaluation used only in problem-oriented charting and establishes ongoing care

older adult considerations

process agents slower: toxic effects adverse effects: orthostatic hypotension, sedation, anticholinergic adverse effects increased anxiety is associated with use of trycyclic antiderpressants may experience higher incidence of cardia dysfuntion

Good Samaritan law-

protect from liability those who provide emergency care to someone who needs medical services

Americans with disabilities act-

protection against discrimination of individuals with disabilities

Safe harbor law-

protects nurse from being suspended, terminated, for refusing to place a patient in harm's way

Hypothermia

provide dry and warms clothing, warm liquids(avoid caffeinated/alcoholic), warm baths, heating blankets.

Clear liquids-

provides fluids to prevent dehydration and supplies simple carbs to help meet energy needs. Includes: water, tea, broth, popsicles, gelatin ·

· Comprehensive assessment

provides holistic information about the client's overall health status. Included: Objective/subjective data, emotional status, spiritual health, functional abilities etc.

Oxygen saturation obtained by pulse oximetry

provides important information on arterial blood oxygen concentration.

PQRST

provocative/palliative, quality, region/radiation, severity, timing

edema

puffy swelling of tissue from the accumulation of fluid when worsening causes weight gain

Biots-

rapid gasps followed by apnea ex: meningitis

Tachycardia

rapid heart rate (>100 bpm)

Hyperventilation-

rapid, deep breathing result in excess loss of CO2. Have patient breathe into cupped hands, paper bag, take slow deep breaths ex: shock, anxiety, hypoxia, diabetes, aspirin

BMR= BASAL METABOLIC RATE -

rate of energy used in the body to maintain essential activitiesThe following are common occasions for assessing vital signs:

Intrinsic-

recent surgery, decreased mobility, confusion, delirium

Integrative healthcare

refers to coordinated care that encompasses all treatments and health practices a patient uses. To provide integrative care a practitioner must know about the interactive effects of conventional and CAM treatments and be able to coordinate all the care modalities.

Discrimination

refers to the behavioral manifestations of that prejudice

Vitamin D-

regulates blood calcium levels, resorption of calcium in bone( fortified milk, sunlight exposure, fish).

Race:

rescue, activate, confine, extinguish (fire)

RACE

rescue, alarm, contain, extinguish

If Patient refuses lifesaving treatment:

respectfully explore underlying reason for refusal. Ensure that the risks and benefits of all treatment options are discussed. Make use of chaplains and spiritual care coordinators to enhance understanding in these difficult conversations with patients and families.

Respiratory pH

respiratory opposite higher number more acidic

False imprisonment-

restraining a patient without proper legal authorization or sedative medications

Consequentialism-

right or wrong of an action depends on the consequences of the act, rather than on the act itself

Ethical-knowledge-

right or wrong. nurse serves as a patient advocate. Ex: Staying late to make sure a patient gets their new medication.

5 rights to delegation

right task right circumstance right person right direction/communication right supervision/evaluation

Patient self-determination act-

right to make own healthcare decisions

Autonomy-

right to self-determination to choose and act on that choose. Ex: you honor autonomy when you respect the pts decision without judgement even if you believe it's not in their best interest

Absorption-

route of administration "movement" of the drug into the bloodstream.

S2

second heart sound loudest over aortic and pulmonic dub/diastole- filling

Extravasation—

seepage of a vesicant substance into the tissues. (A vesicant is a solution that causes the formation of blisters and subsequent tissue sloughing and necrosis.) Causes IV catheter dislodges, or the tip penetrates the vessel wall. Signs and Symptoms Slowed or stopped flow Pain, burning, and swelling at IV site, blanching and coolness of the surrounding skin Blistering is a late sign. If extravasation resulted from vasoconstricting medication may see necrosis (death) of dermis. Nursing Response Treatment depends on the severity of the infiltration. Stop the IV infusion immediately. Administer an antidote, if one is available. (Antidotes alter the pH, alter DNA binding, neutralize the drug, or dilute the extravasated drug.) Apply cold compresses, and elevate the extremity.

Bed alarms=

select right alarm and explain to patient how it works. Try bed/chair alarms or a Patient sitter before resulting to restraints.

Intrapersonal-

self talk

Dehiscence:

separation of outer wound layers rupture (separation) of one or more layers of a wound is called dehiscence

3. CDIFF-

severe diarrhea, lives in GI tract, occurs after antibiotic use or contact with contaminated area or stools. *wash hands with soap/water, clean room with bleach and avoid alcohol-based products.

glasscow coma scale

shows the levels of consciousness **higher number greater risk** Best response is 15 8 or less is comatose client 3 totally unresponsive

lateral position

side lying position

Chvostek

signs a clinical sign of existing nerve hyperecitability tetany seen in hypocalcemia- referee to an abnormal reaction to the stimulation of the facial nerve *trouseeau sign detects early tetany*

Bradycardia

slow heart rate (less than 60 bpm)

Isotonic

solutions are used: to increase the EXTRACELLULAR fluid volume due to blood loss, surgery, dehydration, fluid loss that has been loss extracellularly.

LASA-

sound and look alike drugs can cause med errors. Always question a suspect order or drug name not written clearly. Automated medication system can control errors in transcriptions. Handwritten prescriptions should be legible without abbreviations, both genic/brand name identified and use of the drug. Ex: control of glucose

polyunsaturated=

soybean, fatty fish, seeds, corn are both good fats

Activity-

staying active for as long as you can to enjoy highest life satisfaction (traveling, hobbies, volunteering)

Implementation

step in the nursing process in which the nurse does or delegates the planned interventions

Planning

step within the nursing process in which the nurse and patient determine the desired patient outcomes.

Mu agonists

stimulate mu receptors and are used for acute, chronic, and cancer pain. They include codeine, hydrocodone (Vicodin), morphine, hydromorphone (Dilaudid), fentanyl, methadone, and oxycodone

· Soap

subjective, objective, assessment, and plan used to write nursing and progress notes

Orthostatic hypotension-

sudden drop in BP when moving suddenly from a lying position to a sitting/standing position. Patient may feel dizzy or light-headed. Biggest concern is for falls** hypotension systolic <100

2. Carbs-

supply energy, supply fiber to help food move through the digestive tract · Breads, cereals, rice, pasta, fruits, vegetables

4. Vitamins-

support immune system, necessary for metabolism, preventing a particular deficiency disease

· Vitamin K-

synthesis of clotting factors, bone development( green leafy vegetables)

QSEN-

teamwork and collaboration, evidenced based practice, patient centered care, informatics, safety and quality improvement. 6 skills all nurses must have before graduating.

· Hyperthermia (heat stroke)-

temp above 103 S/S: hot, dry skin, rapid strong pulse, confusion, throbbing headache, impaired judgement. ·

Hypothermia-

temp below 95F S/S: uncontrolled shivering, loss of memory, loss of conscience decreases, cyanotic lips/fingers, decrease respirations and pulse5.

Nursing Process What is Implementation?

the action phase of the nursing process • the emphasis is on doing & carrying out the nursing care plan • specific to each patient and focuses on achievable outcomes • encouraging the client to participate in care Implementation overlaps with: • nursing assessment, diagnosis, planning outcomes & interventions, evaluation Implementation: • provides the opportunity to assess client's at every contact • data discovered during implementation is used to identify new diagnoses or to revise existing ones • client responses to interventions provide data for revising the original goals and nursing orders Review Wilkinson et al, Box 7-1, pg. 121: American Nurses Association Standards of Practice for Implementation

role performance

the actual behavior of an individual in a role

Circadian Rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle

Mechanical soft-

the diet of choice for people with chewing difficulties resulting from missing teeth, jaw problems, or extensive fatigue. Includes: soft vegetables and fruits, chopped/ground meat, breads, eggs, pastries ·

S1

the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close loudest at the tricuspid and mitral lub/systole emptying

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

sexual orientation/identity

the inclination to feel sexual desire toward people of a particular gender or toward both genders

Remittent-

the patients temp doesn't return to normal, although it varies a few degrees in either direction. Ex: viral respiratory tract

Constant(sustained)-

the patients temp remains above normal with minimal variations(less than 1F) these fevers may be caused by drugs

Systemic Complications Septicemia—

the presence of microorganisms or their toxic products in the circulatory system Causes: A break in aseptic technique, or contaminated IV solution Signs and Symptoms Fluctuating fever, chills, tachycardia, confusion, hypotension, altered mental status, elevated WBC count Nursing Response Discontinue the IV infusion immediately. Consult the primary care provider. Treatment often involves antibiotics, fluids, and medications to support vital signs.

perspiration

the process of sweating

Infiltration—

the seepage of nonvesicant solution or medication into surrounding tissues Causes IV catheter dislodges or the tip penetrates the vessel wall Signs and Symptoms Slowed or stopped flow Swelling, tenderness, pallor, hardness and coolness at the site The patient may report a burning sensation in the area. Nursing Response Stop the infusion immediately. Restart the IV infusion in a different vein, higher in the extremity or in another extremity. Elevate the affected arm on a pillow to promote absorption of excess fluid.

The 4 types of nursing knowledge.

theoretical knowledge, practical knowledge, self knowledge, and ethical knowledge

nursing process

theoretical knowledge, practical knowledge, self knowledge, and ethical knowledge

Synergistic-

there is an additive affect; that is, the effect of both drugs together is greater than the individual effects. Ex: alcohol can intensify effects

Assault-

threatening a patient with harm

Thrombophlebitis—

thrombosis and inflammation Causes Use of veins in the legs for infusion, use of a hypertonic or highly acidic solution; can be a result of untreated phlebitis Signs and Symptoms Sluggish flow rate, edema, tender and cord-like veins, warmth, and erythema at site Nursing Response Discontinue the IV infusion, and restart in the opposite extremity, using all new equipment. Apply warm, moist compresses. Consult the primary care provider.

· Onset-

time needed for drug concentration to reach a high enough blood level for its effects to appear

Briefing/debriefing-

to go over patients care plan/review and give feedback.

· Focused assessment

to obtain data about an actual, potential, or possible problem that has been identified or is suspected.

Diuretics Side Effects

too little potassium in the blood or too much potassium in the blood (for potassium-sparing diuretics)low sodium levels. headache. dizziness thirst increased blood sugar. muscle cramps. increased cholesterol skin rash gout diarrhea

Erb's point

traditional auscultatory area in the 3rd left intercostal space

Distribution-

transportation of a drug in body fluids to various tissues and organs of the body, the rate of distribution depends on adequate local blood flow in the target area (site where drug effects occurs) ex: shock(vasoconstriction) decreases circulation

Patient has the right to refuse

treatment if they are competent. They need to be aware of diagnosis, recommended treatment, alternative options, risks and benefits, providers involved in treatment regimen in order for a signature.

Erikson's stages of psychosocial development

trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferiority identity vs role confusion intimacy vs isolation generativity vs stagnation integrity vs despair

Standard Precautions

type of precaution used with all clients and in all settings, regardless of suspected or confirmed presence of infection.

• Cultural stereotypes:

unsubstantiated belief people of a certain group are alike in certain respects; may be positive or negative

Urinary #38 Renal perfussion-

urinary out put hourly 30ml minimum per hour

#41 kidney stones

urinary retention causes blockage blocks flow of urine back right up.

Digoxin (Glycosides) and HF

use in pt with HF and Afib. ACEI and Diuretics have failed to control this.

· CUBAN

use this when giving hand off report confidential, uninterrupted, brief, accurate, and named nurse

Handoff report

used to alert next caregiver about the clients status or recent changes in their condition

Check back-

used to clarify information. Repeat back order.

1. Choose my plate( tool to help adults) -

used to consume a nutrient-rich, calorie appropriate, balanced diet that includes variety of foods in moderation, and that will better manage their health and weight includes; fruits, vegetables, grains, protein, and dairy.

Food frequency questionnaire-

used to find out how many times per day, week, or month a particular food group is eaten

Braden scale: uses

used to identify persons at risk for developing pressure ulcers evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer final score reflects the patient's risk lower the score= more likely client will develop a pressure ulcer Score of 18 or less for hospitalized clients indicates risk Braden Scale: assesses 6 factors; assess client on admission, then once a shift or more often

CUS-

used to raise safety concerns. C= I am concerned, U= I am uncomfortable, I think this is a safety issue.

SBAR-

used when communicating with a Doctor. Situation, background, assessment, and recommendation. Ex: your concerns, patients health history, what you seen and how to help the patient.

MEWS-

uses pts vital signs to help identify the earliest signs that a pt. is deteriorating. People who are at high risk are: postoperative pts due to anesthesia which can cause respiratory depression and potential blood loss, decrease BP and increase HR, also deep vein thrombosis which can lead to a pulmonary embolism(blood clot). Very young/very old, pts using opioid analgesia, pts with chronic conditions or multiple comorbidities. Scoring=respiratory rate, heart rate, systolic BP, LOC, temperature, hourly output. 0= low concern, >5 need to call rapid response team right away. PEWS is used for pediatrics

2. Injury-

usually something sudden.

· Invasion of privacy-

violating a patients right to be left alone

· Sodium (Na) -

water balance, acid-base balance, muscle action, convulsion·

Environmental-

weather, bad neighborhood, support system

Primary care-

wellness and prevention. Ex: Dr appts, immunizations

By chemical or pharmacological class-

what the drug is made of · Brand name, official name, nonprescription, over the counter, chemical name, and genetic name

Required

when a patient has a functioning gastrointestinal (GI) tract but cannot get enough nutrients by mouth and becomes at risk for malnutrition

· Drug interaction-

when one drug alters or modifies the action of another

Peak level-

when the drug is at its highest concentration (rate of absorption=elimination) after that, metabolic and excretory begins to remove drug from the tissues and blood

Reservoir-

where germs live (people, animals, food)

· By body system-

where the drug works ex: can act on more than one body system. Valium can be used for anxiety or helps the intestinal system ·

Open-ended questions-

which gives the patient a chance to respond, without using yes or no.

sexual identity

which of the various categories of sexuality one identifies with

Patients

who had trauma, burn, severe malnutrition, neurological disorders that affect swallowing (ex: stroke,) cancer ·

6. Susceptible host-

who is vulnerable to get sick

Self-knowledge-

why did I do that and how did I come up with that? For example: a nurse values the "tough it out" response to pain but, puts that aside because she knows pain is individual and personal.

By usage-

why the drug is used ex: ibuprofen can be an analgesic, inflammatory, and an antipyretic agent

Evisceration

wound separation with protrusion of organs

Libel-

written/published form of defamation of character

Classifications: Nonbenzodiazepines

zolpidem tartrate side effects daytime drowsiness, dizziness, weakness, feeling "drugged" or light-headed; tired feeling, loss of coordination; stuffy nose, dry mouth, nose or throat irritation; nausea, constipation, diarrhea, upset stomach; or. headache, muscle pain.

Disease processes and functional limitations affecting nutrition:

· Alcoholism-poor appetite, decrease intake of some vitamins · Cognitive function- such as; confusion, mental illness may cause a person to forget when/what they ate · Ability to obtain/prepare food- ex; stroke, limited income a person may have to use between buying food, medication, or household utilities · Chewing/swallowing- missing teeth, acute disorders affecting throat such as; pharyngitis making it hard to swallow · Stomach function- heart burn, indigestion, and other disorders are common · Peristalsis- bowel inflammation or infection, tumors, stress can lead to nausea, vomiting, and affect nutrient intake · Medications- decrease appetite, alter metabolism, N/V, chemo and radiation

Ethic and values

· Altruism- concerns for welfare and well-being of others "pt. advocacy · Autonomy- right to self-determination to choose and act on that choose. Ex: you honor autonomy when you respect the pts decision without judgement even if you believe it's not in their best interest · Utilitarianism- greatest positive benefit, good results, usefulness · Deontology- considers action to be right or wrong regardless of its consequences ex: right of self determination · Beneficence- doing and promoting good · Nonmaleficence- do no harm and prevent harm · Fidelity- duty to keep promises, faithfulness ex: going back to check effectiveness of pain medication · Veracity-duty to tell the truth · Justice- obligation to be fair · Consequentialism- right or wrong of an action depends on the consequences of the act, rather than on the act itself

Describe nursing assessment before, during, and following the administration of a drug

· Before- measure vital signs, assess pts general condition is appropriate for medication, know the medication your given and biological factors that affect drug metabolism · While- mental status, coordination, ability to self-administer, swallowing · After- effectiveness of drug, side effects, signs of toxicity/adverse reactions

1. Vascular system:

· Carotid arteries abnormal sound called a bruit (whooshing sound) may indicate narrowing of an artery. Do not assess both at the same time, can make the client pass out · Jugular Venous Distention is seen when the right side of the heart is congested because of inadequate pump function · Peripheral vessels check blood pressure, palpating peripheral pulse ,(normal= regular, strong, and equal bilaterally. Abnormal=weak, absent, or asymmetrical) · Rate pulses: 0=absent, unable to palpate, 1=weak, thread, barely felt, 2=normal, easily palpated, 3=full/bounding · Test for adequate perfusion (not adequately oxygenated) pale, cool skin, cyanosis, hair might not grow, clubbing, paralysis, and erythema · Edema causes: Congestive heart failure, kidney failure, low albumin levels, peripheral vascular disease

1. The Ears and Hearing:

· Cerumen (wax) black, dark red, yellowish, or brown and waxy. Flaky, soft, or hard, with no odor; all normal variations. · Weber test checks for unilateral (one-sided), conductive (middle ear), and unilateral sensorineural (inner ear) hearing loss. Do first* · Rinne test used to primarily evaluate loss of hearing in one ear · Romberg test used for neurological function for balance

1. Prepare the client:

· Consider timing. · Avoid conducting an exam if patient is in pain/hungry/tired/anxious or unwilling to cooperate. · Introduce yourself, establish rapport, ask how the patient likes to be addressed, and explain what you'll be doing. · Have patient void before exam; this promotes relaxation and also makes it easier to palpate the abdomen. · Don't make exam too long and make sure they are in a comfortable position before starting. · Consider developmental and cultural differences. For example, some clients may want family members present or prefer someone from the same sex. Have interpreter present if they speak a different language. · Two Identifiers read wrist band, ask name and DOB

Define drug-drug interaction, antagonistic drug relationships, synergistic drug relationship, drug incompatibility, and medication contraindications

· Drug interaction- when one drug alters or modifies the action of another · Antagonistic- one drug interferes with the actions of another and decreases the resultant drug effect-that is, the combined effect is less than that of one drug given alone · Synergistic- there is an additive affect; that is, the effect of both drugs together is greater than the individual effects. Ex: alcohol can intensify effects · Drug incompatibility- multiple drugs are mixed together, causing a chemical deterioration of one of both drugs

Legal accountability Identify laws and regulations that guide nursing practic

· EMTALA- emergency medical active law act is the right to seek treatment regardless of pay · Patient self-determination act-right to make own healthcare decisions · Americans with disabilities act- protection against discrimination of individuals with disabilities · Mandatory reporting law- duty to report physical, sexual, or emotional abuse of vulnerable individuals(children, elderly, mentally ill) · Good Samaritan law- protect from liability those who provide emergency care to someone who needs medical services · Durable power attorney- identifies a person who will make healthcare decisions in the event the patient is unable to do so (surrogate decision maker/health care proxy) · Living will- prepared by an alert and oriented(competent) individual that gives direction to others about the person's wishes regarding life-prolonging treatments if the person becomes unable to do so · Safe harbor law- protects nurse from being suspended, terminated, for refusing to place a patient in harm's way

1. Dietary guidelines key recommendations:

· Eat a variety of vegetables, fruits, whole grains, fat free/low fat dairy, protein like poultry, eggs, and seafood · Limit saturated and trans-fat foods=added sugars and sodium, limit sodium, sugar, and alcohol intake. · Exercise regularly

Identify factors that influence vital signs: 1. Respirations

· Exercise causes an increase · pain acute can cause increase · stress/anxiety cause increase due to sympathetic stimulation · smoking · fever increase · hemoglobin increase + decrease · disease/medications= increase + decrease

1. The Eyes:

· Eyelids crusting, scales, or swelling of the lid is associated with infection of the eyelids or eyelashes · Sclera and Conjunctiva associated disorders may indicate infection, allergies, injuries, and live disorders · Len and Cornea Normal= transparent, smooth, and moist. Abnormal= roughness or irregularity of the cornea is seen with trauma/ cornel abrasion. Lens= Cataracts are frequently seen in older adults and may impair vision · Pupils PERRLA- Pupils are equal, round, reactive to light, and accommodation. Abnormal Ex: lazy eye, cataracts(cloudy) · Myopia diminished distant vision 20/100 · Hyperopia diminished near vison · Color blindness usually seen in men · Strabismus crossed eye · Amblyopia lazy eye · Visual field related to peripheral vision and extraocular muscle function(EOM). Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma limit the visual field

State approaches of a health assessment:

· Familiarize yourself with their situation. What are the Patient's main health concerns? · What type of health assessment are you doing? (focused, comprehensive etc.) · Do you need supplies? · Will you need assistance? · Has the patient required pain medication before exams in the past? · Demonstrate theoretical/self/ practical knowledge and therapeutic communication skills.

1. My plate for older adults

· Fruits and vegetables-choose canned varieties that are packed in their own juices or low sodium. Instead of fresh-easier to prepare and lasts longer. Important to consider when its difficult for an older adult to make frequent trips to the grocery store. · Fluids- water, tea, coffee, soups, fruits, and vegetables · Herbs and spice- enhance flavor and reduces need to add salt · Healthy oils, gains, dairy, and exercise

Identify factors that influence vital signs: 1. Blood pressure

· Gender- men slightly Higher BP than woman. After, menopause woman's BP tends to increase, due to decrease in estrogen · Family history- increase risk for hypertension developing · Lifestyle- smoking, increased sodium consumption, alcohol can increase BP · Indigestion and caffeine will increase but, no long-term effect · Exercise- temporary increase · Body position- BP is higher when a person is standing than with sitting · Stress- BP increase due to sympathetic stimulation · Pain- causes BP to increase. However, severe or prolonged pain can decrease BP

Identify factors that influence vital signs:

· Gender- women have slightly more rapid pulse rate than men · Exercise-increase · Food- indigestion causes increase · Stress- increase due to sympathetic system · Fever- increase 10 beats per Fahrenheit due to increase in metabolic rate increased and decrease in blood pressure so, body compensates · Blood loss-body compensates from decreased blood volume and increases pulse · Medications- stimulants increase, opioids decrease

1. The Head:

· HEENT head, eyes, nose, and throat. Use all assessment techniques-inspection, palpitation, percussion, and auscultation.

Alterations in fever:

· Hyperthermia (heat stroke)- temp above 103 S/S: hot, dry skin, rapid strong pulse, confusion, throbbing headache, impaired judgement. · Hypothermia- temp below 95F S/S: uncontrolled shivering, loss of memory, loss of conscience decreases, cyanotic lips/fingers, decrease respirations and pulse5. · Interventions: Acetaminophen (Tylenol) or ibuprofen (Motrin) Though, a fever up to 102.2F can be beneficial because it enhances the immune response to fight off infection. However, you want to keep the patient comfortable and from allowing fever to get dangerously high. Avoid making the patient shiver because it produces heat, which can increase temp. Cooling blankets, cloth-covered ice packs to groin, neck, or axillae, alcohol/tepid baths, and fluids. Hypothermia provide dry and warms clothing, warm liquids(avoid caffeinated/alcoholic), warm baths, heating blankets.

1. Speech:

· Inappropriate responses may be associate with psychiatric disorders · Difficulty speaking may indicate a neurological problem · Rapid speech may be a sign of anxiety, hyperactivity, or use of stimulants · Hoarseness could indicate inflammation in the throat from infection, overuse, or perhaps a tumor or other obstructive material. · Slow speech due to depression, sedation from meds, or neurological disorders.

1. Abdomen:

· Inspect/auscultate first before doing percussion and palpation to avoid altering bowel sounds · Normal bowel audible sounds, occurring every 5 to 15 secs or 5 to 30 per min · Hyperactive loud, rushing sounds occurring every 2 to 3 secs (or more than 30 per min) may indicate: diarrhea, early bowel obstruction, or gastroenteritis (infection of GI tract) · Hypoactive very faint and infrequent (fewer than 5 sounds per min) may occur after abdominal surgery, with bowel obstruction, or infection · Absent none after listening for 5 minutes

Demonstrate the techniques used during health assessment: Inspection-

· Inspection- Observe the person's gait, personal hygiene, and behavior. · Your skin - to look for bruising, cuts, moles or lumps · Your face and eyes - to see if they are even and "normal" · Your neck veins - to see if these are bulging, distended (swollen) · Your chest and abdomen (stomach area)- to see if there are any masses, or bulges · Your legs - to see if there are any swelling · Your muscles- to check for good muscle tone · Your elbows and joints - check for swelling and inflammation, if any deformities are present

1. The Chest and Lungs:

· Is respiratory effort easy? · barreled chest? Some COPD patients have · Is a Pacemaker present? · Kyphosis excessive curvature of the thoracic spin · Scoliosis lateral curvature of the spine · Bronchial breath sounds loud, high pitched, tubular sounds; expiration is of longer duration than inspiration. (normal) · Vesicular breath sounds soft, low pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase (normal) · Diminished breath sounds are heard with poor inspiratory effort · Adventitious breath sounds: Crackles (fine) rales= Brief, discontinuous, popping that sounds like wood burning in the fireplace. Crackles (coarse) rales= Same as fine but, louder and longer. Wheezing= continuous w/a musical quality. Low pitched sounds like moaning/snoring. Rhonchi= coarse sounds from fluid or mucous *clears with coughing · Stridor emergency, upper airway obstruction

1. Mental state:

· Lethargy may be due to medications, depression, neurological, thyroid, liver, kidney, or cardiovascular disorder · Confusion and irritability may indicate hypoxia or medication side effects · Older adult mini mental test, not used to diagnose Alzheimer's

Describe interventions for alterations in vital signs and how they affect homeostasis:

· Make sure cuff fits- if not could present false readings. Too big=low reading, Too small=higher reading · Normal-120/80 · Prehypertension- 120-139/80-89 obtained with two readings, 6 mins apart while sitting. Encourage lifestyle changes, recheck in 1 yr. or sooner · Stage 1 hypertension-140-159/90-99 on two or more separate occasions. Encourage lifestyle modifications, follow up with primary in 1-2 months, thiazide-type diuretic may be given · Stage 2 hypertension- >160/>100 encourage lifestyle modification, refer for care within 1 week, or immediately if warranted. Most pts will be given a two-drug combination therapy thiazide-type diuretic with ACE inhibitor · Orthostatic hypotension- sudden drop in BP when moving suddenly from a lying position to a sitting/standing position. Patient may feel dizzy or light-headed. Biggest concern is for falls** hypotension systolic <100 · MEWS-uses pts vital signs to help identify the earliest signs that a pt. is deteriorating. People who are at high risk are: postoperative pts due to anesthesia which can cause respiratory depression and potential blood loss, decrease BP and increase HR, also deep vein thrombosis which can lead to a pulmonary embolism(blood clot). Very young/very old, pts using opioid analgesia, pts with chronic conditions or multiple comorbidities. Scoring=respiratory rate, heart rate, systolic BP, LOC, temperature, hourly output. 0= low concern, >5 need to call rapid response team right away. PEWS is used for pediatrics

Describe interventions for alterations in vital signs and how they affect homeostasis:

· Normal (eupnea)- 12 to 20 breaths · Bradypnea- <10 breaths · Tachypnea >24 breaths · Kussmaul's- deep, rapid breathing pace throughout its duration ex: late-stage diabetic ketoacidosis( blow off excess CO2) · Biots- rapid gasps followed by apnea ex: meningitis · Cheyne-stokes- gradual increase then decrease, followed by apnea ex: brain stem injury, congestive heart failure · Stridor breathing- High pitched sound that is heard without a stethoscope with someone who has an obstructed airway. May be life threatening* · Stretor- labored breathing that produces a snoring sound. Ex: mouth breathing, death rattle · Hyperventilation- rapid, deep breathing result in excess loss of CO2. Have patient breathe into cupped hands, paper bag, take slow deep breaths ex: shock, anxiety, hypoxia, diabetes, aspirin · Hypoventilation- occurs when the rate and depth of respirations decrease, and CO2 is retained ex: COPD, general anesthesia, respiratory failure

Describe interventions for alterations in vital signs and how they affect homeostasis:

· Normal pulse rate is 60-100 and the most accurate reading is apical · Bradycardia- <60 bpm · Tachycardia- >100 bpm · 0- absent; pulse cannot be felt · 1- weak or thread; pulse is barely felt and can be easily obliterated by pressing with fingers · 2- normal quality; pulse is easily palpated, not weak or bounding · 3- bounding or full; pulse is easily felt with little pressure

1. Body mass index

· Normal- 18.5 to 24.9 · Overweight- >25 but <29.9 · Obesity >30 · Underweight <18.5

1. The mouth and Oropharynx:

· Normal- lips, buccal mucosa(cheek), and gums should be smooth, moist, and pink in color · Gingivitis sign of periodontal disease (red, swollen, or spongy, bleeding gingiva and receding gum lines) · Stomatitis inflammation of the oral mucosa · Leukoplakia thick, elevated white patches that do one scrape off · Thrush white, curdy patches that scrape off and bleed indicate a fungal infection · Aphthous ulcers small, painful vesicles with a reddened periphery and a white or pale-yellow base · Canker sores · Tooth decay and periodontal (gum disease) · Glossitis inflammation of the tongue · Black "hairy" tongue associated with fungal infections · Smooth red tongue occur in clients who have a deficiency of iron, vitamin B12 or vitamin B3 · Dry furry tongue dehydration · Limited mobility of the tongue

1. Body type and posture:

· Observe client's body size, build, and gait. · Muscle strength · Mobility · Posture- Ex: slumped position can indicate fatigue, depression, osteoporosis, or pain. · Immobile patients observe how much they can do for themselves · Do they use an assistive device? · Unsteady gait may be associated with joint, muscle, or neurological disorders.

1. The Skin:

· Observe skin color, lesions, and other characteristics · Unpleasant body odor may indicate poor hygiene · Presence of a wound · Excessive sweating may be related to activity, thyroid problems, or overactive sweat glands · Odor of urine or stool may mean they need assistance with care · Temperature- Ex: Fever, warmth over an area of erythema (superficial reddening over the skin) may indicate infection or inflammatory changes. Coolness may be due to poor peripheral circulation, shock, exposure to cold, or hypothyroidism. · Dry skin may result from dehydration, chronic renal failure, hypothyroidism, excessive exposure, or overzealous hygiene · Skin texture should be smooth and soft. Impaired circulation associated with smooth, thin, shiny skin with little to no hair. · Skin turgor refers to elasticity of the skin, provides data about hydration status. Ex: tenting occurs with dehydration but, could also be seen with normal aging. Elderly= decreased elasticity · Edema excessive amount of fluid in the tissues, is an abnormal finding. Common in clients with heart failure, kidney disease, peripheral vascular disease, or low albumin levels. · Skin lesions normal= nevi (moles, freckles, birthmarks), striae (stretchmarks) abnormal= primary skin lesion (disease irritation ex: acne) and secondary skin lesion (develop from primary lesions as a result of continued illness, exposure, injury, or infection) · Evaluate skin lesions using ABCDE (Asymmetry, Border irregularity, Color variation, Diameter greater than 0.5 cm, Elevation above the skin surface.

Define onset, peak, and duration of drug action; therapeutic level, peak, and trough level; and biological half-life

· Onset- time needed for drug concentration to reach a high enough blood level for its effects to appear · Peak action- concentration of medication is highest in the blood · Duration- period of time in which the medication has a pharmacological effect (before metabolism/excretion) if serum level of medication falls below the minimum effective concentration, then the drug is not effective during that time. Drug levels peak level, toxicity occurs · Therapeutic level- concentration of a drug in the blood serum that produces the desired effect without toxicity. · Peak level- when the drug is at its highest concentration (rate of absorption=elimination) after that, metabolic and excretory begins to remove drug from the tissues and blood · Trough level- occurs when the drug is at its lowest concentration, right before the next dose is due · Half-life- amount of time it takes for half of the drug to be removed from the body. Ex: Ambien would take 11 hours (2 hours x 5.5) to be eliminated

1. The Hair:

· Pediculosis (head lice) · Texture exceptionally dry coarse hair could be a sign of hypothyroidism. Very fine, silky hair may indicate hyperthyroidism. · Scalp asymmetrical or bumpy scalp due to trauma or lesions · Scaly flakes or patches due to fungal infection, dandruff, dermatitis, or psoriasis

1. The Nails:

· Pink nails with rapid capillary refill indicate circulation · Pale or cyanotic nailbeds are seen in clients with circulatory or respiratory disorders that result in anemia or hypoxia · Clubbing nails is associated with long term hypoxia state. Ex: chronic lung disease · Thickened nails may result from poor circulation · Soft, boggy nails are seen with poor oxygenation

Compare and contrast primary, secondary, cumulative, and side effects, and adverse, toxic, allergic, anaphylactic, and idiosyncratic reactions

· Primary effect are the reason the drug was prescribed. Where secondary effect is unintended/nontherapeutic(adverse effect) · Side effects- are unintended, often predictable, physiological effects of medication to which patients usually adapt · Adverse reaction- are harmful, unintended, usually unpredictable reactions to the drug administered at the normal dosage · Allergic- immune system identifies a medication as a foreign substance that should be destroyed; can be minor · Anaphylactic- life threatening allergic reaction and occurs immediately · Idiosyncratic- abnormal response to a medication "extreme sensitivity" · Cumulative- Increased response to repeated dose of a drug (opioids)

1. Prepare the environment:

· Provide privacy · Turn off TV/radio or other media · Good lighting · Adjust temperature · Make sure to have all your supplies.

Six rights of medication administration

· Right patient · Right medication · Right dose · Right route · Right time · Right documentation

Think Smart:

· Specific- individualized for the patient · Measurable- patient response compared to standards · Achievable- all aspects considered · Realistic- can it be reached? · Timely- time frame, when will it happen · Ex: acute pain related to right femoral neck fracture as evidenced by c/o pain and moaning SMART

Interpret normal versus abnormal findings in a health assessment

· Speech and behavior appropriate for their developmental stage · Signs of distress, either physical or emotional · Quality of the visible skin ex: excessive wrinkles from smoking/sun exposure. · Illness may make the client appear older than their stated age. · Look for indications of their mood and mental status · Orientation and level of consciousness use Glasgow coma scale · Signs of abuse

Percussion-

· Tapping your fingers on the skin using short strokes. Tapping produces vibrations, and the resulting sound allows you to determine location, size, and density of underlying structures. For example, fluid in lungs or mass in stomach.

Palpation-

· The use of touch to gather data. · Temperature · Skin texture · Moisture · Anatomical landmarks · Abnormalities as edema, masses, or areas of tenderness

Types of medication prescriptions

· Written · Automatic stop date · STAT · Single · Standing orders · Prn

Initial assessment

· completed when the client first comes to the healthcare agency

1. Identify a variety of charting formats and their purposes Source-oriented record

· members of each discipline record their findings in a separate labeled section in the chart. Ex: admission data, advance directive, history and physical, providers orders, progress notes etc.

PES-

· problem, etiology, symptom

· Mandatory reporting law

·duty to report physical, sexual, or emotional abuse of vulnerable individuals(children, elderly, mentally ill)

Catheter embolus

—a piece of catheter breaks off and travels through the vascular system Causes Reinserting a catheter used in an unsuccessful insertion; removing and reinserting a stylet, causing shearing of the catheter; placing the catheter in a joint flexion Signs and symptoms Sharp, sudden pain at IV site, jagged catheter end on removal, dyspnea, chest pain, tachycardia, hypotension Nursing response Apply a tourniquet above the site. Notify the physician and radiologist. Start a new IV line. Prepare the patient for radiographic examination.

Air embolus

—a rare complication involving the introduction of air into the vascular system Causes Loose connections, adding a new IV bag to a line that has run dry without clearing the line of air, air in tubing cassette of infusion pump Signs and symptoms Palpitations, chest pain, light- headedness, dyspnea, cough, hypotension, tachycardia, sudden change in mental status Nursing response Call for help. Place client in Trendelenburg's position on the left side. Administer oxygen. Have emergency equipment available

respiratory acidosis causes

• Depression of the respiratory center. (1) Head injuries. (2) Oversedation with sedatives and/or narcotics. • Conditions affecting pulmonary function. (1) COPD (2) Pneumonia. (3) Atelectasis. • Conditions that interfere with chest wall excursion. (1) Thoracic trauma: flail chest. (2) Diseases affecting innervation of thoracic muscle (Guillain-Barré syndrome, myasthenia gravis, polio). (3) Mechanical hypoventilation.

metabolic acidosis causes

• Incomplete oxidation of fatty acids. May be due to (1) diabetic ketoacidosis, (2) starvation, or (3) shock, resulting in lactic acidosis. • Abnormal loss of alkaline substances. This may be caused by deep, prolonged vomiting (leading to excessive loss of base products) or severe diarrhea and loss of pancreatic secretions. • Renal insufficiency and failure: kidneys lose ability to compensate for acid overload; thus, H⁺ ions are not excreted, nor is HCO₃⁻ retained in normal amounts. • Salicylate poisoning due to accumulation of ketone bodies produced as a result of the increased metabolic rate.

How to protect skin integrity

• Nutrition/hydration Protein: maintains the skin, repair minor defects, and preserve intravascular volume Cholesterol Calorie Intake Vitamin C, zinc, copper: formation of collagen HydrationSensation level• Diminished sensation leads to increased risk for pressure and breakdown

Hypertonic Fluids IV

• Osmolality is higher than that of serum • pull fluids and electrolytes from intracellular and interstitial into the intravascular compartment • help stabilize blood pressure, increase urine output, and reduce edema Examples of hypertonic fluids • ̃D5 0.9% Normal Saline (D5NS) • ̃D5 0.45% Normal Saline (D51/2NS) • D5 Lactated Ringer's • 3% NaCl and 5% NaCl—highly hypertonic; used only • in critical situations ̃D10W, D20W (used as osmotic diuretic to promote diuresis) When hypertonic solutions are used (very cautiously....most likely to be given in the ICU due to quickly arising side effects of pulmonary edema/fluid over load). In addition, it is prefered to give hypertonic solutions via a central line due to the hypertonic solution being vesicant on the veins and the risk of infiltration.

respiratory alkalosis causes

• Primary stimulation of CNS: hyperventilation. Can be due to emotional origin (anxiety, fear, apprehension), CNS infection (encephalitis), or salicylate poisoning. • Reflex stimulation of CNS. Hypoxia stimulates hyperventilation (heart failure, pneumonia, pulmonary emboli). Can also be stimulated by fever. • Mechanical hyperventilation, resulting in "over breathing."

Hyponatremia (Na+)

• Serum Na+ <135mEq/L • Results from excess of water or loss of Na+ • Water shifts from ECF into cells • Signs/Symptoms: cramps, nausea, vomiting, weakness Treatment: Diet:foods high in sodium, IV if hypovolemia cause, diuretic for water excretion not sodium Interventions: Hyponatremia: • Monitor I&O • Monitor sodium level. • If severe: administer IV saline infusion & initiate seizure precautions • Permanent neurological damage can occur when serum Na levels fall below 110 mEq/L

Holistic Mandatory article Animal roles

• Service animals: specially trained to provide assistance to a person with a physical or psychiatric disability • Animal-assisted therapy: a treatment process for specific individuals developed by healthcare or human resource providers • Animal-assisted activities: time spent with animals that isn't part of an individual's treatment goals or designed to assist with a specific disorder Emotional support animals: provide comfort to individuals with psychiatric disabilities, but don't perform assistive tasks

Isotonic Fluids IV

• Tonicity (250 to 375 mOsm/L) similar to blood serum osmolality • When infused remain inside the blood vessels • Used for hypotension or hypovolemia • Commonly prescribed isotonic fluids: • 0.9% sodium chloride (0.9% NaCl), also called normal saline (NS) • Lactated Ringer's (LR) • D5W is classified as both isotonic and hypotonic. • In IV bag it is isontonic, however it is not prescribed for isotonic use because after rapid metabolism, it is hypotonic in the body

Perfusion:

• ability of cardiovascular system to pump oxygenated blood to tissues & return deoxygenated blood to the lungs

Chronic:

• begins as normal grief but continues long term, with little resolution of feelings and inability to rejoin normal life Masked: • occurs when the person is grieving but expressing the grief through other types of behavior

Complicated:

• distinguished from uncomplicated grief by length of time and intensity of emotion • person's responses are maladaptive, dysfunctional, unusually prolonged, or overwhelming • Complicated grief results when the grieving process has been impeded for some reason (e.g., something keeps the person "stuck" in the grief process)

Disenfranchised:

• experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies • In these instances, the bereaved person lacks the communal support that is helpful in grieving

Anticipatory:

• is experienced before a loss occurs

Delayed:

• is grief that is put off until a later time; e.g., "I'll think about it later

Kübler-Ross stages: it is important to understand that dying people and loved ones:

• may not go through every stage • may not go through the stages in a linear fashion, but rather in random order • do not necessarily complete one stage and move on to the next • may experience two or three stages simultaneously • Denial: Shock; This cannot be happening. Gives the person a chance to start preparing • Anger: Why me? This is unfair. Take anger out on 'safe' people • Bargaining: Bargaining with a higher power- God. Ask to live to see a birth, wedding • Depression: Withdrawn sadness; Response to current loss AND future losses Acceptance: Not wanting death, but coming to terms with it and not fighting it

Cognitive disabilities

• traumatic brain injury (TBI) or anoxic brain injury (ABI) • Down syndrome autism spectrum disorders • mental disorders.

Hypocalcemia (Ca++)

• ̃Serum Ca2+ <8.5 mq/dl • ̃Cause: from low intake, vitamin d deficienty, diuretics, parathyroid disorders, renal failure, thyroid surgery • ̃Signs & symptoms: muscle cramps, cardiac irritability, EKG changes, positive Chvostek's & Trousseau's sign • Treatment: diet, IV therapy, supplements Chvostek's sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve: tap facial nerve in front of ear= facial spasm • Trousseau's sign: Carpal spasm occurs when the upper arm is compressed, as by a tourniquet or a blood pressure cuff due to increased neuromuscular excitability

sight nursing assessment

•Check the pupils of your patients ! You must have a good baseline. KNOW WHAT PERRLA is - this is vital to your assessments!

Difference in pre/intra/post operative care

•Nursing care given before, during and after surgery •Pre-operative - before surgery •Intra-operative -during surgery •Post-operative - after surgery