OSCE helpful from HHA (head to toe assessment

normale range and other Normal ranges: HemoglobinA1C (long term sugar)= non diabetic: 4-6%; optimal diabetic control: < or = to 7% Hemoglobin= males: 13-18 g/dL; females: 13-16 g/dL Hematocrit= males: 40-52%; females: 36-48% Serum albumin = 3.5-5.5 g/dL Total protein = 6-8 g/dL Prealbumin = 15-30 mg/dL Transferrin = 200-400 mg/dL Fasting blood sugar = 65-99 mg/dL

Abdomen age specific= pot belly for little baby is normal; striae, linea Niagara (dark line comes from umbilicus to pubis) is normal in childbearing women; abdominal hernia can occur in who plays n do exercise because their rectus abdominis is not well developed; Rigid abdomen in child- emergent problem; Nutrition =subjective data: talk to them abt wt their typical meals like, health hx then decide further assessment of their nutrition that might be related if somebody suddenly lost weight or suddenly gained weight; if somebody gaining 5 pounds in 3 days most likely to related to water (fluid) related to CHF:pitting edema, ..,if they lose weight short period of time sometimes r/t malnutrition, cancer diagnosis, albumin is not great in older pt, mouth dry= dehydrated; looking for moist, pink oral mucosa, for dehydration need to look I&O: wt they taking in n out, look at oral mucosa, skin texture, flaky (dehydrated), r they taking diuretic meds If malnourished n protein n albumin low might have brittle hair n nails With ascites might have protein deficiency (helps to differentiate one abdomen diagnosis vs the other) nutrition AS= older adult: change or sudden loss of appetite significant for adverse meds side effects; poor oral health can impact nutrition ; aspiration is alert that's a problem; disphagia

Dissociative= coping mechanism If somebody physically abused; severely abused; Dissociative identity disorder diagnosis: Alteration in self identify Anxiety Risk for other directed violence Ineffective coping =s&s disorganized thought; AEB withdrawal from relationships No specific meds to treat this disorder bt there is way to interrupt behavior through therapy

COPD: irreversible; typically affects middle-age to older adults Emphysema: loss of lung elasticity n hyperinflation of lung tissue. Causes destruction of alveoli which decreases surface area for gas exchange, carbon dioxide retention, resp acidosis Chronic bronchitis: inflammation of bronchi n bronchioles d/t chronic exposure to irritants Health promotion n disease prevention Promote smoking cessation Avoid exposure to send hand smoke Use protective equipment like mask, ensure proper ventilation while working in env that contain carcinogens or particles in air Influenza n pneumonia immunization r imp for all who have COPD, bt especially for older adults Risk factors: Advanced age: older adult have decreased pulmonary reserved d/t age related lung changes Cigarette smoking is primary risk factor for development of COPD Alpha1-antitrypsin (AAT) deficiency Exposure to environmental factors (air pollution) Expected findings: chronic dyspnea, RR can reach 40-50/min during acute exacerbations; physical assessment findings: Dyspnea upon exertion Productive cough that's most severe upon rising in morning Hypoxemia Crackles n wheezing Rapid n shallow resp Use of accessory muscles Barrel chest or increased chest diameter (with emphysema) Hyper resonance on percussion d/t "trapped air" (wiht emphysema) Irregular breathing pattern Thin extremities n enlarged neck muscles Dependent edema secondary to high-sided heart failure Clubbing of fingers n toes (late stages of disease) Pallor n cyanosis of nail beds n mucous membranes (late stages of disease) Decreased ox saturation levels (expected reference range is 95-100%) In older adults who have dark-colored skin, ox saturation levels can be slightly lower Laboratory tests: Increased hematocrit level is d/t low ox levels Use sputum cults n WBC counts to diagnose acute reps infection ABGs a. Hypoxemia (decreased PaO2 less than 80 mm Hg) b. Hypercarbia (increased PaCO2 greater thank 45 mm Hg) Blood electrolytes Diagnostic procedure Pulmonary function test: used for diagnosis as well as determining effectiveness of therapy - comparisons of forced expiratory volume (FEV) to forced vital capacity (FVC) r used to classify COPD as mild to very severe - As COPD advances, FEV-to-FVC ratio decreases. Expected reference range is 100%. For mild COPD, FEV/FVC ratio is decreased to less than 70%. As the disease progresses to moderate n severe, ratio decrease to less than 50% Ches x-ray: Reveals hyperinflation of alveoli n flattened diaphragm in late stage os emphysema Its often nt useful for diagnosis of early or moderate disease Alpha1 antitrypsin levels: used to assess for deficiency in AAT, enzyme produced by liver that helps regulate other enzymes (which help break down pollutants) from attacking lung tissue Nursing care Encourage deep breathing n use of incentive spirometer Administer breathing tx n meds Administer ox as prescribed. In COPD, low arterial levels of ox serve as primary drive for breathing. However, in most cases, ox levels should be maintained between 88-92% COPD pt can need 2 to 4 L/min of ox via nasal cannula or up to 40% via Venturi mask. Who have chronically increased PaCO2 levels usually require 1 to 2 L/min of ox via nasal cannula Monitor for skin breakdown around the nose n mouth from ox device Promote adequate nutrition - increased work of breathing increases caloric demands - proper nutrition aids in prevention of infection - encourage fluids to promote adequate hydration - dyspnea decreases energy available for eating, so soft, high calorie foods should be encouraged Monitor weight n note any changes Instruct to practice breathing tech to control dyspneic episode - for diaphragmatic (abdominal) treating, instruct to: - - take breaths deep from diaphragm - - lie on back with knees bent - - rest hand over abdomen to create resistance - - if hand rises n lowers upon inhalation n exhalation, breathing is being performed correctly - for pursed-lip breathing, instruct to: - - form mouth as if preparing to whistle - - take breath in through nose n out through lips/mouth - - nt puff the cheeks - - take breaths deep n slow Positive expiratory pressure device - assists to remove airway secretions - inhales deeply n exhales through device - while exhaling, ball inside device moves, causing vibration that results in loosening secretions Exercise conditioning - includes improving pulmonary status by strengthening condition of lungs by exercise - walk daily at self-paced rate until dyspnea occurs, then stops to rest. Once dyspnea resolves, resumes - walk 20 min daily to 2-3 times weekly - determine physical limitation, n structure activity to include periods of rest - provide rest periods for older adult who have dyspnea. Design room n walkways with opportunities for relaxation Provide support to client n family. Talk abut disease n lifestyle changes, including home care services like portable ox Increase fluid intake. Encourage client to drink 2-3 L/day to liquefy mucus Incentive spirometry: used to monitor optimal lung expansion Nursing action: show how to use it Client education: keep tight mouth seal around mouthpiece n inhale n hold breath for 3-5 seconds. During inhalation, needle of spirometry machine will rise which promotes lung expansion Meds: bronchodilators (inhalers): Short acting beta2 agonist like albuterol provide rapid relief Cholinergic antagonists (anticholinergic meds) like ipritropium, block PNS which allows for SNS effect of increased bronchodilation n decreased pulmonary secretions. These meds r long acting n r used to prevent bronchospasm Methylxanthines like theophylline relax smooth muscles of bronchi. Require close monitoring of blood medication levels d/t narrow therapeutic ranges. Use only when other tx ineffective Nursing actions: Monitor for toxicity when taking theophylline. Adverse effects include tachycardia, nausea, diarrhea Watch for tremors n tachycardia when taking albuterol Observe for dry mouth the ntaking ipritropium Client education Suck on hard candies to help moisten dry mouth while taking ipratropium Increase fluid intake, report headaches, or blurred vision Monitor HR. Palpitations can occurs, which indicates toxicity of ipratropium Anti-inflammatory agents: decrease airway inflammation If corticosteroids like fluticasone n prednisone r given systemically, monitor for serious adverse effects (immunosuppression, fluid retention, hyperglycemia, hypokalemia, poor wound healing) Leukotriene antagonists like montelukast; mast cell stabilizers like cromolyn; n monoclonal antibodies like omalizumab can be used Nursing actions Watch for decrease in immunity function] Monitor for delayed wound healing Monitor for hyperglycemia Observe for fluid retention n weight gain. This is common Check the throat n mouth for aphthous lesions (canker sores) Omalizumab can cause anaphylaxis Client education Drink plenty of fluids to promote hydration Report black, tarry stools Take glucocorticoids with food Use medication to prevent n control bronchospasm Avoid people who have respiratory infections Use good mouth care Use meds as prophylactic prevention of COPD manifestations Do not discontinue medication suddenly Mucolytic agents: help thin secretions, making them easier to expel Nebulizer tx include acetylcysteine n dornase alfa Guaifenesin is oral agent that can be taken Combination of guaifenesin n dextromethorphan also can be taken orally to loosen secretions Therapeutic procedures Chest physiotherapy uses percussion n vibration to mobilize secretions Raising foot of bed slightly higher than head can facilitate optimal drainage n removal of secretions by gravity Humidifiers can be useful for who live in dry climate or who use dry heat during winter Interprofessional care Consult resp services for inhalers, breathing tx, suctioning for airway mgmt Contact nutritional services for weight loss or gain r/t meds or diagnosis Consult rehabilitative care if has prolonged weakness n needs assistance with increasing activity level COPD is debilitating for older adult clients. Mgmt of disease is continuous. Referrals to assistance programs like food delivery services can be indicated Set up referral services including home care services like portable ox Provide support to client n family Client education Eat high calorie foods to promote energy Rest as needed Practice hand hygiene to prevent infection Take meds (inhalers, oral meds) as prescribed Stop smoking if needed Obtain immunizations like influenza n pneumonia to decrease risk of infection Use ox as prescribed. Inform other caregivers nt to smoke around the ox d/t flammability Acute infections n other complications often require hospital stays. Report unusual findings or concerns to provider Ensure fluid intake of at least 2 L (68 oz) daily to thin secretions, unless provider recommends otherwise complication Resp infection: result from increased mucus production n poor oxygenation levels Nursing actions Administer ox therapy Monitor oxygenation levels Monitor for indications of infection (increased WBC, CRP, decreased SaO2, change in temp) Administer antibiotics n other meds Client education Avoid crowds n people who have respiratory infection Obtain pneumonia n influenza immunizations Right- sided heart failure (for pulmonale) Air trapping, airway collapse, n stiff alveoli lead to increased pulmonary pressure Blood flow through lung tissue is difficult. This increased workload leads to enlargement n thickening of right atrium n ventricle Manifestations - low oxygenation levels - Cyanosis - Enlarged n tender liver - distended neck veins - Dependent edema Nursing actions - monitor resp status n administer ox therapy - monitor for GI disturbances (nausea, anorexia) - monitor HR n rhythm - administer meds as prescribed - administer IV fluids n diuretics to maintain fluid balance

Asthma: chronic disorder of airways that results in intermittent n reversible airflows obstruction of bronchioles; obstruction d/t inflammation or airway hyperresponsiveness; can occur at any age; cause unknown; manifestation: mucosal edema, bronco constriction/spasm, excessive mucus production Health promotion n disease prevention If smokes, promote smoking cessation Advise to use protective equipment (mask) n ensure proper ventilation while working in environments that contain carcinogens or particles in air Encourage influenza n pneumonia vaccination for older adults n all who have asthma Instruct how to recognize n avoid trigging agents A. Environmental factors like changes in temp (esp warn to cold) n humidity B. Air pollutants c. Strong odors (perfume) d. Seasonal allergens (grass, tree, weed pollens) n perennial allergens (mold, feathers, dust, roaches, animal dander, foods treated with sulfites) E. Stress n emotional distress f. Meds (aspirin, NSAIDs, beta-blocker, cholinergic) g. Enzyme, including those in laundry detergents h. Chemicals (household cleaners) i. Sinusitis with postnasal drip j. Viral respiratory tract infection Teach how to self-administer meds (nebulizer n inhaler) Educate regarding infection prevention tech Encourage regular exercise as part of asthma therapy a. Promotes ventilation n perfusion b. Maintains cardiac health c. Enhances skeletal muscle strength d. Can require premedication Instruct to use hot water to eliminate dust mites in bed linens Assessment: diagnosis is based on findings n classified into one of the following 4 categories Mild intermittent: symptoms occur less than twice a week Mild persistent: " arise more than twice a week bt not daily Moderate persistent: daily symptoms occur in conjunction with exacerbation twice a week Severe ": symptoms occur continually, along with frequent exacerbation that limits physical activity n quality of life Risk factors: Older adults have decreased pulmonary reserves d/t physiological lung changes that occur with aging process a. more susceptible to infection b. Sensitivity of beta-adrenergic receptors decreases with age. As the beta receptors are n lose sensitivity, there r less able to respond to agonist, which relax smooth muscle n can result in bronchospasm Family hx of asthma Smoking Secondhand smoke exposure Environmental allergies Exposure to chemical irritants or dust GERD Expected finding: dyspnea, chest tightness, anxiety or stress; coughing, wheezing, mucus production, use of accessory muscles, prolonged exhalation, poor ox saturation (low SaO2), barrel chest or increased chest diameter Obtain hx regarding current n previous asthma exacerbations Onset n duration Precipitation factors (stress, exercise, exposure to irritant) Changes in medication regimen Meds that provide relief Other meds taken Self-care methods used to promote relief Laboratory tests: ABG= hypoxemia (decreased PaO2 less than 80 mm Hg); hypocarbia (decreased PaCO2 less than 35 mm Hg: early in attack); hypercarbia (increased PaCO2 greater than 45 mm Hg: later in attack) Sputum cultures: bacteria can indicate infection Diagnostic procedures: Pulmonary function tests (PFTs) r most accurate tests for diagnosing asthma n its severity a. Forced vital capacity (FVC) is volume of air exhaled from full inhalation to full exhalation b. Forced expiratory volume in first second (FEV1) is volume of air blown out as hard n fast as possible during first second of most forceful exhalation after greatest full inhalation c. Peak expiratory flow is fastest airflow rate reached during exhalation D. Decrease in FEV1 by 15% to 20% below the expected value is common in clients who have asthma. Increase in these values by 12% following the administration of bronchodilators is diagnostic for asthma Chest x-ray is used to diagnose changes in chest structure over time Nursing care Position to maximize ventilation (high-Fowler's) Administer ox therapy as prescribed Monitor cardiac rate n rhythm for changes during acute attack (can be irregular, tachycardic, or wiht PVCs) Monitor respiratory rate n rhythm for changes in effort, symmetry, SaO2; auscultate lung sound Initiate n maintain IV access Remain calm n reassuring Provide rest periods for older adult clients who have dyspnea. Design room n walkways with opportunities for rest. Incorporate rest into ADLs Encourage prompt medical attention for infections n appropriate immunization Administer meds as prescribed Meds: Bronchodilator (inhaler) Short-acting beta 2 agonist like albuterol, provide rapid relief of acute manifestation n prevent exercise induced asthma Anticholinergic meds like ipratropium, block parasympathetic nervous system. This allows for sympathetic nervous system effects of increased bronchodilation n decreased pulmonary secretions. These meds r long-acting n used to prevent bronchospasm Methylxanthines like theophylline require close monitoring oxblood medication levels due to narrow therapeutic range. Use only when other tx r ineffective Long-acting beta 2 agonist like salmeterol primarily r used for asthma attack prevention Nursing actions: Albuterol: watch for tremors n tachycardia Ipratropium: observe for dry mouth Theophylline: monitor blood levels for toxicity. Adverse effects include tachycardia, nausea, diarrhea Client education: Ipritropium: suck on hard candies to help relief dry moth; increase fluid intake; report headache, blurred vision, or palpitations, which indicates toxicity of ipratropium. Monitor HR Salmeterol: use to prevent asthma attack n nt at the onset of attack Anti-inflammatory agents: these meds r for prophylaxis n r used to decrease airway inflammation Corticosteroids like fluticasone n prednisone Leukotriene antagonists like montelukast Mast cell stabilizers like cromolyn Monoclonal antibody like omalizumab Nursing action: Watch for decreased immunity function n wound healing Monitor for hyperglycemia Observe for fluid retention n weight gain. This can be common Monitor throat n mouth for aphthous lesions (canker sores) Omalizumab can cause anaphylaxis Client education Report black, tarry stools Drink plenty of fluids to promote hydration Take prednisone with food Use good mouth care n hand washing regimen avoid people who have respiratory infection Use these meds to prevent asthma, nt for the onset of attack Do not discontinue medication suddenly Perform daily peak flow meter assessments. If only able to achieve reading in red zone, immediately use reliever meds n seek emergency care Combination agents (bronchodilator n anti-inflammatory) If prescribed separately for inhalation administration at the same time, administer bronchodilator first in order to increase absorption of anti-inflammatory agent Ipratropium n albuterol Fluticasone n salmeterol Interprofessional care: Respiratory service should be consulted for inhalers n breathing tx for airway mgmt Nutritional services can be contacted for weight loss or gain r/t meds or diagnosis Rehabilitation care can be consulted if client has prolonged weakness n needs assistance wiht increasing level of activity Complications: Respiratory failure: persistent hypoxemia r/t asthma can lead to respiratory failure nursing action: monitor oxygenation level n acid base balance; prepare for intubation n mechanical ventilation Status asthmatics: life threatening episode of airway obstruction that is often unresponsive to common tx. Involves extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, n creates risk for cardiac n/or resp arrest Nursing actions: Prepare for emergency intubation Administer IV fluids, ox, bronchodilator, epinephrine. Initiate systemic steroid therapy

Flunitrazepam is also known as the date rape drug; it produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur Crisisinterventionisprovidedinemergencydepartmentso general hospitals or in community-based crisis intervention centers (ANA et al., 2014).Crisiscaremaybeinitiatedbytheindividual, riends, amily,health care provider, or law en orcement personnel. Some patients are involun- tarily committed. Psychiatric emergencies may include suicidal (or hom- icidal) ideation, acute psychosis, or behavioral responses to drugs. The stayinsuch acilitiestendstobeshort,usuallylessthan24hours.Atthat point the patient may be discharged to home, re erred or inpatient care, or trans erred to another community acility such as a shelter. Residential treatment programs are structured short- or long- term 24-hour living environments in which individuals are provided withvaryinglevelso supervisionandsupport(ANAetal.,2014).Psy- choeducationisprovided orsymptommanagementandmedications. Vocational training and even training or daily activities o living may also be part o the program. The residents learn to access community support as an alternative to hospitalization and are encouraged to achieve maximal independence. refeeding syndrome, a potentially catastrophic treatment complication in which the demands o a replenished circulatory sys- temoverwhelmthecapacityo anutritionallydepletedcardiacmuscle, which results in cardiovascular collapse

from fundamental Values, Ethics, & Advocacy (Chapter 6) - Key Terms; Nurse as a Patient Advocate; Ethical Situations. Legal Dimensions (Chapter 7) - Key Terms. Laws that govern nursing practice laws. Malpractice. Safety. Sentinel & Never Events. Table 7-1. Box 7 - 3, Frequent Allegations/Nursing Malpractice. Table 7-2, Elements of Liability. Student Liability. Informed consent. Impaired Nurse. Rest & Sleep (Chapter 34-see table above for pages) - Assessment of patients. Effects of hospitalization. Interventions. Terms. Medications. Chapter 34 Care Plan. Sensory Functioning (Chapter 44) - Assessment of patients. Review interventions for specific sensory situations/definitions. Implement safety standards. Fluids, Electrolytes, & Acid-Base Balance (Chapter 40)- Lots of tables that summarize information. Tables listed and noted on chapter podcast are important. Clinical manifestations of disorders/conditions—risk factors and assessment findings Nursing Diagnoses Table 40 - 4: Clinical Assessment. I&O; Urine Volume & Concentration; Body Weight - 1 kg (2.2 lbs) of body weight is used as an indicator of gain or loss of 1 liter of fluid. How much fluid is a patient retaining when there is a weight gain of 8 lbs? Answer- approximately 3.6 liters of fluid. Table 40-1. Major Electrolytes—use these values. EXCEPT - Use Table 40-5 for Bicarbonate—do not confuse values that are venous when you need arterial values for ABGs. Know the following values: o Electrolytes- Sodium, Potassium, Chloride, Magnesium, Total Calcium, Phosphate (Table 40- 1) o ABGs- pH; PaCO2; HCO3— Table 40- 5 (Arterial) o Interpreting ABG values. Table 40- 5. Use arterial blood/serum values and not venous. Know numbers and descriptions of conditions. What conditions are associated with acid-base imbalances? IV Therapy (Chapters 29 & 40) - Intravenous exam items are not intended to include techniques, such as how to angle the IV catheter for insertion. However, you will need to focus on monitoring for complications and nursing interventions. Chapter 29- "Administering Medication Intravenously". Vascular Access Devices. Complications of IV therapy- Table 40-9. Types of IV solutions- Table 40-7. Knowledge of high alert medications administered via IV- such as heparin, insulin, and potassium. Blood Therapy (Chapter 40)- Pre-administration assessment and safety steps; on-going monitoring; post-administration steps and patient assessment. Types of reactions- Table 40-10. No questions on matching specific blood type and compatibility. However, remember the universal donor is O negative and the universal recipient is AB positive. TPN (Chapters 36 & 40) - Caring for a patient who is receiving TPN. Guidelines for care- 36-2. Preventing complications. Nutrition (Chapter 36)- Not intended to test information that you learned in Health Promotion. Make sure you are prepared to make decisions regarding care for patients in the hospital setting- such as types of diets, assisting patients with meals, etc. Enteral nutrition is a focus. Review complications of enteral feedings. Special Considerations- Box 36-5 & Box 36-6. Self-Concept (Chapter 41)- Terms. 4 Components of Self-Concept= Personal identity, Body image, Role performance, Self-esteem. Personal Strengths. Box 41-1. Nursing Interventions. Loss, Grief & Dying (Chapter 43)- Focus on applications of terms. Types of Loss. 5 Stages of Dying/Grief by Kubler Ross. Signs of impending death; and other interventions during the dying process. Post-mortem care. Spirituality (Chapter 46) - Terms and Concepts. Three Spiritual Needs. Interventions to support a patient's spiritual practices. Implementing care. Holistic Care. Table 46-1 Medication Dosage Calculations- Format- Multiple-choice or fill in the numerical number.

Foundation exam 2 exam 2 missed question on test= Chronic pt needs clock wise medication nt PRN; albuterol causes palpatation n headache; while putting eye drop press inner canthus to prevent systemic reaction; pain in bone n tendon= somatic pain Ebook Link= https://coursepoint.vitalsource.com/books/9781975101336 intramuscular= 72, 90 degree angle; subcutaneous= 45, 90 degree; intradermal= 5-15 degree Specific Medications to review- o Coumadino Heparino Insulin o Morphineo Enoxaparino Inhaled Medications (Devices)o Transdermal Preparations (in general) Urinary Elimination (37) 8 - 10 Comfort & Pain (35) 6 - 8 Oxygenation & Perfusion (39) 12 - 14 Perioperative Nursing (30) 6 - 8 Medications (29) 14 - 16 Dosage Calculation 2 - 3 Content Topics - Taylor textbook chapters are in parenthesis (xx). Has end-of-chapter practice questions. For all chapters in Taylor, please review end of chapter skills, especially information in "red" and unexpected situations. "What should the nurse do first?" "What is a priority intervention?" For all PowerPoints, please review chapter boxes, tables, and guidelines. Boxes listed below may not have been included in the PowerPoint and are listed for study purposes. Med Lab - Review techniques and all medications routes (except IV route); review how to read medication orders; know injection sites; needles/syringes -Table 29-5. Chapter 29 --Medications—ATI: Chapter 46, 47, 48, 50, 51. Patient teaching and evaluating a patient's knowledge. Such as a patient is to self-administer an injection or assessing a patient's knowledge of medications. Think safety—Prevention of medication errors; actions to take in the event of an error; monitoring patients for complications; etc. Types of adverse drug effects, side effects, and other interactions. Critical Thinking Examples- What assessment data would you need prior to administering an anti-hypertensive med or a transdermal patch-topical/skin medication or a medication administered by an enteral tube? Medications to Know from Chapter 29- Review medications listed on PP slides for Chapter 29. Chapter 37-Urinary Elimination- - Review A&P and age-related changes in each chapter - not a big focus yet helps in decision-making. Key Terms. Care of patient who has a catheter. Urinary diversions. Chapter Skills. Diagnostic Procedures- patient teaching. Chapter 35 -Comfort and Pain Management - Review interventions and Key Terms. Pharmacological and Non-pharmacological interventions. Box 35-1: Common Responses to Pain. Guidelines for Nursing Care 35-1 regarding Epidural Opioids. PCA pump. Chapter 30-Perioperative Nursing- Phases; Surgical Procedure Classification; Informed Consent; Pre-Operative Teaching; Patient Safety: Prevention of injury and Monitoring for complications. Post-Operative Nursing Care. The Joint Commission safety mandates. Chapter Skills. Chapter 39-Oxygentation and Perfusion- Focused Assessment; Common Diagnostic Tests, Diagnostic Studies & Procedures; Promoting Optional Function; Medications in Table 39-3; Safety in Oxygen Delivery; Patient Teaching regarding treatment and oxygen delivery systems safety; Oxygen delivery at home; Case Study presented in class. Chapter Skills. Medication Dosage Calculations- Format- Multiple-choice or fill in the numerical number.

OSCE introduce urself->Hand hygiene->identify pt look at armband n chart both->ask allergy->if s ask what is ur reaction?->provide privacy->I am going to do a head to toe assessment->it should nt be painful bt u might feel some discomfort ->I am gonna walk u with step by step procedure bt if u have any question in mean time feel free to ask me->do u have any qsn for me right now->are you ready to get started->can I see ur IV site (IV site is intact, no inflammation, pt is having IV fluid of 500 mL of sodium chloride which is infusion at a 100 mL/hr)->do u know where u at right now->do u know what's the today's date->do u know the time (pt is alert n oriented times 4)->can u smile for me->face is nice n symmetrical->do u see how many fingers I am holding->pt's hear n vision is intact->can u close one nose n breath in out for me->can u close other one n breath in out->nasal passage is clear->on a scale of 0-10, 0 being no pain n 10 being the worse pain possible->do u have any pain right now->now I am gonna assess ur oral mucosa (hand hygiene n put gloves)->can u open ur mouth for me->oral mucosa is pink, moist, n free of lesions->can u move ur tongue up for me->and side to side->tongue is also moist, pink, n free of lesions->(hand hygiene) now I am gonna listen to ur lungs->(clean stethoscope) can u sit down for me->I am gonna provide for ur privacy as much as I can but I am gonna listen scope to ur skin->every time I put stethoscope in ur area I want u to take deep breath in n out ok->(anterior 6 places) can u raise ur gown up for me->can u put ur arm just across (listen lateral side; 4 places)->posterior 8 places->lungs sound clear anterior posterior n laterally n no adventitious sound r heard->now going to listen to ur heart->switch to the bell to listen murmur->S1 is heard loudest at apex n S2 is heard loudest at base, heart rate is regular, no S3 n S4 sounds r heard n no murmur heard as well->now I am gonna do abdominal exam->can u lay down please->can u pull ur shirt up->inspect= skin is normal to ethnicity, the contour is flat, no lesions n pulsation noted->I am going to listen to ur abdomen ok->soft, clicks n gurgles r heard n these sounds r normal so bowel sound r normal->I am gonna percuss ur abdomen (before percuss (do u have any pain right now)-can u flex ur leg slightly->tympani is heard in all 4 quadrants->now I am going to slightly palpate ok->let me know if there is any discomfort->abdomen is soft there is no lesions or masses r noted n pt stated no discomfort-> can u sit down n put ur leg down for me->now I am gonna assess musculoskeletal system->assess for temp (temp is warm to touch, skin color is black, no lesion or abnormalities noted)- now going to do radial pulses (do both same time)->radial pulses r strong bilaterally n they r rated as 2 out of 3 which is normal->now capillary refill->capilary refill is less than 2 times 10->now range of motion (if u could repeat after me wt I am doing)->can u flex for me (hand goes up) so that's flexion->can u extend for me that's extension->can u flex like this for me->range of motion is full->now ROM against resistance->can u push against me, can u pull->muscle strength 5 out of 5 which is normal against the resistance n against the gravity->lower extremity->assess skin for the temp->skin is warm to touch, no lesion or abnormalities noted->dorsal pedis pulses->dorsal pedis pulses strong bilaterally n they r rated 2 out of 3 which is normal-> capillary refill in all 10 toes->cap refill less than 2 sec on all 10 toes->assess for edema->no edema is noted->ROM, can u flex ur knees like this (bend leg)->can u extend them all the way out->can u point down ur toes n point up ur toes->ROM of lower extremities is full->now against resistance, can u push against my hand (up leg), can u pull->muscle strength is 5 out of 5 which is normal against the resistance n gravity->that completes head toe assessment we gonna put u back into bed n doc will be with u shortly->go ahead n lay down in bed->bed in Lowest position->2 side rails up would u like the third, call bell is right here at ur side, do u have any pain right now->hand hygiene

Head to toe assessment

TB: infectious disease caused by Mycobacterium tuberculosis; transmitted trough aerosolization (airborne route) Once inside lung, body encases TB bacillus with collagen n other cells. This can appear as round nodule or tubercle on chest x-ray Only small % of people infected with TB actually develop active form of infection. TB bacillus can lie dormant for many yrs before producing disease; affects lungs bt can spread to any organ in blood. Risk of transmission decreases after 2-3 weeks of anti tuberculin therapy Health promotion n disease prevention Clients who live in high-risk areas for tuberculosis should be screened on yearly basis Family members of clients who have TB should be screened Screening is particularly imp for people born outside U.S. n migrant workers Early detection n tx r vital. TB slow onset, n client might not be aware until disease is advanced. TB diagnosis should be considered for any hemoptysis, dyspnea, fever, night sweats, or chills National n global health goals for TB include increasing % of clients who complete tx for TB Individuals who have been exposed to TB but have not developed disease can have latent TB. Means that Mycobacterium tuberculosis is in body, bt body has been able to fight off the infection. If not treated, it can lie dormant for several yrs n the n become active as the individual becomes older or immunocompromised Risk factors Frequent n close contact with untreated individual Lower socioeconomic status n homelessness Immunocompromised status (HIV, chemotherapy, kidney disease, diabetes mellitus, Crohn's disease) Poorly ventilated, crowded environments (correctional or long-term care facilities) Advanced age Recent travel outside of U.S. to areas where TB is endemic Immigration (especially from Mexico, Philippines, Vietnam, China, Japan, Eastern Mediterranean countries) Substances use Health care occupation that involves performance of high-risk activities (resp tx, suctioning, coughing procedures) Expected findings Persistent cough lasting longer than 3 weeks Purulent sputum, possibly blood streaked Fatigue n lethargy Weight loss n anorexia Night sweats n low grade fever in afternoon Physical assessment findings: older adults often present with atypical findings of disease (altered mentation or unusual behavior, fever, anorexia, weight loss) Laboratory tests Nucleic acid amplification testing - detects presence of M. TB in resp secretions n can check for rifampin resistance. Results r available in less than 2 hr - most rapid n accurate screening test for TB Quantiferon-TB gold: blood test that detects release of interferon-gamma (IFN-g) in fresh heparinized whole blood from sensitized people -diagnostic for infection, whether active or latent - results r available within 24 hr Acid fast bacilli smear n culture - positive acid fast test suggests active infection - diagnosis is confirmed by positive culture for Mycobacterium tuberculosis Nursing actions Obtain 3 early morning sputum samples Wear personal protective equipment when obtaining specimens Samples should also be obtained in negative airflow room Diagnostic procedures Montoux test - client will have positive intradermal TB test within 2-10 weeks of exposure to infection - intradermal injection of extract of tubercle bacillus is made. Read in 48-72 hr - Induration (palpable, raised, hardened area) of 10 mm or treated in diameter indicates positive skin test - induration of 5 mm is considered positive test for immunocompromised clients - Positive Mantoux test can indicate that active disease is present - clients who have had positive Mantoux test or have received Bacillus Calmette-Guerin vaccine within past 10 yrs can have false positive Mantoux test. These clients need chest x-ray or Quantiferon-TB Gold test t evaluate presence of activeTB infection - Clients experiencing immunocompromise can demonstrate anergy, or lack of response to Mantoux testing, even if M. Tuberculosis is present in body. In this case, other diagnostic testing is indicate to rule out infection - individuals who have latent TB can have positive Mantoux test n can receive tx to prevent development of active form of disease - Clients who r immunocompromised (like those who have HIV) n older adult clients should be tested for TB. Clients starting immunocomppressive therapy (like tumor necrosis factor antagonists) should be tested for TB prior to starting tx Client education: return for reading of injection site by health care personnel between n 72 hr Chest x-ray: prescribed to detect active lesions in lungs Nursing care Administer heated n humidified ox therapy as prescribed Prevent infection transmission - wear N95 HEPA filter or peered air purifying respirator when caring for clients who r hospitalized with TB - place in negative airflow room, n implement airborne precautions - use barrier protection the risk of hand or clothing contamination exists - have client wear surgical mask if transportation to another department is necessary. Transport using shortest n least busy route - teach to cough n expectorate sputum into tissues that r disposed of by client into provided plastic bags or no touch receptacles Administer prescribed meds Promote adequate nutrition - encourage fluid intake n well balanced diet for adequate caloric intake - encourage foods that r rich in protein, iron, vitamin C n B Provide emotional support Meds: due to resistance that is developing against anti tuberculin meds, combination therapy of 2 or more meds at a time is recommended Bec these meds must be taken for 6-12 months, medication noncompliance is significant contributing factor in development of resistant strains of TB Typical 4 medication regimen includes isoniazid, rifampin, pyrazinamide, ethambutol Client education: complete series of prescribed medication to ensure all bacteria r eliminated n to decrease chance of resistance Isoniazid: commonly referred to as INH, is bactericidal n inhibits growth of mycobacteria by preventing synthesis of mycelia acid in cell wall Nursing actions Take on empty stomach Monitor for hepatotoxicity (jaundice, anorexia, malaise, fatigue, nausea) n neurotoxicity (like tingling of hands n feet) Vitamin B6 (pyridoxine) is often prescribed concurrently to prevent neurotoxicity form isoniazid Liver function testing should be completed prior to n monthly after starting INH Client education Do not drink alcohol while taking isoniazid, Bec it can increase risk for hepatotoxicity Report any manifestations of hepatotoxicity Rifampin: commonly referred t was RIF; bacteriostatic n bactericidal antibiotic that inhibits DNA dependent RNA polymerase activity in susceptible cells Nursing actions Observe for hepatotoxicity Liver function testing should be completed prior to n at least monthly after starting RIF Client education Urine n other sectarians will be orange Immediately report pain or swelling of joints, loss of appetite, jaundice, or malaise Can intern with efficacy of oral contraceptive Pyrazinamide: commonly referred to as PZA, bacteriostatic n bactericidal. Exact mechanism of action is unknown Nursing actions Observe for hepatotoxicity Assess for hx of gout, as the medication will cause adverse effect of non gouty Liver enzymes should be completed baseline n every 2 weeks after starting PZA Client education - drink glass of water with each dose n increase fluids during day to help prevent gout n kidney problems Immediately report yellowing of skin or eyes, pain or selling of joints, loss of appetite, or malaise - avoid using alcohol while taking pyrazinamide Ethambutol - commonly referred to as EMB, bacteriostatic n works by suppressing RNA synthesis, subsequently inhibiting protein synthesis Should not be given to children younger than 8 yrs of age Nursing actions Obtain baseline visual acuity tests, n complete monthly after starting tx Determine color discrimination ability before starting tx, n periodically. Stop medication immediately if ocular toxicity occurs Client education: report changes in vision immediately Streptomycin sulfate: amino glycoside antibiotic. Potentiate efficacy of macrophages during phagocytosis Nursing actions D/t its high level of toxicity, this medication should be used only in clients who have multi drug resistant TB Streptomycin can cause ototoxicity, so monitor hearing function n tolerance often Report significant changes in urine output n renal function studies Client education Drink at least 2 L of fluid daily Notify the provider if hearing declines Interprofessional care Contact social services if client will need assistance in obtaining prescribed meds Refer client to community clinic as needed for follow-up appointment to monitor medication regimen n status of disease Client education TB is often treated in home setting Airborne precautions r not needed in home setting Bec family members have already been exposed Exposed family members should be tested for TB Continue medication therapy for its full duration of 6-12 months, even up to 2 yrs for multi drug resistant TB. Failure to take meds can lead to resistant statin of TB Continue with follow-up care for 1 full yr Sputum samples r needed every 2-4 weeks to monitor therapy effectiveness Clients r no longer considered infectious after 3 consecutive negative sputum culture, n can resume work n social interaction Practice proper hand hygiene Cover mouth n nose when coughing or sneezing Contaminated tissues should be disposed of in plastic bags Complications Military TB: organism invades bloodstream n can spread to multiple body organs with complications including: Headaches, neck stiffness, n drowsiness (can be life threatening) Pericarditis: dyspnea, swollen neck veins, pleuritic pain, n hypotension d/t accumulation of fluid in pericardial sac that inhibits heart's ability to pump effectively Nursing actions: tx is same as for pulmonary TB

Med surg exam 3 Anemia & Blood Problems: 8 questions 1. Describe general clinical manifestations and complications of anemia & sickle cell anemia. 2. Discuss collaborative & nursing management of these diseases Content: Anemias Sickle Cell anemia HIV Infection and AIDS 6 questions 1. Describe and discuss the epidemiology and pathophysiology of AIDS. 2. Explain the clinical course of HIV infection and treatment Content: A. HIV Infection and AIDS Gender Specfic 8 questions 1. Identify nursing responsibilities in caring for persons undergoing mastectomy, including infection and pain control. 2. Formulate nursing diagnoses and therapeutic nursing interventions for patients with selected reproductive system disorders, including sexually transmitted diseases. 2. Outline therapeutic nursing interventions for a person undergoing gender specific surgery. Content: A. Breast Disorders 1. fibrocystic disease 2. breast cancer 3. surgical procedures B Female Reproductive System 1. pelvic inflammatory disease 2. endometriosis /cancer 3. surgical procedures C. Male Reproductive System 1. benign prostatic hypertrophy 2. prostatic cancer 3. surgical procedures Urinary Tract Problems 8 questions 1. Identify risk factors for the development of urinary tract infection. 2. Describe the medical/nursing management of a person with a urinary tract infection. 3. Summarize the clinical manifestations and nursing care of a person with a urinary tract calculus or urethral stricture. 4. Discuss care of the patient with urinary issues. Content: 1. Cystitis 2. Acute Pyelonephritis 3. Urethitis Obstructive Uropathies 1. Urinary Calculi Urinary incontinence Musculoskeletal Disorders 20 questions 1. Describe the nursing assessment of a person with a musculoskeletal problem. 2. Describe the medical/nursing management and common complications associated with fracture injury and fracture healing. 3. Differentiate between open reduction, closed reduction, traction, fixation devices, and plaster immobilization as to purpose, complications and nursing management. 4. Explain the medical/nursing management (conservative and surgical) for problems of the lower back. 5. Explain the clinical manifestations and management (medical and nursing) of persons with arthritis and related rheumatic problems. 6. Identify the preoperative and postoperative teaching and management of the person with reconstructive joint surgery and amputation. Explain the pharmacological management and therapeutic nursing interventions associated 7. With arthritic and arthritic related problems. 8. Identify appropriate nursing interventions to meet the physical, psychological, and sociological needs of the person with musculoskeletal, arthritic, and related diseases and problems. 9. Identify and prioritize potential complications related to musculoskeletal problems Content I. Musculoskeletal Disturbances A. Strains and B. Sprains/Dislocations C. Fractures a. types b. treatment modalities (cast, traction, fixation devices) D. Osteomyelitis E. Low back pain F. Osteoporosis II. Arthritis and Related Rheumatic Problems A. types B. treatment modalities and nursing care C. Joint replacement. D. (Review amputation as needed) E. Gout III. SLE (Autoimmune Disease) Breast cancer Mammogram: compress breast between 2 place; compare one yr to next Hysterectomy can cause hormone issues On exam 3: BPH, prostate cancer; breast cancer, mastectomy, hysterectomy HIV https://web.microsoftstream.com/video/46324f58-5b82-44ba-9c15-0c78d4830243

Assessment Health History nursing assessment of patient with musculoskeletal dysfunction includes health history n physical examination that evaluate effects of musculoskeletal disorder on patient. nurse is concerned with assisting patients who have musculoskeletal problems to maintain their general health and functional status, accomplish their ADLs, and manage their treatment programs. nurse must promote healthy lifestyle by discussing the importance of nutrition and nutritional supplements, regular exercise, maintaining appropriate weight. nurse should also address problems associated with immobility and advocate for evidence-based periodic musculoskeletal health screenings. Through individualized plan of nursing care, nurse helps the patient achieve optimal health. Common Symptoms nurse is responsible to assess and document pain, tenderness, and altered sensations. Pain Most patients with diseases and traumatic conditions or disorders of muscles, bones, joints experience pain. Bone pain is typically described as a dull, deep ache that is "boring" in nature. This pain is not typically related to movement and may interfere with sleep. Muscular pain is described as soreness or aching and is referred to as "muscle cramps." Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve. Joint pain is felt around or in joint and typically worsens with movement TABLE 39-1 Age-Related Changes of Musculoskeletal System Musculoskeletal System Structural Changes Functional Changes History and Physical Findings Bones Gradual, progressive loss of bone mass after 30 years of age Vertebral collapse Bones fragile and prone to fracture—vertebrae, hip, wrist Loss of height Postural changes Kyphosis Loss of flexibility Flexion of hips and knees Back pain Osteoporosis Fracture Muscles Increase in collagen and resultant fibrosis Muscles diminish in size (atrophy); wasting Tendons less elastic Loss of strength and flexibility Weakness Fatigue Stumbling Falls Loss of strength Diminished agility Decreased endurance Prolonged response time (diminished reaction time) Diminished tone Broad base of support History of falls Joints Cartilage—progressive deterioration Thinning of intervertebral discs Stiffness, reduced flexibility, and pain interfere with activities of daily living Diminished range of motion Stiffness Loss of height Ligaments Lax ligaments (less-than-normal strength; weakness) Postural joint abnormality Weakness Joint pain on motion; resolves with rest Crepitus Joint swelling/enlargement Osteoarthritis (degenerative joint disease) Rest relieves most musculoskeletal pain. Pain that increases with activity may indicate joint sprain, muscle strain, or compartment syndrome, whereas steadily increasing pain points to the progression of an infectious process (osteomyelitis), a malignant tumor, or neurovascular complications. Radiating pain occurs in conditions in which pressure is exerted on a nerve root. The time of day that the pain occurs may be important to evaluate. Those experiencing pain with a rheumatic disorder experience pain that is worse in the morning, especially upon waking. Tendonitis worsens during the early morning and eases by midday, whereas osteoarthritis worsens as the day progresses. Pain is variable, and its assessment and nursing management must be individualized. Specific assessments that the nurse should make regarding the pain include the following: Is the body in proper alignment? Are the joints symmetrical or are bony deformities present? Is there any inflammation or arthritis, swelling, warmth, tenderness, or redness? Is there pressure from traction, bed linens, a cast, or other appliances? Is there tension on the skin at a pin site? patient's pain and discomfort must be managed successfully. Not only is pain exhausting, but also, if prolonged, it can force patient to become increasingly withdrawn and dependent on others as the musculoskeletal disorder continues. Altered Sensations Sensory disturbances are frequently associated with musculoskeletal problems. patient may describe paresthesias, which are sensations of burning, tingling, or numbness. These sensations may be caused by pressure on nerves or by circulatory impairment. Soft tissue swelling or direct trauma to these structures can impair their function. nurse assesses the neurovascular status of the involved musculoskeletal area. Questions that the nurse should ask regarding altered sensations include the following: Is the patient experiencing abnormal sensations, such as burning, tingling, or numbness? If the abnormal sensation involves an extremity, how does this feeling compare to sensation in the unaffected extremity? When did the condition begin? Is it getting worse? Does the patient also have pain? (If the patient has pain, then the questions and assessments for pain discussed previously should be followed.) Past Health, Social, and Family History When assessing the musculoskeletal system, the nurse should gather pertinent data to include in the patient's health history, such as occupation (e.g., does the patient's work require physical activity or heavy lifting?), exercise patterns, alcohol consumption, tobacco use, and dietary intake (e.g., calcium and vitamin D). Concurrent health conditions (e.g., diabetes, heart disease, chronic obstructive pulmonary disease, infection, and preexisting disability) and related problems (e.g., familial or genetic abnormalities) need to be considered when developing and implementing the plan of care. Any previous history of trauma or injury to the musculoskeletal system or a history of falls should be included as well. Chart 39-1 GENETICS IN NURSING PRACTICE Musculoskeletal Disorders Genetic musculoskeletal disorders vary in presentation and can tend to present at different points in time across the life span. Consideration must be given to other genetic disorders that will impact the musculoskeletal system. Some examples of inherited genetic musculoskeletal disorders include: Autosomal Dominant: Achrondroplasia Nail-Patella syndrome Osteogenesisimperfecta Polydactyl Van der Woude syndrome Autosomal Recessive: Tay Sachs Forms of Muscular Dystrophy: Becker muscular dystrophy Congenital muscular dystrophy Distal muscular dystrophy Duchene muscular dystrophy (X-linked) Emery-Dreyfuss muscular dystrophy (X-linked) Facioscapulohumeral muscular dystrophy (autosomal dominant) Limb-girdle muscular dystrophy (autosomal dominant and autosomal recessive forms) Other genetic disorders that impact the musculoskeletal system: Amyotrophic lateral sclerosis (neurologic disorder) Ehlers-Danlos syndrome (connective tissue disorder) Marfan syndrome (connective tissue disorder) Spina bifida (neurologic disorder) Stickler syndrome (connective tissue disorder) Nursing Assessments Family History Assessment Related to Genetic Musculoskeletal Disorders Assess for other similarly affected family members in the past three generations. Assess for the presence of other related genetic conditions (e.g., hematologic, cardiac, integumentary conditions). Determine the age at onset (e.g., fractures present at birth such as osteogenesis imperfecta, hip dislocation present at birth in DDH, or early-onset osteoporosis). Patient Assessment Specific to Genetic Musculoskeletal Disorders Assess stature for general screening purposes (unusually short stature may be related to achondroplasia; unusually tall stature may be related to Marfan syndrome). Assess for disease-specific skeletal findings (e.g., pectusexcavatum, scoliosis, long fingers [Marfan syndrome], osteoarthritis of the hip or waddling gait). Assessment findings that could indicate a genetic musculoskeletal disorder include: Bone pain Enlarged hands or feet Excessive height, short stature, or decrease in height Flat feet or highly arched feet Frequency of bone-related injuries or unexplained fractures Hypermobility of joints Large or small head circumference Protruding jaw or forehead Unexplained changes in muscle tone (hypotonia) Genetics Resources The National Osteoporosis Foundation, www.nof.org NIH Osteoporosis and Related Bone Diseases National Resource Center, www.niams.nih.gov/Health_Info/Bone DDH, developmental dysplasia of the hip(s) The Fracture Risk Assessment Tool (FRAX®) Fracture Risk Assessment Tool (FRAX®) is a tool that predicts a patient's 10-year risk of fracturing a hip or other major bone, which includes the spine, forearm, or shoulder. tool may be accessed online, where it automatically calculates a patient's odds of fracture. Data entered are validated risks for fracture, and include: age (risk increases with increasing age) gender (risk is higher in females) body mass index (risk is higher with lower body mass indices) history of a previous fracture parental history of hip fracture current cigarette smoker current use of a corticosteroid (e.g., prednisone) history of rheumatoid arthritis alcohol intake of 3 or more drinks per day history of secondary causes/risks for osteoporosis, which include any of the following: type I diabetes osteogenesis imperfecta untreated long-standing hyperthyroidism hypogonadism or premature menopause chronic malnutrition or malabsorption syndromes chronic liver disease An additional validated risk factor that may be entered into the FRAX® is the patient's bone mineral density (BMD), based upon bone densitometry results, if those results are hip-based (see later discussion). However, while entering BMD results in the FRAX® provides a more accurate fracture risk calculation, it is not necessary. Thus, the FRAX® provides a good estimate of fracture risk in patients who may not have submitted to BMD testing. Patients who should be assessed for hip or major bone fracture risk include men and postmenopausal women over the age of 50, patients with known low BMD, and patients with known secondary causes/risks for osteoporosis Physical Assessment examination of musculoskeletal system ranges from basic assessment of functional capabilities to sophisticated physical examination maneuvers that facilitate diagnosis of specific bone, muscle, and joint disorders. extent of assessment depends on patient's physical complaints, health history, and physical clues that warrant further exploration. nursing assessment is primarily a functional evaluation, focusing on patient's ability to perform ADLs Techniques of inspection and palpation are used to evaluate the patient's posture, gait, bone integrity, joint function, and muscle strength and size. In addition, assessing the skin and neurovascular status is an important part of a complete musculoskeletal assessment. The nurse should also understand and be able to perform correct assessment techniques on patients with musculoskeletal trauma. When specific symptoms or physical findings of musculoskeletal dysfunction are apparent, the nurse carefully documents the examination findings and shares the information with the primary provider, who may decide that a more extensive examination and a diagnostic evaluation are necessary. Posture The normal curvature of the spine is convex through the thoracic portion and concave through the cervical and lumbar portions. Common deformities of the spine include kyphosis, which is an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture. The second deformity of the spine is referred to as lordosis, or swayback, an exaggerated curvature of the lumbar spine. A third deformity is scoliosis, which is a lateral curving deviation of spine. Kyphosis can occur at any age and may be caused by degenerative diseases of the spine (e.g., arthritis or disc degeneration), fractures related to osteoporosis, and injury or trauma. It may also be seen in patients with other neuromuscular disease. Lordosis can affect persons of any age. Common causes of lordosis include tight low back muscles, excessive visceral fat, and pregnancy as the woman adjusts her posture in response to changes in her center of gravity. Scoliosis may be congenital, idiopathic (without an identifiable cause), or the result of damage to the paraspinal muscles (e.g., muscular dystrophy). During inspection of the spine, the entire back, buttocks, and legs are exposed. The examiner inspects the spinal curves and trunk symmetry from posterior and lateral views. Standing behind the patient, the examiner notes any differences in the height of the shoulders or iliac crests. Shoulder and hip symmetry, as well as the line of the vertebral column, is inspected with the patient erect and with the patient bending forward (flexion). Scoliosis is evidenced by an abnormal lateral curve in the spine; shoulders that are not level; an asymmetric waistline; and a prominent scapula, which is accentuated by bending forward. The examiner should then instruct the patient to bend backward (extension) with the examiner supporting the patient by placing hands on the posterior iliac spine. Older adults experience a loss in height due to the loss of vertebral cartilage and osteoporosis-related vertebral compression fractures. Therefore, an adult's height should be measured during each health screening. Gait Gait is assessed by having the patient walk away from the examiner for a short distance. The examiner observes the patient's gait for smoothness and rhythm. Any unsteadiness or irregular movements (frequently noted in older adult patients) are considered abnormal. A limping motion is most frequently caused by painful weight bearing. In such instances, the patient can usually pinpoint the area of discomfort, thus guiding further examination. If one extremity is shorter than another, a limp may also be observed as the patient's pelvis drops downward on the affected side with each step. The knee should be flexed during normal gait; therefore, limited joint motion may interrupt the smooth pattern of gait. Evaluation of the knee involves the joints, bones, ligaments, tendons, and cartilage, and may include tests for the anterior and collateral ligaments, medial and lateral ligaments, and medial meniscus. In addition, a variety of neurologic conditions are associated with abnormal gait, such as a spastic hemiparesis gait (stroke), steppage gait (lower motor neuron disease), and shuffling gait (Parkinson's disease). Figure 39-4 • A normal spine and three abnormalities. A. Kyphosis: an increased convexity or roundness of the spine's thoracic curve. B. Lordosis: swayback; exaggeration of the lumbar spine curve. C. Scoliosis: a lateral curvature of spine. Bone Integrity The bony skeleton is assessed for deformities and alignment. Symmetric parts of the body, such as extremities, are compared. Abnormal bony growths due to bone tumors may be observed. Shortened extremities, amputations, and body parts that are not in anatomic alignment are noted. Fracture findings may include abnormal angulation of long bones, motion at points other than joints, and crepitus (a grating or crackling sound or sensation) at the point of abnormal motion. Movement of fracture fragments must be minimized to avoid additional injury. The nurse should include the following observations: If the affected part is an extremity, how does its overall appearance compare to the unaffected extremity? Can the patient move the affected part? If an extremity is involved, does each toe or finger have normal sensation and motion (flexion and extension), and is the skin warm or cool? What is the color of the part distal to the affected area? Is it pale? Dusky? Mottled? Cyanotic? Does rapid capillary refill occur? (The nurse can gently squeeze a nail until it blanches, then release the pressure. The amount of time for the color under the nail to return to normal is noted. Color normally returns within 3 seconds. The return of color is evidence of capillary refill.) Is a pulse distal to the affected area palpable? If the affected area is an extremity, how does the pulse compare to the pulse of the unaffected extremity? Is edema present? Is any constrictive device or clothing causing nerve or vascular compression? Does elevating the affected part or modifying its position affect the symptoms? Joint Function The articular system is evaluated by noting range of motion, deformity, stability, tenderness, and nodular formation. Range of motion is evaluated both actively (the joint is moved by the muscles surrounding the joint) and passively (the joint is moved by the examiner). The examiner is familiar with the normal range of motion of major joints. Precise measurement of range of motion can be made by a goniometer (a protractor designed for evaluating joint motion). Limited range of motion may be the result of skeletal deformity, joint pathology, or contracture (shortening of surrounding joint structures) of the surrounding muscles, tendons, and joint capsule. In older adult patients, limitations of range of motion associated with osteoarthritis may reduce their ability to perform ADLs. If joint motion is compromised or the joint is painful, the joint is examined for effusion (excessive fluid within the capsule), swelling, and increased temperature that may reflect active inflammation. An effusion is suspected if the joint is swollen and the normal bony landmarks are obscured. The most common site for joint effusion is the knee. If large amounts of fluid are present in the joint spaces beneath the patella, it may be identified by assessing for the balloon sign and for ballottement of the knee. If inflammation or fluid is suspected in a joint, consultation with a specialist (e.g., orthopedic surgeon or rheumatologist) is indicated. Joint deformity may be caused by contracture, dislocation (complete separation of joint surfaces), subluxation (partial separation of articular surfaces), or disruption of structures surrounding the joint. Weakness or disruption of joint-supporting structures may result in a weak joint that requires an external supporting appliance (e.g., brace). Palpation of the joint while it is moved passively provides information about the integrity of the joint. Normally, the joint moves smoothly. A snap or crack may indicate that a ligament is slipping over a bony prominence. Slightly roughened surfaces, as in arthritic conditions, result in crepitus as the irregular joint surfaces move across one another. The tissues surrounding joints are examined for nodule formation. Rheumatoid arthritis, gout, and osteoarthritis may produce characteristic nodules. The subcutaneous nodules of rheumatoid arthritis are soft and occur within and along tendons that provide extensor function to the joints. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule itself. They may rupture, exuding white uric acid crystals onto the skin surface. Osteoarthritic nodules are hard and painless and represent bony overgrowth that has resulted from the destruction of the cartilaginous surface of bone within the joint capsule. They are frequently seen in older adults Often, the size of the joint is exaggerated by atrophy of the muscles proximal and distal to that joint. This is seen in rheumatoid arthritis of the knees, in which the quadriceps muscle may atrophy dramatically. In rheumatoid arthritis, joint involvement assumes a symmetric pattern Muscle Strength and Size The muscular system is assessed by noting muscular strength and coordination, the size of individual muscles, and the patient's ability to change position. Weakness of a group of muscles may indicate a variety of conditions, such as polyneuropathy, electrolyte disturbances (particularly potassium and calcium), myasthenia gravis, poliomyelitis, and muscular dystrophy. By palpating the muscle while passively moving the relaxed extremity, the nurse can determine the muscle tone. The nurse assesses muscle strength by having the patient perform certain maneuvers with and without added resistance. For example, when the biceps are tested, the patient is asked to extend the arm fully and then to flex it against resistance applied by the nurse. A simple handshake may provide an indication of grasp strength. nurse may elicit muscle clonus (rhythmic contractions of a muscle) in ankle or wrist by sudden, forceful, sustained dorsiflexion of foot or extension of wrist. Fasciculation (involuntary twitching of muscle fiber groups) may be observed. The nurse measures the girth of an extremity to monitor increased size due to exercise, edema, or bleeding into the muscle. Girth may decrease due to muscle atrophy. The unaffected extremity is measured and used as the reference standard for the affected extremity. Measurements are taken at the maximum circumference of the extremity. It is important that the measurements be taken at the same location on the extremity, and with the extremity in the same position, with the muscle at rest. Distance from a specific anatomic landmark (e.g., 10 cm below the medial aspect of the knee for measurement of the calf muscle) should be indicated in the patient's record so that subsequent measurements can be made at the same point. For ease of serial assessment, the nurse may indicate the point of measurement by marking the skin. Variations in size greater than 1 cm are considered significant. Chart 39-2 ASSESSMENT Assessing for Peripheral Nerve Function Assessment of peripheral nerve function has two key elements: evaluation of sensation and evaluation of motion. The nurse may perform one or all of the following during a musculoskeletal assessment. Nerve Test of Sensation Test of Movement Peroneal Prick the skin midway between the great and second toe. Ask the patient to dorsiflex the foot and extend the toes. Tibial Prick the medial and lateral surface of the sole. Ask the patient to plantar flex toes and foot. Radial Prick the skin midway between the thumb and second finger. Ask the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. Ulnar Prick the distal fat pad of the small finger. Ask the patient to abduct all fingers. Median Prick the top or distal surface of the index finger. Ask the patient to touch the thumb to the little finger. In addition, observe whether the patient can flex the wrist. Skin In addition to assessing the musculoskeletal system, the nurse inspects the skin for edema, temperature, and color. Palpation of the skin may reveal whether any areas are warmer, suggesting increased perfusion or inflammation, or cooler, suggesting decreased perfusion, and whether edema is present. Cuts, bruises, skin color, and evidence of decreased circulation or inflammation can influence nursing management of musculoskeletal conditions. Neurovascular Status nurse must perform frequent neurovascular assessments of patients with musculoskeletal disorders (especially of those with fractures) because of risk of tissue and nerve damage. needs to be particularly aware of signs and symptoms of compartment syndrome when assessing patient with a musculoskeletal injury. This neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Assessment of neurovascular status is frequently referred to as assessment of CMS (circulation, motion, sensation).

Pulmonary embolism: occurs when substance (solid, gaseous, or liquid) enters venous circulation n forms blockage in pulmonary vasculature Emboli originating from venous thormboembolism, aka DVT (most common cause); other types of emboli: fat, air, septic (d/t bacterial invasion of thrombus), amniotic fluid Increase hypoxia to pulmonary tissue n impaired blood flow can result from large embolus; medical emergency Health Promotion n Disease Prevention Promote smoking cessation Encourage maintenance of appropriate weight for height n body frame Prevent DVT by encouraging leg exercises, wear compression stockings, avoid sitting for long periods of time Risk factors Long term immobility Oral contraceptive use n estrogen therapy Pregnancy Tobacco use Hyper coagulability (elevated platelet count) Obesity Surgery (esp orthopedic surgery of lower extremities or pelvis) Central venous catheters Heart failure or chronic atrial fibrillation Autoimmune hemolytic anemia (sickle cell) Long bone fractures Cancer Trauma Septicemia Advanced age: - older adult have decreased pulmonary reserves d/t normal lung changes including decreased lung elasticity n thickening alveoli. Can decompensate more quickly Certain pathological conditions n procedures that predispose to DVT formation (peripheral vascular disease, HTN, hip n knee arthroplasty) r more prevalent in older adults Many older adults experience decreased physical activity levels, thus predisposing them to DVT formation n pulmonary emboli Expected findings Anxiety Feeling of impeding doom Sudden onset of chest pressure Pain upon inspiration n chest wall tenderness Dyspnea n air hunger Cough Hemoptysis Physical assessment finding Pleurisy Pleural friction rub Tachycardia Hypotension Tachypnea Adventurous breath sounds (crackles) n cough Heart murmur in S3 n S4 Diaphoresis Low-grade fever Decreased ox saturation levels (expected reference range 95-100%, low SaO2, cyanosis Petechiae (red dots under skin) over chest n axillae Distended neck veins Syncope Cyanosis Laboratory tests ABG analysis PaCO2 levels r low (expected reference range 35-45 mm Hg) d/t initial hyperventilation (resp alkalosis) As hypoxemia progresses, resp acidosis occurs Further progression leads to metabolic acidosis d/t buildup of lactic acid from tissue hypoxia D-dimer: elevated above expected reference range in response to clot formation n release of fibrin degradation products (expected reference range is less than 0.4) Diagnostic procedures: CT scan: multidetecto-row computed tomography angiography (MDCTA) is criterion standard for detecting PE when available, as it provides high-quality visualization of lung parenchyma

Funds Final exam Fluid electrolyte, medication, skin integrity= 4-5; ox., asepsis, safety security= 3-4 1. Nursing Process- Focus on how Nursing Process is used for nursing decisions. 2. Communication & Documentation- SBAR/ISBARR; hand-off communication; Informatics; Tables19-2 & 19-3: RE: Error-Prone Abbreviations & "Do Not Use List" 3. Safe & Effective Care Environment- 1. Management of Care- Review policies, legal rights and care interventions —such as- informed consent; delegating tasks to UAP; patient confidentiality; patient advocacy; ethical practice. 2. Safety & Infection Control- Review interventions directed at protecting patients and health care workers- such as standard precautions and transmission-based precautions for isolation; patient accident and injury prevention; health care workers ergonomic principles; National Patient Safety Goals. 4. Health Promotion & Maintenance- Review prevention and/or early detection of health problems and strategies to decrease risk- such as- self-care; disease prevention; screening tests; health promotion- chronic or long-term conditions- COPD, Diabetes, conditions of vSim patients; substance abuse; patient teaching. 5. Psychosocial Integrity-Review psychosocial aspects of nursing care—statements and actions are therapeutic, non-judgmental, patient-centered care (not nurse-centered), n based on evidence n best practices—such as therapeutic communication techniques, end-of-life care, spiritual and religious influences. 4 Components of Self-Concept= Personal identity, Body image, Role performance, Self-esteem; Personal Strengths. Kubler-Ross 5 Stages of Dying/Grief. 6. Physiological Adaptation 1. Basic Care and Comfort- Review interventions regarding providing comfort and assistance for ADLs—such as- assistive devices; urinary and bowel elimination; mobility/immobility; rest & sleep; personal hygiene including incontinence care; nutrition & hydration; non-pharmacological comfort measures. 2. Pharmacological & Parenteral Therapies- Review interventions regarding medication administration—such as- types and parts of medication orders; "Rights" of Med Administration and "3 Safety Checks"; central venous access devices: possible complications; blood transfusions; dosage calculation; all medication routes; IV solutions; TPN: monitoring and complications; pain management; general medication knowledge and how to administer meds listed on Chapter 29 PowerPoint- Coumadin; Heparin; Insulin, Morphine, Enoxaparin, Inhaled Meds in general, Transdermal in general. Medication reconciliation process; monitoring IV infusions. 3. Reduction of Risk Potential- Review interventions regarding preventing and decreasing possible patient complications related to treatments and procedures—such as—signs of a complication- infection, hemorrhage, post-operative complications, aspiration, CAUTIs & other health-care acquired infections; diagnostic procedures for urinary and GI systems; Braden Scale and tissue integrity; enteral tubes; oxygenation; wound care; positioning of patients. Lab values for Exam 3, including ABGs. 1. Lab Values- Sodium, Potassium, Total Calcium, Magnesium, Chloride, Phosphate (Table 40-1) 2. ABGs- Values—Table 40-5 (arterial blood) 4. Physiological Adaptation- Review interventions for caring for patients who have acute or chronic physical health conditions- such as—wound care and dressing changes; vSim Patients; providing care to patients who have--wound drains and devices; electrolyte imbalances; dialysis access; impaired oxygenation and use of devices and equipment; performing suctioning of the respiratory tract; pre-operative teaching and post-operative care. Signs of impending death; and other interventions during the dying process as well as post-mortem care. STIs- Table 45-2. Sleep - interventions to promote. 7. Check-Off Skills- Rationale for each step, unexpected situations and interventions. Skills: HW/Hand Hygiene & PPE; Donning Sterile Gloves and Adding Items to a Sterile Field; Urinary Bladder Catheter; NGT. 8. Chapter Skills & Delegation - Delegation decisions; what can be delegated to Unlicensed Assistive Personnel; what is the responsibility of the RN; what tasks are not routinely delegated. This is a legal issue. Final Exam 22% of Course Grade Included in 70% Weighted Exam Average Requirement Total # of Questions = 55 Exam Length = 83 minutes (based on 1.5 minutes/question) Approximate # of Questions Self-Concept (41). S 2-3 Loss, Grief, & Dying (43). S 2-3 Dosage Calculation 1-2 Values, Ethics, & Advocacy (6). S 1-2 Communication (8). S 2-3 Safety, Security, Emergency Preparedness (27). S 3-4 Asepsis & Infection Control (24). S 3-4 Hygiene (31). S 2-3 Activity (33). S 2-3 Skin Integrity & Wound Care (32). S 4-5 Perioperative Nursing (30). S 2-3 Oxygenation & Perfusion (39). S 3-4 Nursing Process - Blended Competencies (13 - 18) Nursing Process is incorporated as a process and not separate steps. S 1-2 Urinary Elimination (37). S 2-3 Bowel Elimination (38). S 2-3 Nutrition (36) Does not include TPN- start on page 1293. S 2-3 Documenting & Reporting (19). S 1-2 Medications (29). S 4-5 Comfort & Pain Management (35). S 1-2 Sensory Functioning (44). S 1-2 Fluid/Electrolytes/Acid-Base (40). S 4-5 Meds & Nutrition Part 2- IV, Blood Therapy & TPN. S 1-2 Leading, Managing, & Delegating (10). S 1-2 Legal Dimensions (7). S 1-2 Rest & Sleep (34) start on page 1205. S 1-2 Sexuality (45). S 2-3 Spirituality (46). S 1-2

Respiratory Disorders NURSING OF ADULTS `Worksheet for Lower Respiratory issues AtelectasisThis is the closure or collapse of alveoli. What are some of the causes? May occur as a result of reduced ventilation (nonobstructive atelectasis) or any blockage that obstructs passage of air to and from the alveoli (obstructive atelectasis), thus reducing alveolar ventilation. What are clinical manifestations? Development is usually insidious, S&S include increasing dyspnea, cough, and sputum production. S&S of acute atelectasis listed below. S&S of chronic include those similar to acute, but the chronic nature of the alveolar collapse predisposes patients to infections distal to the obstruction. Therefore, S&S of a pulmonary infection may also be present. Low-grade fever dyspnea, cough, and sputum production.Describe acute atelectasis: Occurs most often in the postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern. What are the hallmark signs of acute atelectasis? S&S same as above, but also marked by respiratory distress, tachycardia, tachypnea, pleural pain, and central cyanosis (a bluish skin huge that is a late sign of hypoxemia), patients characteristically have difficulty breathing in the supine position and are anxious. What lung sounds will be heard over the affected area? Decreased breath sounds and crackles. A chest x-ray will be done - what are the expected findings? May reveal patchy infiltrates or consolidated areas. What are the Nursing measures to prevent atelectasis? (chart 23-1)-Change position frequently especially supine to upright position, to promote ventilation and prevent secretions form accumulating (turn, cough, deep breathe)-Encourage early mobilization- bed to chair then ambulate-Encourage C&DB to mobilize secretions. And prevent them from accumulating.-Educate /reinforce appropriate technique for incentive spirometer-Administer prescribed opioids and sedatives judiciously to prevent respiratory depression -Perform postural drainage and chest percussion if indicated-Institute suctioning to remove secretions if indicated Important: Before initiating more complex, costly, and labor-intensive therapies, the nurse should ask several questions: Has the patient been given an adequate trial of deep-breathing exercises? Has the patient received adequate education, supervision, and coaching to carry out the deep-breathing exercises? Have other factors been evaluated that may impair ventilation or prevent a good patient effort (e.g., lack of turning, mobilization; excessive pain; excessive sedation)? What is the ICOUGH method?Incentive spirometryCoughing and deep breathing Oral care (brushing teeth and using mouthwash 2x/day) Understanding (patient and staff education)Getting out of bed at least 3x/dayHead-of-bed elevation List management interventions: The goal of the treatment is to improve ventilation and remove secretions. Chest physiotherapy (chest percussion and postural drainage) may be used to mobilize secretions. Nebulizer treatments with a bronchodilator or sodium bicarbonate may be used to assist patients in the expectoration of secretions. If respiratory measures fail to remove the obstruction, a bronchoscopy is performed. To understand this section better, you may want to read the 'Management' section on pgs 585-586. PneumoniaPneumonia can be classified into four types: chart 23-31. Community acquired (CAP)2. Medical care-associated pneumonia (Hospital acquired - occurs 48 hours or longer after hospital admission. Ventilator associated - , health care associated - )3. Aspiration pneumonia4. Opportunistic pneumonia risk factors for developing pneumonia: abdominal or thoracic surgery,age>65 y/o, air pollution, altered LOC, chronic disease, immunosuppressed, resident of long- term care facility, smoking, tracheal intubation, upper respiratory infection. Aspiration Pneumonia What are the Risk Factors? Seizure activity, brain injury, decreased LOC, flat body position, stroke, swallowing disorder, cardiac arrest.What are some preventative measures to take? Keep head of bed elevated >30 degrees, avoid stimulation of gag reflex with suctioning or other procedures, check for placement before tube feedings, thickened fluids for swallowing problems. (table 23-2) Clinical Manifestations of pneumonia: Varies in S&S depending on the type, causal organism, and presence of underlying disease. However, it is not possible to diagnose a specific form or classification of pneumonia by clinical manifestations alone. Vary, can't diagnose based on symptoms streptococcal (pneumococcal) pneumonia - may present with: sudden onset of chills,rapidly rising fever (38.5° to 40.5°C [101° to 105°F]),pleuritic chest pain that is aggravated by deep breathing and coughing.The patient is severely ill, with marked tachypnea (25 to 45 breaths/min) - is the patient in respiratory distress? Yes (shortness of breath and the use of accessory muscles in respiration) What are some of the other symptoms? Headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis. After a few days, mucoid or mucopurulent sputum is expectorated. In severe pneumonia, the cheeks are flushed, and the lips and nail beds demonstrate central cyanosis (a late sign of poor oxygenation - hypoxemia). diagnosis of pneumonia is made by:history - what is important to ask about? Recent respiratory tract infectionphysical examination,chest x-ray,blood culture what are they looking for? Blood stream invasion - bacteremia - occurs frequently)Sputum collection for culture: what are the 4 steps? The sputum sample is obtained by having patients do the following: (1) rinse the mouth with water to minimize contamination by normal oral flora, (2) breathe deeply several times, (3) cough deeply, and (4) expectorate the raised sputum into a sterile container. The sputum sample is obtained by having patients do the following:(1) rinse the mouth with water to minimize contamination by normal oral flora (2) breathe deeply several times, (3) cough deeply, and(4) expectorate the raised sputum into a sterile container. How can you prevent pneumonia? Pneumococcal vaccination reduces the incidence of pneumonia, hospitalizations for cardia solutions, and deaths in the older adult population. About 1 million adults in the US get pneumococcal pneumonia every year and about 18,000 will die from it. What are the recommendations? Two types of vaccine for adults - pneumococcal conjugate vaccine (PCV13) and a pneumococcal polysaccharide vaccine (PPSV23). Recommended for all adults 65 years of age or older and for those adults 19-64 years of age who smoke cigarettes or who have asthma. Also recommended for adults 19 years or older with conditions that weaken the immune system, such as HIV infection, organ transplant, leukemia, lymphoma, and severe kidney disease. Medical Management Antibiotic - determined by the results of a culture and sensitivity. Hydration, why? Fever and tachypnea may result in insensible fluid losses. Antipyretics - may be used to treat headache and fever.Antitussive - may be used for the associated cough.Oxygen, if needed Complications Hypotension, Septic shock, and Respiratory failure - especially with gram-negative bacterial disease in older adult patients, these complications are encountered chiefly in patients who have received no specific treatment or inadequate or delayed treatment. These complications are also encountered when the infecting organism is resistant to therapy, when a comorbid disease complicates the pneumonia, or when the patient is immunocompromised. Pleural effusion - accumulation of pleural fluid in the pleural space (space between the parietal and visceral pleurae of the lung). A parapneumonic effusion is any pleural effusion associate with bacterial pneumonia, lung abscess, or bronchiectasis. After the pleural effusion is detected on a chest x-ray, a thoracentesis may be performed to remove the fluid, which is sent to the lab for analysis.Empyema - occurs when thick, purulent fluid accumulates within the pleural space, often with fibrin development and a loculated (walled-off) area where the infection is located. A chest tube may be inserted to treat pleural infection by establishing proper drainage of the empyema. NURSING PROCESS The Patient with Pneumonia Assessment What is the nurse going to assess for? Past history, medication history, potential objective finding - fever, lethargy, tachypnea, increase work of breathing, crackles, production of sputum, tachycardia, change in mental status. IMPROVING AIRWAY PATENCYList interventions: Removing secretions (interfere with gas exchange and may slow recovery), encourage hydration (2-3 L/day) because it thins and loosens secretions and improves ventilation, a high-humidity facemask (using either compressed air or oxygen) delivers warm, humidified air to the tracheobronchial tree helps liquefy secretions, and relieves tracheobronchial irritation. Coughing can be initiated either voluntarily or by reflex. Lung expansion maneuvers, such as deep breathing with an incentive spirometer, may induce cough. See page 597 and read the section on nursing interventions. PROMOTING REST AND CONSERVING ENERGYList interventions: Encourage the debilitated patient to rest and avoid overexertion and possible exacerbation of symptoms. The patient should assume a comfortable position to promote rest and breathing (semi-Fowler's position) and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion. Outpatients must be instructed to avoid overexertion and to engage in only moderate activity during the initial phases of treatment. PROMOTING FLUID INTAKEList interventions: The respiratory rate of patients with pneumonia increases because of the increased workload imposed by labored breathing and fever. An increased respiratory rate leads to an increase in insensible fluid loss during exhalation and can lead to dehydration. Therefore, unless contraindicated, increased fluid intake (at least 2 L/day) is encouraged. Hydration must be achieved more slowly and with careful monitoring in patients with preexisting conditions such as heart failure. MAINTAINING NUTRITIONList interventions: Many patients with SOB have a decreased appetite and consume only fluids. Fluids with electrolytes may help provide fluid, calories, and electrolytes. Other nutritionally enriched drinks such as oral nutritional supplements may be used to supplement calories. Small, frequent meals may be advisable. In addition, IV fluids and nutrients may be given if necessary. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Continuing Symptoms After Initiation of Therapy. The patient is observed for response to antibiotic therapy; patients usually begin to respond to treatment within 24-48 hours after antibiotic therapy is initiated. If the patient started taking antibiotics before evaluation by culture and sensitivity of the causative organisms, antibiotics may need to be changed once the results are available. The patient is monitored for changes in physical status (deterioration of condition or resolution of symptoms) and for persistent recurrent fever, which may be a result of medication allergy (signaled possibly by a rash); medication resistance or slow response (greater than 48 hours) of the susceptible organism therapy; pleural effusion; or pneumonia cause by an unusual organism such as P. jiroveci or Aspergillus fumigatus. Failure of pneumonia to resolve or persistence of symptoms despite changes on the chest x-ray raises the suspicion of other underlying disorders, such as lung cancer. When should they begin to respond to treatment? Within 24-28 hours after antibiotic therapy is initiated. Shock and Respiratory Failure. Interventions: Assess for S&S of septic shock and respiratory failure by evaluating the patient's vital signs, pulse oximetry values, and hemodynamic monitoring parameters. The nurse reports signs of deteriorating patient status and assists in administering IV fluids and medications prescribed to combat shock. Intubation and mechanical ventilation may be required if respiratory failure occurs. Pleural Effusion If pleural effusion develops and thoracentesis is performed to remove fluid, the nurse assists in the procedure and explains it to the patient. After thoracentesis, the nurse monitors the patient for pneumothorax or recurrence of pleural effusion. If a chest tube needs to be inserted, the nurse monitors the patient's respiratory status. Delirium A patient with pneumonia is assessed for delirium and other subtle changes in cognitive status; this is especially true in the older adult. The Confusion Assessment Method (CAM) is a commonly used screening tool. Confusion, suggestive of delirium, and other changes in cognitive status resulting from pneumonia are poor prognostic signs. Delirium may be related to hypoxemia, fever, dehydration, sleep deprivation, or developing sepsis. The patient's underlying comorbid conditions may also play a part in the development of confusion. Addressing and correcting underlying factors as well as ensuring patient safety are important nursing interventions. Aspiration How to prevent? chart 23-6 -Maintain head-of-bed elevation at an angle of 30-45 degrees, unless contraindicated-Use sedatives as sparingly as possible-Before initiating enteral tube feeding, confirm the tip location-For patients receiving tube feedings, assess placement of the feeding tube at 4-hour intervals, assess for GI residuals (<150 ml before next feeding) to the feedings at 4-hour intervals -For patients receiving tube feedings, avoid bolus feedings in those at high risk for aspiration -Consult with primary provider about obtaining a swallowing evaluation before oral feedings are started for patients who were recently extubated but were previously intubated for >2 days -Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is deflated TbRisk factors chart 23-7Transmission spread by airborne transmission (person to person) Chart 23-8 health care precautions for TB patientsAre there symptoms with TB? S&S are insidious, most patients have low-grade fever, cough, night sweats, fatigue, and weight loss. The cough may be nonproductive, or mucopurulent sputum may be expectorated. Hemoptysis also may occur. Both the systemic and the pulmonary symptoms are chronic and may have been present for weeks to months. Older adult patients usually present with less pronounced symptoms than younger patients. Diagnostic testingWhat is the preferred test for a person who received BCG? TB blood tests are the preferred diagnostic tests for patients who have received the BCG vaccine and for patients who are not likely to return for a second appointment to look for a reaction to the TB skin test. Medical Management Treatment is for 6 to 12 months.- Why? A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. - First-Line Antituberculosis Medications for Active Disease Be aware of nursing considerations Nursing Management- look at specific interventions, how to help with adherence, any special points to discuss with medications, how to prevent transmission.promoting airway clearance, advocating adherence to the treatment regimen, promoting activitynutritionpreventingtransmission. **Read the sections on these topics on pages 604-605!!** Empyema- SECTION GIVES MORE DETAILS -Accumulation of thick, purulent fluid within the pleural space, often with fibrin development and a loculated (walled-off) area where infection is located.-Patho, clinical manifestations, assessment, diagnostics, medical management, and nursing management are on pages 608-609. Pulmonary Embolism- discussed in vascular. This section provides more detail -Pages 614-618 ARDS, RESP. FAILUREAND PULMONARY HYPERTENSION, CHEST TRAUMA AND PNEUMOTHORAX WILL BE COVERED IN COMPLEX ADults

BMI Values (Taylor) Underweight: <18.5 Normal: 18.5-24.9 *HealthyWeight Overweight: 25.0-29.9 Obesity: Class 1- 30.0-34.9 Class 2- 35.0-39.9Extreme Obesity: > 40.0

type of dressing With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.