Exam 2 Blueprint

Caring for patients with an indwelling catheter

· Wash hands before and after dealing with patient · Clean catheter thoroughly with mild soap by cleaning meatus outward · Encourage generous fluid intake · Encourage patient to move around as ordered · Note output every 8 hours (volume and characteristics) · Do not open drainage system to collect sample · Educate patient on importance of personal hygiene · Promptly report signs of infection · Help patient shower, if possible

Promoting proper body alignment (Pg. 1068-1069)

-Devices include: pillows, mattresses, adjustable beds, trapeze bars, cradle (metal frame that supports bed linens away from pt), sandbags, trochanter rolls, side rails. -Teach pt/family correct positioning techniques, at least every 2 hours

The professional nurse

-Nurses committed to person-centered care are careful to assess whether or not they possess the prerequisite personal attributes along with learned knowledge, blended competencies, and QSEN competencies. PERSONAL ATTRIBUTES- Openmindedness: -This might also be termed humility. Are you open to learn what your patients, families, and colleagues have to teach you? Profound sense of the value of the person: -Do you believe that everyone, literally everyone, matters? Can you think of anyone who deserves less than your best care effort? Are you willing to go to bat for the most vulnerable in our midst? Are you committed to learning how to advocate for those not well served by today's health care system? Self-awareness and knowledge of own beliefs and values: -Do you know what you believe, why you believe it, and the consequences of your beliefs? Are you sensitive to how your beliefs and values influence your professional relationships? Sense of personal responsibility for actions: -At the end of the day, will people (your patients and team) be better because of their experiences with you? Are you committed to using your personal expertise, time, and power to coordinate all the care patients and families need? Motivation to do what you do to the best of your ability because you care about the well-being of those entrusted to your care: -Does love get you up and motivate your study and practice? Do you want to be your personal best for those who will count on you Leadership skills. Have you tried to use your influence to help others attain valued goals? Are you committed to using your leadership strengths with patients, families, and colleagues to achieve valued health goals? Bravery to question the "system:" -When the plan of care isn't working for a patient or your work environment is interfering with your ability to give good care, are you willing to challenge the status quo, and can you do this effectively? Denise Thornby, previous president of the American Association of Critical Care Nurses, was famous for challenging nurses to "make waves" when change was needed—even when this demanded personal courage. She reminded all of us that the day we don't wake up we will have already created our legacy: "Every day, every moment, you make choices on how to act or respond. Through these acts, you have the power to positively influence. As John Quincy Adams sagely said, 'The influence of each human being on others in this life is a kind of immortality.' So I ask you: What will be your act of courage? How will you influence your environment? What will be your legacy?" When the day arrives that you are no longer able to show up for practice, what do you want colleagues to say about you? What will be your legacy? Knowledge Base: -In order to reason through a clinical situation, you must be able to draw upon a body of nursing knowledge that comes from the sources of knowledge described in Chapter 2. Added to this must be research evidence. Box 10-4, outlines the knowledge required for competent clinical reasoning in nursing. The specific knowledge in a given care interaction depends on the actual clinical situation. For example, if the situation calls for reasoning about the manifestation of a clinical problem, the nurse will need to understand the disease or condition, its epidemiology, the mechanisms of its pathophysiology, its physical and psychological manifestations, signs and symptoms, and the probabilities of its progression or outcome. If the clinical situation involves a problematic hospital discharge of a patient with disabilities, for example, the nurse's knowledge base must include knowledge of support services available in the local community or knowledge of how and when to contact other team members with this expertise (Dempsey et al., 2013, pp. 257-258). These knowledge requirements are essential for the development of clinical reasoning and judgment, discussed later in this chapter. Blended Competencies: -Nurses aim to design and manage each patient's care scientifically, holistically, and creatively. To do this successfully, nurses need many cognitive, technical, interpersonal, and ethical/legal competencies, along with the willingness to use them creatively and critically when working with patients to promote or restore health, to prevent disease or illness, and to facilitate coping with altered functioning. Understanding the importance of these competencies helps you work consciously to develop them while beginning to master the nursing process. Cognitive and technical competencies equip nurses to manage clinical problems stemming from the patient's changing health or illness state. Interpersonal and ethical skills are essential, moreover, for nurses concerned about the patient's broader well-being. This text uses the term "blended competencies" because in most instances, nursing actions require all four competencies. A nurse who sets out to suction a patient, for example, must understand the evidence that supports this action, be skilled in handling the required equipment, use the encounter to promote the patient's sense of well-being, and practice in an ethically and legally defensible manner. Few nurses excel naturally in all four of these competencies, and even experienced nurses continue working on becoming more proficient in the knowledge, attitudes, and skills that lead to excellence. These competencies were first introduced and defined in Chapter 1. Box 10-3 will help you to assess your proficiency in these competencies.

Elements of critical thinking

-thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned; a systematic way to form and shape one's thinking that functions purposefully and exactingly. evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. -reasoning has a logical or cognitive (thinking) component as well as an emotional or affective (feeling) component, both of which are affected by the personal attributes of the thinker. Critical thinking is also affected by one's beliefs and values. For example, nurses must be independent thinkers. Nurses who are independent thinkers are careful not to allow the status quo or a persuasive person to control their thinking. When confronted with an intellectual challenge, such as "Why does this patient resist change?" the nurse should proceed cautiously, consulting with the patient and respected colleagues and reviewing the literature. Only then can the nurse reach a true clinical judgment. Compare this with a nurse who makes a snap judgment that a patient is "unreasonable" based only on hearing the comments of another nurse—even if this nurse is the nurse manager. -to develop the critical thinking skills essential to quality nursing practice, nurses find it helpful when posed with a challenge to work methodically through a set of five types of considerations: the purpose of thinking, adequacy of knowledge, potential problems, helpful resources, and critique of judgment/decision. Purpose of Thinking: -The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. This helps to discipline your thinking by directing your thoughts toward the goal. The purpose of critical thinking might be to make a judgment about a particular patient or situation or to make a decision about how best to intervene. Adequacy of Knowledge: -At the outset of critical thinking, you need to judge whether the knowledge you have is accurate, complete, factual, timely, and relevant. If you reason with false information or a lack of important data, it is impossible to draw a sound conclusion. You also want to be sure that you understand all the details relevant to the issue. What is at stake? How much time do you have to make a decision? How much room is there for error? Potential Problems: -As you become skilled in critical thinking, you will learn to "flag" and remedy pitfalls to sound reasoning. Common problems include working with untested or faulty assumptions, accepting an unproven claim or line of argument, allowing bias to color your thinking, and reasoning illogically, such as making a generalization on the basis of a single experience or case or allowing emotion to rule reason. The more familiar you are with these common blocks to critical thinking, the easier it is to detect them in your own thinking. Helpful Resources: -Wise professionals are quick to recognize their limits and seek help to remedy their deficiencies. Experienced clinicians know that learning is continuous and expect their practice to involve challenges that demand new knowledge. Critical thinkers know what help they need to assist their reasoning and what resources to tap. Key resources include experienced clinicians, texts and journals, institutional policies and procedures, and professional groups and writings. Critique of Judgment/Decision: -Ultimately, you must identify alternative judgments or decisions, weigh the merits of each, and reach a conclusion. It helps to try to predict the consequences of your major options before concluding your reasoning. You will also want to evaluate the alternative you selected as your decision begins to influence your actions. After using this method to work through an intellectually challenging situation, critique your use of the method in light of the standards for critical thinking: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair. Focused Critical Thinking Guides: -The display box Focused Critical Thinking Guide 10-1 illustrates the use of these five considerations to facilitate critical thinking about a care dilemma experienced by a nursing student. The merits of thinking critically about which of the options is most likely to meet that patient's needs are easily seen. Because nurses are accountable for the well-being of their patients, sloppy reasoning is both dangerous and inexcusable—even for someone new to nursing and clinical practice. Other examples of this method are found throughout the book.

Factors affecting movement and alignment

1. Numerous factors, including growth and development, physical health, mental health, lifestyle variables, attitude and values, fatigue and stress, and external factors such as weather, influence a person's posture, movement, and daily activity level. 2. Developmental considerations a) A person's age and degree of neuromuscular development markedly influence body proportions, posture, body mass, movements, and reflexes. b) Fig. 32.3 pg 1044 3. Physical health a) Problems in the musculoskeletal or nervous systems can have a negative influence on body alignment and movement. Similarly, illness or trauma involving other body systems may interfere with movement because of either the underlying pathology or the treatment regimen. 4. Congenital or acquired postural abnormalities a) A newborn with developmental hip dysplasia, torticollis (inclining of head to affected side) or a clubfoot; a teenager with lordosis (exaggerated anterior convex curvature of the spine) or scoliosis (lateral curvature of the spine); and an older person with kyphosis (increased convexity in the curvature of the thoracic spine) are all experiencing postural abnormalities that affect their appearance and mobility. 5. Problems with bone formation or muscle development a) Congenital problems, such as achondroplasia, in which premature bone ossification (bone tissue formation) leads to dwarfism, or osteogenesis imperfecta, which is characterized by excessively brittle bones and multiple fractures both at birth and later in life b) Nutrition-related problems, such as vitamin D deficiency, which results in deformities of the growing skeleton (rickets) c) Disease-related problems, such as Paget disease, in which excessive bone destruction and abnormal regeneration result in skeletal pain, deformities, and pathologic fractures d) Age-related problems, such as osteoporosis, in which bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily e) The muscular dystrophies are a group of genetically transmitted disorders that share a common progressive degeneration and weakness of skeletal muscles. They vary in terms of the muscle groups involved and their clinical course. Myasthenia gravis is a weakness of the skeletal muscles caused by an abnormality at the neuromuscular junction that prevents muscle fibers from contracting. Myotonic muscular dystrophy involves prolonged muscle spasms or stiffening after use. Duchenne muscular dystrophy involves a muscle decrease in size, as well as weakening of muscles over time. 6. Problems affecting joint mobility a) Inflammation, degeneration, and trauma can all interfere with joint mobility. b) The term arthritis describes more than 100 different diseases that affect areas in or around joints. Arthritis is characterized by inflammation, pain, damage to joint cartilage, and/or stiffness. c) Osteoarthritis is a noninflammatory, progressive disorder of movable joints, particularly weight-bearing joints, characterized by the deterioration of articular cartilage and pain with motion. Once the articular cartilage is damaged, bony deposits (bone spurs) may form in the joints, causing more pain with movement of the joint. d) Trauma to a joint may result in a sprain or a dislocation. A sprain occurs with the wrenching or twisting of a joint, resulting in a partial tear or rupture to its attachments. A dislocation is characterized by the displacement of a bone from a joint with tearing of ligaments, tendons, and capsules. Any condition restricting joint mobility has potentially crippling effects. 7. Trauma to the musculoskeletal system a) Injury to the musculoskeletal system can result in fractures and soft-tissue injuries. A fracture, a break in the continuity of a bone or cartilage, may result from a traumatic injury or some underlying disease process. Healing requires realignment of the bone fragment, immobilization, and restoration of the bone's function. Soft-tissue injuries include sprains, strains, and dislocations. A strain, the least serious of these injuries, is a stretching of a muscle. 8. Problems affecting the CNS a) A problem in any of the principal parts of the brain or spinal cord involved with skeletal muscle control can affect mobility. The cerebral motor cortex assumes the major role of controlling precise, discrete movements. A cerebrovascular accident (stroke) or head trauma may damage the motor cortex and produce temporary or permanent voluntary motor impairment. Basal ganglia integrate semivoluntary movements such as walking, swimming, and laughing. In Parkinson disease, there is progressive degeneration of the basal ganglia of the cerebrum, thus affecting walking and coordination. Unnecessary skeletal movements result in tremors and muscle rigidity, which interfere with voluntary movement. The cerebellum assists the motor cortex and basal ganglia by making body movements smooth and coordinated. In multiple sclerosis, the myelin sheaths of neurons in the CNS deteriorate to hardened scars or plaques. Plaque formation in the cerebellum may produce lack of coordination, tremors, and/or weakness. 9. Problems involving other body systems a) Acute or chronic illnesses such as COPD, anemia, angina, cardiac arrhythmias, and heart failure. 10. Mental health a) A person's mental health influences body appearance and movement as much as the person's physical health. Body processes tend to slow down in depression, and there is a lack of visible energy and enthusiasm. Body posture also may be affected. b) Fig 32-4 pg 1047 11. Lifestyle a) Many variables—including occupation, leisure activity preferences, and cultural influences—influence a person's lifestyle, whether active or sedentary. 12. Attitude and values a) In some families, such as those who hike, swim, or play ball together, children learn early to value regular exercise. As these children mature, they often continue to value exercise and find new ways to incorporate regular exercise into their daily routine. 13. Fatigue and stress a) Chronic stress may deplete body energy to the point that fatigue makes even the thought of exercise overwhelming. Ironically, regular exercise is energizing and can better equip a person to deal with daily stresses. Excessive exercise, however, may stress the body and lead to injury as well as to fatigue. 14. External factors a) A bright sunny day, or cold and snowy day may affect the way you feel throughout you day. Others include financial stability, lack of free time, unsafe neighborhoods, air pollution, or gym memberships.

Phases of Wound healing

I. Hemostasis- occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing. II. Inflammatory- follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. III. Proliferation- The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. The new tissue, called granulation tissue, forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily. In wounds that heal by first intention, epidermal cells seal the wound within 24 to 48 hours, thus the granulation tissue is not visible. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. Depending on the size of the wound, collagen deposit continues for several weeks or even years. By the end of the second week following the injury, the majority of white blood cells have left the wound area, and the wound is lighter in color. The systemic symptoms now typically disappear. During this phase, adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care considerations. Wounds that heal by secondary intention eventually follow the same process but take longer to heal and form more scar tissue (Grossman, 2014). Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of granulation tissue formed. IV. Maturation- The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scar, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line. Scar tissue is less elastic than uninjured tissue. The strength of the scar tissue remains less than that of normal tissue, even many years following injury and it is never fully restored (Baranoski & Ayello, 2012, p. 91). Wounds that heal by secondary intention take longer to remodel and form a scar smaller than the original wound. If the scar is over a joint or other body structure, it may limit movement and cause disability.

Physical assessment procedures

1. Health history 2. Appearance and behavior 3. Height and weight 4. BMI 5. VS 6. Pain 7. Skin, hair and nails a) Color b) Vascularity and lesions c) Palpating skin temp, texture, moisture, and turgor 8. Head and neck a) PERRLA b) Ear i) Hearing and otoscope c) Nose i) Palpate sinuses ii) Inspect mouth and pharynx iii) Thyroid gland iv)Palpating the trachea and lymph nodes 9. Thorax and lungs a) Inspect, palpate and auscultate the lung sounds 10. Asses CVS a) Heart sounds b) Pulse c) Cap refill 11. Breasts and axillae a) Inspect and palpate 12. Abdomen a) Inspect, auscultate, then palpate b) Bowel sounds 13. Perineal area a) Inspect/palpate 14. Rectum and anus a) Inspect/palpate 15. Musculoskeletal a) range of motion 16. Neurological a) LOC- oriented to person, place, and time b) Memory c) Speech

Types of nursing diagnoses

-ACTUAL nursing diagnoses: represent problems that have been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor. -RISK nursing diagnoses-are clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation. -POSSIBLE Nursing diagnoses-are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. -WELLNESS Diagnoses-are clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness. Wellness diagnoses are often more applicable in nursing settings that deal primarily with healthy patients. Two cues must be present for a valid wellness diagnosis: A desire for a higher level of wellness An effective present status or function -SYNDROME Nursing diagnoses- comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post-Trauma Syndrome.

Terms used to describe urinary problems

-ANURIA: 24-hour urine output is less than 50 mL; synonyms are complete kidney shutdown or renal failure -DYSURIA:Painful or difficult urination -FREQUENCY: Increased incidence of voiding -GLYCOSURIA:Presence of sugar in the urine -NOCTURIA: Awakening at night to urinate -OLIGURIA: Scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400 mL -POLYURIA:Excessive output of urine (diuresis) -PROTEINURIA: Protein in the urine; indication of kidney disease -PYURIA: Pus in the urine; urine appears cloudy -SUPPRESSION: Stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h -URGENCY: Strong desire to void -URINARY INCONTINENCE: Involuntary loss of urine -AUTONOMIC BLADDER: bladder no longer controlled by the brain because of injury or disease; void by reflex only -BACTERIURIA: condition that occurs when bacteria enter the bladder during catheterization, or when organisms migrate up the catheter lumen or the urethra into the bladder; bacteria in the urine -CONTINENT URINARY RESERVOIR: a surgical alternative that uses a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma -CUTANEOUS URETEROSTOMY: a type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin -ENURESIS: involuntary urination; most often used to refer to a child who involuntarily urinates during the night -EXTERNAL CONDOM CATH: soft, pliable sheath made of silicone material applied externally to the penis -FUNCTIONAL INCONT: state in which a person experiences an involuntary, unpredictable passage of urine -HEMATURIA: blood in the urine; if present in large enough quantities, urine may be bright red or reddish brown -ILEAL CONDUIT: urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall -INDWELL CATH: catheter that remains in place for continuous urine drainage; synonym for Foley catheter -INTERMITTENT CATH: straight catheter used to drain the bladder for short periods (5-10 minutes) -KEGEL EXERCISES: repetitious contraction and relaxation of the pubococcygeal muscle to improve vaginal tone and urinary continence -MICTURITION: process of emptying the bladder; urination; voiding -MIXED INCONT: symptoms of urge and stress incontinence are present, although one type may predominate -NEPHROTOXIC: capable of causing kidney damage -NOCTURIA: excessive urination during the night -OVERFLOW INCONT: involuntary loss of urine associated with overdistention and overflow of the bladder -POSTVOID RESIDUAL (PVR): urine that remains in the bladder after the act of micturition; a synonym for residual urine -REFLEX INCONT: emptying of the bladder without the sensation of the need to void -SPECIFIC GRAVITY: a characteristic of urine that can be determined with manufactured plastic strips or an instrument called a urinometer or hydrometer -STRESS INCONT: state in which the person experiences a loss of urine of less than 50 mL that occurs with increased abdominal pressure -SUPRAPUBIC CATH: catheter inserted into the bladder through a small abdominal incision above the pubic area -TOTAL INCONT: continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation -TRANSIENT INCONT: occurrence that appears suddenly and lasts for 6 months or less and usually is caused by treatable factors, such as confusion secondary to acute illness, infection, and because of medical treatment, such as the use of diuretics or intravenous fluid administration -URGE INCONT: urge incontinence: state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void -URINARY DIVERSION: surgical creation of an alternate route for excretion of urine -URINARY INCONT: any involuntary loss of urine -URINARY RETENTION: inability to void although urine is produced by the kidneys and enters the bladder; excessive storage of urine in the bladder -URINATION: process of emptying the bladder; micturition; voiding -VOIDING: process of emptying the bladder; also called micturition or urination

The nursing process (ADPIE)

-ASSESS-Systematically collect patient data -DIAGNOSING- Clearly identify patient strengths and actual and potential problems -PLANNING-Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes -IMPLEMENTING-Execute the plan of care -EVALUATING-Evaling the effectiveness of the plan of care in terms of patient goal achievement (Various words and phrases have been used to describe the nursing process. Key descriptors include systematic, dynamic, interpersonal, outcome oriented, and universally applicable) ASSESS: -Collection, validation, and communication of patient data -Make a judgment about the patient's health status, ability to manage his or her own health care, and need for nursing. -Plan individualized holistic care that draws on patient strengths and is responsive to changes in the patient's conditions. -Establish the database: Nursing history, Physical assessment, Review of patient record and nursing literature, Consultation with the patient's support people and health care professionals, Continuously update the database, Validate data, Communicate data. DIAGNOSING: -Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve -Develop a prioritized list of nursing diagnoses. -Interpret and analyze patient data, Identify patient strengths and health problems, Formulate and validate nursing diagnoses, Develop prioritized list of nursing diagnoses. Outcome identification and PLANNING: -Specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions -Develop an individualized plan of nursing care. -Identify patient strengths that can be tapped to facilitate achievement of desired outcomes. -Establish priorities, Write outcomes and develop an evaluative strategy, Select nursing interventions, Communicate plan of nursing care. IMPLEMENTING: -Carrying out the plan of care -Assist patients to achieve desired outcomes—promote wellness, prevent disease and illness, restore health, and facilitate coping with altered functioning. 1. Carry out the plan of care. 2. Continue data collection, and modify the plan of care as needed. 3. Document care. EVAL: -Measuring the extent to which the patient has achieved the outcomes specified in the plan of care; identifying factors that positively or negatively influenced outcome achievement; revising the plan of care if necessary -Continue, modify, or terminate nursing care. -Measure how well the patient has achieved desired outcomes, Identify factors that contribute to the patient's success or failure, Modify the plan of care (if indicated).

Skin lesions

-Areas of diseased or injured tissues such as bruises, scratches, cuts, burns, insect bites, and wounds -Primary lesion: may arise from previously normal skin -Secondary lesion: result from changes in primary lesions -Petechiae (1-2 mm size, red or purple macule, flat/nonpalpable) Think of as tiny bruise -Ecchymoses: -Larger bruising -Color variations: black, yellow, green -Hematoma: localized collection of blood -Elevated -Angiomas- cherry is normal change of aging -Spider seen with liver diagnosis, pregnancy, and vit B deficiency -Telangiectasis (venous star)-bluish or red, non blanching, spider like or linear -Superficial dilation seen with varicosities

Factors affecting urination

-Developmental considerations: Children under 5 have trouble controlling their bladder but older children and adults control urine voluntarily. -Food and fluid intake: Alcohol is a diuretic. Foods high in water produce more urine while foods high in salt produce less urine. -Psychological variables: Many individual, family, and sociocultural variables influence a person's normal voiding habits. Voiding may be considered private which means patients may have trouble voiding in front of nurses. -Pathologic conditions: Certain renal or urologic problems can affect both the quantity and the quality of urine produced -Medications: Certain medications may affect urination, such as: o Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. o Diuretics can lighten the color of urine to pale yellow. o Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine. o The antidepressant amitriptyline (Elavil) or B-complex vitamins can turn urine green or blue-green. o Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.

Equipment and assistive devices

-Gait belts -stand-assist and repositioning aids -lateral- assist devices -friction-reducing sheets -mechanical lateral-assist devices -transfer chairs -powered stand-assist -repositioning lifts -powered full- body lifts

Types of wounds

-Incision: Cutting or sharp instrument used, edges close and aligned -Contusion: Blunt instrument. Overlying skin remains intact -Abrasion: Friction. Rubbing or scraping of epidermal layers -Laceration: Tearing of skin with a blunt or irregular object, skin is not aligned -Puncture: Blunt or sharp object puncturing the skin -Penetrating: Foreign object entering the skin or mucous membrane and lodging in underlying tissue -Avulsion: Tearing a structure from normal anatomical positioning -Chemical: Toxic agents such as, drugs, acids, alcohols, metals, and substances released during cellular necrosis -Thermal: High or low temperatures -Irradiation: Ultraviolet light or radiation exposure -Pressure Ulcer: Compromised circulation secondary to pressure combined with friction -Venous Ulcers: Injury and poor venous return -Arterial Ulcer: Injury and underlying ischemia. Could be caused by atherosclerosis or thrombosis -Diabetic ulcer: Injury and underlying diabetic neuropathy, peripheral arterial disease, and diabetic foot syndrome.

Types of catheters

-Indwelling catheter: or retention/foley catheter, used for long periods of time to remain in bladder with the help of an inflated balloon -Intermittent catheter: or straight catheters, are used to drain the bladder for shorter periods before being removed -Suprapubic catheter: surgically inserted through a small incision above the pubic area for long-term, continuous drainage -Condom catheter: self-adhesive, soft, pliable sheath made of silicone material applied externally to the penis. The catheter is connected to drainage tubing and a collection bag, and can be used with a leg bag.

Developmental considerations

-Infants: Mucous membranes are easily injured and infected Children under 2: Weaker, thinner skin Children: Skin becomes increasingly resistant to injury and infection Older adults: Prolonged maturation of epidermal cells leads to easier tears. -Decreased circulation and collagen repair leads to decreased elasticity and increased pressure risks

Alterations in skin integrity

-Intentional Wounds: the result of a planned invasive therapy or treatment -Unintentional Wounds: accidental; occur from unexpected trauma -Open Wound: the skin surface is broken -Closed Wound: skin not broken, but soft tissue is damaged. Internal bleeding and hemorrhage may occur -Acute Wound: heal in days to weeks, close wound edges, decreased risk of infection -Chronic Wound: any wound that does not heal in the expected continuum. Remains in inflammatory stage.

Urinary incontinence

-Involuntary leakage of urine -Most common chronic health problem -More prevalent in women and increases with age -Long term use of disposable products discouraged due to risk of skin breakdown. If necessary, discuss: o Functional disability of the patient o Type and severity of incontinence o Gender o Availability of caregivers o Failure of previous treatment programs o Patient preference

Risk factors altered skin and wound

-Lifestyle variables -Illness -Age -diagnostic measures -Changes in Health -Therapeutic measures

Promoting normal urination

-Nursing care to promote normal urination includes interventions to support normal voiding habits, fluid intake, strengthening of muscle tone, stimulating urination and resolving urinary retention, and assisting with toileting. Nurses working with patients to promote appropriate behaviors related to urine elimination should examine their own behaviors as factors in the success off the plan. Nurses who role model good health behaviors are more effective teachers. Use the display, Promoting Health 36-1, for yourself before using it with others. MAINTAINING NORMAL VOIDING HABITS: -schedule, urge to void, privacy, position, and hygiene. Promote fluid intake, Strengthen muscle tone with exercises.

Braden Scale

-Predicts pressure ulcer risk Accounts for: -Mental status -Continence -Mobility -Activity -Nutrition 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk 10-12 = high risk 9 or lower = very high risk

Reporting Care

-Report: give an account of something seen, heard, done, or considered. -Forms of report: oral, written, or computer-based communication of patient data to others -Common methods: face to face, phone conversation, written methods, audiotape, or computer methods ISBAR: -Identity/Introduction: Communicate who you are, where you are, and why you are communicating. -Situation: Communicate what is occurring and why the patient is being handed off to another department or unit. -Background: Explain what led up to the current situation and put in context if necessary. -Assessment: Give your impression of the problem. -Recommendation: Explain what you would do to correct the problem. (When giving report be professional, correct, and concise. Keep focused on discussion of the patient.)

Types of Exercise

1. Isotonic- involves muscle shortening and active movement. a)Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Potential benefits include increased muscle mass, tone, and strength; improved joint mobility; increased cardiac and respiratory function; increased circulation; and increased osteoblastic or bone-building activity. 2. Isometric- involves muscle contraction without shortening. a)Examples include contractions of the quadriceps and gluteal muscles, such as what occurs when holding a Yoga pose. Potential benefits are increased muscle mass, tone, and strength; increased circulation to the exercised body part; and increased osteoblastic activity. 3. Isokinetic- involves muscle contraction with resistance. a) Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Using the device, the person takes the muscles and joint through a complete range of motion without stopping, meeting resistance at every point. 4. Aerobic exercises a) Refers to sustained (often rhythmic) muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning. Examples of aerobic activities include swimming, walking, jogging, cross-country skiing, aerobic dancing, bicycling, jumping rope, and racquetball. Aerobic exercise may be further distinguished as having high or low impact. 5. Stretching a) involve movements that allow muscles and joints to be stretched gently through their full range of motion, increasing flexibility. Specific warm-up and cool-down exercises, Hatha yoga, and some forms of dance are examples. Benefits include increased range-of-joint movements, improved circulation and posture, and relaxation. 6. Strength and endurance a) involve movements that allow muscles and joints to be stretched gently through their full range of motion, increasing flexibility. Specific warm-up and cool-down exercises, Hatha yoga, and some forms of dance are examples. Benefits include increased range-of-joint movements, improved circulation and posture, and relaxation. 7. Movement and ADL's a) include housecleaning, running after playful toddlers, climbing stairs instead of riding in elevators, and so on. Household activities can also contribute to an active lifestyle.

Urine specimen collection

-Routine urinalysis: Sterile specimen not required. Have patient void into a clean bedpan or urinal and avoid contamination with feces. Instruct patient not to place toilet paper in specimen and note if a woman is on her period. Label appropriate container with patient's name, date, and time of collection. Take sample to the lab as soon as possible. -Clean catch or midstream specimen: Collect urine midstream because it is most like what the body is actually producing. Patient can perform procedure alone. -Sterile specimen: Obtained by catheterizing the patient or by taking a sample from an indwelling catheter. Always collect specimen from the specified port, never the bag. If urine is not present in the tube, clamp the tube below the access port briefly (not to exceed 30 minutes) to allow urine to accumulate. -Urinary diversion specimen: Preferred method is to catheterize the stoma. Clean stoma appliance with warm water and insert catheter, using sterile technique, 2-2.5in. If resistance occurs rotate catheter and advance. After a sufficient specimen is collected, reapply stoma appliance. -24hr specimen: Record start and stop time in the 24hr period and collect all urine voided. Depending on type of examination urine may be collected in separate containers or in one receptacle. Lab may use a preservative or urine may need to be kept in the refrigerator. -Infant/Child specimen: Plastic disposable collection bags are available for collecting urine specimens from infants and young children who have not achieved voluntary bladder control.

Urinary retention

-The Inability to void although urine is produced in kidneys and enters bladder; excessive storage of urine in bladder -Can be caused by decreased bladder contractility -Intermittent catheter can be used to clear urine from bladder

Types of urinary incontinence

-Transient incontinence: occurs suddenly and lasts 6 months or less -Stress incontinence: related to intra-abdominal pressure -Mixed incontinence: urine loss with features of two or more types of incontinence -Overflow incontinence: overdistention and overflow of the bladder -Functional incontinence: inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation. -Reflex incontinence: missing the sensation to void. -Total incontinence: continuous and unpredictable loss of urine

Body Mechanics and Ergonomics

-Use of proper body positions to provide protection from stress of movement and activity -Patient handling tasks are primary cause of musculoskeletal disorders among nurses -Ergonomics: practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care -Mechanical lifts and other patient handling devices reduce effect of trauma and injuries -Back belt does not prevent back injury -Repetitive motions and lifting are high risk -< 200 lbs - use friction reducing device with 2-3 caregivers -> 200 lbs - use friction reducing device with at least 3 caregivers -Patient unable to assist - use full body sling lift and 2 or more caregivers -Lock wheels -Wide base, face direction of movement -Push rather than pull, keeping arms close to body -Work as close to object or person as possible -Use arms and legs rather than back

Documentation guidelines

-the patient record is the only permanent legal document that details the nurse's interactions with the patient and is the nurse's best defense if a patient or patient surrogate alleges nursing negligence. Unfortunately, there are often crucial omissions in the nursing documentation, along with meaningless repetitious or inaccurate entries. Although these errors might go undetected and have no effect on the patient, they might also seriously affect the care the patient receives, undermine nursing's credibility as a professional discipline, and cause legal problems for the nurses responsible. -complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. -dont say normal -dont use a pencil or eraser

Effects of exercise on major body systems

1. CVS a) To meet the demand for oxygen created by the rhythmic contraction and relaxation of skeletal muscle groups, the supply of oxygenated blood to skeletal muscle needs to be increased. The cardiovascular system meets this challenge by increasing the heart rate, increasing the contractile strength of the myocardium, and increasing stroke volume (volume of blood ejected), thus increasing cardiac output. Arterial (systolic) blood pressure is increased, and blood is shunted from the nonexercising tissues to the heart and muscles. Exercise also improves venous return because the contracting muscles compress superficial veins and push blood back to the heart against gravity. Over time, regular exercise results in cardiovascular conditioning and produces the following benefits: i) Increased efficiency of the heart ii) Decreased heart rate and blood pressure iii) Increased blood flow to all body parts iv) Improved venous return v) Increased circulating fibrinolysin (substance that breaks up small clots) 2. Resp system a) The respiratory and cardiovascular systems work together to make increased oxygen available to the muscles. During exercise, the depth of respiration, respiratory rate, gas exchange at the alveolar level, and rate of carbon dioxide excretion are increased. Over time, regular exercise leads to improved pulmonary functioning. Improvements in pulmonary function include: i) Improved alveolar ventilation ii) Decreased work of breathing iii) Improved diaphragmatic excursion 3. Musculoskeletal system a) The rhythmic contraction and relaxation of muscle groups during exercise result in increased muscle mass, tone, strength, and increased joint mobility. The more a person exercises, the more strength the individual has to exercise or work in the future. Regular exercise produces the following benefits: i) Increased muscle efficiency (strength) and flexibility ii) Increased coordination iii) Reduced bone loss iv) Increased efficiency of nerve impulse transmission b) Regular exercise is also believed to slow the effects of aging. For example, exercise has been shown to help prevent osteoporosis (the process of bone demineralization) associated with aging. Exercise has also been associated with minimizing bone loss during chemotherapy. 4. GI system a) During exercise, blood is shunted away from the stomach and intestines to the exercising muscles. With regular exercise: i) Appetite is increased. ii) Intestinal tone is increased, which improves digestion and elimination. iii) Weight may be controlled. 5. Urinary system a) Regular exercise increases blood circulation, including improved blood flow to the kidneys. This allows the kidneys to maintain the body's fluid balance and acid-base balance more efficiently and to excrete body wastes. 6. Skin a) Increased circulation resulting from regular exercise nourishes the skin. Thus, regular exercise aids in promoting the overall general health of the skin. 7.Psychosocial outlook a) Some of the most important benefits of regular exercise are psychological. These benefits include: i) Increased energy, vitality, and general well-being ii) Improved sleep iii) Improved appearance (body image) iv) Improved self-concept v) Increased positive health behaviors

Effects of immobility on the body

1. CVS a) the primary and serious effects of immobility on the cardiovascular system include increased cardiac workload, orthostatic hypotension, and venous stasis, with resulting venous thrombosis. Immobility results in an increased workload for the heart. With immobility, the skeletal muscles that normally compress valves in the leg veins and help to pump the blood back to the right side of the heart do not adequately contract. There is less resistance offered by the blood vessels and blood pools in the veins, thus increasing the venous blood pressure and changing the distribution of blood in the immobile person. As a result, the heart rate, cardiac output, and stroke volume increase. b) Immobility predisposes the patient to thrombi formation because of venous stasis, especially in the legs, where normal muscular activity helps move blood toward the central circulatory system. During periods of immobility, calcium leaves the bones and enters the blood, where it influences blood coagulation, leading to an increased risk of thrombus formation. c) A person who is immobile is more susceptible to developing orthostatic hypotension. 2. Resp System a) The effects of immobility on the respiratory system are related to decreased ventilatory effort and increased respiratory secretions. Immobility causes a decrease in the depth and rate of respirations, in part because of a reduced need for oxygen by body cells. When areas of lung tissue are not used over time, atelectasis (incomplete expansion or collapse of lung tissue) may occur. Immobility results in a poor exchange of carbon dioxide and oxygen, upsets their balance in the body, and eventually causes an acid-base imbalance. b) When a person is immobile, the movement of secretions in the respiratory tract is decreased, causing secretions to pool and leading to respiratory congestion. These conditions predispose the person to respiratory tract infections. Hypostatic pneumonia is a type of pneumonia that results from inactivity and immobility. The situation worsens when the person is dehydrated or using pharmacologic agents that increase the tenacity of secretions, depress the coughing mechanism, and/or depress respirations. c) Decreased movement in the thoracic cage during respirations also occurs with immobility. This decrease may be due to loss of tonus in muscles involved with respirations, pressure on the chest wall because of the patient's position in bed, or depression of the respiratory system by various pharmaceutical agents. 3. Musculoskeletal system a) Effects of immobility on the musculoskeletal system are rapidly seen in patients confined to bed. People attempting to walk after several days of bed rest are often surprised to find how weak their legs have become. Immobility (musculoskeletal disuse) leads to decreased muscle size ( atrophy), tone, and strength; decreased joint mobility and flexibility; bone demineralization; and limited endurance, resulting in problems with ADLs. b) Immobility is often the cause of contractures and ankylosis, a consolidation and immobilization of a joint. Contractures result from atrophy of muscles and from a decrease in the muscle's strength, coordination, and endurance, resulting in an inability to function. A joint can be permanently fixed when ankylosed. c) The process of bone demineralization (osteoporosis) is also increased in immobile patients. Normally, the stress and strain of weight-bearing activity stimulate bone formation and balance it with the natural destruction of bone. With immobility, however, bone formation slows while breakdown increases, resulting in a net loss of bone calcium, phosphorus, and bone matrix. This condition, disuse osteoporosis, is characterized by bones that may be either spongy or brittle. Bone demineralization may result in pathologic fractures related to the bone's brittleness, bone deformities related to the bone's sponginess, arthropathy (joint disease) related to calcium depletion in the joints, or renal calculi (stones) related to the excessive excretion of calcium through the kidneys and urinary tract. 4. Metabolic process- a) Because the resting body requires less energy, the cellular demand for oxygen is decreased, leading to a decreased metabolic rate. In many immobilized patients, however, factors such as fever, trauma, chronic illness, or poor nutrition can actually increase the body's metabolic demands and increase catabolism (the breakdown of the body's protein stores to provide energy to meet the body's energy requirements). If unchecked, this process results in muscle wasting and a negative nitrogen balance. Anorexia, or decreased appetite, often accompanies and compounds this problem. Negative nitrogen balance and poor nutrition thus worsen the muscle atrophy and weakness already resulting from immobility. Numerous fluid and electrolyte imbalances, alterations in the exchange of nutrients and gases at the cellular level, and gastrointestinal (GI) problems can all result from metabolic disturbances. 5. GI a) Immobility leads to disturbances in appetite, decreased food intake, altered protein metabolism, and poor digestion and utilization of food. If people increase food intake while decreasing energy expenditure, weight gain will result. Normal muscular activity in the GI tract also slows down in an immobile person, which often results in constipation, poor defecation reflexes, and an inability to expel feces and gas adequately. 6. Urinary a) In a nonerect patient, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile patient. b) Immobility also predisposes the patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. 7. Skin a) In patients who are immobile, especially those who are older or debilitated, the impaired circulation that accompanies immobility may result in serious skin breakdown. Prolonged pressure over bony prominences produces areas of breakdown, leading to pressure ulcers. 8. Psychosocial outlook a) When a person can no longer move the body purposefully and needs to depend on someone else for assistance with simple self-care activities, the person's sense of self is often threatened. Skeletal deformities can influence body image, an inability to meet role expectations can decrease self-concept, and a prolonged period of lying dependent in bed can lead to feelings of worthlessness and diminished self-esteem. b) Immobility can produce exaggerated emotional responses to the stresses of everyday living. Patients can become apathetic, possibly because of decreased sensory stimulation, and develop altered thought processes. Lack of mobility can also diminish a person's opportunities to interact socially and deprive that person of normal support systems. Coping difficulties are common for both immobilized patients and their families. Furthermore, the amount of time immobilized patients spend resting often disrupts their usual sleep-wake patterns and may interfere with both the quantity and quality of their sleep.

Surgical assessment

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Addressing age-related changes

AGE-RELATED CHANGES AFFECTING URINARY ELIMINATION: -Nocturia -Frequency -Urgency -Incontinence UTI, NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING NUTRITION: -Altered ability to chew related to loss of teeth, ill-fitting dentures, and gingivitis. -Loss of senses of smell and taste. -Decreased peristalsis in the esophagus. -Gastroesophageal reflux. -Decreased gastric secretions. -Slowed intestinal peristalsis. -Lowered glucose tolerance. -Reduction in appetite and thirst sensation. -Nutritional deficiencies related to alcohol intake. -Loss of appetite associated with depression and loneliness. -Physical handicaps. -Low income, malnutrition, Increased risk for drug-nutrient interactions.

Person-centered care

All team members are considered caregivers: -Identify the team members you worked with while implementing the plan of care. Everyone in the workforce from housekeeping staff to the CEO is part of the patients' plan of care. -Next to each describe what they contributed to person-centered care for your patient. -Star or highlight those with whom you had meaningful conversations and briefly describe what you learned. Care is based on continuous healing relationships: -Describe what you did to make your interactions with the patient/family qualify as a healing relationship versus a mere business transaction or provision of a service. -This principle reinforces a focus on the continuum of care. In what ways did your care anticipate and prepare your patient and family for the days ahead. Care is customized and reflects patient needs, values, and choices. -Describe what you learned about this patient/family as unique individuals (strengths, needs, values, and preferences) that allowed you to creatively individualize the plan of care. -What strategies did you use to elicit the patient's needs, values, and choices? -In what specific ways is your plan of care different from any standardized plan of care? Knowledge and information are freely shared between and among patients, care partners, physicians, and caregivers: -Describe one way you shared information with the patient/family and one way you shared information with the health care team that enhanced the partnership and the plan of care. -What did you learn from other members of the team that enhanced your ability to care for this patient/family? Care is provided in a healing environment of comfort, peace, and support. -When we think healing environment we usually think of music, healing gardens, soothing colors. Assess your patient's healing environment and describe what you did to facilitate the creation of such an environment. How can you adapt these principles in critical caresettings, emergency rooms, clinics, etc.? -In what ways are you able to address variables that negatively influence healing: Poverty, noise, time pressures, etc. -What percentage of the plan of care and your plan of careaddresses patient needs other than physiological needs? -To what degree are the psycho-social-spiritual needs of the patients identified and addressed? To what degree do they appear in your plan of care? -Describe the measures you used to promote the patient's/family's comfort and peace and to provide support? Families and friends of the patient are considered an essential part of the care team: -Has the patient identified family members or others he/she wishes to be part of the care team? If the patient is not able to articulate preferences, is there a legally valid surrogate making decisions? In what ways have you communicated with these individuals and provide the information and support they need to help the patient? Patient safety is a visible priority. -What is the institutional commitment to safety measures like hand hygiene and other protocols to prevent hospital-acquired infections, medication and other errors, falls, etc.? -In what ways is this particular patient at risk for safety concerns, falls, infection, violence, etc. and what have you done to address these risks? Transparency is the rule in the careof the patient. -True person-centered care requires transparency between providers and patients and among providers. Patients or their designees need information so they can make informed decisions. Does your patient have the information he/she needs to make informed decisions? If not, in what ways are you addressing this? All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient: -In what ways are clinical decisions or institutional policies motivated by goals other than the best interests and personal goals of the patient and how is this constraining the plan of care? What have you done to address these variables? -What institutional resources exist to help you address these variables? The patient is the source of control for their care: -Assess the degree to which your patient or her/his designee is the source of control for the plan of care. -What factors are constraining this and what are you doing to address these factors?

Electronic Medical Records

An EMR is an electronic patient care record created by an agency or agencies having common ownership. Although these EMRs today are often called EHRs, they are not true EHRs because the data is not shared between providers in agencies under different ownership.

Maintaining Confidentiality: Changes in practice & the environment

Because PHI can be in oral, written or electronic form; facilities are charged with not only training staff about HIPAA regulations but also altering the physical layout of nurses stations, office reception areas, or waiting rooms to assure protected patient information is not accidently seen or overheard. STAFF- also need to be reminded that whether they practice in a hospital, clinic, physician's office, or pharmacy that they must make sure any conversations they have with a colleague about a patient cannot be overheard by others who are nearby. PROFESSIONALS- should never talk about a patient in a public area such as a hallway, elevator, lunchroom, cafeteria, or parking lot, or even the front of a nurses station or reception desk where visitors or other patients may be present. In addition, no matter where the providers are, their voices should be low. If they are not in a private area, they should watch for individuals who closely pass them by. Privacy regulations have also impacted clinics and physicians' offices. While many of the same practices that are utilized in hospital nurses stations can be applied to the area where the receptionist sits, there are also other issues that must be addressed as well. Patient records and other files with PHI must be in a protected area and kept in locked cabinets. At the front desk, there is usually a sign-in sheet that individuals fill in on their arrival to the office. This is usually a piece of paper affixed to a clipboard with lines for names, time of appointment, and the physician to be seen. Needless to say, each person who fills in his name can see the identities of all the other patients who came in before him. However, now there are new types of sign-in sheets, where each signature can either be covered immediately or easily removed by the staff member sitting at the desk. Upon arrival, each patient must be given written information about HIPAA regulations and sign a form indicating he or she has read and understands them. In addition, the patient must give written consent to share his PHI with payers as well as others he wants to have access to his medical status. When the nurse calls the patient in the waiting room to follow her into the office, first names should be used, but other identifiers, such as confirming date of birth, should be done privately in the exam room. PHARMACIES- Pharmacies are also covered by HIPAA. Because they are often found in warehouse, grocery, or other types of stores; it is critical that conversations about patients between the pharmacists and techs be held in private places, away from public access. In addition, there should be a place where the pharmacist can talk quietly with the patient about the medication prescribed and any special information about it, such as instructions on how to take it—for example, with or without out without food—and well as potential side effects. COMMUNICATION ISSUES- There are some communication issues that affect hospitals, offices, clinics, and pharmacies. One concerns phone calls. Oftentimes, physician's staff will call to remind a patient about an appointment, procedure preparation; or a pharmacy tech can call about picking up a prescription. Unless the patient has given permission to leave a message concerning his PHI on the phone number listed in the chart, the receptionist should just leave a call back number. Likewise, a physician should not leave messages about test results, diagnoses, or treatment options. If information is to be mailed to the patient, staff should find out if it can go to the patient's home or to a P.O. box. In either case, the envelope should be marked, "confidential." It is also important to remember that if an interpreter is utilized, that he or she understands HIPAA regulations concerning patient privacy and the penalties that can be imposed for breaking these laws. Finally, staff must remember that not only are written materials considered confidential, but so are photographs. It is not uncommon for unusual skin conditions or traumatic injuries to be captured by camera for teaching purposes. However, these items are considered part of a patient's PHI and he or she must give permission to share them.

Characteristics of urine

COLOR: - A freshly voided specimen is pale yellow, straw-colored, or amber, depending on its concentration. Urine is darker than normal when it is scanty and concentrated. Urine is lighter than normal when it is excessive and diluted. Some foods can alter the color; for example, beets can cause urine to appear red. Certain drugs, such as cascara, L-dopa, and sulfonamides, alter the color of urine. ODOR: -Normal urine smell is aromatic. As urine stands, it often develops an ammonia odor because of bacterial action. TURBIDITY: -Fresh urine should be clear or translucent; as urine stands and cools, it becomes cloudy. Cloudiness observed in freshly voided urine is abnormal and may be due to the presence of red blood cells, white blood cells, bacteria, vaginal discharge, sperm, or prostatic fluid. PH: -The normal pH is about 6.0, with a range of 4.6 to 8. (Urine alkalinity or acidity may be promoted through diet to inhibit bacterial growth or urinary stone development or to facilitate the therapeutic activity of certain medications.) Urine becomes alkaline on standing when carbon dioxide diffuses into the air. high-protein diet causes urine to become excessively acidic. Certain foods tend to produce alkaline urine, such as citrus fruits, dairy products, and vegetables, especially legumes. Certain foods such as meats tend to produce acidic urine. Certain drugs influence the acidity or alkalinity of urine; for example, ammonium chloride produces acidic urine, and potassium citrate and sodium bicarbonate produce alkaline urine. SPECIFIC GRAVITY: -This is a measure of the concentration of dissolved solids in the urine. The normal range is 1.015 to 1.025. Concentrated urine will have a higher than normal specific gravity; diluted urine will have a lower than normal specific gravity. In the absence of kidney disease, a high specific gravity usually indicates dehydration and a low specific gravity indicates overhydration. CONSTITUENTS: -Organic constituents of urine include urea, uric acid, creatinine, hippuric acid, indican, urine pigments, and undetermined nitrogen. Inorganic constituents are ammonia, sodium, chloride, traces of iron, phosphorus, sulfur, potassium, and calcium. Abnormal constituents of urine include blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile.

Care of client with a urinary diversion

Caring for a Patient with a Urinary Diversion: -Obstructions or tumors in the urinary tract may require some patients to have urinary flow diverted surgically. Urinary diversions may also be used as part of the treatment for patients with a neurogenic bladder, radiation cystitis, or congenital anomalies of the lower urinary tract. An ileal conduit is a type of incontinent cutaneous urinary diversion. An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. This separated section of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma, a surgically created opening on the body surface. Figure 36-14 shows how the ureters are diverted in an ileal conduit. A cutaneous ureterostomy is another type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin. These cutaneous diversions are usually permanent, and the patient wears an external appliance to collect the urine because elimination of the urine from the stoma cannot be controlled voluntarily. Another option for diversion of urine is a continent urinary reservoir (e.g., the Indiana pouch and the Kock pouch). Figure 36-15 shows how the ureters are diverted into a segment of ileum and cecum in an Indiana pouch. This is a surgical alternative that uses a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma. The external stoma or outlet must be catheterized at regular intervals to drain the urine that has collected in this reservoir.

Nail Assessment

Describe what you see and how it feels -Raised or flat? -Solid or fluid filled? -Palpable or nonpalpable? -Skin color change? Nail variations -Spoon shaped (koilonychias) = trauma to cuticles or nail folds, iron deficiency anemia, endocrine or cardiac disease -Yellow nails, brittle, and thick = older adult -In younger adult grow slow and are curved = AIDS, respiratory syndromes -Paronychia (redness where skin and nail meet) = infection -Longitudinal ridging: seen in elderly, otherwise nonsignificant -Half white, half pink may indicate renal disease -Pitting (small indents or depressions on nail surface) may be seen with psoriasis

Diagnostic reasoning and avoiding pitfalls

Diagnosis is considered accurate if precise and supported by defining characteristics: -Novice nurses think of things as "right and wrong." Experts realize shades of grey between right and wrong -Novice nurses focus on details and may miss big picture -Experts have broader perspective Novice nurses become better by avoiding the several pitfalls of diagnosing: -Pitfalls decrease reliability of defining characteristics -Pitfalls decrease diagnostic accuracy Two sets of pitfalls: Occur during assessment phase: -Too many or too few data -Unreliable or invalid data -Insufficient number of cues (characteristics) available to support diagnosis Occur during analysis phase: -Cues (characteristics) are clustered but unrelated Other pitfalls: -Diagnosing too quickly without considering other diagnoses -Incorrectly wording diagnostic statement -Overlooking cultural background of patient

Diagnostic reasoning and avoiding pitfalls

Diagnosis is considered accurate if precise and supported by defining characteristics: -Novice nurses think of things as "right and wrong." Experts realize shades of grey between right and wrong -Novice nurses focus on details and may miss big picture -Experts have broader perspective Novice nurses become better by avoiding the several pitfalls of diagnosing: -Pitfalls decrease reliability of defining characteristics -Pitfalls decrease diagnostic accuracy Two sets of pitfalls: Occur during assessment phase: -Too many or too few data -Unreliable or invalid data -Insufficient number of cues (characteristics) available to support diagnosis -Occur during analysis phase -Cues (characteristics) are clustered but unrelated Other pitfalls: -Diagnosing too quickly without considering other diagnoses -Incorrectly wording diagnostic statement -Overlooking cultural background of patient

Wound drains

Penrose: -Provides sinus tract -Ex. after incision and drainage of abscess, in abdominal surgery T-tube: -Bile drainage -Ex. after gallbladder surgery Jackson-Pratt: -Decreases dead space by collecting drainage -Ex. after breast removal, abdominal surgery Hemovac: -Decreases dead space by collecting drainage -Ex. after abdominal. Orthopedic surgery Gauze, iodoform gauze, NuGauze: -Allowing healing from base of wound -Ex. infected wounds, after removal of hemorrhoids

Patient teaching

General Guidelines: Teach about supplies used, infection prevention, and wound healing. In addition, pressure ulcer prevention and care.

Confirm or rule out nursing diagnoses

Is my patient database (assessment data) sufficient, accurate, and supported by nursing research?

Factors in wound healing

LOCAL factors: those occurring directly in the wound -pressure -desiccation (dehydration) -maceration (overhydration) -trauma -edema -infection -excessive bleeding -necrosis (death of tissue) -presence of biofilm (a thick grouping of microorganisms) SYSTEMIC factors: those occurring throughout the body -age -circulation to and oxygenation of tissues, -nutritional status -wound condition -health status -immunosuppression -medication use

Verbal orders

In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. The order must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist, who receives, reads back, documents, and executes the order. Verbal orders may not be given, received, or executed under any other circumstances.

Wound complications

Infection: -Risk of infection increased in surgical wounds created during procedure involving intestines -Hospital acquired infections -Symptoms develop in 2-7 days -Symptoms include -Purulent drainage -Increased drainage -Pain -Redness -Swelling -Increased body temp -Increased WBC count -Hemorrhage -May occur from slipped suture, dislodged clot at wound site, infection, or erosion of blood vessel by foreign body -Check dressing and wound frequently after surgery -Internal hemorrhage causes formation of hematoma -Dehiscence and evisceration -Most serious post op wound complications -DEHISCENCE: partial or total separation of wound layers due to excessive stress on unhealed wound -EVISCERATION: wound completely separates with protrusion of viscera through incision area -People at increased risk: -Obese -Malnourished -Smoke tobacco -Use anticoagulants -Have infected wounds -Experience excessive coughing, vomiting, or straining -"Something has suddenly given away" -Dehiscence and evisceration of abdominal wound is a medical emergency -Place in low Fowler's position -Cover exposed abdominal contents -Do not leave patient alone -Notify primary care provider -Fistula formation -An abnormal passage from an internal organ or vessel to outside of body or from one internal organ or vessel to another -May be created purposefully -Often result of an infection that has developed into an abscess (collection of infected fluid that hasn't drained) -Increase risk for delayed healing, additional infection, fluid and electrolyte imbalance, and skin breakdown

Factors placing an individual at risk for skin alterations

Lifestyle variables: -Homosexuality -History of multiple sexual partners -Intravenous drug users -Hemophiliacs -Bisexual male -Partners of these demographics above: -High risk for HIV/AIDS -Assess skin for purple blotches-may indicate Kaposi's sarcoma -Occupation or other activity that gives an individual prolonged exposure to sun -High risk for skin cancer -Body piercing -Potential interference with airway -Risk for infection, scarring, nerve damage, tissue trauma, deformity -Age -Subcutaneous and dermal tissue become thin -Easily injured -Less insulation -Wrinkles easier -Sensation of pressure and pain is reduced -Activity of sebaceous and sweat glands decreases -Skin becomes dryer -Itching may occur -Cell renewal is shorter -Healing time is delayed -Melanocytes (cells that pigment skin and hair) decline -Hair becomes gray-white -Skin may become unevenly pigmented -Collagen fiber is less organized -Skin loses elasticity -Changes in health state -Dehydration or malnutrition -Skin loses elasticity -prone to breakdown if fluid, -protein, and vitamin C intake is deficient -Reduced sensation -May result in injury -Diagnostic measures -Gastrointestinal series -GI cleansing preparations - can cause diarrhea which irritates skin in perineal area -Illness -Diabetes mellitus -Cuts and sores that don't heal -Lesions on lower extremities that turn to ulcers, necrotic -Recurrent infections -Therapeutic measures -Bed rest -Skin breakdown -Assess pressure points -Casts -Irritate skin -Careful assessment, cover rough edges of cast -Aquathermia unit -May cause skin breakdown if applied for too long -Examine skin between treatments -Medications -May cause rashes -Examine skin for redness and itching -Radiation therapy -Erythema -Loss of skin integrity

Nursing Process Impaired Physical Mobility

Nursing assessment- Physical assessment of mobility: -General ease of movement -Gait and posture -Alignment -Joint structure and function -Muscle mass, tone, and strength -Endurance Nursing diagnosis: Impaired physical mobility/activity intolerance (what action patient has trouble with) related to (physiologic issue) as manifested by: (symptoms). IMPAIRED IMOBILITY: Related factors: Musculoskeletal impairment (fracture arthritis) · Neuromuscular impairment (muscular dystrophy, MS) · Decreased strength and endurance · Pain or discomfort · Depression and anxiety · Decreased muscle control, mass, or strength · Joint stiffness · Pharmaceutical agents (narcotics for pain, sedatives for rest) · Therapy related restrictions on movement (ie order for bed rest, splint, traction) Sample defining characteristics: · Physical inability to move purposefully or a reluctance to move · Limited ROM · Limited ability to perform fine or gross motor skills · Slowed, jerky, or uncoordinated movements · Postural instability

Privacy (??),confidentiality, legal aspects

PRIVACY- CONFIDENTIALITY: -All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. This includes their names and all identifiers such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the patient is sick or in the hospital, office, or clinic, the assessments and treatments the patient receives, and information about past health conditions. Protected health information might be found in the patient medical record, computer systems, telephone calls, voice mails, fax transmissions, e-mails that contain patient information, and conversations about patients among clinical staff. According to HIPAA, patients have a right to: -See and copy their health record -Update their health record -Get a list of the disclosures that a health care institution has made -independent of disclosures made for the purposes of treatment, payment, and health care operations -Request a restriction on certain uses or disclosures -Choose how to receive health information LEGAL ASPECTS: -The U.S. Office for Civil Rights enforces the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; the HIPAA Breach Notification Rule, which requires covered entities and business associates to provide notification following a breach of unsecured protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety (www.HHS.gov). Congress passed HIPAA in 1996. The final regulations were released in August 2002. Most agencies now require workers to undergo HIPAA training and to review and sign a confidentiality agreement both when hired and at each performance review. As a student in a health care setting, you should discuss privacy guidelines with your instructor and nurse mentors.

Performing closed catheter irrigation

Performing intermitted closed catheter irrigation -Open supplies, using aseptic technique. Pour the sterile solution into a sterile basin. Aspirate the prescribed amount of irrigant (usually 30 to 60 mL) into sterile syringe. Put on gloves. -Cleanse the access port on the catheter with antimicrobial swab (Fig. 1). -Clamp or fold the catheter tubing below the access port (Fig. 2). -Attach the syringe to the access port on the catheterusing a twisting motion (Fig. 3). Gently instill solution into the catheter (Fig. 4). -Remove the syringe from the access port (Fig. 5). Unclamp or unfold tubing and allow irrigant and urine to flow into the drainage bag. Repeat procedure, as necessary. -Remove gloves. Secure catheter tubing to the patient's inner thigh or lower abdomen (if a male patient) with anchoring device or tape. Leave some slack in the catheter for leg movement. -Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. -Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of the side rails does not interfere with the catheter or drainage bag. -Remove equipment and discard syringe in appropriate receptacle. Remove gloves and additional PPE, if used. Perform hand hygiene. -Assess the patient's response to the procedure and the quality and amount of drainage after the irrigation. ADMINISTERING A CONTINUOUS CLOSED CATHETER IRRIGATION: -Empty the catheter drainage bag and measure the amount of urine, noting the amount and characteristics of the urine. -Assist the patient to a comfortable position and expose the irrigation port on the catheter setup. Place a waterproof pad under the catheter and aspiration port. -Prepare a sterile irrigation bag for use as directed by the manufacturer. Clearly label the solution as "Bladder Irrigation." Include the date and time on the label. Hang bag on an IV pole 2.5 to 3 feet above the level of the patient's bladder. Secure the tubing clamp and insert the sterile tubing with drip chamber to the container using aseptic technique (Fig. 1). Release the clamp and remove the protective cover on the end of the tubing without contaminating it. Allow the solution to flush the tubing and remove air (Fig. 2). Clamp the tubing and replace the end cover. -Put on gloves. Cleanse the irrigation port on the catheter with an alcohol swab. Using aseptic technique, attach irrigation tubing to the irrigation port of the three-way indwelling catheter (Fig. 3). -Check the drainage tubing to make sure clamp, if present, is open. -Release the clamp on the irrigation tubing and regulate the flow at the determined drip rate, according to the ordered rate (Fig. 4). If the bladder irrigation is to be done with a medicated solution, use an electronic infusion device to regulate the flow. -Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. -Assess the patient's response to the procedure, and quality and amount of drainage. -Remove equipment. Remove gloves and additional PPE, if used. Perform hand hygiene. -As irrigation fluid container nears empty, clamp the administration tubing. Do not allow the drip chamber to empty. Disconnect the empty bag and attach a new full irrigation solution bag. -Put on gloves and empty drainage collection bag as each new container is hung and recorded.

Pressure ulcer risk factors, prevention & staging

RISK FACTORS: -External Pressure -Friction and shear -Immobility -nutrition & hydration -moisture -obesity / underweight -mental status -age -diabetes mellitus PREVENTION: -Repositioning at least every 2 hours -Cleanse skin routinely + when needed -maintain moisturized skin -Keep skin dry from drainage and incontinence - Cushion areas that have pressure on them with pads, dressings, and lubricant. STAGING: I. Intact skin. Nonblanchable redness, painful. Temperature differs from surrounding tissue. Soft/ hard compared to surrounding tissue. II. Partial thickness tissue loss. Shallow, open, ulcer. Pink wound bed. May also be intact or open serum filled blister III. Full thickness tissue loss. Subcutaneous fat may be visible IV. Full thickness tissue loss + visible bone, tendon, or muscle. Often includes undermining or tunneling Unstageable: Full thickness tissue loss. Covered with slough and/ or eschar. Deepness cannot be determined.

Nursing Process Activity Intolerance

Related factors: -any condition that interferes with the transport of oxygenated blood tissue -any condition that causes fatigue -generalized weakness Sample defining characteristics: -decreased ability to perform basic self-care activities -altered response to activity -exertional dyspnea -shortness of breath -excessive increase in respiratory rate -weak pulse -excessive increase in pulse rate/ change in rhythm -BP pressure that fails to increase with activity or decreases -Weakness, pallor, confusion, vertigo -Reports of pain or fatigue with activity Nursing planning: Make a plan and have expected outcomes (short and long term) -Healthy patient- directed toward promotion of physical fitness -Patient at high risk for immobility- require different expected outcomes -Immobile patient- directed toward preventing complications related to inactivity and its effects on body systems Nursing implementation: use of- -Body mechanics -Safe patient handling and moving (safe transfer, use of equipment and assistive devices) -Positioning patients in bed (table 32-6 on p. 1068) -Graduated compression stockings/ pneumatic compression devices -Turning patient in bed -Moving patient up in bed -Moving patient from bed to stretcher -Moving patient from bed to chair -Logrolling patient -Assisting with ROM exercises -Helping patients ambulate -Promoting exercise Nursing evaluation: same as nursing assessment

Safe handling of patients

Safe patient transfer: -Assess patient (diagnosis, capabilities, movements not allowed, devices patient wears) -Assess patient ability to assist with planned movement -Assess patient's ability to understand instructions -Use assessment tool to aid in patient assessment and decision making -Patient is considered fully dependent if caregiver is required to lift more than 35 lbs (also must use assistive device) -Have enough staff available -Assess the area for clutter, accessibility to the patient, and availability of devices. Remove any obstacles that may make moving and lifting inconvenient. -Decide with equipment to use -Plan move carefully before lifting or moving patient -Explain to patient what you are going to do -Administer analgesic if patient is in pain -Elevate bed to working height -Lock all wheels of bed and any devices -Be sure patient is in good body alignment -Support patient's body properly (don't grab extremity by its muscle) -Avoid friction on patient's skin -Use friction-reducing devices whenever possible -Move patient and own body in smooth, rhythmic motion -Use mechanical devices for moving patients (know how it operates) -Ensure that equipment used meets weight requirements Equipment and assistive devices: -Gait belts o Help patient stand o Provides stabilization during pivoting o Used for patients who have leg strength, can cooperate, and require minimal assistance o Do not use on patients with thoracic incisions o Provides stabilization during pivoting o Used for patients who have leg strength, can cooperate, and require minimal assistance o Do not use on patients with thoracic incisions -Stand-assist and repositioning aids o For minimal assistance to stand up -Lateral-assist devices o Reduce patient-surface friction during side-to-side transfers o Make transfers safer and more comfortable for patient o Roller boards, slide boards, transfer boards, inflatable mattresses, and friction-reducing lateral-assist devices -Friction-reducing sheets o Used under patients to prevent skin shearing o Used when moving patients in bed or with lateral transfers o Reduces friction and force required to move patient -Mechanical lateral-assist devices o Include specialized stretchers o Eliminate need to slide patient manually o Slides under patient and moves them to stretcher without pulling by staff -Transfer chairs o Chairs that convert into stretchers o For patients with no weight-bearing capacity, cannot follow directions, or cannot cooperate o Eliminates need for lifting patient -Powered stand-assist and repositioning lifts o For patients who can bear weight on at least one leg, can follow directions, and can cooperate o Assists patient to stand and can then be wheeled around o Some can be used as walkers or scales -Powered full-body lifts o For patients who cannot bear any weight o Some can be lowered to floor to pick up fallen patients

Error prone or Do Not Use abbrev

See table 16-2

Caring for a hemodialysis access

Skill 36-10 in Taylor

The diagnostic reasoning process

Successful implementation of each step of the nursing process requires high-level skills in clinical reasoning. To correctly diagnose health problems: -Be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy. -Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your qualifications and experience can provide. -Respect your clinical intuition, but before writing a diagnosis without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition. -Recognize personal biases and keep an open mind. Questions to facilitate critical thinking during diagnostic reasoning include: -Are my data accurate and complete? Do the objective data support the subjective data? How do I know that this information is reliable? -Have I correctly distinguished normal from abnormal findings and decided if abnormal data may be signs and symptoms of a specific health problem? -Have I made and validated deductions or opinions that follow logically from patient cues? -Has the patient or the patient's surrogates validated (if able to do so) that these are important problems? -Have I given the patient or the patient's surrogate an opportunity to identify problems that I may have missed? Is each diagnosis supported by evidence? Might these cues signify a different problem or diagnosis? -Have I tried to identify what is causing the actualor potential problem, and what strengths/resources the patient might use to avoid or resolve the problem? -Have I followed agency guidelines to correctly document diagnostic statements in a way that clearly communicates patient problems to other health care professionals? -Is this a problem that falls within nursing's independent domain or does it signify a medical diagnosis or collaborative problem.

Caring for patients with urinary tract infections

Urinary Tract Infections are the most common nosocomial infection. Up to 80% are associated with indwelling catheters. Caused by one type of Escherichia coli (E. coli) that normally resides in the intestinal tract, if it migrates to the urinary tract it can lead to UTI. -If UTI is acquired: o Indwelling catheter should be removed (if applicable) o Area should be kept clean, encourage showers as opposed to baths o Increase fluid intake o Void frequently o Use antimicrobial therapy if ordered o Wear cotton underwear -Symptoms include: -burning with urination -frequent urge to pee -pain/pressure in lower abdomen -cloudy or foul smelling urine (If fever or chills are experienced the infection has most likely moved to the kidneys) -Greatest risk: o Sexually active women o Postmenopausal women o Diaphragm contraceptives o Indwelling catheter o Diabetes mellitus o Older adults

Referrrals

process of sending or guiding someone to another source for assistance.

Urinary diagnostic procedures

box 36-2 in Taylor

Abnormal Assessment findings

checklists abnormal findings

Normal Assessment Findings

checklists for normal findings