med surg test 1 pp, med surge test 2, med surge test 3 pp, med surge final

Cardiovascularxl ASSESSMENT cardioxl

*Cardiovascular* Affect the ability of the heart to work as an efficient pump. Coronary Artery Disease MI within 6 months before surgery Angina Hypertension Dysrhythmias watkins ecg, ekg, eco to be cleared for sx *Respiratory* Decrease pulmonary function, increase the risk of respiratory infection, and may be exacerbated by general anesthesia. Chronic respiratory problems -Emphysema -*Asthma* -Bronchitis *Smoking* -Increases carboxyhemoglobin blood level and deceases oxygen delivery *DV* *watkins* derease them from getting o2 exchanged on anestesia, *Renal/Urinary* Renal disease/impairment affects the patient's ability to excrete many medications, including anesthetic agents. *watkins* dialysis, what happens is if their kidneys cant get the anestia out of there system, it stays in the body and become toxic causing trouble breathing. *at risk for dvt, pnemonia* dvt=entryembolic stocking, compression boots, pnemonia= deep breathing, incentive sipormeter, prior to sx, so when they wake up they reinforce teaching during the recovery phase Lab assessment- urinalysis for infection,pregnancy test, blood type and cross match for blood transfusion, religious beliefs, cbc,hmg if to low need to get it up prior to having sx, coagualants, pt, inr, if there bld is not clotting they are not going to want to do sx on this ct. chest xray- to make sure lungs is clear, good gas exchange, if not no sx It also affects the body's ability to regulate fluid and electrolytes. *Neurologic* -Determine baseline LOC -Note presence of sensory or perceptual deficits -Assess range of motion and ability to perform activities of daily living *Musculoskeletal* *Nutritional status* Malnutrition and obesity increase surgical risk Patients who are malnourished or obese are at risk for delayed wound healing, infection, and fatigue. Obese clients are also more prone to cardiovascular disorders and impaired pulmonary function. *Skin* *Psychosocial*

Sodium (136-145 mEq/L) Na level in your blood is totally dependent on how much H2O you have in your body

*Hypernatremia* = Dehydration Too much NA; not enough H2O *Hint*: Think Neuro Changes 1st! *Causes*: Hyperventilation, heat stroke, DI *S&S*: dry mouth, thirsty, swollen tongue *Treatment*: Restrict salt, dilute client with fluids, daily weights, I&O, monitor lab work Feeding tube clients tend to get dehydrated *Hyponatremia* = Dilution Too much H2O; not enough H2O *Hint*: Think Neuro Changes 1st! *Causes*: Drinking H2O for fluid replacement (vomiting, sweating), polydipsia (thirsty), D5W, SIADH SIADH= sodium deficit, cb retention of water Syndrome of inappropriate antidiuretic hormone secretion *S&S*: Headache, seizure, coma *Treatment*: Client needs Na, Client doesn't need H2O

COMMON DIAGNOSTIC TESTS 1

*PRIMARY TESTING* Red blood cell count and white blood cell count with differential Fluorescent antinuclear antibody C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) *OTHER DIAGNOSTIC TESTS AND DISEASE-SPECIFIC TESTING* Allergy testing Genetic testing Rheumatoid factors (RFs) Western blot test TORCH antibody panel Organ function tests

Major Electrolytes (cont'd)

*Phosphate (Phosphorus)* ICF anion Bound with calcium in teeth and bones; inverse relationship Activates vitamins and enzymes; assists in cell growth and metabolism Plasma levels of calcium and phosphorus exist in a balanced reciprocal relationship *Bicarbonate* ICF and ECF; acid-base balance Regulated by kidneys Produced by body to act as buffer

Major Electrolytes

*Sodium* Extracellular fluid (ECF): regulates fluid volume Kidney reabsorbs "Where sodium goes water follows" *Potassium* Intracellular fluid (ICF): muscle contraction; cardiac conduction Kidneys eliminate Regulates protein synthesis, glucose use and storage

CLINICAL MANAGEMENT: PRIMARY PREVENTION

*Vaccinations* Vaccinations are administered to people across the lifespan; visit the CDC website at www.CDC.gov for recommended vaccination schedules. *Hygiene* Personal hygiene Food hygiene Patient care hygiene Hand hygiene Infection control practices

ADMINISTRATION OF GENERAL ANESTHESIA generalxl

-Inhalation -IV injection -Balanced anesthesia -Adjuncts to general anesthetic agents: Hypnotics Opioid analgesics Neuromuscular blocking agents

QSEN COMPETENCIES 3

-Teamwork and Collaboration Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care -Targeted KSAs (Knowledge, Skills, Attitudes K: Describe examples of the impact of team functioning on safety and quality of care S: Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care A: Appreciate the risks associated with handoffs among providers and across transitions in care

Facts to remember

1 L of water weighs 2.2 lb, equal to 1 kg Weight change of 1 lb = fluid volume change of about 500 mL Daily weights is the most important intervention when evaluating the hydration of your patient.

Classifications of bones

1. Two major classifications are based on structure: -compact bone (dense) -cancellous bone (spongy) 2. A central shaft (diaphysis) and two end portions (epiphyseals) characterize long bones (e.g., humerus and radius) *book* Long bones, such as the femur, are cylindric with rounded ends and often bear weight.

CT Scan

100 times more sensitive than normal x-rays. Can be done with or without contrast dye. For long bones and joints CT scans can allow for a detailed examination of cross-sections of the areas examined. Defects that can be seen include tumors and fractures. Contrast may be used in joint examination.

STATE BOARD OF NURSING

A state board of nursing holds the legal authority for nursing practice and regulates nursing practice through: Establishing the requirements to obtain a nursing license Issuing nursing licenses Determining the scope of practice Setting minimum education standards Managing disciplinary procedures

Assistive Personnel (APs) uap

ADLs Bathing Positioning every 2 hrs Ambulating oral care 3-4 hrs- with warm saline....mothwash not encouraged bc of alcohol Feeding (without swallowing precautions) Specimen collection Intake and output Vital signs (for stable patients)

Emergency response - Primary survey

at pa caca Assess quality of ventilation (rate, color, auscultate lungs) Take blood pressure Primary survey focuses on airway, breathing, circulation, and neurological disability/deficits (ABCD) Assess level of consciousness and pupillary response, weakness or paralysis of extremities Clear and open the airway Assess for respiratory distress Check pulses for quality and rate Assess for external bleeding

ETHICAL PRINCIPLES

An ethical principle is similar to a camera lens. Camera lenses can have various magnification or filters; likewise, situations can be viewed differently, depending on the lens.

Adverse reaction

An undesired effect of a prescribed medication, whether a severe side effect or a toxicity

Antibody-mediated immunity

B-lymphocyte-Becomes sensitized to foreign cells and proteins with the assistance of macrophages and helper/inducer T-cells Plasma cell-Secretes immunoglobulins in response to the presence of a specific antigen Memory cell-Remains sensitized to a specific antigen and can secrete increased amounts of immunoglobulins specific to the antigen on re-exposure

IMAGING ASSESSMENT Pre-op Diagnostics preopxl

Chest x-ray - Assesses respiratory status and heart size ECG - Assesses preexisting cardiac disease or rhythm abnormalities

EXPERIENCE, KNOWLEDGE, EXPERTISE

Clinical judgment requires deep clinical knowledge and several types of thinking. Experience does matter, but it is not solely responsible for clinical judgment.

ETHICAL PROBLEMS FOR NURSES: SOURCES

Consumer awareness: informed consent Technological advances: we CAN, but should we? Multicultural population: differing ethics Cost containment: unequal access

Malignant Hyperthermia

causes fast increase in body temp severe muscle contractions clinical findings s/s tachycardia, tachypnea, muscle rigidity, resp and metablolic acidosis, skin mottled, cyonitic rationale nursing intervention stop procedure, body coolin measures admin and assess airway admin dantrolene monitor cbc & bmp education genetic predisposition, side effects and contrindications at risk inherited condition allergic rx to anestesia agent Provide appropriate nursing and collaborative interventions to optimize thermoregulation

Short bones

characterized by cancellous bone covered by a thin layer of compact bone (examples: carpals and tarsals) *book* Short bones, such as the phalanges, are small and bear little or no weight.

Flat bones

characterized by two layers of compact bone separated by a layer of cancellous bone (e.g., skull, ribs, scapula, and sternum) *book* Flat bones, such as the scapula, protect vital organs and often contain blood-forming cells.

PACU RECOVERY ROOM pacuxl

During this period, the client is at high risk for respiratory and cardiovascular compromise. As a precaution, the anesthetist and the circulating nurse accompany the client and attend to his needs during transport to the PACU. Ongoing evaluation and stabilization of patients to anticipate, prevent, manage complications after surgery The Joint Commission's NPSGs require circulating nurses and anesthesia providers give PACU nurses verbal hand-off reports including surgical procedure, anesthesia, drugs and IV fluids administered, and estimated blood loss

special consideration and population

cultural & spiritual consideration consideration for older adult 65+ gender--veteran health consideration

PREOPERATIVE CHART REVIEW PREOPxl

Ensure all documentation, preoperative procedures, orders are complete Check surgical consent form and others for completeness Inform patient that area will be marked before procedure begins Document allergies, height, and weight Ensure all laboratory and diagnostic test results are in chart Document/report any abnormal results Report special needs and concerns

NPSGS AND INFORMED CONSENT

Ensure correct site is selected and wrong site is avoided Licensed independent practitioner marks site, involving patient if possible "Time out" procedure adopted by most facilities

ENVIRONMENTAL CONTEXT

Environmental context or the setting of care influences what a nurse notices. Demanding environments of care can add an increased burden on making clinical judgments and can actually interfere with competent clinical judgment.

PROCESS OF EBP

Evidence-based nursing versus research utilization Institute of Medicine (2000; 2001) Quality of health care in question

Exemplars of Pain - Mixed Pain

Fibromyalgia Myofascial pain Pain associated with human immunodeficiency virus (HIV) Pain associated with Lyme disease Some headaches Some types of neck, shoulder, and back pain

Fluid Imbalances (cont'd) fluidsxl

Fluid Volume Excess= full bounding pedal and post tibial pulse pitting edema= feet ankles,calves shallow respirs w/ crackles on auscultation Hypervolemia Overhydration Elevated blood pressure, bounding pulse Pale, cool skin Edema/ascites Crackles

Acid-Base Balance

Fluid contains equal number of positive charges, ions with negative charges Balance occurs by matching rate of hydrogen ion production with loss

Interventions: Respiratory Acidosis Respiratory Acidosisxl

Focus is on improving ventilation and oxygenation, maintaining patent airway *Drug therapy* Bronchodilators Anti-inflammatories Mucolytics Oxygen therapy Pulmonary hygiene Ventilation support Prevention of complications

Fluid & Electrolytes iv Solutions fluidsxl

I*sotonic (normal) Solutions* "Stay where *I* put it!" *Hyp*O*tonic Solutions* "DILUTE"- swollen rbc "Go *O*ut of the vessel" *Hyp*E*rtonic Solutions* "concentrated" "*E*nter the Vessel" shrunken rbc crenated

MODERATE SEDATION

IV delivery of sedative, hypnotic, opioid drugs to reduce level of consciousness Patient maintains *patent* airway, can respond to verbal commands Amnesia action is short

Types of Infusion Therapy Fluids

IV solutions (including parenteral nutrition) Blood and blood components Drug therapy

Immobility related to elimination

May have changes to their pattern of elimination or be at risk of experiencing problems such as constipation or urinary retention.

Arthroscopy

Most often performed in the knee joint, an arthroscopy is an endoscopic procedure used to diagnose and repair meniscal, patellar, extrasynovial, and synovial diseases. Biopsies can also be performed. *book* Arthroscopy may be used as a diagnostic test or a surgical procedure. An arthroscope is a fiberoptic tube inserted into a joint for direct visualization of the ligaments, menisci, and articular surfaces of the joint. The knee and shoulder are most commonly evaluated. In addition, synovial biopsy and surgery to repair traumatic injury can be done through the arthroscope as an ambulatory-care or same-day surgical procedure.

Filtration

Movement of fluid through cell or blood vessel membrane because of differences in water volume pressing against confining walls

Skeletal Disease: Kyphosis

Posterior curvature of the thoracic spine greater than 45 degrees Often results from osteoporosis (hunchback) Treatment can be accomplished with bracing or spinal infusion if cardiopulmonary problems or pain occur

NURSING INTERVENTIONS: PRESSURE ULCER

Prevention Meticulous skin care and moisture control Adequate nutrition Frequent repositioning Therapeutic mattresses Client/family teaching

Fluid Intake

Primarily through drinking fluids IOM recommendation: 2,700 mL/day women, 3,500 mL/day men 20% from food/metabolism of food Fluid intake regulated by thirst Change in plasma osmolality Hypothalamus

POTENTIAL FOR INJURY Interventions:

Proper body position Prevent pressure ulcer formation Prevent obstruction of circulation, respiration, nerve conduction

ETHICAL ISSUES IN NURSING

Protecting patients' rights and human dignity Not respecting informed consent treatment Providing care with risk to the health of the nurse Using or not using chemical or physical restraints Understaffing Prolonging the living and dying process with inappropriate measures Policies that could threaten the quality of care Working with unethical or impaired colleagues

SELF-DETERMINATION INTERVENTION

Pt has the right to have or initiate: -Advance directives -Living wills -Durable power of attorney Mandated by the Patient Self-Determination Act Provide legal instructions to healthcare providers ***Surgery does not provide an exception to the patient's advance directives or living will.

CLINICAL MANAGEMENT: PRIMARY PREVENTION

Reducing risk for injury and infection Maintaining good hygiene Properly using safety equipment Properly storing and preparing food

Intervention Strategies for Hyperthermia

Remove excess clothing and blankets Provide external cool packs Provide a cooling blanket Hydrate with cool fluids (oral or intravenous) Lavage with cool fluids Administer antipyretic drug therapy

Intervention Strategies for Hypothermia

Remove the person from cold Provide external warming measures Provide internal warming measures Safety Tip: Core rewarming must be done slowly to minimize the risk for dysthymias. Cardiac monitoring is required when the patient is recovering from severe hypothermia. note Intervention Strategies for Malignant Hyperthermia • Core rewarming methods for moderate hypothermia include administration of warm IV fluids, heated oxygen or inspired gas to prevent further heat loss via the respiratory tract, and heated peritoneal, pleural, gastric, or bladder lavage. • Avoid using active external rewarming with heating devices because it is dangerous and contraindicated due to rapid vasodilation. • The patient who is severely hypothermic is at high risk of cardiac arrest. The treatment of choice is extracorporeal rewarming methods such as cardiopulmonary bypass, hemodialysis, or continuous arteriovenous rewarming.

Acidosis: Patient-Centered Collaborative Care

Respiratory changes Kussmaul respiration Skin changes (metabolic and respiratory acidosis) Warm, dry, and pink (vasodilation) Psychosocial assessment

PACU NURSES FUNCTIONS pacuxl

Respiratory---- first thing you assess in the postop period LOC, TPR, O2 Sat, BP Examine surgical area Discharge from PACU

Specific Immunity

Specific IMMUNITY is an adaptive protection that results in long-term resistance to the effects of invading microorganisms. This means that the responses are not automatic, which is why specific immunity is also known as acquired immunity. The body has to learn to generate specific immune responses when it is infected by or exposed to specific organisms. Lymphocytes develop actions and products that provide true immunity. These cells develop specific actions in response to specific invasion (Fig. 17-7). The two divisions of specific immunity are antibody-mediated immunity and cell-mediated immunity. As indicated by Fig. 17-4, activation of both types of specific immunity require interactions with actions and cells of innate immunity.

Human factors

Study of the interrelationships among people, technology, and the work environment. Consider the ability or inability to perform tasks while attending to multiple things at once. Work of nurses in acute care environment is very complex. Focus is on supporting health professionals and eliminating hazards.

safety exemplers

Tear Fired cw PM Dc Team system Environmental systems analysis systems regulatory system-- natl' quality benchmarks fall precaution invasive procedures recognition of/action on adverse events error reporting documentation/ electronic records communication with pts/fam/other hcp work process prevention of decubitus ulcer medication administration diagnostic procedures care coordination

Pathophysiology of Pain Central nervous system (CNS)

Thalamus and somatosensory cortex

KNOWLEDGE DEFICIT: GOALS - OUTCOMES

The PT will: verbalize in own words purpose and expected results of surgery understanding of preoperative preparations ask questions when terms or procedure is not known adhere to NPO requirements demonstrate correct use of exercises and techniques to be used after surgery to prevent complications

Time out

The circulating nurse, in the role of patient advocate, is usually the team member who initiates the time out. A correctly performed time out includes verifying the correct: -patient -procedure -site -side (laterality) -surgeon -position As well as that proper equipment, instrumentation, and implants are available.

Athrography

The injection of air, contrast medium, or both into a joint, which is then examined either by plain X-rays, CT scan, or MRI. Once considered the mainstay in diagnosing cartilage lesions or damage, plain radiographic (X-ray) arthrography is SELDOM used today.

UNIQUE SITUATION

The nurse must recognize the unique situation of the patient, including a deep understanding of both the clinical situation and the nurse's contribution to the patient care situation. Each patient situation and each nurse is different; so, too, is the clinical reasoning that leads to clinical judgment.

MALPRACTICE

Tort law or law of medical liability is the legal discipline for malpractice. Four elements must be satisfied: duty, breach, causation, and harm. Is a failure to "follow the standard of care" and is the direct cause of harm. The profession establishes the standard, making this a unique characteristic of medical malpractice.

Sentinel event

Unexpected occurrence involving death or serious injury **Always signals the need for immediate investigation and response

Adverse event

Unintended harm by an act of commission or omission rather than as a result of disease process

Pain

Unpleasant sensory

Fluid Output

Urine: 1,500 mL/day Minimum 30ml/day - acknowledge kidney function Skin: perspiration Lungs: exhalation Feces: 100-200 mL/day

OBJECTIVES - ATI - NCLEX Safe and Effective Care Environment

Use appropriate patient identifiers when administering drugs or marking surgical sites. Verify that the patient has given informed consent for the surgical procedure. Examine individual patient factors for potential threats to safety, especially for older adults. Differentiate the roles and responsibilities of intraoperative personnel. Understand the principles of infection prevention as they apply to aseptic technique in setting up a sterile field. Explain correct technique to apply and remove surgical attire. Understand the nurse's role in monitoring all OR personnel for possible breaks in sterile technique

Clinical Management: Nonpharmacologic Interventions

Used alone or with drug therapy Physical measures Physical and occupational therapy Cognitive/behavioral measures

joint and connective tissue dz: gout meds

Used to decrease the production of uric acid and promote the production of it acute- colchicine- colsalide and an nsaid ibuprofen--Motrin-- chronic-allopurinol zyloprim

FACTORS IN MORAL DECISION MAKING

Values Belief about the worth of something Highly prized ideals, customs, conduct, goals Freely chosen Learned through observation and experience Vary from person to person -------- Attitudes Feelings toward person, object, idea Includes thinking and feeling component What a person thinks ------ Beliefs Something that one accepts as true Not always based on fact

PROCESSES FOR ETHICAL PRACTICE

Values clarification Identify moral dilemmas Use a decision-making model -M O R A L Participate on an ethics committee

Diseases that result in inflammatory process

Viruses Bacteria Pneumonia fungi Protozoa Others ---------------------------- Antibiotic-resistant organisms Asthma Allergic disease Response to allergens and irritants ------------------------------- Diseases caused by inflammatory effect Self-induced inflammatory reaction Arthritis Myocardial infarction Obesity

Diagnostic test for Lyme disease

Western blot test to confirm positive ELISA (enzyme-linked immunosorbent assay) test

Sources of Acids & Bicarbonate

When acid is present, free hydrogen ions dissociate and must be controlled for pH balance Body continuously generates acids and hydrogen ions as metabolism waste products

left shift or bandemia

When analyzing the differential of a normal WBC count, a left shift or bandemia indicates that the patient's bone marrow cannot produce enough mature neutrophils to keep pace with the continuing infection and is releasing immature neutrophils into the blood. These immature cells are of no benefit because they are not capable of phagocytosis.

Acid-Base Control Actions & Mechanisms: Respiratory

When chemical buffers alone cannot prevent blood pH changes, respiratory system is second line of defense: Hyperventilation Hypoventilation

Compartment Syndrome

When increased tissue perfusion in a confined space causes decreased flow to the area Compartments of the leg in cross section.

Drug Therapy

When nonpharmacologic methods are not helpful Administer before procedures (e.g., surgical debridement, complex dressing change) Three drug groups: Non-opioids Opioids Adjuvants

WASH YOUR HANDS birthday

When you arrive in the unit Use soap and water if there is potential for exposure to Bacillus anthracis (or other spore-producing bacteria such as C. difficile). Alcohol-based solutions are not effective against spores. When you leave the unit Before and after restroom use Before and after client contact Before and after contact with client belongings Before gloving After glove removal Before and after touching your face Before and after eating After touching a contaminated article When you see visible dirt on your hands

skeletal disease osteomalacia at risk

dam rl diet deficient in vitamin d low endogenous production of vitamin d bc lack of sunlight exposure anticonvulsant therapy malabsorption renal tubule disease liver, pancreatic, billliary system dz *billliary-autoimmune disease

informatics and technology

definition- the acsess and use of information and electronic technology to communicate, manage knowledge,prevent error, and support decision-making purpose: safety quality of health retrieval of data for ebp & quality improvement

care coordination

deliberate organization and communication about client care activities b/t 2 or more members of health care team, including patient in order to facilitate app. and continuous health care to meet client's needs care coordination: case manager aka discharge planner who is a nurse or social worker

arthritis dz: osteoarthritis s&S

dice hbp deformities immobility of joint and limb due to pain and joint changes crepitation enlarged nodular joints Heberden's nodules Bouchard's nodules pain and stiffness, esp in the morning

health care disparities

differences in patient access to or availability of appropriate health care services a major focus of the u.s *healthy people 2020* intiative is to decrease healthcare disparities caused by: poor communication healthcare access health literacy health care provider biases and discrimination

older adult factors affecting safety drug use and misuse

dipped dm fhp dz interaction intolerance to standard drug dosages physiologic changes affect absorption polypharmacy- the simultaneous use of multiple drugs to treat a single ailment or condition. excretion distribution drugs metabolism food herb polymedicine

emergency and disaster preparedness psychological response of survivers

disaster experience can produce immediate and long lasting effects life-style, roles, routines may be altered coping ability may be severely stressed nurses communicate and provide a sense of safety monitor signs for pstd ies- r questionnaire????

skeletal disease bisphosphonates: alendronate fosamax

dm m d dose: 40 mg once daily for 3 months MUST be taken on an empty stomach with 6-8 oz of water may be taking any time during the day, as long as there is no food for 30 min after dose do not lie down for 30min after dose

General care guidelines for immobilized patient

dr.mn sfw -Deep breathing -Range of motion -Measures to optimize elimination -Nutrition -Skin assessment and skin care -Frequent turning, positioning, alignment -Weight bearing (if possible)

incentive spirometer incentivexl

encourage incentive spirometer, deep breathing and coughing exercises every 2 hours while awake to prevent atelectasis and pneumonia

muscle fibromyalgia meds

fans for fibromyalgia treatment - pregabalin Lyrica antidepressants nsaids- ibuprofen skeletal muscle relaxants- cyclobenzaprine

Inflammation

is an immunologic defense against tissue injury, infection, or allergy.

Fever

is elevation in body temperature due to a change in the hypothetical set point

Normothermia

is the normal body temperature (ranges between 36.5 C and 37.2 C)

Ethics

is the study or examination of morality through a variety of different approaches. reflecting is critical for dev. of knowledge and improvement in reasoning How you respond to an ethical situation is a reflection of the core values, beliefs, and character that make you the person who you are and, ultimately, the professional who you will become. -Systematic study of right and wrong conduct. -Formal process for making consistent moral decisions.

Exercise therapy

jabs Joint mobility Ambulation Balance Stretching

arthritis dz: osteoarthritis risk factors

jog ao joint injury occupation - athletes that use the same joints continuously genetics aging obesity

individual factors affecting safety

lc begs siips mv lifestyle cognitive awareness Balance Emotional health gait Safety awareness sensory and perceptual status impaired communication impaired mobility physical and emotional well-being safety awareness mobility Visual acuity

developmental factors affecting safety infants- Birth- 1 year toddlers- 1-3 years

leading cause of death/ accidents motor vehicle accident is the leading cause of death for toddlers. * dcf is m* drowning choking falls ingestion of poisons SIDS mva risk factors can't recognize danger Tactile exploration of environment-- curious totally dependent

developmental factors affecting safety school- age 6-12 years

leading cause of death/ accidents mva and falls risk factors -try new activities without practice -more time outside of the home -stranger danger

emergency and disaster preparedness mass- casualty

local medical capabilities overwhelmed may require collaboration of multiple agencies and health care facilities to handle

urethritis in the urethra

mall inflammation of the urethra that causes s/s similar to uti men s/s- burning or difficulty with urination and discharge from the urethral meatus- most common cause is std women s/s- pyuria, dysuria syndrome, frequency, dysuria syndrome,Trigonitis syndrome and urethral syndrome tx- with antibiotics therapy and stress prevention student: bacteria, antibiotics, std, discharge, no irritating soaps, pain when urinating, blood in urine- safe sex- e-coli causes this dx w/ urine sample and bld test

emergency and disaster preparedness emergency preparedness plan

mandated by the joint commission

The Gate-Control Theory

pain is perceived by the inter- play between two different kinds of fibers—those that produce pain and those that inhibit pain. The gate control theory is the basis for development and use of transcu- taneous electrical nerve stimulation (TENS) to relieve pain Descending impulses from the brain, including impulses re- lated to mood or emotion, are also thought to open or close the gate. For this reason, medications for depression are sometimes used for patients with chronic pain. Nonmedication therapies, such as meditation, exercise, relaxation techniques, and laugh- ter, may also compete with C fiber impulses and block the gate.

skeletal disease kyphosis

posterior curvature of the thoracic spine greater than 45 degrees often results from osteoporosis "hunchback"

medical- surgical nursing

promote restore maintain optimal health for patients 18 years of age or older

older adult factors affecting safety stress, loss and coping

rapid environmental changes lifestyle changes acute and chronic loneliness loss of significant other financial hardship

transition management

safe seamless movement of clients among health care setting, health care providers- community for *ongoing care* to meet cts needs joint commission recommendation for effective care coordination n transition management LEO MU. K list of community and *outpatient*--ambulatory care-- resources and referalls explanation of self care activities ongoing or emergency care information medication reconciliation-- joint commission national patient safety goal understandable discharge instruction for client in family knowledge of the clients language, culture and health liteacy

peptic ulcer dz pud pepticxl

sn acid damage walls of stomach, duodeum c/b h-pylori, no nsaids, s/s pain in chest or upper abdomen, heart burn, n/v, ab discomfort dx: esopheal duodemn, egd aka endoscopy is a conscious sedation using vesed where camera goes into mouth to see inflammation watkins: similair w/ gastritis- no spicy foods, nsaids, alcohol, no aspirin, red sauce, no caffeine proton pump inhibitor settles everything down

gastritis- proton pump inhibitor gastxl

sn bloating, pain watkins: no eating spicy foods, caffeine, alcohol. no nsaids, acidic foods: red sauce, tomatoes,pizza, spaghetti,avoid stress

Symptoms of Lyme disease

spf 90 Symptoms can begin as soon as three days after the bite or as late as 30 days: Patient usually reports being active outside in the last 2-4 weeks, may or may not report bite Flu-like symptoms (low grade fever, fatigue, muscle and bone aches, chills, and malaise) 90% of cases report erythema migrans (which is the circular rash that continues to grow often resembling a bullseye)

skeletal disease scoliosis

spinal deformity characterized by lateral curve, spinal rotation causing asymmetry, and less than normal curvature in the thoracic spine

safety hazard: healthcare facility

sr mwf fr ben pecc side-rails restraints mercury poising workplace violence *falls risk assessment* fires/electrical hazards radiation injury back injury equipment related accidents needles stick injury Prevention: yearly facility training; following facility policy environmental safety clean, dry floors client education

Immobility Interventions - Teach

tee Teach family to modify home environment (rugs, steps, shower, etc.) Explore regular activity schedule (work, volunteer, etc) Explore energy conservation techniques (activity during energetic time and scheduled rest periods, etc)

evidence based practice

the integration of the best current evidence and practice to make decisions about client care things to consider clients preference and values one's on clinical expertise for the delivery of optimal health care the best source of evidence is research promotes safety for clients, families, staff, health care system bc it is based on reliable studies, guidelines, consensus, expert opinion

the joint commission- national patient safety goal 2018

tjc requires that healthcare organizations create a culture of safety: bs p blame- free approach serious- sentinal events must be reported patient and families are encoraged to become safety partners with healthcare providers and organizations *2018 national patient safety goal* u pp iii u use alarms safely prevent infections prevent mistakes in surgery identify patient safety risk identify patients correctly improve staff communication use medicines safely

skeletal disease scoliosis s&s

uneven pants and shirt length pain is not an issue until the deformity has progressed Adams bending forward test- test done in schools to help observe curvature in the spine

older adult factors affecting safety impaired nutrition and hydration

vd lp fit cg vitamins a/c/d diminished taste and smell loneliness poor dentures fiber increased need for ca tooth loss constipation geriatric failure to thrive-gftt

Inflammation infxl macxl

watkins: what are responsible for recognizing and ingesting foreign antigens as they enter the body? phagocytes. they recognize ingest and eat ---------------------- Neutrophil-Nonspecific ingestion and phagocytosis of microorganisms and foreign protein Macrophage-Nonspecific recognition of foreign proteins and microorganisms; ingestion and phagocytosis. Assists with antibody-mediated immunity and cell-mediated immunity Monocyte-Destruction of bacteria and cellular debris; matures into macrophage Eosinophil-Releases vasoactive amines during allergic reactions to limit these reactions Basophil-Releases histamine and heparin in areas of tissue damage

Considerations for Older Adults: Opioids

• For older adults, the guideline is to "start low and go slow" with all drug dosing. "Start low and go slow"; initially use no more than half of recommended dose Evaluate patient response and drug effectiveness Older adults feel moderate and severe pain as much as younger adults

key points thermoregulation

• Nurses should always teach prevention to promote safe and effective care environments. Education should include: o How to prevent thermoregulation problems, including heat-related illnesses o How to prepare for cold environments, including proper clothing and avoidance of wind and wet weather o How to prevent arthropod bites and stings and snakebites. • Nurses should assess high-risk patients, especially older adults, for their knowledge of safety precautions to prevent heat-related and cold-related injuries, and those who do not know how to swim, for their knowledge of safety precautions to avoid submersion accidents. • High temperature and humidity are the most common environmental factors for heatrelated illnesses. These thermoregulation-related illnesses range from mild, as in heat exhaustion, to severe, as in heat stroke. • Some of the most vulnerable, at-risk populations for these problems include: o Older adults o Those with mental health conditions o People who work outside, such as construction and agricultural workers (more men than women) o Homeless people o Illicit drug users (especially cocaine users) o Outdoor athletes (recreational and professional) o Members of the military who are stationed in countries with hot climates (e.g., Iraq and Afghanistan) • Older adults and homeless individuals are at risk as a result of comorbidities, decreased body fluid volume, overexposure to the sun, and medications. Interprofessional Collaborative Care • Mental status changes occur as a result of thermal injury to the brain. Manifestations can include confusion, bizarre behavior, seizures, or even coma. • Cardiac troponin I is frequently elevated during non-exertional heat-related illnesses and is a cost-effective way to predict severity and organ damage at the beginning of heat stroke. • The first priority for collaborative care is to monitor and support the patient's airway, breathing, and circulatory status. • Provide high-concentration oxygen therapy, start several intravenous (IV) lines with 0.9% saline solution, and insert a urinary catheter. • Rapid cooling is the first priority of care after ensuring the patient has a patent airway, effective breathing, and circulation. • Continue aggressive interventions to cool the patient until the rectal temperature is 102° F (38.9° C). • Shivering can be treated with a benzodiazepine such as diazepam (Valium) or Lorazepam (Ativan). Seizure activity can further elevate body temperature. • Complications of thermoregulation failure include organ dysfunction syndrome, renal impairment, electrolyte and acid-base disturbances, coagulopathy, pulmonary edema, and cerebral edema. Any of these can lead to death. • Two families of poisonous snakes in the United States are the pit vipers—rattlesnakes, copperheads, and cottonmouths—and coral snakes found in the southern states. • The management of a patient who has a snakebite depends on the severity of envenomation (venom injection). • Both local and systemic manifestations can occur. • The first priority for first aid when a patient has a snakebite is to move the patient to a safe area and encourage rest to decrease the venom circulation. • The affected extremity is immobilized snugly with an elastic bandage or roller gauze dressing to impede lymphatic flow and then splinted to slow the spread of venom. A tourniquet is not advised in pit viper bites. • Antivenom drugs are available for most types of poisonous snakebites; monitor for an allergic response when these medications are given. • Acute care in a hospital is required as envenomation is a medical emergency. • Take a photograph of the snake to aid in snake identification. Health Promotion and Maintenance • Teach people how to avoid getting bitten by a snake. North American Pit Vipers • The majority of poisonous snakebites in the United States are pit vipers, including rattlesnakes, copperheads, and cottonmouths. These can be identified by the triangular-shaped head and retractable fangs; nonpoisonous snakes do not have these features. Coral Snakes • Coral snakes account for less than 1% of venomous snakebites in the United States. • Their ability to inject venom is less efficient than that of the pit vipers. • Coral snake venom has two toxins: a nerve toxin and a muscle toxin. The amount of venom in an adult coral snake is enough to kill an adult. • A helpful memory aid for identifying coral snakes is "red on yellow can kill a fellow" and "red and black, venom lack." Be aware that this saying applies only to coral snakes found in the United States! • Because coral snake venom does not destroy tissue, the field treatment to limit the spread of venom includes the use of pressure immobilization techniques. The affected extremity is encircled snugly with an elastic bandage or roller gauze dressing to impede lymphatic flow and then splinted. ARTHROPOD BITES AND STINGS • Bites from some spiders, including the brown recluse, black widow, and tarantula, and venomous arthropods, such as scorpions, bees, and wasps, may produce toxic reactions in humans. Brown Recluse Spider • The bite of a brown recluse spider can cause impaired TISSUE INTEGRITY, including necrosis, and in rare cases systemic manifestations can occur, including death. • Cold application should be used as first aid for poisonous spider bites since it helps decrease the enzyme activity of the venom and may limit tissue necrosis. • Supportive care and ongoing monitoring for complications meet the needs of most patients with a brown recluse spider bite. Black Widow Spider • Black widow spiders, found in every state except Alaska, have venom that produces a syndrome known as latrodectism, from neurotransmitter release from nerve terminals. • Severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting are common. • The priority intervention in the prehospital setting is to apply an ice pack because cold application decreases the action of the neurotoxin. • Antivenom is available for black widow spider bites. Although it can cause anaphylaxis and serum sickness, antivenom is considered effective in treating severe reactions. Scorpions • Scorpions inject venom through a stinging apparatus on their tails, usually producing a mild reaction with local discomfort, inflammation, and self-limiting systemic symptoms. • Because bark scorpion venom is neurotoxic, clinical manifestations result from cranial nerve and/or skeletal muscle involvement. It may be associated with a severe, potentially fatal systemic response. • Monitor the patient for respiratory failure that may require mechanical ventilation. • The first priority of patient management is vital sign assessment and continuous monitoring for several hours in a hospital emergency department or critical care unit. Bees and Wasps • Insect stings can produce a wide range of reactions from discomfort at the sting site to severe discomfort and life-threatening anaphylaxis in allergic individuals. • Single bee and wasp stings cause local reactions unless the person is allergic to them. • Reactions are more severe with multiple stings and may be fatal because venom doses have cumulative toxic effects. • The person who is stung by a bee or wasp first has a local reaction of immediate discomfort and a wheal-and-flare skin reaction. • Swelling can be extensive and involve an entire limb or body area. Systemic effects can then develop based on the venom load and the person's sensitivity to the venom. • All patients who have sustained multiple stings (particularly more than 50) are observed in an emergency care setting for several hours to monitor for the development of toxic venom effects. ---------------- • Anaphylaxis is evidenced by respiratory distress with bronchospasm and laryngeal edema, hypotension, deterioration in mental status, and cardiac dysrhythmias. • Epinephrine is the drug of choice for bee and wasp sting allergic reactions, followed by an antihistamine drug. • Teach anyone who develops an allergic reaction to bee or wasp stings to always carry a prescription epinephrine auto-injector and wear a medical alert tag or bracelet. LIGHTNING INJURIES • Lightning is responsible for multiple injuries and deaths each year. • The best way to prevent lightning injuries is to avoid places where lightning is likely to strike. • Lightning causes central nervous system and cardiovascular complications, as well as skin burns. • Known as keraunoparalysis, a classic finding is an immediate but temporary paralysis that affects the lower limbs to a greater extent than the upper limbs. • A characteristic manifestation of lightning is the appearance of tree-like branching or ferning marks on the skin called Lichtenberg figures or keraunographic markings, thought to be due to the coagulation of blood cells in the capillaries. • Both the cardiopulmonary and central nervous systems are profoundly affected. • The most lethal initial effect of massive electrical current discharge on the cardiopulmonary system is cardiac arrest. • Apnea results in hypoxia-induced ventricular fibrillation. • Once in the acute care setting, the focus of care is advanced life support management including cardiac and respiratory support. • Collaborate with the health care team to identify obvious and hidden traumatic injuries because the patient may have suffered a fall or blast effect during the strike. • A computed tomography (CT) scan of the head may be performed to identify intracranial hemorrhage. • A creatine kinase measurement may be requested to detect skeletal muscle damage. In severe cases, rhabdomyolysis can lead to renal failure. • Burn wounds are assessed and treated according to standard burn care protocols. Tetanus prophylaxis is necessary for burns or any break in skin integrity. COLD-RELATED INJURIES • Two common cold injuries are hypothermia and frostbite. • Teach patients to prevent these injuries by selecting appropriate layered clothing to avoid impaired thermoregulation, which can range from mild discomfort to major systemic complications. Health Promotion and Maintenance • Teach people how to prepare for cold environments and avoidance of wind and wet weather. • Teach the importance of layering and wearing synthetic clothing because it moves moisture away from the body and dries fast; cotton should not be worn. • Environmental temperature below 82° F (28° C) can produce hypothermia in any susceptible person. Therefore people, especially older adults, are actually at risk on a year-round basis in most areas of the world. ALTITUDE-RELATED ILLNESSES • High altitude, especially an elevation above 5000 feet, can produce a range of physiologic responses in the body and can be fatal, primarily due to hypoxia. But millions of people worldwide who ascend to or live at altitudes above 2500 feet are at risk for acute and chronic mountain sickness. • High altitude illnesses, also known as high altitude disease (HAD) or altitude sickness, cause pathophysiologic responses in the body as a result of exposure to low partial pressure of oxygen at high elevations. • Research is being conducted to identify specific gene variations that contribute to altitude-related illnesses. • The priority for care of the patient is descent to a lower altitude. • Given orally, acetazolamide (Diamox, Apo-Acetazolamide) is the drug of choice for prevention and treatment of mild altitude-related illness. • Teach patients best practice strategies for preventing, recognizing, and treating altituderelated illnesses. DROWNING • Assess high-risk patients, including those who do not know how to swim, for their knowledge of safety precautions to avoid drowning events. • Drowning is a leading cause of accidental death in the United States. • Drowning occurs when a person suffers primary respiratory impairment from submersion or immersion in a liquid medium. • Suffocation most commonly results from aspiration of fresh or salt water into the lungs or from laryngospasm with subsequent glottic closure followed by asphyxiation. • The patient who has been submersed in water is at risk for pulmonary infection, acute respiratory distress syndrome, and central nervous system impairment. • Once the individual is safely removed from the water, airway and cardiopulmonary support interventions should begin, including oxygen administration, endotracheal intubation, and cardiopulmonary resuscitation if necessary. • The duration and severity of hypoxia are the two most important factors that determine outcomes for victims of drowning. Very cold water seems to have a protective effect. • Do not attempt to get the water out of the victim's lungs; deliver abdominal or chest thrusts only if airway obstruction is suspected.

key points Chapter 15: Care of Intraoperative Patients

• Nursing care during this period affects the patient's physical needs, spiritual needs, comfort, SAFETY, dignity, and psychological status. Patient-centered care is the key to optimal outcomes in the operating room. Recognizing the patient as the source of control and including the family in the plan of care plan assures compassionate and coordinated care based on the preferences, values, and needs of the patient (QSEN, 2016). • The patient undergoing surgery may recognize the experience as a time of great anxiety, fear, and vulnerability. Few other episodes of care put patients in such a defenseless condition as a surgical procedure. • Continual communication with the patient provides a level of comfort and control in a situation that seems out of their control. Patient engagement and positive patient experiences have been linked to clinical SAFETY and effectiveness. MEMBERS OF THE SURGICAL TEAM • The intraoperative period begins when the patient enters the surgical suite and ends at the time of transfer to the postanesthesia recovery area, same-day surgery unit, or intensive care unit. • The priorities for perioperative nurses are SAFETY and patient advocacy by preventing, reducing, avoiding, and managing the risk factors in the perioperative environment. • Perioperative nursing as a specialty, in the inpatient or ambulatory setting, provides care for patients undergoing operative or other invasive procedures and has a distinct clinical focus. • Nursing observations and actions can prevent, reduce, control, and manage many hazards. • In the operating room (OR), the patient is at risk for infection, impaired skin integrity, increased anxiety, altered THERMOREGULATION and altered body temperature, and injury related to positioning, and other hazards, including unfamiliar experiences and uncertain outcomes. • The challenges of managing patient care during surgery require expertise and INTERPROFESSIONAL TEAMWORK AND COLLABORATION within the perioperative team. • The surgical team consists of the surgeon, one or more surgical assistants, the anesthesia provider, and the OR nursing staff. • The number of assistants, circulating nurses, and scrub nurses depends on the complexity and projected length of the surgical procedure. • The anesthesiologist is a physician who specializes in giving anesthetic agents. • A certified registered nurse anesthetist (CRNA) is a registered nurse with additional education and credentials who delivers anesthetic agents under supervision. • The anesthesia provider induces and maintains anesthesia, delivers other drugs as needed, gives IV fluids including blood products, and monitors cardiopulmonary function, capnography, vital signs, and intake and output. • Perioperative, or OR, nurses include the holding area nurse, circulating nurse, scrub nurse, and specialty nurse. • OR nurses use clinical decision-making skills, develop a plan of care, and coordinate care delivery to patients and their family members. • Holding area nurses work in presurgical holding areas coordinating care, reviewing the medical record and preoperative checklist, verifying that the operative consent forms are signed, and documenting the risk assessment. • Circulating nurses or "circulators" are registered nurses who coordinate the patient's nursing care in the OR, setting up the OR and ensuring that supplies are available as needed. The circulator may assume the responsibilities of the holding area role. • The circulator also assists the OR team in the patient transfer to the bed, positioning the patient and protecting bony areas, providing comfort and reassurance, inserting a Foley catheter if needed, and scrubbing the surgical site. • Scrub nurses set up the sterile field, drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. • A specially trained person who is not a nurse may perform the scrub role; these include OR technicians or surgical technologists. PREPARATION OF THE SURGICAL SUITE AND TEAM SAFETY • The OR environment is focused on patient outcomes to prevent infection, impaired skin TISSUE INTEGRITY, increased anxiety, inadequate thermoregulation and altered body temperature, and injury related to positioning and other intraoperative interventions. • SAFETY is ensured through proper equipment function, sterilization, and counting all instruments and sponges. • Providing a cool and low-humidity room is optimal for reducing the risk of fire with use of hazardous or toxic substances. • Communication systems, traffic flow, room layout, access to post-surgery units, and lighting are all considerations to reduce the incidence of INFECTION and provide for the safety of the patient in the OR. ANESTHESIA • Anesthesia is an induced state of partial or total loss of sensory perception, with or without loss of consciousness, to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve unconsciousness. • General anesthesia is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system, resulting in analgesia and amnesia. • Other drugs, such as hypnotics, opioid analgesics, and neuromuscular blocking agents, may be used as part of the anesthesia. • Complications of general anesthesia can range from minor and annoying, such as sore throat, to death. • Recognize and respond to prevent respiratory and circulatory complications resulting from the anesthesia effect on breathing and GAS EXCHANGE. • Malignant hyperthermia is an acute, life-threatening complication of certain drugs used for general anesthesia. • Overdose of anesthesia can occur if the patient's metabolism and drug elimination are slower than expected. • Unrecognized hypoventilation occurs as an anesthesia-induced complication. Failure of adequate GAS EXCHANGE can lead to cardiac arrest, permanent brain damage, and death. • Intubation complications can include broken or injured teeth and caps, swollen lip, or vocal cord trauma. • Local anesthesia is delivered topically and by local infiltration (injected directly into the tissue around an incision, wound, or lesion) and reduces SENSORY PERCEPTION to a local area. • Regional anesthesia is a type of local anesthesia that blocks multiple peripheral nerves in a specific body region and reduces SENSORY PERCEPTION. • Moderate sedation (conscious sedation) is the IV delivery of drugs to reduce SENSORY PERCEPTION but allow the patient to maintain a patent airway and respond to verbal commands. • Autologous blood transfusion, which is reinfusing the patient's own blood, may be used for surgery. INTERPROFESSIONAL COLLABORATIVE CARE • Good personal hygiene and frequent handwashing help prevent and control infection. • Correct identification of the patient is the responsibility of every member of the health care team. The patient's identity is verified with two types of identifiers according to hospital policy. Check the patient's identification bracelet and ask, "What is your name and birthdate?" • When the procedure involves a specific site, validating the side on which a procedure is to be performed is the responsibility of each health care professional before and at the time of surgery. • The Joint Commission now recommends that the patient and the professional who knows the most about the patient (usually the surgeon performing the surgery) mark the surgical site. • Before proceeding, each professional thoroughly investigates any discrepancy and notifies the surgeon and anesthesia provider. • To decrease errors in the OR, the Joint Commission (TJC) developed a Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. • The circulating nurse and anesthesia provider review the patient's medical record in the holding area or the OR. • Review preoperative checklist and informed consent forms. • Review allergies and previous reactions to anesthesia or blood transfusions. • Notice laboratory and diagnostic tests out of normal range that can be life threatening during surgery, i.e. if Hgb is less than 10 g/dL, oxygen transport and GAS EXCHANGE are reduced, affecting the amount and type of anesthesia used. • Highlight any known allergies. • Apply grounding pads as needed. • Complete any needed skin preparation. • Ask the patient when was the last time he or she had anything to eat or drink. • Assess the patient for tachycardia, increased end-tidal carbon dioxide level, and increased body temperature as indicators of malignant hyperthermia. • Perform a final assessment for threats to patient SAFETY. • Report to the surgeon any discrepancy between what type of surgery the patient says is going to be performed and what the informed consent form indicates. • Check the patient's attire to ensure adherence with facility policy. • Perform an accurate "sharps" and sponge count with the scrub nurse or surgical technologist. • Maintain the malignant hyperthermia cart. • Encourage the patient to express his or her feelings about the surgical procedure or its possible outcome. • Communicate patient preferences or fears about anesthesia to the anesthesia provider. • Preserve the patient's privacy and dignity by keeping body exposure to a minimum. • Stay with the patient during induction of anesthesia. • Communicate information about the patient's status to waiting family members. • Ensure that the patient's wishes, as expressed in the advance directives statement, are honored in the surgical setting. • As a patient advocate, the nurse may have to intervene on behalf of the patient's rights and wishes in ethical dilemmas, so be familiar with the advance directives for each patient, which are honored in the surgical environment. • The OR nurse ensures that there is an adequate number of personnel to assist in positioning the patient. • Apply padding to the OR bed to maintain the patient's TISSUE (skin) INTEGRITY. • Position the patient comfortably, safely, and with dignity • Apply warming blanket to maintain normal body temperature. • During surgery, the scrub person with the circulating nurse maintains an accurate count of sponges, sharps, instruments, and amounts of irrigation fluid and drugs used. • During surgery, the circulating nurse monitors traffic, assesses the amount of urine and blood loss, reports findings to the surgeon and anesthesia provider, and ensures that the surgical team maintains sterile technique and a sterile field. • The circulator also anticipates the patient's and surgical team's needs, communicates information about the patient's status to family members during long or unique procedures, and documents care, events, interventions, and findings. • Before the procedure is over, the circulating nurse completes documentation; notes the length of the surgery; counts all sponges, sharps, and instruments; and notifies the postanesthesia care unit of the patient's estimated time of arrival and any special needs. • Specialty nurses may be in charge of a particular type of surgical specialty and are responsible for nursing care specific to patients needing that type of surgery. • Because the patient is unable to protect him- or herself during surgery, SAFETY precautions are TAKEN by all members of the surgical team. o The patient is never left unattended. o The OR layout helps prevent infection by reducing contaminants through air exchanges in the room, maintaining recommended temperature and humidity levels, and limiting the traffic and activities in the OR. o Safety straps are used for the patient, and the operating bed is locked in place. o Blankets or warming units are used to prevent hypothermia, and interventions are used to prevent skin breakdown, including positioning, padding, and gel pads. o The nurse ensures electrical safety through proper placement of grounding pads and electrical equipment that meets safety standards. • Minimally invasive surgery (MIS) is the preferred technique for many types of surgery, since it reduces surgery time for some surgeries, allows smaller incisions, reduces blood loss, and promotes faster recovery time and less pain. • With robotic technology, the surgeon inserts the required instruments and positions the articulating arms, then breaks scrub and performs the surgery while sitting at the console. This technology requires a perioperative robotics nurse specialist who provides education for patients and family and training for members of the surgical team. • Laser surgery uses a laser to cut tissue instead of a scalpel. A laser may be used in different cases, such as in routine surgical procedures, in eye surgery, and in soft-tissue surgery in which soft tissue with high water content is vaporized. • All members of the surgical team and all OR personnel must wear clean and appropriate scrub attire for their role. Ensure that all personnel entering the OR are wearing proper OR attire for their role. • The nurse evaluates the care of the patient during surgery on the basis of the identified nursing diagnoses and collaborative problems. • Aseptic technique must be strictly practiced by all OR personnel to ensure that the patient is free from infection. • Monitor the patient's airway, level of consciousness, oxygen saturation, electrocardiogram, and vital signs during and immediately after moderate sedation. • Assess all skin areas and document findings before transferring the patient to the postanesthesia care unit. • Patients are at risk in the OR for surgical injuries, disuse syndrome, hypothermia, fear, anxiety, fluid volume deficit, and peripheral neurovascular dysfunction. • Mechanical trauma and thermal injury are two categories of injury that a patient can incur during MIS and robotic surgery. • Surgical wound infections interfere with the patient's recovery, delay wound healing, contribute to rising health care costs, and are a major source of hospital-acquired (nosocomial) infections. • The nurse reflects on the expected outcomes of surgery including: o Patient is safely anesthetized without complications. o Patient remains injury-free related to surgical positioning or equipment. o Patient is free of skin or tissue contamination and infection during surgery and is free of skin tears, bruises, redness, abrasion, or maceration over pressure points and elsewhere. o Patient maintains normal thermoregulation and body temperature.

Immobilization

tss cpb Traction Slings Shoulder immobilizers Casts and splints Pillows Braces

Diffusion

Is the free movement of particles (solute) across a permeable membrane from an area of higher concentration to an area of lower concentration (down a concentration gradient) This action controls the movement of solute particles in solution across various body membranes.

Active ROM

Isotonic exercises of each joint in body that are performed by client Can maintain or improve muscle strength Prevent deterioration of joint movement and subsequent contractures

nurses must have the ksa to be

tap ccl transition manager advocate for patient and family patient educator care giver care coordinator leader

Osteoarthritis Medications:

maca meloxicam acetaminophen cortisone (orally, injections) arthritic rubs

emergency and disaster preparedness the life safety code

published by the national fire protection asso. requires every health care facility to practice at least 1 fire drill or actual fire response annually

healthcare organizations

purposely designed and structured systems in which healthcare is provided by members of nursing and interprofessional teams. an healthcare organization is characterized by its mission and philosphy organizational structure workforce( health care & ancillary) patients services provided: these characteristics allow the agency to provide safe, quality patient care that the public or local community can trust

skeletal disease osteomylitis dx procedures

bnb be cc bone biopsy culture needle aspiration of affected area bone scan bone x-ray ESR (will be elevated) CBC (elevated WBC's) CRP (will be elevated)

Implementing a fall prevention program after fall assessment

do u beak kkk Do not use full-length bed side-rails for confused clients; do not leave confused client alone—evaluate need for constant companion Orient client to nurse call system and encourage use Use a bed or chair monitoring device if necessary for clients at risk for falls Be sure nurse call system is within reach Encourage use of nonskid footwear Assess ability to ambulate and transfer Keep room tidy and free of clutter Keep bedside table and chair near bed Keep hospital bed in low position Keep crib side-rails up when child is unattended

see pp for

car seat recc. for kids

Hydrostatic Pressure

"Water-pushing pressure" Force that pushes water outward from a confined space through a membrane Amount of water in any body fluid space determines pressure

PICC Complications

**phlebitis** a patient's IV insertion site red, warm, and slightly edematous. The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism. ------- **infiltration** Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue. Phlebitis Thrombophlebitis Catheter-related bloodstream infections (CR-BSI) Infiltration and extravasation rare Can accommodate all types of therapy

FACTORS AFFECTING SKIN INTEGRITY

*Age* Infants, are born with varying amounts of vernix caseosa, a creamy substance that protects their skin. Their skin is thinner and more permeable than that of adults, which predisposes in- fants to skin breakdown (e.g., diaper rash). The subcutaneous layer (brown fat) and sweat glands are not fully developed, es- pecially for preterm infants. As a result, in the first few weeks of life infants' temperature-regulating systems are immature, which is why they need be swaddled to maintain body heat. Sex hormones released during puberty increase sebaceous and sweat gland activity, which leads to perspiration odor and sometimes acne. Older adult skin: less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury book The activity of the sebaceous and sweat glands diminishes with aging, resulting in drier skin. *Xerosis* (itchy, red, dry, scaly, cracked, or fissured skin) is a problem for up to 85% of older adults and can be a threat to the integrity of their skin. Along with loss of lean body mass, the subcutaneous tissue layer thins, giving the normal-weight individual a sharp, angular appearance. Changes in collagen fibers decrease the elasticity of the dermal layer, thus weakening the strong bond between the epidermis and dermis. These changes make the skin prone to breakdown and prolong wound-healing time. Regeneration of healthy skin takes at least twice as long in an 80-year-old as in a 30-year-old. In addition, many older adults have chronic diseases that interfere with healing. Diabetes, for instance, predisposes to infection; and liver dysfunction inter- feres with synthesis of blood-clotting factors. *Mobility status* Increased pressure, shearing, and friction can lead to breakdown book Impaired Mobility A healthy person moves and shifts position unconsciously when he senses pressure or discomfort. However, for people who cannot move independently, the weight of the body on the bed or chair causes an increase in pressure and may lead to skin breakdown. Impaired mobility is caused by conditions that require complete bedrest or that severely limit activity (e.g., paralysis, high-risk pregnancy, sedation, casts, and altered sensory perception). *Nutrition/hydration* Poor nutrition, less regeneration -------Protein. Healthy skin requires protein to maintain in- tegrity, repair minor defects, and preserve intravascular vol- ume. If protein levels decline from excess loss or inadequate intake, minor defects cannot be repaired, fluid leaks from the vascular compartment of dependent areas, and edema (excess fluid in the tissues) develops. Edema decreases skin elasticity and interferes with the diffusion of oxygen to the cells. There- fore, the skin becomes prone to breakdown. -------Cholesterol. Abnormally low cholesterol levels predis- pose patients to skin breakdown and inhibit wound healing. Patients on low-fat tube feedings may experience deficiencies in fatty acids and linoleic acid, as well as cholesterol. Together, these fats aid in providing calories for wound healing and maintain a waterproof barrier in the stratum corneum. ----Calorie Intake. If calorie intake is inadequate, the body uses proteins for energy (catabolism). Proteins are then un- available for building and maintenance functions (anabolism) (see Chapter 28 as needed). When undernutrition is prolonged, the person experiences loss of subcutaneous tissue, and muscle atrophy. As a result, there is less padding between the skin and the bones, predisposing the skin to pressure ulcers. ------Ascorbic Acid, Zinc, and Copper. Vitamin C, or ascor- bic acid, is involved in the formation and maintenance of col- lagen, so a deficiency can delay wound healing. Zinc and cop- per are also involved in collagen formation, and deficiencies of either may impair healing. -----Hydration. Poor skin turgor may occur as a result of dehydration, whereas edema may result from overhydration. For further discussion on fluid requirements, Dehydration = poor turgor *Sensation level* Diminished sensation leads to increased risk for pressure and breakdown book Clients with peripheral vascular disease, spinal cord injury, di- abetes, cerebrovascular accident, trauma, or fractures often have diminished tactile sense. They are therefore more prone to skin breakdown. If you've ever touched a hot surface and quickly pulled back your hand, you know the importance of tactile sensation. *A client with diminished sensation* is less able to sense a hot surface and would likely suffer a burn. A cut or wound in an area with limited sensation may go unnoticed and therefore untreated. The client with diminished sensation is also unable to feel pressure in an affected area. As a result, he may not shift position to relieve pressure over bony prominences or be aware that shoes or clothing are constricting. *Clients with impaired cognition* (i.e., Alzheimer's disease, de- mentia, altered level of consciousness) are at higher risk for skin breakdown because they are not aware of the need to reposition.

Fluid Overload: Collaborative Care

*Assessment* *Interventions* Patient safety Pulmonary edema Drug therapy Nutrition therapy Monitoring of I&O

Dehydration: Collaborative Care

*Assessment* History *Physical assessment/clinical manifestations:* Cardiovascular Respiratory Skin Neurologic- mental status Renal

COLLABORATIVE CARE: EXAGGERATED IMMUNE RESPONSE 3

*Clinical outcomes:* Adequate ventilation Restoration of blood pressure and pulse to pre-reaction normal levels Adequate urine output indicating adequate circulatory volume Modulation of hypersensitivity response Management of pain experience Maintenance of join and muscle mobility; self-care for ADLs where possible; restoration or maintenance of adequate levels of physical activity

WOUNDS wz

*Classification of Wounds* Open- open if there is a break in the skin or mucous membranes. Open wounds include abrasions, lacerations, puncture wounds, compound fractures (projection of bone through the skin), and surgical incisions. closed- If there are no breaks in the skin, the wound is de- scribed as closed. Contusions (bruises) or tissue swelling from fractures are common closed wounds. Acute- Acute wounds are expected to be of short duration. In a healthy person, these wounds heal spontaneously without complications through the three phases of wound healing (inflammation, proliferation, and maturation). chronic- Wounds that exceed the expected length of recovery are classified as chronic wounds. The natural healing progression has been interrupted or stalled because of infection, continued trauma, ischemia, or edema. Chronic wounds include pres- sure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with 7rl types of bacteria, and healing is slow because of the underlying disease process. Unless the wound is properly diagnosed and the underly- ing disease treated, a chronic wound may linger for months or years Clean Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacte- ria). There is little risk of infection for a clean wound. Clean/contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. contaminated- include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds. infected- Wounds are considered infected when bacteria counts in the wound tis- sues are above 100,000 organisms per gram of tissue. How- ever, the presence of beta-hemolytic streptococci, in any number, is considered an infection. Signs of wound infection include erythema and swelling around the wound, fever, foul odor, se- vere or increasing pain, a large amount of drainage, or warmth of the surrounding soft tissue. Superficial- Superficial wounds involve only the epidermal layer of the skin. The injury is usually the result of friction, shearing, or burning. partial- extend through the epidermis but not through the dermis. full-thickness extend into the subcutaneous tissue and beyond Penetrating- The descriptor penetrating is sometimes added to indi- cate that the wound involves internal organs. Wound depth is a major determinant of healing time: The deeper the wound, the longer the healing time. *Types of Wound Drainage* *Serous exudate*: straw-colored book Clean wounds typically drain serous exu- date. It is watery in consistency and contains very little cellu- lar matter. Serous exudate consists of serum, the straw-colored fluid that separates out of blood when a clot is formed. *Sanguineous*: bloody drainage book You will often see sanguineous exu- date (bloody drainage) with deep wounds or wounds in highly vascular areas. It indicates damage to capillaries. Fresh bleeding produces bright red drainage, whereas older, dried blood is a dark, red-brown color. *Serosanguineous*: mix of bloody and straw-colored fluid book In new wounds, you will most commonly see serosanguineous drainage, a combination of bloody and serous drainage. *Purulent*: yellow, contains pus book The thick, often malodorous, drainage that is seen in infected wounds is called purulent exudate. It contains pus, a protein-rich fluid filled with WBCs, bacteria, and cellular debris. It is commonly caused by infection from pyogenic (pus-forming) bacteria, such as streptococci or staphylococci. Normally, pus is yellow in color, although it may take on a blue-green color if the bacterium Pseudomonas aeruginosa is present. ■Purosanguineous Exudate. Red-tinged pus is called purosanguineous exudate. It indicates that small vessels in the wound area have ruptured.

NURSING ASSESSMENT: PRESSURE ULCERS

*Determine stage* book *Stage I Pressure Ulcer* - Localized area of intact skin with nonblanchable redness, usually over a bony prominence. - The area may be painful, firm, soft, or warmer or cooler as compared to adjacent tissue. - Discoloration will remain for > 30 min after pressure is relieved. - Dark skin may not have visible blanching; its color may differ from that of the surrounding area.Therefore, stage I may be difficult to detect. *Stage II Pressure Ulcer* -Involves partial-thickness loss of dermis. -Stage II pressure ulcers are open but shallow and with a red pink wound bed. -There is no slough. -May also be an intact or open/ruptured serum- filled blister, or a shiny or dry shallow ulcer without slough or bruising. -Do not use this stage to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. -Do not mistake moisture-associated skin damage or fungal infections for stage II pressure ulcer. -Stage II ulcers do not involve sloughing or bruising *Stage III Pressure Ulcer* -A deep crater characterized by full- thickness skin loss with damage or necrosis of subcutaneous tissue. -May extend down to, but not through, underlying fascia. -Undermining (deeper- level damage under boggy superficial layers) of adjacent tissue may be present. -Bone/tendon is not visible or directly palpable. -Some stage III pressure ulcers can be extremely deep when located in an area with significant adipose layers. *Stage IV Pressure Ulcer* -Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. -Exposed bone/tendon is visible or directly palpable. -Slough or eschar may be present. -Undermining and sinus tracts (blind tracts underneath the epidermis) are common. -The depth of a stage IV pressure ulcer varies by location.They can be shallow on the bridge of the nose, ear, occiput, and malleolus because these areas do not have subcutaneous tissue. -Stage IV ulcers can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule). --Often require a full year to heal. Even once healed, the site remains at risk for future injury because the scar is not as strong as the original tissue. Stages I-IV: classified by tissue involvement Stages III and IV: involve tissue necrosis Suspected deep tissue injury- An area of skin that is intact but discolored. It might be purplish or deep red, painful, boggy, or have a blister.---Occurs due to damage of underlying soft tissue from pressure or shear.-----Findings can be subtle enough that often DTI is not recognized until after severe tissue damage has occurred.-----May heal or evolve further and become covered by thin eschar, rapidly exposing additional layers of tissue even with optimal treatment.-----In darker pigmented individuals, discoloration might go undetected. **a wound that has 100% eschar can not be staged** *Unstageable Pressure Ulcer* -Involves full-thickness skin loss. -The base of the wound is obscured by slough (tan, yellow, gray, green, or brown necrotic tissue) or eschar (tan, black, or brown leathery necrotic tissue). -Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. -Stable eschar is dry, adherent, and intact without erythema or fluctuance. Do not remove stable eschar, as it serves as "the body's natural cover." Escharxl is thick, hard, and black or brown, also known as an unstageable pressure ulcer. Sloughxl is usually soft, stringy, and pale yellow or gra Use PUSH tool Wet → dry it Open → cover it Unclean → clean it Necrotic → don't scrub it Dry → moisten it

COMPLICATIONS OF WOUND HEALING

*Hemorrhage* Whenever a capillary network is interrupted or a blood vessel is cut, bleeding occurs. Hemostasis (cessation of bleeding) usu- ally occurs within minutes of the injury. Possible causes include a slipped suture, erosion of a blood vessel, a dislodged clot, or infection. The risk of hemor- rhage is greatest in the first 24 to 48 hours following surgery or injury. Bleeding may be internal or external. ----Internal Bleeding. Swelling of the affected body part, pain, and changes in vital signs (i.e., decreased blood pressure, elevated pulse) may indicate internal bleeding. Internal bleed- ing, in this chapter, includes hematoma, a red-blue collection of blood under the skin, which forms as a result of bleeding that cannot escape to the surface. The amount of blood in a hematoma varies. A large hematoma causes pressure on sur- rounding tissues. If it is located near a major artery or vein, it may impede blood flow. ------External Hemorrhage. Compared to internal bleeding, external hemorrhage is easier to recognize. You will see bloody drainage on the dressings and in the wound drainage devices. When there is a brisk hemorrhage, blood often pools under- neath the client as the dressings become saturated. To be sure that you recognize the full extent of the bleeding, remember to look underneath the patient. *Infection* Microorganisms can be introduced to a wound during an injury, during surgery, or after surgery. Suspect infection if a wound fails to heal. Localized swelling, redness, heat, pain, fever (temperatures higher than 38°C [100.4°F]), foul-smelling or purulent drainage, or a change in the color of the drainage may also indicate infection. The symptoms are likely to occur in a contaminated or traumatic wound within 2 to 3 days. In a clean surgical wound, you will usually not see signs and symptoms of an infection until the fourth or fifth postopera- tive day. Incisions that begin draining within 5 to 7 days of surgery are at risk for dehiscing. *Dehiscence* Rupture (separation) of one or more layers of a wound is called dehiscence. Wound dehiscence is most likely to occur in the inflammatory phase of healing, before large amounts of collagen have been deposited in the wound to strengthen it. The most common causes of dehiscence are poor nutritional status, inadequate closure of the muscles, or wound infection. Obese clients are also more likely to experi- ence dehiscence because fatty tissue does not heal readily and the patient's mass increases the strain on the suture line. Dehiscence is usually associated with abdominal wounds. Patients often report feeling a pop or tear, especially with sud- den straining from coughing, vomiting, or changing positions in bed. Usually there is an immediate increase in serosan- guineous drainage. Nursing interventions include maintain- ing bedrest with head of bed elevated at 20° and the knees flexed. To prevent evisceration, a binder may be applied and activity modified. The surgeon should be notified of the dehiscence and may visit the patient to examine the wound. *Evisceration* Evisceration is total separation of the layers of a wound in which internal viscera protrude through the incision (Fig. 36-5). Evisceration is a rare complication and is a surgical emer- gency. Immediately cover the wound with sterile towels or dress- ings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bac- teria. Have the patient stay in bed with knees bent to minimize strain on the incision. Notify the surgeon and ready the patient for a surgical procedure (see Chapter 40 for perioperative care) *Fistula formation* A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Fistulas often result from infection. An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway. Chronic drainage from the fistula may lead to skin breakdown and delayed wound healing. The most common sites where fistulas form are the gastrointestinal and genitourinary tracts. Figure 36-6 illustrates a fistula between the rectum and vagina.

EXAGGERATED IMMUNE FUNCTIONING*

*SYMPTOMS* Allergic symptoms Pain Fatigue Fever *CLINICAL FINDINGS* Allergic response Mild allergic response Severe allergic response Autoimmune disorders Can range from vague findings to findings associated with organ failure *Note: Symptoms of autoimmune disorders tend to be vague. Clinical findings vary widely based on the severity of the problem.

Interstitial Cystitis sisxl

*watkins*: similar to a uti, uti is more in the tract, then it n goes up to the bladder, then kidneys Chronic Inflammation/infection of the bladder, can be caused by irritation or more commonly infection... ecoli,staph, saprophyticus, Klebsiella pneumoniae prevention decrease use of foleys, use strict sterile techniques, increase fluids, good hygiene, bathe daily, Avoiding caffeine, carbonated beverages, and tomato products may decrease bladder irritation and promote COMFORT during cystitis. *s/s* siss/s frequency, urgency,dysuria, cloudy urine, foul smelling, blood tinged s/s: burning frequency, dysuria--difficulty urinating--, wbc in the urine from when they do a urine analysis. *labs* sislabs leukocyte and nitrates, presence of wbc with rbc's, urinalysis------A urinalysis usually shows WBCs and RBCs but no bacteria. Common findings in interstitial cystitis are a small-capacity bladder, the presence of Hunner's ulcers (a type of bladder lesion), and small hemorrhages after bladder distention. *rf*-- sisrf bad personal hygiene, wiping back to front, *dx* sisdx Cystoscopy identifies abnormalities that increase the risk for cystitis. Such abnormalities include bladder calculi, bladder diverticula, urethral strictures, foreign bodies (e.g., sutures from previous surgery) *drugs* sisdrugs urinary antiseptics or antibiotics, analgesics, antispasmodics for uncomplicated cystitis recommend nitrofurantoin, trimethoprim/sulfamethoxazole, or fosfomycin as first-line therapy *pt teaching* sisteach COMFORT and teaching about drug therapy, fluid intake, prevention measures ashlii Presentations of I.C. include: Urgency Frequency Nocturia Dysuria Hematuria may be present All of these with no evidence of infection! *Pain*: sispain Pain ranges from mild to severe. Pain is most prominent as the bladder fills between voiding. Suprapubic pain is a common finding, but a person may also feel pain in the bladder, the urethra, the area below the umbilicus, the lower back, or the area around the vagina. Men may also feel pain in the scrotum, testes, or penis. Pain can come and go or it can be constant. It can increase during sex, and some women find that it is worse when they are having their period.

peritonitis is life threatening perixl

*watkins: sepsis/shock/death* antibiotics mall life threatening acute inflammation of the viceral/ parietal peritoneum and endothelial lining of the abdominal cavity *pericauses causes* appendicitis, diverticulitis, pud, external penetrativity wound, gangrenous gallbladder, bowel obstruction, genital tract infection *bacteria* strep, e.coli,staph, gonoccocus peris/s s/s elastic, rigid,board-like *abdominal pain*, distension, n/v, anorexia, decreased bowel sounds, cant pass gas or feces, *rebound tenderness* increased fever, increased hr, poor skin turgor, dehydration, decrease urine output, hiccups, *respiratory distress* tests increased wbc, bmp creatinine, bun,hgb/hct, o2sats and co2 monitoring *peritx tx* iv fluids, broad spectrum antibiotics, I & O, daily weight, NG tube, npo status, analgesics surgery goal/focus- control contamination, remove foreign material, draining collected fluid *maintain pt in semi-fowlers* to promote drainage of peritoneal contents into the lower regions of the abdominal cavity and increase respirations sn inflammation/ infection in perium abdominal wall rf- trauma, ulcers - appendix diverticulitis. leakage or hole in the intestine such as a bursting appendix even if the fluid is sterile s/s vomiting, fever, ab distension, tenderness, pulse bp is high, thyroids is low n.i: maintain fluid and electrolyte imbalance, decreased pain, mdications, iv fluids dx- cbc urine- ct, xray, sx

Postop: Respiratory system assessment postopxl

-*Patent airway*, adequate gas exchange -Note artificial airway when applicable -Rate, pattern, depth of breathing -Breath sounds -Accessory muscle use -Snoring and stridor -Respiratory depression or hypoxemia *decrease risk of respiratory compromise incentive spirometer coughing and deep breathing oral care getting out of the bed 3x's daily head of bed elevation*

Safety hazards for healthcare workers

-Back injury -Needle stick injury -Radiation injury -Workplace violence Prevention: -Body mechanics -Sharps awareness; proper disposal -Radiation precautions -Environmental awareness of personal safety

REGIONAL ANESTHESIA regionalxl

-Blocks multiple peripheral nerves in specific body region Field Nerve Spinal Epidural

Stressxl Incontinence- *kegal* chapt 66

-mall the involuntary loss of urine during activities that increase abdominal and detrusor pressure. patients cannot tighten the urethra sufficiently to overcome the increased detrusor pressure; leakage of urine results ashlii patho An involuntary loss of small amounts of urine with increased intra-abdominal pressure. involuntary loss of urine of less than 50 mL occurring with increased abdominal pressure through coughing, laughing, or lifting, jogging - stresscause cause weakening of bladder neck supports; associated with childbirth - intrinsic sphincter deficiency caused by such congenital conditions as epispadias( abnormal location of the urethra on the dorsum of the penis) or myelomeneningocele -acquired anatomic damage to the urethral spincter (from repeated incontinence sx,prostatectomy, radiation therapy, and trauma) -Vaginal prolapse from vaginal birth or aging. sn muscle is weak in pelvis, urine leak when laugh, cough, or sneeze, pick up something, standup, anything that causes stress to the body leaky urine, could be from child birth, weak pelvic floor muscle kegal exercise or sx --------- *stresss/s s/s* urine loss with physical exertion, cough, sneeze, or exercise- usually only small amounts of urine are lost with each exertion -normal voiding habits< 8 times per day, <2 or fewer times per night -postvoid residual usually < 50ml. pelvic examination shows hypermobility of the urethra or bladder neck with valsalva maneuvers. common after child birth d/t stretched weakened pelvic muscles, decreased estrogen levels after menopause causing weakened, vaginal, urethral, pelvic floor muscles Sudden increase in intra-abdominal pressure causes involuntary leakage *s/s* Can occur during coughing,sneezing, laughing, or physical activities such as heavy lifting,exercising, Leakage usually in small amounts and may not be daily stressdrugs *meds * with topical estrogen to the perineal and vaginal orifice is used to treat postmenopausal women with stress incontinence. Estrogen may increase the blood flow and tone of the muscles around the vagina and urethra, thus improving the patient's ability to contract those muscles during times of increased intra-abdominal stress. ANTICHOLINEGICS, antihistamines *stressdx dx* *Ultrasonography, cystography* (to show the presence of bladder herniation), measurement of residual urine by bladder ultrasound, and urine culture and sensitivity testing. Radiographic imaging of urinary anatomy and voiding function is useful in determining the degree of cystocele (prolapse). dx-urine sample to check for bld, urine stress test to see how much urine is being lost, not lost; physical exam--urethral device happens from child birth, weak pelvic floor muscles Stress incontinence may be treated by a surgical sling or bladder suspension procedure ------------ *stressni ni* Pelvic floor muscle exercises( kegel exercises), weight loss if obese, cessation of smoking, topical estrogen products, book n.i Initial interventions for patients with stress incontinence include *keeping a diary* and pelvic muscle exercises (Kegel exercises) Surgery also may be an option if other interventions are not effective.Explain the purpose of a detailed diary in which the patient records times of urine leakage, activities, and food eaten. The diary is then used by the primary health care provider to plan and evaluate interventions. *Collection devices, absorbent pads, and undergarments* may be used during the often lengthy process of assessment and treatment and by patients who elect not to pursue further interventions. Other interventions for stress incontinence include behavior modification, psychotherapy, and electrical stimulation devices to strengthen urethral contraction. Intravaginal and intrarectal electrical stimulation devices have been used with varying degrees of success. *stressrf* Most common in women with relaxed pelvic floor muscles( Afterbirth mothers, use of instrumentation during vaginal delivery, or multiple pregnancies Structure of the female urethra loss when estrogen decreases Prostate surgery for BPH or prostate cancer stressteaching pt teaching Kegel exercises( tighten your pelvic floor muscle quickly, squeeze hard for 2 sec and then relax the muscle Long squeezes 5-10 seconds before you relax Use behavioral techniques, such as Kegel exercises, limiting fluids such as caffeinated or carbonated beverages or other bladder irritants, voiding before bedtime and upon arising from bed, voiding at predetermined frequencies (such as every hour or two, and slowly increasing time interval as able) Wear clothing that is easily removed for ease in toileting Use assistive devices, such as raised toilet seats, bedside commode, and urinal or bedpan as needed ----

Axial section

1. Each vertebra is constructed like a ring, one on top of another, with a padding of cartilage between; vertebral rings are studded with bony projections called processes, which function as attachments for muscles and points of articulation with bones 2. Twelve pairs of ribs attach to thoracic vertebrae; upper 7 opposing pairs attach at front to sternum; 3 of remaining 5 pairs attach to rib immediately above by cartilage, and lowest 2 pairs are unattached

Just Culture

A health care system's value is in reporting errors without punishment. Seeks to find a balance between the need to learn from mistakes and the need for disciplinary action against employees.

Combination (acute and chronic)

By Duration Intractable Resistant to treatment • Three major types of pain have been identified—acute, chronic cancer, and chronic non cancer.

Chapter 12: Assessment and Care of Patients with Problems of Acid-Base Balance The priority concept for concept exemplar in this chapter is ACID-BASE BALANCE.

ACID-BASE BALANCE • Body fluid pH is a measure of the body fluid's free hydrogen ion level, which has the narrowest range of normal and the tightest control mechanisms of all electrolytes. • The normal pH of the body's extracellular fluids (including blood) is 7.35 to 7.45. • The body keeps blood pH between 7.35 and 7.45 in a similar manner; however, this value is not strictly neutral (7.0 is neutral) but, rather, is slightly alkaline. • The normal pH of arterial blood is slightly higher (less acidic) than venous blood. • Lower pH values (below 7.35) mean acidosis is present. • Higher pH values (above 7.45) mean alkalosis is present ------------------------------------------- Acid-Base Chemistry • Normal body fluid pH remains at a near-neutral value when the acids and bases are nearly balanced, limiting the total number of free or unbalanced hydrogen ions. • Balance occurs through control of hydrogen ion (H+ ) production and elimination. • The more hydrogen ions present, the more acidic the fluid. • The fewer hydrogen ions present, the more alkaline the fluid. • Any change in pH is significant as a 1 pH unit change actually represents a tenfold change in free hydrogen ion level. • Abnormal pH interferes with many normal physiologic functions, including the o function of hormones and enzymes. o distribution of other electrolytes. o activity of the heart, nerves, muscles, and GI tract. o effectiveness of many drugs. • Acids are substances that release hydrogen ions when dissolved in water (H2O). • A base is a substance that binds free hydrogen ions in solution. • Liquids with a pH of 7.0 are neutral—they have a free hydrogen ion level in which the numbers and strengths of acids and bases are equal. • ACID-BASE BALANCE is regulated by chemical, respiratory, and kidney actions. • The lungs control the amount of CO2 that is retained or exhaled. • The kidneys regulate the amount of hydrogen and bicarbonate ions that are retained or excreted by the body. • ACID-BASE BALANCE occurs by matching the rate of hydrogen ion production (which is a continuous normal process) with hydrogen ion loss. • Compensation is the process in which the body uses its three regulatory mechanisms (chemical, respiratory, and renal) to correct for changes in the pH of body fluids. • If a lung problem causes retention of carbon dioxide, the healthy kidney compensates by increasing the amount of bicarbonate that is produced and retained. • The best way to determine acid-base balance is to analyze arterial blood gases (ABGs). • Check the serum potassium level for any patient who has acidosis. o Hyperkalemia occurs with acidosis as hydrogen ions are exchanged with potassium and are pulled inside the cell. Once the patient has been treated for acidosis, the serum potassium levels fall and the patient will require supplementation of potassium. • Assess heart rate and rhythm at least every 2 hours for any patient with an acid-base imbalance. ------------------------------------------ Body Fluid Chemistry • The pH in the body can be described as the relationship of bicarbonate to carbonic acid, or a 20:1 ratio. • A key concept in understanding acid-base balance is the carbonic anhydrase equation, driven by the enzyme carbonic anhydrase, showing how hydrogen ion levels and CO2 levels are directly related to one another so that an increase in one causes an equal increase in the other. • Because the normal ratio of carbonic acid and bicarbonate level in extracellular fluid is 1:20, the only factor that changes is the carbon dioxide level. • Whenever the CO2 level changes, the pH changes to the same degree in the opposite direction since carbon dioxide is the most changeable component of carbonic acid. • The carbon dioxide content of a fluid is directly related to the amount of hydrogen ions in that fluid. Anything that increases the CO2 level in the blood increases the hydrogen ion content and lowers the pH. • How is the relationship between free hydrogen ions and carbon dioxide helpful? CO2 is a gas that can be eliminated during exhalation, and this action is important for ACID-BASE BALANCE. • Acids are normally formed in the body as a result of metabolism and incomplete breakdown of glucose and fats. • Incomplete breakdown of glucose, which occurs whenever cells metabolize under anaerobic conditions, forms lactic acid. • Anaerobic conditions occur with hypoxia, sepsis, and shock. • Incomplete breakdown of fatty acids, occurring when large amounts of fatty acids are being metabolized, forms ketoacids. ------------------------------------------------ Acid-Base Regulatory Actions and Mechanisms • Compensation is the process in which the body uses its chemical, respiratory, and renal regulatory mechanisms to keep the free hydrogen ion level within the narrow range of normal to maintain ACID-BASE BALANCE. • Chemical buffers are the immediate way that acid-base imbalances are corrected. o Chemical buffers are paired mixtures, usually a weak base and an acid salt. o Buffers can either release a hydrogen ion into a fluid (act as an acid) or bind a hydrogen ion from a fluid (act as a base) to try to bring the fluid as close as possible to normal. o The common buffers are bicarbonate, phosphate, and proteins. • The respiratory system is the second line of defense against changes. o The respiratory system's response in acid-base balance is rapid—efforts occur within seconds to minutes. o Respiratory compensation occurs through the lungs, usually to correct for acid- base imbalances from metabolic problems. o Breathing controls the amount of free hydrogen ions by controlling the amount of carbon dioxide in arterial blood. This action is important for ACID-BASE BALANCE. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to increase the rate and depth of breathing; this is called hyperventilation. o When the amount of arterial CO2 returns to normal, the rate and depth of breathing return to levels that are normal for the person. o Central receptors also sense low CO2 levels and stop or slow the neuron activity in the respiratory centers, decreasing the rate and depth of breathing; this is called hypoventilation. • The kidneys are the third line of defense against wide changes in body fluid pH. o Renal mechanisms are stronger for regulating acid-base balance but take longer (1 to 2 days) than chemical and respiratory mechanisms to completely respond. o Renal compensation results when a healthy kidney works to correct for changes in blood pH that occur when the respiratory system either is overwhelmed or is not healthy. o The kidneys regulate the amount of hydrogen and bicarbonate ions that are retained or excreted by the body. o In some cases, the respiratory problem causing the acid-base imbalance is so severe that kidney actions can only partially compensate, and the pH is not quite normal. o Bicarbonate reabsorption is the first renal control mechanism. If a lung problem causes retention of carbon dioxide, the healthy kidney compensates by increasing the amount of bicarbonate that is produced and retained. o Formation of acids is the second renal control mechanism. o Formation of ammonium is the third renal control mechanism. ----------------------------------------- ACID-BASE IMBALANCES • Acid-base imbalances are problems of ACID-BASE BALANCE resulting from changes in the blood hydrogen ion level or pH. • Imbalances in which blood pH is below normal reflect acidosis (pH below 7.35) and imbalances in which blood pH is above normal reflect alkalosis (pH above 7.45). --------------------------------- Acidosis • Acidosis reduces the excitability of cardiovascular muscle, neurons, skeletal muscle, and GI smooth muscle. • Acidosis can result from an actual or relative increase in the amount or strength of acids. • Acidosis can be caused by metabolic problems, respiratory problems, or combined metabolic and respiratory problems. • The hallmark of a base excess acidosis is an ABG result with an elevated pH and an elevated bicarbonate level along with normal oxygen and carbon dioxide levels. • Remember that metabolic and respiratory acidosis can occur at the same time. ------------------------------------------------ Alkalosis • Alkalosis increases the sensitivity of excitable tissues, allowing them to over-respond to normal stimuli and even respond without stimulation. • In patients with alkalosis, the ACID-BASE BALANCE of the blood is disturbed and has an excess of bases, especially bicarbonate. • Alkalosis can result from an actual or relative increase in the amount or strength or both of bases. ------------------------------------------------ OTHER GENERAL CARE OF PATIENTS WITH ACID-BASE IMBALANCES • Use caution in giving oxygen to people who have chronic obstructive pulmonary disease, and monitor their respiratory effort at least hourly. • Monitor respiratory status hourly and intervene to prevent complications. Listen to breath sounds, and check for presence of muscle retractions, use of accessory muscles, and presence of grunting or wheezing. Assess nail beds and oral membranes for cyanosis (a late finding). • Assess heart rate and rhythm at least every 2 hours for any patient with an acid-base imbalance. • Assess for signs of decreased perfusion and changes in blood pressure at least every 2 hours because hypotension occurs with vasodilation and loss of blood volume. • Monitor the neurologic status at least every 2 hours in patients being treated for an acid- base imbalance. • Assess and document the condition of the site from which an ABG sample was obtained at least every 2 hours for the first 24 hours. • Teach all patients to take drugs as prescribed, especially diuretics, antihypertensives, and cardiac drugs. • Assist patients interested in smoking cessation to find an appropriate smoking cessation program. • Identify patients at increased risk for falls as a result of muscle weakness with acid-base imbalances. • Assess the oxygenation status of any patient with acute confusion.

Acid-Base Imbalances

Acidosis Serum pH below 7.35 Respiratory cause: retention of CO2 Metabolic cause: loss of bicarbonate

Clinical Significance: Osmosis & Filtration

Act together at capillary membrane to maintain normal ECF and ICF volumes Thirst mechanism is example of how osmosis helps maintain homeostasis Feeling of thirst caused by activation of brain cells responding to changes in ECG osmolarity

Immobility related to pain

Acute or chronic pain may interfere with mobility Some conditions associated with immobility cause pain

Pain Pharmacologic Therapy Classification: Adjuvants

Adjuvant Analgesics. Adjuvant analgesics (sometimes called co-analgesics) are drugs that have a primary indication other than pain but are analgesic for some painful conditions. For example, the primary indication for antidepressants is depression, but some antidepressants help relieve some types of pain. The adjuvant analgesics are the largest and most diverse of the three analgesic groups. Drug selection and dosing are based on both experience and evidence-based practice guidelines. SSRIs Anti-epileptic drugs (AEDs) Anticonvulsants (also called antiepileptic drugs [AEDs] when used for seizure management) produce analgesia by blocking sodium and calcium channels in the CNS, thereby diminishing the transmission of pain. The gabapentinoids gabapentin (Neurontin) and pregabalin (Lyrica) are recommended as first-line analgesics for persistent neuropathic pain. Gabapentin may also be administered as an epidural injection. These drugs are increasingly being added to postoperative treatment plans to address the neuropathic component of surgical pain. Primary side effects are sedation and dizziness, which are usually transient and most notable during the titration phase of treatment. Antidepressants relieve pain on the descending modulatory pathway by blocking the body's reuptake of the inhibitory neurochemicals norepinephrine and serotonin. Antidepressant adjuvant analgesics are divided into two major groups: the tricyclic antidepressants (TCAs) and the newer serotonin and norepinephrine reuptake inhibitors (SNRIs). Evidence-based guidelines recommend the TCAs desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment (D'Arcy, 2014). The most common side effects of the TCAs are dry mouth, sedation, dizziness, mental clouding, weight gain, and constipation. Orthostatic hypotension is a potentially serious TCA side effect, making TCAs a poor choice for older adults. The most serious adverse effect is cardiotoxicity, especially for patients with existing significant heart disease. The SNRIs have a more favorable side effect profile and are better tolerated than the TCAs. The most common SNRI side effects are nausea, headache, sedation, insomnia, weight gain, impaired memory, sweating, and tremors. Muscle relaxants/antispasmotic drugs Alpha-2 adrenergics Local anesthetics/analgesics Local anesthetics relieve pain by blocking the generation and conduction of the nerve impulses necessary to transmit pain. The local anesthetic effect is dose related. A high enough dose of local anesthetic can produce complete anesthesia, and a low enough dose (subanesthetic) can produce analgesia. The lidocaine patch 5% (Lidoderm) is 10 cm by 14 cm and contains 700 mg of lidocaine. The patch is placed directly over or adjacent to the painful area for absorption into the tissues directly below. A major benefit of the drug is that it produces minimal systemic absorption and side effects. The patch is left in place for 12 hours and then removed for 12 hours (12-hours-on, 12-hours-off regimen). This application process is repeated as needed for continuous analgesia. Topical local anesthetic creams for superficial procedures such as IV insertion include EMLA (eutectic mixture of local anesthetics) and LMX-4- EMLA contains a combination of lidocaine 2.5% and prilocaine 2.5% and is applied to intact skin for 60 to 120 minutes before the procedure. LMX-4 contains 4% lidocaine and is applied 30 minutes before the procedure. EMLA has a longer duration of action (2 hours) than LMX-4 (30 minutes) after cream removal. Topical local anesthetic side effects are rare and usually transient, with local skin reactions being the most common. Liposomal bupivacaine (Exparel) for postoperative wound infiltration is a sustained-release formulation injected as a single dose into the surgical site by the surgeon. The sustained-release formulation has been shown to produce prolonged analgesia, which decreases the need for potent opioids. For many years regional anesthesia has been administered by single-injection peripheral nerve blocks using a long-acting local anesthetic such as bupivacaine or ropivacaine to target a specific nerve or nerve plexus. This technique is highly effective in producing pain relief, but the effect is temporary (4-12 hours). Continuous peripheral nerve block (also called perineural regional analgesia) offers an alternative with longer-lasting analgesia. A continuous peripheral nerve block involves establishment by an anesthesia provider of an initial block followed by placement of a catheter through which an infusion of local anesthetic is administered continuously, with or without PCA capability. When PCA capability is added, this is referred to as patient-controlled regional analgesia (PCRA). Just as with epidural and intrathecal analgesia, nurses are responsible for monitoring and managing the therapy. NMDA antagonists Cannabinoids (cannabis extracts)

Exemplars of Pain - Neuropathic Pain Peripherally-Generated Pain

Alcohol-nutritional neuropathy Diabetic neuropathy Nerve root compression, nerve entrapment Pain of Guillain-Barré syndrome Post-herpetic neuralgia Some types of neck, shoulder, and back pain Trigeminal neuralgia

TRANSMISSION-BASED PRECAUTIONS Airbornexl airxl

Airborne Precautions Pathogen is spread via air currents Transmission via ventilation systems, shaking sheets, sweeping Precautions include Same as those for contact, with addition of special room, special mask, and mask for patient when transported book *When to Use:* Use airborne precautions to control the spread of infections that are trans- mitted person-to-person on air currents.These include tuberculosis, varicella (chickenpox), SARS, and rubeola (measles). Pathogens spread by this method are very small and can be easily transmitted through ventilating systems as well as by any activities that stir the air, such as fanning sheets, shaking out towels, or sweeping the floor. *Patient Placement and Transport * ■ Place the patient in an airborne infection isolation room (AIIR)—one with negative pres- sure that discharges and exchanges the air outside or through a high-efficiency particulate air (HEPA) filtration system. Monitor air pressure daily (usually this is via an electronic device with an alarm). ■ If such a room is not available, transfer the patient to a facility where one is available. ■ Keep the room door closed when not required for entry and exit.To maintain the nega- tive pressure and contain the airborne organisms. ■ In the event of an outbreak involving large numbers of patients who require airborne pre- cautions, consult with infection preventionists for patient placement. ■ Limit transport of the patient outside the room to medically necessary purposes. If trans- port is necessary, cover any infectious skin lesions and have the patient wear a mask.The transporter is not required to mask if the patient is wearing a mask and infectious skin lesions are covered. Notify the receiving department.The receiving department can then take airborne precautions. ■ Ambulatory care: Triage and identify patients with suspected airborne precautions upon entry to the agency. Place the patient in an AIIR as soon as possible. If one is not available, place a mask on the patient and place him in an exam room. Do not reuse the room for at least an hour after the patient leaves it. *Personal Protective Equipment * ppexl ■ Keep airborne isolation supplies just outside the patient's room on a cart. ■ Don a mask on entering the room. Wear a special, fit-tested, approved mask (e.g., N95 respirator) if the patient is suspected of having pulmonary tuberculosis or smallpox. ■ Remove your respirator/mask outside the room after closing the door. If the respirator is not disposable, clean and store according to the manufacturer's instructions. ■ When using a respirator mask, check the seal. Hold your hands over the respirator and exhale. If you feel air around your nose, adjust the nosepiece; if you feel air at the edges, adjust the straps. ■ When the patient has rubeola, varicella (chickenpox), or disseminated zoster, the CDC makes no recommendation about use of PPE if, based on your history of vaccination or disease, you think you are presumed immune to the disease. ■ If the patient has or is suspected of having rubeola or varicella, only immune caregivers should provide care. Immune caregivers do not need to wear masks.

Risk Factors: Populations at Greatest Risk

All individuals, regardless of age, gender, or race, are potentially at risk Populations at greatest risk for problems with thermoregulation are Very young persons Very old persons Poor persons Persons living in very hot or cold climates

Amphiarthroses

Allow for limited movement. (e.g. the joints between the vertebrae and the pubic bones

Hormonal Regulation

Antidiuretic hormone (ADH) Renin-angiotensin system Aldosterone Thyroid hormone Brain naturetic factor

CLINICAL MANAGEMENT: COLLABORATIVE INTERVENTIONS

Antimicrobial therapy Rest and comfort care measures Nutritional support Fluids Disinfection of physical environment

OTHER ANTIMICROBIAL AGENTS

Antiviral Antifungal Antiprotozoal

OBJECTIVES - ATI - NCLEX Physiological Integrity

Assess patients for specific problems related to positioning during surgical procedures. Understand anatomic principles for modifying patient positioning and OR bed padding to prevent skin breakdown, promote comfort, and prevent positioning injury during surgical procedures. Coordinate appropriate care for the patient with malignant hyperthermia.

X-ray

Assist in the diagnosis of fractures, abnormal fracture healing, tumors, arthritic conditions, and osteomyelitis.

Clinical Management: Primary Prevention

Avoid exposure to temperature extremes Maintain the optimal ambient temperature in the home Dress appropriately for the temperature Engage in physical activity appropriate to temperature conditions

Immune responses to bacterial invasion:

B lymphocytes are activated, resulting in the production of antibodies. T lymphocytes are activated, resulting in phagocytosis. Complement system is activated to enhance overall response. Bacteria release endotoxins or exotoxins, which damage the cells of the host and initiate an inflammatory response.

Normal Blood pH

Balance of acids and bases in body fluids *Normal for:* Arterial blood = 7.35 to 7.45 Venous blood = 7.31 to 7.41 *Changes can affect:* Shape of hormones and enzymes Distribution of other electrolytes (fluid and electrolyte imbalance) Excitable membranes Effectiveness of hormones and drugs

PREVENTION OF CARDIOVASCULAR COMPLICATIONS

Be aware of patients at greater risk for DVT Antiembolism stockings Pneumatic compression devices Leg exercises Mobility

PREOPERATIVExl PERIOD preopxl

Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite *watkins* if we have someone weeks prior to sx were going to be teaching about what to expect, what they need to do prior to the sx, everything they need to do from the night before to the morning of check all allergies, (shell fish, betadine, latex, bananas) labwork, preparation ( no jelwry, piercing, dentures, informed consent.) education as to what to expect, what to do; WHAT IS THE CT GOING TO BE EXPERIENCING? what do we need to know about that ct? ANXIETYxl no matter how many x's they had sx, distractions for anxiety, SEDATIVES, OPIODS, VERSED(calmn), ZANTAC H2 histamine blockers, something for nausea zofran, w/ morphine/versed assessing their respiration's, w/ anesthesia it slows everything down. NEED to be Well educated. what to expect, ex. we have a ped client, to comfort them bring in a stuffed animal family, keeping family around as much as possible MEDS per dr order for anxiety meds GO to bathroom b4 giving meds. Bed in lowest position, 2 siderails up, any allergies== checking all safety factors ask what is making them anxious, *CONSENT 4 SX* to make sure they understand procedures and complications Nurses never educate on this info it is the PHYSICIAN Nurses is a witness to say that this is the actual person who signed it. soooo if t hey go to sign the consent, and you ask them what procedure they are having and they say idk, THEY WILL NOT SIGN THE CONSENT, CALL dr to educate them if someone cant write an *x* can count as their signature. we just need to make sure they are who they say they are. if under 18, legal guardian is signing *ASSESSING* for complications, assessment, health hz, any MEDS, look at issues b4 and after sx. *MAKE SURE NNNOO!!!!! NSAIDS, ANTICOAGULANTS CAUSE BLEEDING, herbal= garlic st. johns wort*, HYPETENSIVE MEDS. complications to anesthesia, anyone in the family...*malignant hyperthermia* (GENETIC).. these meds should be stopped 4-7 days prior to sx if they did not stop they will not be able to have the sx no sx high risk *preoperative checklist* education, consent form, lab work is fine, meds if they follow what the dr said. npo if eat causes aspiration, did they do enema, if they didnt postpone sx, cardiac, seizure meds can take in morning but depends on dr, *skin prep* no infection, hair removal, clip and clean, if its not clean risk for infection *pt teaching* making sure pt n fam know what they are going to see after..tubes and drains, devices, intabation... fam needs to be prepped to know what gonna see. Nurse functions as educator, advocate, promoter of health and safety begins with decision to have surgery and ends with transport of client to operating room (OR); general nursing activities include client identification, client assessment, identifying potential or actual health problems, and beginning teaching about postoperative self-care • Preoperative care focuses on preparing the patient for the surgery and ensuring patient SAFETY, including education and interventions required to reduce anxiety and complications and to promote patient cooperation for postoperative procedures. • Use at least two appropriate identifiers (e.g., medical record number, the identification band, asking the patient to state his or her name) to identify the patient. Room numbers or bed numbers are not used to identify patients. o Ensure that the patient is wearing proper identification, including allergy, limb alert, and fall risk bracelets, if applicable.

Significance of Fluid Balance: Renin-Angiotensin II Pathway

Blood (plasma) volume and intracellular fluid most important to keep in balance Kidneys are major regulator of water and sodium balance; maintain blood and perfusion pressure to all tissues/organs poor perfusion= flattened neck veins supine position, normal veins are distended When the kidneys sense a low parameter, they secrete renin

Pathophysiology of Pain Peripheral nervous system

Cranial and spinal nerves

Hyperthermia

Brain injury Environmental exposure Fever Heat exhaustion Heat exhaustion is a syndrome resulting primarily from dehydration. It is caused by heavy perspiration and inadequate fluid and electrolyte intake during heat exposure over hours to days. Profuse diaphoresis can lead to profound, even fatal, dehydration and hyponatremia caused by excessive sodium lost in perspiration. If untreated, heat exhaustion can lead to heat stroke, which is a true emergency condition that has a very high mortality rate. Heat Exhaustion • In heat exhaustion, patients usually have flu-like symptoms with headache, weakness, nausea, and/or vomiting. • Heat exhaustion is a syndrome primarily caused by dehydration. Assess the patient for orthostatic hypotension and tachycardia, especially the older adult who is predisposed to rapid dehydration. Older adults who are already dehydrated often experience acute confusion and are at risk for falls. • Treat the patient by immediately stopping physical activity, moving him or her to a cooler place, and using cooling measures. • Hospital admission is indicated only for cases where the heat-related illness compounds other health problems or with severe dehydration and significant physiologic compromise. • If untreated, heat exhaustion can lead to heat stroke, which is a true emergency condition that has a very high mortality rate. Heatstroke Heat stroke is a true medical emergency in which body temperature may exceed 104° F (40° C). It has a high mortality rate if not treated in a timely manner. The victim's thermoregulation mechanisms fail and cannot adjust for a critical elevation in body temperature. If the condition is not treated or the patient does not respond to treatment, organ dysfunction and death can result. Exertional heat stroke has a sudden onset and is often the result of strenuous physical activity (especially when wearing too heavy clothing) in hot, humid conditions. Classic heat stroke, also referred to as nonexertional heat stroke, occurs over a period of time as a result of chronic exposure to a hot, humid environment such as living in a home without air conditioning in the high heat of the summer. Victims of heat stroke have a profoundly elevated body temperature (above 104° F [40° C]). Although the patient's skin is hot and dry, the presence of sweating does not rule out heat stroke—people with heat stroke may continue to perspire. Mental status changes occur as a result of thermal injury to the brain and are the hallmark findings in heat stroke. Symptoms can include confusion, bizarre behavior, seizures, or even coma (Chart 9-2). The patient may have hypotension, tachycardia, and tachypnea. Cardiac troponin I (cTnI) is frequently elevated during nonexertional heat-related illnesses; research indicates that this test can be used to cost effectively predict severity and organ damage at the beginning of heat stroke, even in a remote setting • Vital sign changes, including: • Hypotension • Tachycardia • Tachypnea (increased respiratory rate) • Electrolyte imbalances, especially sodium and potassium • Decreased renal function (oliguria) • Coagulopathy (abnormal clotting) • Pulmonary edema (crackles) • Body temperature more than 104° F (40° C) • Hot and dry skin; may or may not perspire • Mental status changes such as: • Acute confusion • Bizarre behavior • Anxiety • Loss of coordination • Hallucinations • Agitation • Seizures • Coma Emergency Care of the Patient With Heat Stroke: Restoring Thermoregulation At the Scene • Ensure a patent airway. • Remove the patient from the hot environment (into air-conditioning or into the shade). • Remove the patient's clothing. • Pour or spray cold water on the patient's body and scalp. • Fan the patient (not only the person providing care, but all surrounding people should fan the patient with newspapers or whatever is available). • If ice is available, place ice in cloth or bags and position the packs on the patient's scalp, in the groin area, behind the neck, and in the armpits. • Contact emergency medical services to transport the patient to the emergency department. At the Hospital • Give oxygen by mask or nasal cannula; be prepared for endotracheal intubation. • Start at least one IV with a large-bore needle or cannula. • Administer normal saline (0.9% sodium chloride) as prescribed, using cooled solutions if available. • Use a cooling blanket. • Do not give aspirin or any other antipyretics. • Insert a rectal probe to measure core body temperature continuously or use a rectal thermometer and assess temperature every 15 minutes. • Insert an indwelling urinary drainage catheter. • Monitor vital signs frequently as clinically indicated. • Obtain baseline laboratory tests as quickly as possible: serum electrolytes, cardiac enzymes, liver enzymes, and complete blood count (CBC). • Assess arterial blood gases. • Administer muscle relaxants (benzodiazepines) if the patient begins to shiver. • Measure urine output and specific gravity to determine fluid needs. • Stop cooling interventions when core body temperature is reduced to 102° F (39° C). • Obtain urinalysis and monitor urine output. Heat Stroke • Heat stroke is a true medical emergency in which the victim's thermoregulation (heat regulatory) mechanisms fail and cannot adjust for a critical elevation in body temperature. Body temperature may exceed 104° F and result in organ dysfunction and death if not treated immediately and aggressively. • Exertional heat stroke has a sudden onset and is often the result of strenuous physical activity in hot, humid conditions. • Classic heat stroke, also referred to as non-exertional heat stroke, occurs over a period of time as a result of chronic exposure to a hot, humid environment. It generally affects ill and older adults. Hyperthyroidism Infection: bacterial/viral Malignant hyperthermia Thyroid storm

SURGICAL SCRUBBING

Broad-spectrum, surgical antimicrobial solution Vigorous rubbing that creates friction used from fingertips to elbow Scrub continues for 3 to 5 min

Acid-Base Regulation

Buffer systems Respiratory mechanisms Renal mechanisms

Infection Control

CDC recommends aseptic preparation and technique including: Hand hygiene Clip hair; do not shave Ensure skin is clean Wear gloves Prepare skin with 70% alcohol or chlorhexidine

Catheter-Related Bloodstream Infection (CR-BSI)

CR-BSI one of several preventable hospital-acquired infections (Institute for Healthcare Improvement) www.ihi.org

Electrolyte Imbalance

Can occur in healthy people as result of changes in fluid intake and output Can be life threatening if severe; can occur in any setting

Scope of errors - Latent

Care coordination Documentation Electronic records

Pain Mechanisms and Pathways Transmission

Carrying pain information to brain Incoming pain activates T cells

EXAGGERATED IMMUNE RESPONSE / CONSEQUENCES 2

Chronic body-wide system disease Autoimmune disorder occurs when immune system attacks and destroys healthy cells of the "self" following a breakdown of what has ben termed "self tolerance" 80 autoimmune disorders identified - may have more than 1 simultaneously 3 potential outcomes for autoimmune disorder Destruction of body tissue Abnormal organ growth Change in organ function

OLDER ADULTS: CONSIDERATIONS FOR PREOPERATIVE CARE preopxl

Chronic illness Malnutrition Impaired self-care ability Allergies Inadequate support systems

Systemic Complications of IV Therapy

Circulatory overload Speed shock Allergic reaction Catheter embolism

MAINTAINING A CLEAN ENVIRONMENT

Clean spills and dirty surfaces promptly Remove pathogens through chemical means (disinfect) Remove clutter Consider supplies brought to the client room as contaminated Consider items from the client's home as contaminated

NURSING INTERVENTIONS RELATED TO WOUND CARE

Cleansing/irrigating *Caring for a drainage device* Jackson-Pratt; Hemovac *Débriding a wound* Sharp Mechanical Chemical Enzymatic Autolysis

Fluid Balance

Closely linked to/affected by electrolyte concentrations Fluid intake Fluid loss Minimum urine amount needed to excrete toxic waste products = 400 to 600 mL Insensible water loss - through skin, lungs, stool

Exemplars of Pain - Neuropathic Pain Centrally-Generated Pain

Complex regional pain syndrome Pain following spinal cord injury Phantom pain as a result of peripheral nerve damage Post-stroke pain

Safety hazards in the home - Fires

Cooking fires, smoke inhalation, home heating equipment Prevention: -Smoke alarms -Caution with cigarettes -Fire extinguisher -No candles unattended -Safety with holiday lights -Care with electrical cords

visceral pain "deep pain" Nociceptive pain visceralxl

Crohn's disease Irritable bowel syndrome Organ-involved cancer pain Pancreatitis Ulcerative colitis appendicitis Visceral pain is caused by the stimulation of deep internal pain receptors- Organs and the linings of the body cavities Poorly localized Diffuse, deep cramping or pressure, sharp, stabbing source of pain: Chest tubes, abdominal tubes and drains, bladder distention or spasms, intestinal distention ischemic inflammation, not localized, deep squeeze, pressure aching *ex* heart, lung, abdominal, pelvic pain, ibs, chrons, appendicitis, gall stones, pancreatitis, cranium, thorax,Menstrual cramps, Labor pains (uterine contractions) , gastrointestinal infections, bowel disorders, and organ cancers all produce visceral pain. liver metastases, colitis *meds* Tylenol (analgesics) (antidepressant) maoi, ssri, acupuncture (alt) book Visceral pain may vary from local, achy discomfort to more widespread, intermittent, and crampy pain. The description of the quality and extent of the pain often serves as a strong clue to the cause.

Assistive devices

Crutches Canes Walkers Wheelchairs Prostheses

Surgical interventions

Curative versus palliative

PATIENT - CENTERED COLLABORATIVE CARE Assessment preopxl

Current medications - complementary or alternative herbs Medical history - Family history Cardiovascular Pulmonary Previous surgical procedures and anesthesia Pain control Management of nausea / vomiting Blood donation Discharge planning - support system

Clinical Significance: Edema

Develops with changes in normal hydrostatic pressure differences Pitting edema in a patient with heart failure.

FACTORS THAT INCREASE INFECTION RISK

Developmental stage- Children frequently begin to have more infections when they start interacting with people outside their family (e.g., when they begin day care or start school). This is a natural process known as acquiring active immunity. Older adults are also susceptible hosts because the immune response declines with aging. Skin, a primary defense, becomes less elastic and more prone to breakdown with aging. Elders also tend to be less active, and their nutrition may be inadequate. Breaks in the skin- A break in the skin, whether caused by a surgical procedure, skin breakdown, an insect bite, or insertion of an intravenous device, creates a portal of entry for infectious microorganisms Illness/injury, chronic disease- Recuperation from infection or injury lim- its the physical resources available to combat a new pathogen. Smoking, substance abuse Tobacco Use. Smoking is a major risk factor for pul- monary infections. Smoking interferes with normal respira- tory functioning, including the ability to move the chest, cough, sneeze, or have full air exchange. Chemicals in tobacco paralyze cilia; thus, secretions pool in the lower airways, creat- ing a hospitable environment for bacterial growth. People exposed chronically to secondhand smoke (e.g., bartenders, children of smokers) are also at increased risk for infection. Substance Abuse. Alcohol curbs hunger. As a result, many chronic alcohol users do not consume an adequate diet. Alcohol is also toxic to the liver and to the cells lining the intes- tinal mucosa. Inhaled substances, such as marijuana and cocaine, affect respiratory cilia in a manner similar to tobacco. Any substances that affect orientation and energy level will diminish food intake, activity, rest, and hygiene—factors that support host defenses. Injecting substances leads to breaks in skin integrity, further increasing the risk of infection. Multiple sex partners- The more sexual partners a person has, the higher his risk of acquiring a sexually transmit- ted infection (STI). Medications that inhibit/decrease immune response--Some medications are given for the purpose of reducing the immune response, for example, to patients receiving organ or tissue transplants. For most patients, though, decreased immunity is an unwanted side effect of treatment. Even common medications, such as nonsteroidal anti-inflammatory agents (NSAIDs) (e.g., ibuprofen), decrease the immune response. As a side effect, some medications, such as chemotherapeutic agents, decrease the production of white blood cells or cause the cells produced to be abnormal. Even antibiotics can increase the risk for infection. For example, an antibiotic given for a respiratory infection may cause a vaginal yeast infection because it destroys colonies of normal vaginal flora, allowing the harmful microbes to thrive. These are considered *superinfections* (opportunistic growth of harmful transient pathogens that are normally kept in check), and some can be extremely challenging to treat. Nursing/medical procedures--Several procedures are associated with an increased risk of infection. For example, urinary catheterization may injure the fragile urethral mucosa, provide a direct pathway for pathogens into the bladder, and prevent the normal flushing of the urethra. Also, an IV line inserted to infuse an antibiotic may serve as a portal of entry for pathogens.

ATI - NCLEX - QSEN Safe and Effective Care Environment

Differentiate among the various types and purposes of surgery. Examine individual patient factors for potential threats to safety, especially for older adults. Use appropriate patient identifiers when providing instruction, administering drugs, marking surgical sites, and performing any procedure. Verify that the patient has given informed consent for the surgical procedure and that the presurgical checklist is complete and accurate. Identify patient conditions or issues that need to be communicated to other members of the surgical and postoperative teams.

ACE Inhibitors

Disrupt renin-angiotensin II pathway by reducing amount of ACE produced With less angiotensin II, less vasoconstriction and reduced peripheral resistance Greater excretion of water and sodium in urine By locking angiotensin II receptors, blood pressure lowers

Seizure precautions

Do not attempt to insert anything into mouth of client during seizure bite-stick, airway instead remove objects that could lead to client harm Do not attempt to restrain or limit movement during a seizure use oxygen mask after seizure activity has ceased Keep suction and oxygen equipment near bed Explain purpose of seizure precautions Pad head and side-rails of bed with blankets and linens to prevent injury

Who draws an ABG?

Doctor respiratory therapist anestielogist phlabomist *nurse interprets*

Bisphosphonates: Alendronate (Fosamax)

Dose: 40 mg once daily for three months MUST be taken on an empty stomach with 6 to 8 ounces of water It may be taken any time during the day, as long as there is no food for 30 minutes after the dose Do NOT lie down for at least 30 minutes after taking the dose

Post-surgical patient education: Diet dietxl

Drink at least 6 to 8 glasses of fluid daily unless otherwise ordered (water is beneficial) Adhere to any diet restrictions (provide individualized instruction according to diet) Eat well-balanced meals that are high in vitamin C and protein to aid wound healing

APPLYING EVIDENCE-BASED CONCEPT

EBP* Effectiveness of care improves when research guides care EBP in nursing Process of moving research into practice Improves patient care

Near miss

Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance

LAWSxl

Established to protect society Nursing practice guided by legal principles Purpose of laws Protect clients/society Define scope of nursing practice Identify minimum level of care to be provided

COMMON MALPRACTICE CLAIMS

Failure to assess and diagnose Failure to plan Failure to implement a plan of care Failure to evaluate

Negligence

Failure to perform as a reasonable, prudent person would Failure to follow standards of practice No intent to harm is present

CRIMINAL LAW

Federal or state government prosecutes Offense against society Can lead to a fine, imprisonment, or death Misdemeanor Minor crime; DUI Felony *Homicide*

HCO3 (BICARBONATE)

HCO3 is the KIDNEY chemical (think metabolic) Normal HCO3 range is 22 to 26 mmHg If the HCO3 is less than 22 = acidosis If the HCO3 is greater than 26 = alkalosis

ETHICAL DECISION MAKING

Health care decisions that present an ethical dilemma are not made by individuals alone. Health care organization's compliance officer and compliance committee are charged with the responsibility of ensuring that ethical standards are met. Institutions have reporting mechanisms for unethical behaviors.

COMMUNITY-BASED CARE

Home care management Teaching for self management Health care resources

Interventions: Metabolic Acidosis

Hydration *Drug therapy* Bi A Bicarbonate (only with low serum level) Insulin to treat DKA Antidiarrheals

PAIN

Interventions: Drug therapy Complementary & alternative therapies: Positioning Massage Relaxation/diversion techniques

Hyperacute Rejection

Hyperacute rejection begins immediately on transplantation and is a result of antigen-antibody complexes that form in the blood vessels of the transplanted organ (Abbas et al., 2015). The recipient's blood has pre-existing antibodies to the antigens (including blood group antigens) present in the donated organ. The antigen-antibody complexes adhere to the lining of blood vessels and activate complement, which triggers small blood clots to form throughout the new organ. Widespread clotting occludes blood vessels and leads to ischemic necrosis, inflammation with phagocytosis of the necrotic blood vessels, and release of enzymes into the new organ. The enzymes cause massive cellular destruction within the transplanted organ. Hyperacute rejection occurs mostly in transplanted kidneys but is less common now with better HLA matching. Symptoms of rejection are apparent within minutes of attachment of the donated organ to the recipient's blood supply. The process usually cannot be stopped once it has started, and the rejected organ is removed as soon as hyperacute rejection is diagnosed. Acute Rejection Acute rejection first occurs within 1 week to 3 months after transplantation and sporadically after that as a result of two mechanisms. The first mechanism is antibody mediated and results in vasculitis within the transplanted organ. This reaction differs from hyperacute rejection in that blood vessel necrosis (not occlusion) leads to organ destruction. The second mechanism is cellular. The recipient's cytotoxic/cytolytic T-cells and NK cells enter the transplanted organ through the blood, penetrate the organ cells, start an inflammatory response, and cause lysis of the organ cells. Diagnosis of acute rejection is made by laboratory tests that show impaired function of the donated organ and by biopsy of the donated organ. Symptoms of acute rejection vary with each patient and with the specific organ transplanted. For example, when acute rejection occurs in a transplanted kidney, the patient usually has some tenderness in the kidney area and may have other general symptoms of inflammation. An episode of acute rejection after solid organ transplantation does not automatically mean that the patient will lose the new organ. Drug management of the recipient's immune responses at this time may limit the damage to the organ and allow the graft to be maintained. Chronic Rejection The origin of chronic rejection is related to chronic inflammation and scarring. The smooth muscles of arteries overgrow and occlude these vessels (Abbas et al., 2015). The organ tissues are replaced with fibrotic, scarlike tissue, and function is reduced in proportion to the amount of scarring. This type of reaction is long-standing and occurs continuously as a response to chronic ischemia caused by blood vessel injury. The results of chronic rejection are unique to different transplanted organs. For example, in transplanted lungs chronic rejection thickens small airways. In transplanted livers chronic rejection destroys bile ducts. In transplanted hearts this process is called accelerated graft atherosclerosis (AGA) and is the major cause of death in patients who have survived 1 or more years after heart transplantation. Although good control over the recipient's immune function can delay this type of rejection, the process probably occurs to some degree with all transplanted solid organs obtained from donors who are not identical siblings of the recipients. Because the fibrotic changes are permanent, there is no cure for chronic graft rejection. When the fibrosis increases to the extent that the transplanted organ can no longer function, the only recourse is retransplantation. Management of Transplant Rejection Rejection of transplanted solid organs involves all three components of IMMUNITY, although cell-mediated immune (CMI) responses contribute the most to the rejection process. Maintenance therapy is the continuous immunosuppression used after a solid organ transplant. The drugs used for routine therapy after solid organ transplantation are combinations of a calcineurin inhibitor, a corticosteroid, and an antiproliferative agent Corticosteroids cause a general immunosuppression, which leave the patient at greater risk for infection. Although corticosteroids remain a part of therapy, the dosages are lower than in the past. Calcineurin inhibitors and antiproliferative agents are part of "selective immunosuppressant" therapy These drugs more specifically target immunity components that are responsible for rejection. Which drugs are used depends on the transplant type and other patient-specific conditions. These are all oral agents and must be taken for the life of the transplanted organ. All are immunosuppressive to some degree, and the dosage is adjusted to the immune response of each patient. Treatment with these agents increases the risk for bacterial and fungal infections and for cancer development. Rescue therapy is used to treat acute rejection episodes. The drug categories for this purpose are the monoclonal and polyclonal antibodies Approved drugs used to manage transplant rejection are Corticosteroids Broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression Prednisone (Deltasone) Oral Hypertension Hyperlipidemia Osteoporosis Weight gain Cushingoid appearance Opportunistic infection Glaucoma GI ulcer formation Hyperglycemia ---- Calcineurin Inhibitors—The inhibition of calcineurin stops the production and secretion of IL-2, which then prevents the activation of lymphocytes involved in transplant rejection Cyclosporine (Sandimmune, Neoral, Gengraf) Oral Nephrotoxic Hypertension Tremor Coronary artery disease Hirsutism Gingival hyperplasia Opportunistic infections Malignancies Hyperuricemia Hepatoxicity ---- Tacrolimus (Astagraf XL, HECORIA, Prograf) -Oral, Nephrotoxic Hypertension Hyperkalemia Hypomagnesemia Hyperglycemia Opportunistic infections Malignancies ----

FLUID, ELECTROLYTE, & ACID-BASE BALANCE

I & O Hydration status IV fluids Vomitus Urine Wound drainage NG tube drainage Acid-base balance

Remember...

If osmolarity is >600 mOsm/L, best infused in central circulation where greater low provides adequate hemodilution TPN has osmolarity >1400 mOsm/L TPN should never be infused in peripheral circulation—can damage blood cells and endothelial lining of vein

older adult factors affecting safety.. test neglect

caregiver failure to provide basic needs

IMPLEMENTING SURGICAL ASEPSIS

Includes Creation of a sterile environment Use of sterile equipment/supplies Sterilization of reusable supplies Surgical hand scrub Surgical attire Sterile gloves Sterile field Use of sterile technique

NURSING RESPONSE: INFLAMMATION

Imbalanced nutrition (less than body requirements) Caloric intake and protein Oxygenation Enteral nutrition

POTENTIAL FOR HYPOXEMIA

Highest incidence occurs on 2nd postoperative day Interventions: -Airway maintenance -Monitor (Spo2) -Semi-Fowler's position -Oxygen therapy, breathing exercises -Mobilization as soon as possible

Acidosis: Patient-Centered Collaborative Care

History CNS changes *Neuromuscular changes* ↓ muscle tone, deep tendon reflexes *Cardiovascular changes* Early: ↑ heart rate, cardiac output changes Worsening: hyperkalemia; ↓ heart rate; T wave peaked and QRS widened; weak peripheral pulses; hypotension

PATIENT - CENTERED COLLABORATIVE CARE Assessment

History - general health - type of surgery planned Knowledge and understanding of events during peri-op period Age - older patients Allergies Drugs and substance use Tobacco, alcohol, illicit substances Current medications - complementary or alternative herbs Medical history - Family history Previous surgical procedures and anesthesia Pain control Management of nausea / vomiting Blood donation Discharge planning - support system ashlii-Pre-op assessment includes: Current medications - complementary or alternative -herbs -OTC meds Medical history & Family history -Cardiovascular -Pulmonary Previous surgical procedures and anesthesia -Pain control -Management of nausea / vomiting Blood donation Discharge planning - support system

Sources of Acids

Incomplete breakdown of glucose Destruction of cells Bicarbonate *Normal ratio of carbonic acid to bicarbonate is 1:20.

PHYSICAL & EMOTIONAL SIGNS OF ACUTE PAIN painxl

Increased pulse and blood pressure Increased respiratory rate Profuse sweating Restlessness Confusion (older adults) facial expression. Wincing, moaning, crying children gets pain meds around the clock for a few days then go to prn pain scale

individual rf

Individuals who are unable to communicate are at risk for experiencing pain and have poor pain management.

Nursing Diagnosis

Ineffective coping Fear and anxiety Spiritual distress Deficient diversional activity

Post-op: NG tube drainage

Inserted during surgery to: Decompress and drain stomach Promote GI rest Allow lower GI tract to heal Provide enteral feeding route Monitor any gastric bleeding Prevent intestinal obstruction **Assess drained material every 8 hr

RELATED TERMS

Inference Interpretation Decision Clinical reasoning Critical thinking

Local Complications of IV Therapy

Infiltration Phlebitis and post-infusion phlebitis Thrombosis Thrombophlebitis Ecchymosis and hematoma Site infection Venous spasm Nerve damage

POTENTIAL FOR INFECTION Interventions include:

Interventions include: Plastic adhesive drape Skin closures, sutures and staples, nonabsorbable sutures Insertion of drains Application of dressing Patient transfer from OR table to stretcher

SURGICAL SETTINGS

Inpatient -Same day admission • More patients are admitted as inpatients after a procedure than preoperatively. Outpatient -Same day surgery • The terms outpatient and ambulatory refer to a patient who goes to the surgical area the day of the surgery and returns home on the same day. • Hospital-based ambulatory surgical centers, freestanding surgical centers, physicians' offices, and ambulatory care centers are common settings. • Two-thirds of all surgical procedures in North America are performed in outpatient ambulatory centers. Ambulatory -Free standing centers -Physician offices -Ambulatory care centers

Delegation

Initial assessment of a wound, as well as ongoing evaluation of a wound that requires treatment, must be done by the reg- istered nurse. You may delegate to nursing assistive person- nel (NAP) inspection of the skin for evidence of skin break- down. Instruct the NAP to notify you of redness, tissue warmth, or drainage. You may also delegate turning and position changes to the NAP. Turning and movement prevent tissue damage from ischemia, thereby preventing pressure ulcers. You may delegate turning and position changes to the NAP. Turning and movement prevent tissue damage from ischemia, thereby preventing pressure ulcers Taping a Dressing:As a nurse, you are responsible for assessing the wound and evaluating interventions. However, this procedure may be del- egated to nursing assistive personnel (NAP). Placing Skin Closure: This procedure itself may be delegated to a NAP unless it is a new wound requiring sterile technique. Assessment of the incision line or wound is a licensed professional's responsibil- ity and should not be delegated. Applying Binders/ Applying Bandages: This procedure itself may be delegated to a NAP.Assessment of the incision line or wound is a licensed professional's responsibility and should not be delegated. Removing Sutures and Staples: This procedure itself may be delegated to a NAP who has been trained in the skill. Assessment of the incision line or wound is a licensed professional's responsibility and should not be delegated. Shortening a Wound Drain/ Emptying a Closed-Wound Drainage System: This procedure may be delegated to a NAP who has been ap- propriately trained in the skill.Assessment of the incision line or wound is a licensed professional's responsibility and should not be delegated. NOOOOooo delegation Removing and Applying Dry Dressings: This procedure requires knowledge of wound healing. It should be performed by a registered nurse. Do not delegate this skill. also, do not delegate, Removing and Applying Wet-to-Damp Dressings no dele--As a nurse, you are responsible for assessing the wound and evaluating interventions.You should not delegate application of a negative pressure wound therapy device to a NAP. How- ever, you may ask the NAP to report to you any changes in the wound dressing, pressure in the unit, or alarm Applying and Removing a Transparent Film Dressing: Because assessment of the wound and knowledge of clean technique are important, you should not delegate this procedure to a NAP. Obtaining a Needle Aspiration Culture From a Wound is an invasive procedure that requires knowledge of wound healing. It should be performed by a registered nurse or an LPN trained in the correct procedure. Do not delegate this skill to nursing assistive personnel (NAP) -Performing a Sterile Wound Irrigation: This is an invasive, sterile procedure that requires nursing assessment, judgment, evaluation, and teaching during the pro- cedure. It requires knowledge of wound healing and should be performed by a registered nurse. Do not delegate this skill to nursing assistive personnel (NAP). Turning and Repositioning. Reposition the patient at least every 2 hours However, patients with very fragile skin or little subcutaneous tissue might need to be repositioned more frequently. At-risk individuals who are chair bound should be repositioned every hour or taught to shift their weight every 15 minutes. Place a turning schedule at the bedside so that all caregivers can participate in the prevention strategy. For an example of a patient turning schedule, Inspect Skin Daily Skin care begins with regular inspection of the skin—at least daily for patients at risk—and usually every 8 to 12 hours for institutionalized patients. You must have adequate light to detect subtle, early skin changes. Use a penlight to inspect bony prominences if direct sunlight is not available. Be sure to check pressure points for erythema, tenderness, or edema. Instruct family members and caregivers about the impor- tance of early detection of skin problems. In obese patients, skin damage can occur under breasts, abdominal folds, or anywhere skin contacts skin. Use the "rule of 30" to guide your positioning: Elevate the head of the bed 30° or less, and when the patient is on her side, position the patient at a 30° angle to avoid direct pres- sure on the trochanter. If the head of the bed is elevated more than 30°, limit the time in this position to minimize pressure and shear. To protect skin during turning or repositioning, use lift devices or drawsheets, heel and elbow protectors, or sleeves and stockings. Never drag a patient when pulling her up in bed. Support surfaces include specialty mattresses, integrated bed systems, mattress replacements, and overlays. These products may consist of air, gel, foam, or water, and are available in various sizes and shapes for beds, chairs, exam tables, and operating room tables

TORTS AND NURSING PRACTICE Quasi-Intentional Torts contd'

Intentional Torts Assault and battery Performing a procedure without consent False imprisonment Restraining a client against her/his will Fraud Failing to provide essential information for informed consent Invasion of privacy Breach of confidentiality- HIPAA

MAJOR FEATURES OF EBP

Interdisciplinary Evidence summary Translation to clinical practice guidelines Provider and organizational factors guide integration Evaluation Steps in conducting systematic review Formulate question Locate relevant studies Select and appraise studies Summarize and synthesize results Interpret findings Update regularly Review of literature Sources of evidence for clinical practice Sources of evidence summaries Clinical practice guidelines Priority health topics ashlii Interdisciplinary Evidence summary Translation to clinical practice guidelines Provider and organizational factors guide integration Evaluation

Alternative Sites for Infusion

Intra-arterial therapy Intraperitoneal (IP) infusion Subcutaneous infusion Intraspinal infusion Intraosseous therapy

nursing responsibilities during preoperativexl period preopxl

Interview: current health status, allergies, medication currently taking, previous surgical experiences, mental status, understanding of surgical procedure and anesthesia, smoking habit, alcohol and drug use, coping strategies, social resources, and cultural considerations Arranging for preadmission testing, consultations, and education about postsurgical recovery Scheduling appropriate prescribed laboratory tests, electrocardiogram, x-rays Ensuring reports are available on chart Reporting to surgeon or anesthesiologist any pertinent abnormalities Asking client if arrangements for autologous or directed blood donation (family/friends) have been made; if so, attach pertinent lab requisitions NCLEX® Day of surgery: after appropriate identification of client, verify completion of paperwork and secure valuables; if procedure is being performed on an outpatient basis, verify transportation home; then complete these activities: Determine client's cognitive understanding of procedure and obtain signed *informed consent* form; ensure consent is obtained before administering premedication with sedative effects; *some agencies have client mark limb that will be operated on, if appropriate* Perform a physical assessment and record vital signs (VS) Implement preoperative teaching for postoperative care *Physical preparation: may include skin preparation, antiembolism stockings, catheterization, and starting an intravenous (IV) infusion * Complete preoperative checklist: client wears identification and allergy bracelets; consents are signed for anesthesia, surgical procedure, and for blood transfusion; limb disposal or sterilization procedure, if appropriate; history and physical exam, consultations, lab and diagnostic test results are in record; assist client to remove clothing, jewelry, dentures, and other articles and to don hospital gown If client refuses to remove wedding band, tape in place and notify operating room personnel; leave eyeglasses in place if consistent with hospital policy; keep hearing aid(s) in place Have client void before administering any preoperative medications that affect level of consciousness (narcotics, sedatives); after medicating client, raise side rails as per agency policy and ensure call bell is in reach watkins: Get IV started, bld work, meds, everything is ready to go, we check all our boxes on pre-op list, now were going to intra-op w/ another nurse o Preoperative imaging studies are based on patient need, medical history, and the nature of the surgical procedure. o An electrocardiogram may be required for all patients older than a specific age who are to have general anesthesia, or for those with a history of or risk for cardiac disease. o Any abnormal assessment findings are reported to the surgeon and anesthesiology personnel. o Psychosocial assessment determines the patient's level of anxiety, coping ability, and support systems. o Most patients have some degree of anxiety before surgery, while others may be fearful after surgery. o Reactions vary according to the type of surgery, perceived effects of the surgery, and potential outcomes.

EXTERNAL PNEUMATIC COMPRESSION DEVICES

Kendall SCD machine, sleeves, and TED stockings. Venodyne pneumatic compression system. Flowtron DVT calf garments.

NURSES AS ETHICAL AGENTS

Know the difference between right and wrong Understand abstract moral principles Apply moral principles in decision making Weigh alternatives; plan to achieve goals Decide and choose freely Act according to choice

EVIDENCE-BASED PRACTICE (EBP)

Knowledge bases for clinical decisions Definition: -Research evidence -Clinical expertise -Patient preference Sociopolitical forces in quality of care EBP is using the best research and proven assessments and treatments in our day-to-day clinical care and service delivery. Why it is important to patient care: The patient gets up-to-date care that has already been done in studies.

Nursing Diagnoses - Surgery

Knowledge deficit (surgical experience) related to unfamiliarity with surgical procedures and preparation. Anxiety related to new or unknown experiences, possibility pain, and possible surgical outcomes.

**safety patient harm & errors generally occur as a result of

LLL LIE LIE Lack of clear or adequate communication lack of attentiveness & patient monitoring lack of clinical judgement lack of mandatory reporting inadequate measures to prevent health complication errors in medication administration lack of professional accountability n pt advocacy inability to carry out interventions in an appropriate & timely manner errors in interpreting authorized provider prescriptions

COMMON DIAGNOSTIC TESTS

Laboratory tests CBC WBC with differential CRP ESR Serologic tests to detect specific antibodies or viruses Radiographic studies MRI CAT PET scans colonoscopy -------------------- Risk for infection: Lab values Assessment of site Monitoring Documentation Standard precautions

Hemodialysis Catheter

Large lumens accommodate hemodialysis or pheresis procedure (harvests specific blood cells) Catheter-related bloodstream infections (CR-BSI), vein thrombosis are common problems Do not use for administering other fluids/medications (except in emergency)

SCOPE OF CONCEPT

Legislation is the process of introducing, adopting, changing, or repealing law. ---- Regulation is the process of putting laws into action through the establishment of rules. ---- Litigation is the process of seeking help through the courts to address a perceived wrong.

Peripherally Inserted Central Catheter (PICC)

Length of 18 to 29 inches (45 to 72 cm) Chest x-ray determines placement *Power ICCs used for contrast * injection; can also attach to transducers for CVP monitoring

CONSEQUENCES OF AN EXCESSIVE OR INEFFECTIVE INFLAMMATORY RESPONSE

Local tissue damage from compression Development of chronic inflammation Systemic pathology: Atherosclerosis Chronic renal disease Neurologic disorders ---------------------------- NEUROLOGIC SYSTEM Cerebral functioning Motor and sensory assessment after epidural or spinal anesthesia

CONSEQUENCES OF AN EXCESSIVE OR INEFFECTIVE INFLAMMATORY RESPONSE

Local tissue damage from compression Development of chronic inflammation Systemic pathology: Atherosclerosis Chronic renal disease Neurologic disorders

Risk for falls - Goals/outcomes

Long term: -Client will not experience any falls during stay -Client will make necessary physical changes in environment to ensure increased safety within first week of returning home Short term: -Client will identify factors that increase potential for injury by the end of the day -Client will remain free of falls per shift

REVIEW OF IMMUNE SYSTEM ANATOMY AND PHYSIOLOGY

Lymphoid organs Lymphoid cells Immune response Types of immunity

REVIEW OF IMMUNE SYSTEM ANATOMY AND PHYSIOLOGY

Lymphoid tissues Leukocytes (WBCs) Neutrophils Monocytes Eosinophils Basophils Lymphocytes Immune response Types of immunity • The human body has many protective systems that promote homeostasis. • Physiologic mechanisms provide structural and functional defenses that maintain IMMUNITY and protect people from stressors such as infection. • When these mechanisms fail to work properly or are overcome with microbes, infection can result. • Infections and infectious diseases have been the major cause of millions of deaths worldwide for centuries.

REVIEW OF IMMUNE RESPONSE 1

Major histocompatibility complex (MHC) Surface proteins Divided into 2 classes Class I - found on all cells Class II - on specialized cells Function - to differentiate cells of the "self/host" from foreign protein. "non-self are capable of initiating an immune response Organs involved with immune response Are spread throughout the body - termed lymphoid organs Include: bone marrow, thymus gland, spleen, tonsils, adenoids, and appendix Lymphocytes are formed, grow, mature, and released into the body from these organs

Closing....Keys to success

Make sure that you have reviewed your lecture notes, PPT, handouts, case studies Make sure you have reviewed the objectives at the beginning of the chapter. Make sure to have reviewed the key points at the end of the chapter. Make sure that you have reviewed the ATI skill modules

COMPLICATIONS FROM GENERAL ANESTHESIA generalxl

Malignant hyperthermia Overdose Unrecognized hypoventilation Problems with specific anesthetic agents Intubation problems

Immobility related to nutrition

May be unable to purchase, prepare, and/or consume adequate nutrition Individuals with inadequate nutrition may have decreased mobility because of excessive fatigue

Immobility related to impairments in intracranial regulation

May become immobile as a result of unsteadiness and imbalance

Immobility related to impairments in gas exchange

May become immobile because of excessive fatigue. Are at risk of developing complications associated with gas exchange, such as stasis pneumonia.

Administering iv Medications

Medication safety Rapid therapeutic effect Never assume IV administration is same as giving that drug by other routes Prescribing infusion therapy

Tunneled Central Venous Catheter

Portion lies in subcutaneous tunnel Used for frequent and long-term infusion therapy Has cuff of antibiotic-containing material to help reduce infection

Skeletal Disease: Osteomalacia

Metabolic disease that causes poor & delayed mineralization of the bone cells in mature bones Main cause is a Vitamin D deficiency At risk: diet deficient in vitamin D, low endogenous production of vitamin D (lack of sunlight exposure), malabsorption, renal tubule disease, anticonvulsant therapy, liver, pancreatic, and biliary system disease S&S: generalized skeletal pain & tenderness without a history of injury (hips are the most common site), reluctant to ambulate, low back pain, pain in the ribs, feet, & other areas, waddling gait Diagnostic Procedures: serum calcium, phosphate, vitamin D, BUN, creatinine, bone densitometry x-rays Treatment: Prevention - sunlight exposure & vitamin D supplements Diagnosed - ergocalciferol and calcium is prescribed

Mobility

Mobility is a state or quality of being mobile or movable. Other terms: Immobility Disuse syndrome Deconditioned

COLLABORATIVE CARE: IMMUNODEFICIENCY

Monitor immune function Nutrition Prevent opportunistic infections Monitor and treat opportunistic infections Drug therapy

IMPLEMENTING DIETARY RESTRICTIONS

NPO: Patient not to ingest anything by mouth for 6 to 8 hours before surgery: -Decreases risk for aspiration -Give patients written/oral directions to stress adherence -Surgery can be canceled if instructions not followed

Side Effects of Opioids

Nausea/vomiting • Use a multimodal antiemetic preventive approach (e.g., dexamethasone plus ondansetron in moderate- to high-risk patients). • Assess cause of nausea and eliminate contributing factors if possible. • Reduce opioid dose if possible. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses. • Treat with antiemetic drug as prescribed. • Consider switching to another opioid for unresolved N/V. Constipation • Assess previous bowel habits. • Keep a record of bowel movements. • Remind patients that tolerance to this side effect does not develop, so a preventive approach must be used; administer a stool softener plus mild stimulant laxative for duration of opioid therapy; do not give bulk laxatives because these can result in obstruction in some patients. • Provide privacy, encourage adequate fluids and activity, and give foods high in roughage. • If ineffective, try suppository or Fleet's enema. • For long-term opioid-induced constipation (OIC) in patients with chronic pain, drug therapy may be used (e.g., lubiprostone [Amitiza], methylnaltrexone [Relistor]). Sedation • Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy. • Use a simple sedation scale to monitor for unwanted sedation (see Table 4-8). • If excessive sedation is detected, reduce opioid dose to prevent respiratory depression. • Eliminate unnecessary sedating drugs such as antihistamines, anxiolytics, muscle relaxants, and hypnotics. If it is necessary to administer these drugs during opioid therapy, monitor sedation and respiratory status closely. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses. • Be aware that stimulants such as caffeine may counteract opioid-induced sedation. • Consider switching to another opioid for unresolved excessive sedation during long-term opioid therapy. Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If undetected or left untreated, excessive sedation can progress to clinically significant respiratory depression. Many of the drugs used to treat opioid side effects are sedating, such as the antihistamines (diphenhydramine) for pruritus and the antiemetics promethazine (Phenergan) and hydroxyzine (Vistaril) for nausea. It is important to recognize that administration of these drugs together has an additive sedating effect. If administered, closely monitor for sedation and assess respiratory status frequently. Respiratory depression • Be aware that counting respiratory rate alone does not constitute a comprehensive respiratory assessment. Proper assessment of respiratory status includes observing the rise and fall of the patient's chest to determine depth and quality in addition to counting respiratory rate for 60 seconds. • Recognize that snoring is respiratory obstruction and an ominous sign (see text). • Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy (see Sedation section). • Stop opioid administration immediately for clinically significant respiratory depression, stay with patient, continue attempts to arouse patient, support respirations, call for help (consider Rapid Response Team or Code Blue), and consider giving naloxone. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses. Preventing clinically significant opioid-induced respiratory depression begins with administering the lowest effective opioid dose (multimodal analgesia with a nonopioid foundation), careful titration, and closely monitoring sedation and respiratory status throughout therapy. Unless the patient is at the end of life, promptly reduce opioid dose or stop titration whenever increased sedation is detected to prevent respiratory depression. In some patients (e.g., those with obstructive sleep apnea, pulmonary dysfunction, multiple comorbidities), mechanical monitoring such as capnography (to measure exhaled carbon dioxide) and pulse oximetry (to measure oxygen saturation) is needed. Unless the patient is at the end of life, promptly administer the opioid antagonist naloxone (Narcan) IV to reverse clinically significant opioid-induced respiratory depression, usually when the respiratory rate is less than 8 breaths per minute or according to agency protocol. When giving the opioid antagonist naloxone, administer it slowly until the patient is more arousable and respirations increase to an acceptable rate. The desired outcome is to reverse just the sedative and respiratory depressant effects of the opioid but not the analgesic effects. Giving too much naloxone too fast not only can cause severe pain but also can lead to ventricular dysrhythmias, pulmonary edema, and even death. Continue to closely monitor the patient after giving naloxone because its duration is shorter than that of most opioids and respiratory depression can recur. Sometimes more than one dose of naloxone is needed.

self-tolerance

Non-self proteins and cells include infected body cells, cancer cells, cells from other people, and invading organisms. Recognizing self versus non-self is called self-tolerance. This action prevents IMMUNITY from harming healthy body cells. Self-tolerance is possible because of the different proteins present on cell membranes. • WBCs are the only body cells able to recognize non-self cells and to attack them.

PATIENTS AT RISK FOR VTE

Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury Smoking History of VTE, PE, varicose veins, edema Oral contraceptives History of decreased cardiac output Hip fracture, total hip/knee surgery

CLINICAL MANAGEMENT: SCREENING

No routine screenings for general population Human immunodeficiency virus (HIV) screening for those with specific risk factors

CLINICAL MANAGEMENT: SECONDARY PREVENTION

No specific screenings are performed for the general population as it relates to this concept.

Arthritis Disease: Osteoarthritis

Nonsystemic, noninflammatory progressive disorder of movable joints Changes are associated with increasing age and/or trauma Risk Factors: aging, obesity, genetics, joint injury, occupation (those that use same joints continuously, for example athletes) S&S: pain & stiffness (especially in the morning), immobility of the joint or limb due to the pain or joint changes, enlarged and/or nodular joints, crepitation, deformities, Heberden's nodules, Bouchard's nodules Treatment: (2 main goals provide comfort & maintain function/mobility), application of heat, TENS unit, weight loss, nonpharmacological techniques for pain relief, if function is completely lost joint replacement surgery would then have to be explored Medications: acetaminophen, meloxicam, cortisone (orally, injections), arthritic rubs

Intravenous Solutions

Normal serum osmolarity (adults) = 270 to 300 mOsm/L: Isotonic = 270 to 300 mOsm/L Hypertonic = fluids >300 mOsm/L Hypotonic = fluids < 270 mOsm/L

iv solutions

Normal serum osmolarity (adults) = 270 to 300 mOsm/L: Isotonic = 270 to 300 mOsm/L Hypertonic = fluids >300 mOsm/L Hypotonic = fluids < 270 mOsm/L

CLINICAL JUDGMENT PROCESS

Noticing Interpreting Responding Reflecting Clinical judgment is not a linear process.

MINIMIZING MALPRACTICE RISK

Observe mandatory standards of care Use nursing process; follow professional standards Avoid medication and treatment errors Report and document accurately Obtain informed consent Attend to client safety Maintain client confidentiality Provide education and counseling Delegate, assign, and supervise properly Accept appropriate assignments Participate in continuing education Observe professional boundaries Observe mandatory reporting regulations Be aware of legal safeguards for nurses

Clinical Management: Hierarchy of Pain Measures

Obtain patient self-report • Pain is what the patient says it is. Self-report is always the most reliable indication of pain. Consider patient condition or exposure to painful procedures Observe for behavioral signs of pain Evaluate psychological indicators Conduct an analgesic trial

Toxic reaction

Occurs when prescribed medication dosage is excessive or poisonous to an individual; this may be due to client's size, health condition, or other medications being taken

CONSEQUENCE OF UNCONTROLLED INFECTION

Once the body's compensatory mechanisms (e.g., vascular, renal, nervous, respiratory) are overcome, the following process occurs.

Overflow Incontinence overxl

Occurs when pressure of urine in overfull bladder overcomes sphincter control Cause: bladder or urethral outlet obstruction ( bladder neck obstruction, urethral stricture, pelvic organ proplapse, neurogenic bladder *The involuntary loss of urine associated with overdistention of the bladder when the bladder's capacity has reached its maximum. The urethra is obstructed, so it fails to relax sufficiently to allow urine to flow, resulting in incomplete bladder emptying or complete urinary retention, causing overflow incontinence.* ashlii The loss of urine in combination with a distended bladder. Overflow incontinence occurs when the detrusor muscle fails to contract and the bladder becomes overdistended. This type of incontinence (reflex incontinence or underactive bladder) occurs when the bladder has reached its maximum capacity and some urine must leak out to prevent bladder rupture. Causes may include an underactive bladder muscle or a urethral obstruction. Causes for the underactive (acontractile) bladder may or may not be determined. A partially obstructed urethra can fail to relax enough to allow urine flow. Incomplete bladder emptying or urinary retention from urethral obstruction results in overflow incontinence. *Causes of Overflow* Incontinence include fecal impaction, neurological disorders, and enlarged prostate. -*Diabetic neuropathy; side effects of drugs; after radical pelvic surgery or spinal cord damage; outlet obstruction. -Causes external to the mechanism of the urethra: an enlarged prostate (male patients) and large genital prolapse (female patients). -When the cause is intrinsic to the urethra, abnormal contraction of the skeletal muscle occurs, causing obstruction. This condition, called detrusor dyssynergia, is seen in patients with spinal cord injuries and multiple sclerosis.* *overs/s* Leakage of small amounts of urine is frequent throughout the day and night, urination may also occur frequently in small amounts Bladder remains distended and is usually palpable-----Bladder distention, often up to the level of the umbilicus. Constant dribbling of urine *Bladder distention, often up to the level of the umbilicus. Constant dribbling of urine.* ????? overdx dx A urinalysis and urine culture are typically obtained to diagnose urinary tract infection and microscopic hematuria.-----*(TRUS) and an MRI,cystoscope* • A complete blood count (*CBC*) to evaluate any evidence of systemic infection (elevated WBCs) or anemia (decreased red blood cells [RBCs]) from hematuria • Blood urea nitrogen (*BUN) and serum creatinine* levels to evaluate renal function (both are usually elevated with kidney disease) • *A prostate-specific antigen (PSA) and a serum acid phosphatase* level if prostate cancer is suspected (both are typically elevated in patients who have prostate cancer) • *Culture and sensitivity of prostatic fluid (if expressed during the examination)* overni n.i Insert urinary catheterization to decompress bladder Adrenergic blockers, surgery to relieve the obstruction, prostate removal, repair of uterine prolapse *overdrugs meds* short-term management--Bethanechol(Urecholine): to enhance bladder contractions/increases bladder pressure. overteaching pt edu, Post-void dribbling and overflow incontinence may cause embarrassment and prevent the patient from socializing or leaving his home. For some patients, this social isolation can affect quality of life and lead to clinical depression and/or severe anxiety

NURSING CARE IS NOT LINEAR

One must consider multiple complex variables for clinical reasoning.

What to do if patient is confused in the PACU

Orient the patient. Let them know where they are, how they got there, the time, day, etc.

Movement of Fluids and Electrolytes

Osmosis Diffusion Filtration Active transport

Barriers to pain assessment and pain management

Outdated norms Inadequate knowledge by health care providers Patient beliefs and values Communication • Communication and collaboration among the health care team are essential when caring for the patient with pain. Ethical considerations Patients who are unable to report their pain using the customary self-report assessment tools are at higher risk for undertreated pain than those who can report. These include patients who are cognitively impaired, critically ill (intubated, unresponsive), comatose, or imminently dying. Patients who are receiving neuromuscular blocking agents or are sedated from general anesthetics and other drugs given during surgery are also among this at-risk population. The Hierarchy of Pain Measures is recommended by many professional organizations today as a framework for assessing pain in patients who cannot self-report. The key components of the Hierarchy require the nurse to (1) attempt to obtain self-report; (2) consider underlying pathology or conditions and procedures that might be painful (e.g., surgery); (3) observe behaviors; (4) evaluate physiologic indicators; and (5) conduct an analgesic trial.

ELEMENTS OF HISTORY

Past medical history Family history Genetic history Current medications Allergies to medications or other substances Lifestyle behaviors Occupation Social environment

key points Chapter 11: Assessment and Care of Patients with Problems of Fluid and Electrolyte Balance Assessment and Care of Patients with Problems of Fluid and Electrolyte Balance

PHYSIOLOGIC INFLUENCES ON FLUID AND ELECTROLYTE BALANCE • Body fluids are composed of water and particles dissolved or suspended in water. • The solvent is the water portion of fluids. • Solutes are the particles dissolved or suspended in the water. • When solutes express an overall electrical charge, they are known as electrolytes. • Body function depends on keeping the correct balance of fluid and electrolytes within each body fluid space. • Specific processes control normal FLUID AND ELECTROLYTE BALANCE so the internal environment remains stable even when the external environment changes. • These processes are filtration, diffusion, and osmosis. • They determine how, when, and where fluids and particles move across cell membranes ------------------------------------------- FLUID BALANCE Body Fluids • A person's age, gender, and amount of fat affect the amount and distribution of body fluids. o An older adult has less total body water than a younger adult. o An obese person has less total body water than a lean person of the same weight because fat cells contain almost no water. o Women of any age have less total body water than men of similar sizes and ages, related to more body fat. --------------------------------------- • Assessment is key in managing imbalances. o Assess patients who have a sudden change in cognition for fluid and electrolyte imbalances. o Assess skin turgor on the forehead or the sternum of older patients. o Use daily weights to determine fluid gains or losses. o Ask patients about the use of drugs such as diuretics, laxatives, salt substitutes, and antihypertensives that may alter fluid and electrolyte status. o Correctly interpret laboratory electrolyte values. o Assess any patient with a fluid or electrolyte imbalance for falls risk. o Cardiovascular changes are good indicators of hydration status because of the relationship between plasma fluid volume, blood pressure, and PERFUSION. --------------------------------------- o Monitor the cardiac and pulmonary status at least every hour when patients with dehydration are receiving IV fluid replacement therapy. o Assess the bowel sounds; heart rate, rhythm, and quality; and muscle strength to evaluate the patient's responses to therapy for an electrolyte imbalance. ------------------------------------------------ • Use a gait belt when assisting a patient with muscle weakness to walk or transfer. • Do not give oral fluids to an unconscious patient. • Offer or ensure that oral care is performed at least every 4 hours for patients with dehydration. • The minimum amount of urine output per day to excrete toxic waste products, called the obligatory urine output, is 400 to 600 mL. • Other normal water loss occurs through the skin, the lungs, and the intestinal tract. • Insensible water loss from skin, lungs, and stool is about 500 to 1000 mL/day. If not balanced by intake, insensible water loss can lead to severe dehydration and electrolyte imbalances. ----------------------------------------------- Hormonal Regulation of Fluid Balance • The endocrine system helps to control FLUID AND ELECTROLYTE BALANCE. • Three hormones that help control these critical balances are aldosterone, antidiuretic hormone (ADH), and natriuretic peptide (NP). --------------------------------------------------- Significance of Fluid Balance • The human body requires a balance of body fluids, electrolytes, and acids and bases for best function. • The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid [ICF]). • The most critical fluid balance to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate PERFUSION and oxygenation of all organs and tissues. • Balance of both water and electrolytes is needed for this very vital function. • Once the kidneys sense that PERFUSION is at risk, renin is secreted into the blood. Renin then activates angiotensinogen. • Activated angiotensinogen is angiotensin I, which is relatively weak. It is then acted on by another enzyme known as angiotensin-converting enzyme (ACE), which converts angiotensin I into its most active form, angiotensin II. • Angiotensin II starts several different activities that all work to increase blood volume and blood pressure. • Used to treat hypertension, the "ACE inhibitors" are drugs that disrupt the renin- angiotensin II pathway by reducing the amount of ACE made so that less angiotensin II is present. • With less angiotensin 2, there is less vasoconstriction and reduced peripheral resistance,less aldosterone production, and greater excretion of water and sodium in the urine. All of these responses lead to decreased blood volume and blood pressure. ------------------------------------------- FLUID IMBALANCES Dehydration • All patients are at risk for some degree of fluid imbalance because many health problems can disrupt fluid intake or output. • In dehydration, fluid intake is less than what is needed to meet the body's fluid needs, resulting in a fluid volume deficit. • Management of dehydration aims to prevent injury, prevent further fluid losses, and increase fluid compartment volumes to normal ranges. • Main strategies include assuring patient safety, fluid replacement, and drug therapy. • Ensure access to adequate fluids for patients who are unable to talk or who have limited mobility. • Older adults are at high risk for dehydration because they have less total body water than younger adults. They also may take drugs such as diuretics, antihypertensives, and laxatives that increase fluid excretion. For this reason, always assess the FLUID AND ELECTROLYTE BALANCE status of all older adults. ------------------------------------------- Fluid Overload • Fluid overload, also called overhydration, is an excess of body fluid. • Fluid overload may be either an actual excess of total body fluid or a relative fluid excess. • Careful assessment of fluid overload and development of pulmonary edema is essential to prevent potential for death. • The patient with fluid volume overload and edema is at risk for skin breakdown. • Interventions for patients with fluid overload ensure patient safety, restore normal fluid balance, provide supportive care until the imbalance is resolved, and prevent future fluid overload. Use a pump or controller to deliver intravenous fluids to patients with fluid overload. ---------------------------------------------- ELECTROLYTE BALANCE AND IMBALANCES • Electrolyte imbalances can occur in healthy people as a result of changes in fluid intake and output, which are usually mild and easily corrected. • Severe electrolyte imbalances are life threatening. • Electrolyte homeostasis balances the dietary intake of electrolytes with the renal excretion or reabsorption of electrolytes. ------------------------------------------------- Sodium • The extracellular fluid (ECF) sodium (Na+ ) level determines whether water is retained, excreted, or moved from one fluid space to another. • Serum sodium balance is regulated by the kidney under the influences of aldosterone, ADH, and NP. • Hyponatremia is a serum sodium level below 136 mEq/L. o Sodium imbalances often occur with fluid volume imbalances because the same hormones regulate both sodium and water balance. o Cerebral changes are the most obvious problems of hyponatremia. Behavioral changes result from cerebral edema and increased intracranial pressure. o Noticing the cause determines to plan appropriate management including drug therapy, nutrition therapy, preventing fluid overload or a too-rapid change in serum sodium level. o Priorities include monitoring patient's response to therapy, preventing hypernatremia, and fluid overload. ------------------------------------------------ • Hypernatremia is a serum sodium level over 145 mEq/L. o When serum sodium levels are high, severe cellular dehydration with cellular shrinkage occurs. o Notice nervous system changes starting with altered cerebral function, assessing attention span and cognitive function. o Skeletal muscle changes can begin with muscle twitching. o Drug and nutrition therapies decrease high serum sodium levels. o Interventions include ensuring patient safety, skin protection, monitoring response, and patient and family teaching similar to those for fluid overload. o Interventions used when sodium levels become life threatening include hemodialysis and blood ultrafiltration. ------------------------------------------------- Potassium • Keeping the large difference in potassium (K+ ) concentration between the ICF and the ECF is critical for excitable tissues to depolarize and generate action potentials. • Other functions of potassium include regulating protein synthesis and regulating glucose use and storage. • Hypokalemia is a serum potassium level below 3.5 mEq/L, which can be life threatening because every body system is affected. o Drug and nutrition therapies help restore normal serum potassium levels. o The priorities for nursing care of the patient with hypokalemia are ensuring adequate gas exchange, patient safety for falls prevention, prevention of injury from potassium administration, and monitoring the patient's response to therapy. o Assess the respiratory status of all patients with hypokalemia. o Follow facility policy for cardiac monitoring in the presence of hypokalemia. o Before infusing any IV solution containing potassium chloride, check and recheck the dilution of the drug in the IV solution container. o Do not give intravenous potassium at a rate greater than 20 mEq/h. o Never give potassium supplements by the intramuscular, subcutaneous, or IV push routes. o Use a pump or controller when giving intravenous potassium-containing solutions. o Because potassium is a severe irritant to the vein, assess the IV site hourly, and ask the patient whether he or she feels burning or pain at the site. o Immediately stop the infusion of potassium-containing solutions if infiltration or phlebitis is suspected. o Oral potassium preparations have a strong, unpleasant taste and can cause nausea and vomiting. Give the drug during or after a meal and advise patients to not take it on an empty stomach at home. -------------------------------------------- • Hyperkalemia is a serum potassium level greater than 5.0 mEq/L. o Even slight increases above normal values can affect excitable tissues, especially the heart. o The priorities are assessing for cardiac complications (most common cause of death), patient safety for falls prevention, monitoring the patient's response to therapy, and health teaching. o Assess all patients with hyperkalemia for cardiac dysrhythmias and electrocardiographic abnormalities, especially tall T waves, conduction delays, ventricular fibrillation, and heart block. o Patients at greatest risk include those with renal dysfunction; chronically ill, debilitated patients; and older adults. o The nurse's response to hyperkalemia is to focus on reducing the serum potassium level, preventing recurrences, and ensuring patient safety. ---------------------------------------- Calcium • Calcium (Ca2+) is a mineral with functions closely related to those of phosphorus and magnesium. • It is important for maintaining bone strength and density, activating enzymes, allowing skeletal and cardiac muscle contraction, controlling nerve impulse transmission, and allowing blood clotting. • Calcium enters the body by dietary intake and absorption through the intestinal tract and is stored in the bones. • When more calcium is needed, parathyroid hormone (PTH) is released from the parathyroid glands. PTH increases serum calcium levels through a variety of mechanisms. • When excess calcium is present in plasma, PTH secretion is inhibited and the secretion of thyrocalcitonin, a hormone secreted by the thyroid gland, is increased. • Hypocalcemia is a total serum calcium level below 9.0 mg/dL or 2.25 mmol/L. o Because the normal blood level of calcium is so low, any change in calcium levels has major effects on function. o Most symptoms of acute hypocalcemia are caused by overstimulation of the nerves and muscles. o Notice neuromuscular changes of hypocalcemia by testing for Trousseau's and Chvostek's signs. Paresthesias, tingling and numbness, and tetany can occur. o Postmenopausal women are at risk for chronic calcium loss related to reduced weight-bearing activities and a decrease in estrogen levels. o Use a lift sheet to move or re-position a patient with chronic hypocalcemia to prevent fracture of brittle, fragile bones. o The nurse responds to restore normal calcium levels and prevent complications which include drug therapy, nutrition therapy, reducing environmental stimuli, and preventing injury. o Patient safety during restoration of serum calcium levels is a nursing care priority. o Because phosphorus and calcium are interrelated, decreases in serum phosphorus levels cause increases in serum calcium levels. ---------------------------------------- • Hypercalcemia is a total serum calcium level above 10.5 mg/dL or 2.62 mmol/L. o Small increases have severe effects on all systems. o Because of an increased risk blood clots do form more easily whenever blood flow is poor; notice for slowed or impaired PERFUSION. o Interventions for responding to hypercalcemia aim to reduce serum calcium levels through drug therapy, dialysis, rehydration, cardiac monitoring, and depending on the cause and severity, dialysis o Management of hyperphosphatemia entails the management of hypocalcemia since hypocalcemia results when serum phosphorus levels increase. ------------------------------------------- Magnesium • Magnesium (Mg2+) is critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation, and cell growth. • Extracellular magnesium regulates blood coagulation and skeletal muscle contractility. • Hypomagnesemia is a serum magnesium level below 1.2 mEq/L. o Avoid administering magnesium sulfate by the intramuscular route. o Since hypocalcemia often occurs with it, interventions also aim to restore normal serum calcium levels. • Hypermagnesemia is a serum magnesium level above 2.1 mEq/L. o In severe hypermagnesemia, excitable membranes may not respond to any stimulus. o All oral and parenteral magnesium preparations are discontinued. o In the absence of kidney failure, magnesium-free IV fluids and loop diuretics can reduce serum magnesium levels. o With severe cardiac problems, giving calcium may reverse the cardiac effects of hypermagnesemia. -------------------------------- ASSESSMENT OF PATIENTS WITH ADEQUATE FLUID AND ELECTROLYTE BALANCE • Vital Signs o Heart rate and rhythm within usual range o Respiratory rate and depth within usual range • Physical Assessment o Skin turgor normal, no tenting, no edema o Skin color normal (no cyanosis or pallor) o Lung sounds clear o Oral mucous membrane and nail beds pink with rapid capillary refill o Strong and equal peripheral pulses o Deep tendon reflexes present and normal o Muscle strength consistent with what is normal for the patient o Urine output approximately equal to fluid intake • Psychological Assessment o Oriented and not confused o Easily aroused from sleep • Laboratory Assessment o Serum electrolyte values within normal limits o Normal electrocardiogram ---------------------------------------- PATIENT EDUCATION • Explain the purpose of fluid restriction to the patient and the family to ensure cooperation and prevent misunderstanding. • Encourage all patients to maintain a fluid intake minimum of 3 L/day unless another condition requires fluid restriction. • Teach all people to increase fluid intake when exercising, in hot or dry environments, or during conditions that increase metabolism, such as fever. • Teach people that beverages with caffeine can increase fluid loss, as can drinks containing alcohol; thus these beverages should not be used to prevent or treat dehydration. • Instruct patients who exercise heavily (athletes) to take scheduled fluid replacement breaks. • Instruct patients at risk for fluid imbalance to weigh themselves on the same scale daily, close to the same time each day, and with about the same amount of clothing on each time, and to monitor these daily weights for changes or trends. • Instruct caregivers of older adults who have cognitive impairments or mobility problems to schedule offerings of fluids at regular intervals throughout the day. • Prevent dehydration in older adults in long-term care facilities by routinely offering residents fluids every hour or two during the day and when administering medications. • Teach patients to determine electrolyte content of processed foods by reading labels. • Determine the patient's food preferences and dislikes when planning an electrolyterestricted diet. • Teach patients who are prescribed diuretics to take the drugs as prescribed. • Teach patients who are taking digoxin or diuretics to measure their pulse for rate, rhythm, and quality. • Include the person who prepares the patient's meals when teaching about dietary electrolyte restrictions. -----------------------------------

PACO2

PaCO2 is the LUNG chemical Normal PaCO2 range is 35 to 45 mmHg If the PaCO2 is less than 35 = alkalosis If the PaCO2 is greater than 45 = acidosis If the PaCO2 is increased = decreased LOC If the PaCO2 is increased = decreased O2 CO2 and O2 have an inverse relationship

Blood Transfusions and Other Components

Packed red blood cells Platelets Fresh frozen plasma Albumin Several specific clotting factors

Pain Mechanisms and Pathways Perception

Pain threshold and tolerance Thresholds and need for pain relief vary Tolerance can vary within individuals Numerous factors influence both Perception is the third broad process involved in nociception. Perception, which may be viewed as the end result of the neural activity associated with transmission of information about noxious events, involves the conscious awareness of pain (see Fig. 4-1). It requires the activation of higher brain structures, including the cortex, and involves both awareness and the occurrence of emotions and drives associated with pain. The physiology of pain perception is very poorly understood but presumably can be targeted by therapies that activate higher cortical functions and COGNITION to achieve pain control or coping. Cognitive-behavioral therapy and specific approaches such as distraction and imagery (discussed later in the chapter) have been developed based on evidence that brain processes can strongly influence pain perception.

Postop: Discomfort/pain assessment painxl

Pain/discomfort expected after surgery Physical and emotional signs of pain Consider type, extent, length of surgical procedure in assessing patient's discomfort, need for medication

Pathophysiology of Pain Autonomic nervous system

Part of CNS regulating homeostasis Parasympathetic versus sympathetic (fight or flight) systems • Both types of chronic pain do not cause sympathetic reactions. Therefore, some patients do not appear to be in pain, even when they are. • The absence of the physiologic and behavioral responses does not mean the absence of pain.

Interventions

Patient safety Fall precautions Fluid replacement Oral fluids Drug therapy IV fluids Andidiarrheal Antimicrobial Antiemetic Antipyretics

CLASSIFICATION OF ANTIBIOTIC AGENTS

Penicillin Cephalosporins First, second, third, and fourth generation Fluoroquinolones Tetracyclines Macrolides Aminoglycosides

RISK FACTORS

People from all age, socioeconomic, and racial/ethic groups can potentially have impaired immune systems - some however are at greater risk than others. Suppressed immune response- drugs Age Very young Elderly Non-immunized state Susceptible to a number of infections- diseases Rubella, measles, mumps, tetanus, hepatitis, diphtheria, etc Environmental factors Poor nutrition, exposure to pollutants, heavy metals, and other stressors Unsafe sanitary conditions, contaminations, poor hand hygiene Chronic illnesses Primary immunodeficiency conditions directly impair immune system (HIV) Diabetes, COPD, malnutrition, cancer

OBJECTIVES - ATI - NCLEX Physiological Integrity 2

Perform an ongoing head-to-toe assessment of the postoperative patient. Prioritize nursing interventions for the patient recovering from surgery and anesthesia during the first 24 hours. Apply knowledge of pathophysiology to monitor the patient for the complications of shock, respiratory depression, or impaired wound healing after surgery. Assess the patient's level of postoperative pain, and evaluate his or her responses to coordinated pain management strategies and interventions. Explain the actions, dosages, side effects, and nursing implications for different types of drug therapy for pain management after surgery. Evaluate surgical incisions and wounds for complications. Collaborate with health care team members to perform emergency care procedures for surgical wound dehiscence or wound evisceration

REVIEW OF IMMUNE RESPONSE 4

Phagocytes Found throughout the body Responsible for recognizing and ingesting foreign antigens as they enter body Macrophages and neutrophils are primary phagocytes - first line of defense - macrophages are more effective than neutrophils Macrophages stored in connective tissues, spleen, liver, and lining of respiratory and GI tracts Neutrophils stay circulating n the blood Phagocytosis is the process of ingesting cellular material and involves the ability of phagocytes to be selective in recognizing cells that must be ingested and discarded. "self" cells - smooth and covered with smooth proteins "non-self" - antibody-antigen complexes are rougher surfaces and are particularly susceptible to phagocytic functioning book To protect without causing harm, immune system cells exert actions only against non-self proteins and cells. Immune system cells can distinguish between the body's own healthy self cells and non-self proteins and cells.

Safety hazards in the home - Falls

Prevalent in those older than 65 years Slippery floors, stairs, tubs; low toilet seat; high bed Prevention: -nonskid shoes -tidy clothes -proper lighting -grab bars/rails -no scatter rugs

Interventions: Alkalosis

Prevent further losses of hydrogen, potassium, calcium, chloride ions Restore fluid balance Monitor changes, provide safety Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion

Safety hazards in the home - Carbon Monoxide poisoning

Produced by burning fuel: gas, wood, oil, kerosene Prevention: carbon monoxide detector Treat: 100% humidified oxygen

WHO Analgesic Ladder

Recommended guidelines for prescribing, based on pain level (0-10, 10 = severe pain) Level 1 (1-3 rating)—Use non-opioids Acetaminophen and NSAIDs make up the nonopioid analgesic group. Acetaminophen is thought to relieve pain by underlying mechanisms in the CNS. It has analgesic and antipyretic properties but is not effective for treating inflammation. In contrast, NSAIDs have analgesic, antipyretic, and anti-inflammatory properties. These drugs produce pain relief by blocking prostaglandins through inhibition of the enzyme cyclooxygenase (COX) in the peripheral nervous system- Nonopioid drugs are appropriate alone for mild-to-moderate nociceptive pain (e.g., from surgery, trauma, or osteoarthritis) or are added to opioids, local anesthetics, and/or anticonvulsants as part of a multimodal analgesic regimen for more severe nociceptive pain. However, they have limited benefit for neuropathic pain.- Oral acetaminophen (Tylenol, Abenol) has a long history of safety in recommended doses in all age-groups and most patient populations. It is recommended as first line for musculoskeletal pain (e.g., osteoarthritis) in older adults but has no inflammatory properties. Therefore acetaminophen is less effective than NSAIDs for chronic inflammatory pain (e.g., rheumatoid arthritis). IV acetaminophen (Ofirmev) is approved for treatment of pain and fever in adults and is given by a 15-minute infusion in single or repeated doses. It can be given alone for mild-to-moderate pain or in combination with opioid analgesics for more severe pain. The most serious complication of acetaminophen is hepatotoxicity (liver damage) as a result of overdose. Patient's hepatic risk factors must always be considered before administration of acetaminophen. In the healthy adult a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice in many people in pain, especially older adults NSAIDs have more adverse effects than acetaminophen, with gastric toxicity and ulceration being the most common. Risk factors for NSAID adverse effects include being older than 60 years or having a history of peptic ulcer or cardiovascular (CV) disease. An important principle of NSAID use is to administer the lowest dose for the shortest time necessary. All NSAIDs carry a risk for CV adverse effects through prostaglandin inhibition. The US Food and Drug Administration (FDA) cautions against the use of any NSAIDs after high-risk open-heart surgery because of an elevated CV risk with NSAIDs in this population. Prostaglandins also affect renal function. Be sure that the patient is adequately hydrated when administering NSAIDs to prevent acute renal failure. Level 2 (4-6 rating)—Use weak opioids alone or with adjuvant drug Level 3 (7-10 rating)—Use strong opioids

Clinical Application

Renin-angiotensin II pathway is greatly stimulated with shock, or when stress response is stimulated Patients with hypertension often take ACE inhibitors

FUNCTION OF THE INFLAMMATORY RESPONSE

Restitution of normal, functioning cells after injury Fibrous repair when restitution of functioning cells is impossible

GENERAL ANESTHESIA generalxl

Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS Involves single or combination of agents Depresses CNS, resulting in analgesia, amnesia, and unconsciousness with loss of muscle tone and reflexes

Nursing diagnoses related to safety

Risk for falls Risk for injury

NURSING RESPONSE: INFLAMMATION

Risk for fluid deficit Assessment Intake and output Careful observation Fluid administration Vital signs

SOCIETAL ETHICS

Society provides a normative basis for ethical behavior with laws and regulations. Law is the minimum standard of behavior to which all members of society are held. In nursing, legal standards include: Clinical standards of care Liability Negligence Malpractice

Inverse Relationships

Sodium & Potassium Calcium & Phosphorus

Specialized Infusion Team

Specially trained nurse initiates and maintains infusion therapy Teams promote cost savings, patient satisfaction, patient outcomes

Pain Theories

Specificity theory- Pattern theory Gate control theory 1965 Numerous revisions Latest version Neuromatrix theory Theory of total pain

Foods High in Magnesium magxl

Spinach Mustard Greens Summer Squash Broccoli Halibut Turnip Greens Pumpkin Seeds Peppermint Cucumber Green beans Celery Kale Sunflower Seeds Sesame Seeds Flax Seeds

IMPLEMENTING CDC GUIDELINES

Standard Precautions Protects healthcare workers from exposure Decreases transmission of pathogens Protects clients from pathogens carried by healthcare workers

FOUR STAGES OF GENERAL ANESTHESIA generalxl

Stage 1—analgesia and sedation, relaxation- Beginning of anesthesia; client is drowsy and dizzy; pain sensation is depressed Stage 2—excitement, delirium- Excitement stage; client has irregular breathing, involuntary motor movements; avoid stimulating client, which can trigger vomiting, holding the breath, and increased activity; ensure client safety by proper use of safety straps Stage 3—operative anesthesia, surgical anesthesia- Stage of anesthesia appropriate for surgical procedures; client has skeletal muscle relaxation, constricted pupils, absence of eyelid reflex Stage 4—danger- medullary depression; client is NEAR DEATH; pupils are fixed and dilated, respirations are weak, pulse is rapid and thready Emergence—recovery from anesthesia

MEMBERS OF THE SURGICAL TEAM

Sterile team: -Surgeon and surgical assistant or RNFA -Scrub nurse -Surgical technologist Clean team: -Anesthesia providers -Circulating nurse -ORTs/surgical technologists may be used in addition to nursing staff -Holding area nurse -Specialty nurses

Classification / Categories of Pain By origin

Superficial Visceral Somatic Radiating/referred Phantom Psychogenic

Postsurgical patient education: Wound care woundxl

Take care of incision and/or change dressing as taught (specific information is individualized to client and surgery; provide 1 to 2 days of dressing materials or according to hospital policy) Cover incision with plastic wrap before showering (if allowed) Sutures or staples are often removed in surgeon's office 7 to 14 days post operatively Steri-Strips will fall off by themselves (if used instead of sutures or if applied for support when sutures are removed before discharge) Keep wound clean, dry, and intact

YOUR ACTIONS

Taking appropriate actions in response to ethically challenging situations requires three virtues of health professionals. Failure to act or respond in an ethically appropriate way has been linked to: Serious and potentially dangerous errors Personal stress Professional burnout

Cell Types Involved in Cell-Mediated Immunity book

The WBCs with the most important known roles in CMI include several specific T-lymphocytes (T-cells) along with a special population of cells known as natural killer (NK) cells. T-cells have a variety of subsets, each of which has a specific function. Different T-cell subsets can be identified by the presence of "marker proteins" (antigens) on the cell membrane's surface. More than 200 different T-cell proteins have been identified on the cell membrane, and some of these are commonly used clinically to identify specific cells. Most T-cells have more than one antigen on their cell membrane. For example, all mature T-cells contain T1, T3, T10, and T11 proteins. The names that identify specific T-cell subsets include the specific membrane antigen and the overall actions of the cells in a subset. The three T-lymphocyte subsets that are critically important for the development and continuation of CMI are helper/inducer T-cells, suppressor T-cells, and cytotoxic/cytolytic T-cells. The natural killer cell (NK cell) also contributes to CMI. Helper/inducer T-cells have the T4 protein on their membranes. These cells are usually called T4+ cells or TH cells. The most correct name for helper/inducer T-cells is CD4+ (cluster of differentiation 4). Helper/inducer T-cells easily recognize self cells versus non-self cells. When they recognize non-self (antigen), helper/inducer T-cells secrete cytokines that can enhance the activity of other WBCs and increase overall immune function. These cytokines increase bone marrow production of stem cells and speed up their maturation. Thus helper/inducer T-cells act as organizers in "calling to arms" various squads of WBCs involved in inflammatory, antibody, and cellular protective actions. Suppressor T-cells have the T8-lymphocyte antigen on membrane surfaces. These cells are commonly called T8+ cells, CD8+ cells, or TS-cells. Suppressor T-cells help regulate CMI. Suppressor T-cells prevent hypersensitivity (IMMUNITY overreactions) on exposure to non-self cells or proteins. This action prevents the formation of antibodies directed against normal, healthy self cells, which is the basis for many autoimmune diseases. The suppressor T-cells secrete cytokines that have an overall inhibitory action on most cells of the immune system. Suppressor T-cells have the opposite action of helper/inducer T-cells. For optimal CMI, then, a balance between helper/inducer T-cell activity and suppressor T-cell activity must be maintained. This balance occurs when the helper/inducer T-cells outnumber the suppressor T-cells by a ratio of 2 : 1. When this ratio increases, indicating that helper/inducer T-cells vastly outnumber the suppressor cells, overreactions can occur, some of which are both tissue damaging and unpleasant. When the helper/suppressor ratio decreases, indicating fewer-than-normal helper/inducer T-cells, IMMUNITY is suppressed, and the person's risk for infections increases. Cytotoxic/cytolytic T-cells are also called TC-cells. Because they have the T8 protein present on their surfaces, they are a subset of suppressor cells. Cytotoxic/cytolytic T-cells destroy cells that contain a processed antigen's human leukocyte antigens (HLAs). This activity is most effective against self cells infected by parasites such as viruses or protozoa. Parasite-infected self cells have both self HLA proteins (universal product code) and the parasite's antigens on the cell surface. This allows immune system cells to recognize the infected self cell as abnormal; and the cytotoxic/cytolytic T-cell can bind to it, punch a hole, and deliver a "lethal hit" of enzymes to the infected cell, causing it to lyse and die. Natural killer (NK) cells are also known as CD16+ cells and are very important in providing CMI. These cells have direct cytotoxic effects on some non-self cells without first being sensitized. They conduct "seek and destroy" missions in the body to eliminate non-self cells. The NK cells are most effective in destroying unhealthy or abnormal self cells such as cancer cells and virally infected body cells Cytokinesxl Cell-mediated IMMUNITY (CMI) regulates the immune system by producing cytokines. Cytokines are small protein hormones produced by the many WBCs (and some other tissues). Cytokines made by the macrophages, neutrophils, eosinophils, and monocytes are called monokines. Those produced by T-cells are called lymphokines. In addition, many other body cell types can produce and respond to cytokines. Cytokines work like hormones: one cell produces a cytokine, which in turn exerts its effects on other cells of the immune system and on other body cells. Cytokines control many inflammatory and immune responses and are controlled by interactions with other systems. Cytokines include the interleukins (ILs), interferons (INFs), colony-stimulating factors, tumor necrosis factor (TNFs), and transforming growth factors (TGFs). The interleukins are the largest group of cytokines, with interleukin-33 (IL-33) being the most recently defined

Reason's Swiss Cheese Model of Accident Causation

The model shows how errors occur when situational factors align, despite multiple layers of safeguards for the prevention of errors.

Pain Assessment Obtaining a complete pain history:

The primary role in pain and COMFORT management is to advocate for patients by accepting their reports of pain and acting promptly to relieve it while respecting their preferences and values. • Initial and ongoing pain assessments are required. • Nurses are responsible for thorough PAIN assessment. Patient self-report of pain • Self-report is the gold standard for assessing pain. It may be difficult for the person to describe or explain it to others. They may report pain in the absence of any observable or documented physiologic changes. • A complete pain assessment includes location, intensity, onset and duration, aggravating and relieving factors, effect of pain, and function on quality of life. • Location(s): Ask the patient to state or point to the area(s) of pain on the body. Sometimes allowing patients to make marks on a body diagram is helpful in gaining this information. Patients may present with more than one specific painful site. Encourage those who cannot identify the painful areas and state that they "hurt all over" to focus on parts of the body that are not painful. Ask them to begin with the hand and fingers of one extremity and identify the presence or absence of pain. By focusing attention on selected areas of the body, the patient is assisted in better localizing painful areas. People who state that they hurt everywhere often begin to realize that some parts of the body are not painful. Identifying painful areas helps the patient understand the origin of the pain. This understanding is particularly important for those with cancer because every new pain often raises the suspicion of metastasis (spread of disease). The pain may have other causes such as immobility or constipation. Pain may be described as belonging to one of four categories related to its location: 1. Localized pain is confined to the site of origin. 2. Projected pain is diffuse around the site of origin and is not well localized. 3. Referred pain is felt in an area distant from the site of painful stimuli. 4. Radiating pain is felt along a specific nerve or nerves. Intensity Ask the patient to rate the severity of the pain using a reliable and valid assessment tool. Various self-report scales have been developed to help patients communicate pain intensity. Once a scale is selected, be sure to use the same scale over time for that patient and assess intensity both with and without activity. The most common intensity rating scales are: • Numeric Rating Scale (NRS): The NRS is usually presented as a horizontal 0-to-10 point scale, with word anchors of "no pain" at one end of the scale, "moderate pain" in the middle of the scale, and "worst possible pain" at the end of the scale. Some patients relate better to a vertical presentation of the scale. • Wong-Baker FACES® Pain Rating Scale: The FACES scale consists of six cartoon faces with word descriptors, ranging from a smiling face on the left for "no pain (or hurt)" to a frowning, tearful face on the right for "worst pain (or hurt)." The faces are most commonly numbered 0 to 10. Patients are asked to choose the face that best describes their pain. It is important to appreciate that faces scales are self-report tools; clinicians should not attempt to match a face shown on a scale to the patient's facial expression to determine pain intensity. • Faces Pain Scale—Revised (FPS-R): The FPS-R has seven faces to make it consistent with other scales using the 0-to-10 metric. The faces range from a neutral facial expression to one of intense pain. As with the Wong-Baker FACES® scale, patients are asked to choose the face that best reflects their pain. Some research shows that the FPS-R is preferred by both cognitively intact and impaired older adults. • Verbal Descriptor Scale (VDS): A VDS uses different words or phrases to describe the intensity of pain such as "no pain, mild pain, moderate pain, severe pain, very severe pain, and worst possible pain." The patient is asked to select the phrase that best describes the pain intensity. •Quality Ask the patient to describe how the pain and discomfort feels. He or she may use one word or a group of words to convey the SENSORY PERCEPTION of the pain. Avoid suggesting descriptive words for the pain; allow patients to use their own words to describe it. Descriptors such as "sharp," "shooting," or "burning" may help identify the presence of neuropathic pain. Ask the patient whether the pain is superficial or deep. In general, those with pain involving superficial or cutaneous (skin) structures describe it as superficial and can often localize the pain to a specific area. •Onset and duration Ask the patient when the pain started and whether it is constant or intermittent. • Alleviating or relieving factors Ask the patient about the pain experience, including precipitating, aggravating, and relieving factors; the nature of adjustments in life or family responsibilities; localization, character quality, and duration; and beliefs. •Effect of pain on quality of life and functional status The effect of pain on the ability to perform recovery activities should be evaluated regularly. It is particularly important to ask patients with persistent pain about how it has affected their lives. Are they able to sleep? Ask what they could do before the pain began that they can no longer do and what they want to do but cannot do. • Comfort-function (pain intensity) outcomes: For patients with acute pain, identify expected short-term functional outcomes. Reinforce to the patient that adequate pain control will lead to more successful achievement of those outcomes. For example, tell surgical patients that they will be expected to ambulate or participate in physical therapy after surgery. Ask patients to identify a level of pain that will allow accomplishment of the expected outcomes. A realistic outcome for most patients is 2 or 3 on a scale of 0 to 10. Pain intensity that is consistently above the desired level requires further evaluation and consideration of possible adjustment of the treatment plan. • In response to many organizations and The Joint Commission, many hospitals and agencies have implemented interprofessional pain initiatives to ensure patients receive the best possible care in management of pain and promotion of COMFORT. • The primary role in pain and COMFORT management is to advocate for patients by accepting their reports of pain and acting promptly to relieve it, while respecting their preferences and values. Assessment tool: 1. vitals- increase if its acute 2. pain scale 4. painad scale (dementia) & hospice pt ppl who cant communicate. • Because of difficulty reporting their pain, patients with COGNITION problems are at high risk for undertreatment. There are common behavioral assessment tools that are used for cognitively impaired patients with delirium or dementia. Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia. The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10: • Breathing (independent of vocalization) • Negative vocalization • Facial expression • Body language • Consolability (ability to calm the patient) Simple descriptor scale Verbal graphic rating 7. flacc scale- grimacing, breath, HR and gives # 8. facial grimacing, LOC 9. guarding, moaning, diaphrasesis, n/v 10. muscle rigidity (tense) 11. The Visual Analog Scale pqrst P: Precipitating or palliative Q: Quality or quantity R: Region or radiation S: Severity scale T: Timing For patients who are mechanically ventilated or may not be able to use other tools for communication, try these interventions: • Establish a reliable yes-no signal (e.g., thumbs up or down, head nods, or eye blinks) to determine the presence of pain. • Use communication boards, alphabet boards, computer, or picture boards with word labels for patients with COGNITION problems. • Correctly interpret lip reading by maintaining eye contact, encouraging the patient to speak slowly, and using dentures if required.

WHAT DOES THE BODY DUE TO MAINTAIN HOMEOSTASIS?

The priority concept in this chapter is FLUID AND ELECTROLYTE BALANCE. The most important interrelated concept for this chapter is PERFUSION. HOMEOSTASIS • The body has many control mechanisms, called homeostatic mechanisms, to prevent fluctuations in fluid and electrolytes. Compensating Organ: Kidneys Remove acid through urine Hold or excrete bicarb (depending on the need at the time) It does take the kidneys hours to even days to do their job --------------------------- Compensating Organ: Lungs Get rid of CO2 via exhalation During hypoventilation the client is retaining CO2 During hyperventilation the client is elimination CO2 The lungs respond faster than the kidneys

STEPS IN AN ACUTE INFLAMMATORY RESPONSE

Tissue injury and the release of chemical mediators Vasodilation and increased blood flow Swelling and retraction of activated endothelial cells Increased vascular permeability and leakage of small plasma proteins "Walling off" Movement of immune response cells to the site of injury Exudate formation Movement of glucose and oxygen to the site needing repair Release of chemical repair factors from activated endothelial cells

RESPIRATORY ALKALOSIS Treatment

Treatment Can not wait until the kidneys kick in Breath into a paper bag May have to sedate client to decrease respiratory rate Treat the cause Monitor ABGs

RESPIRATORY ACIDOSIS

Treatment If hypoxic make sure they have a patent airway then give them O2 Pneumonia Postural drainage, percussion, suctioning, deep breathing exercises, fluids, elevate HOB, teaching and use of IS Pneumothorax Chest tube Post-op Cough & deep breathing exercises (bubbles for kids) • To manage acidosis, collect data about risk factors related to the development of acidosis, specifically age, nutrition, and presenting symptoms. • Remember that older adults are more at risk for problems leading to acid-base imbalance, including cardiac, renal, or pulmonary impairment. • Some manifestations of acidosis include central nervous system, neuromuscular, cardiovascular, respiratory, skin, and behavioral changes. • The best way to determine acid-base balance and evaluate the effectiveness of therapy is by analyzing ABGs. Arterial blood pH is the laboratory value used to confirm acidosis. • Notice fluid volume changes, decreased cardiac output, falls related to skeletal muscle weakness, impaired memory, ineffective breathing, and fatigue. • Interventions for responding to respiratory acidosis aim to maintain a patent airway and enhance gas exchange. • Assess the airway and oxygenation status of any patient who has acute respiratory acidosis or acute confusion. • Instruct all patients at continuing risk for respiratory acidosis to stop smoking.

remember

Use of IV pumps does not decrease the nurse's responsibility to carefully monitor the patient's infusion rate and site!

Central IV therapy

Vascular access device (VAD) placed in central circulation, specifically within superior vena cava (SVC) near junction with right atrium Chest x-ray to confirm placement

remember

Veins cannot be used in patients with: Mastectomy Axillary lymph node dissection Lymphedema Paralysis of upper extremities Dialysis graft or fistulas

EMPLOYER/EMPLOYEE LIABILITY

Vicarious liability Employer liable for the acts of its employee if the employee was acting as an agent of the employer and the actions resulted in injury within that scope of employment

CARDIOVASCULAR ASSESSMENT

Vital signs every 15 mins until stable Heart sounds Cardiac monitoring Peripheral vascular assessment -Monitor for VTE

Hypertonic Solutions--- D10W, 3% NS, 5% NS, D5LR, D5 ½ NS, D5 NS, TPN, Albumin

Volume expanders that will draw fluid into the vascular space from the cell (solutions cause fluid to move out of the cells, resulting in shrinkage of the cells). *Examples*: D10W, *3%* NS, *5%* NS, D5LR, D5 ½ NS, D5 NS, TPN, Albumin (***hyper people are skinny, skinny people = tiny #'s <30%***) *Uses*: Client with hyponatremia or a client who has shifted large amounts of vascular volume to a third space3rd or has severe edema, burns, or ascites *Alert* Must watch for fluid volume excess, monitor in an ICU setting with frequent monitoring of BP, P, and CVP especially if they are receiving *3% NS or 5% NS*

Clinical Nursing Skills for Thermoregulation External warming devices

Warm blankets Administer warm oral fluids

Clinical Nursing Skills for Thermoregulation Active core warming

Warm intravenous fluids Heated humidified oxygen Warm fluid lavage

HAND WASHING GUIDELINES

Wash for at least 15 seconds in nonsurgical setting; 2-6 minutes in surgical setting. Remove jewelry and clean beneath fingernails. Use a bactericidal solution or use water if hands are visibly soiled. Use warm water, not hot Apply soap to wet hands Use friction Rinse soap Towel or hand dry

Body Fluid

Water is the primary body fluid Water content varies with age, sex, adipose tissue Water contains solutes Electrolytes Nonelectrolytes Homeostasis - proper functioning of all body systems; requires fluid and electrolyte balance

Bicarbonate

Weak base Major buffer of ECF From intestinal absorption of ingested bicarbonate into ECF, kidney absorption and breakdown of carbonic acid

PATIENT SAFETY THROUGHOUT THE PERIOPERATIVExl PERIOD PERIOPxl

World Health Organization (WHO) The Joint Commission (TJC) Association of perioperative Registered Nurses (AORN) National Patient Safety Goals (NPSG) Surgical Care Improvement Project (SCIP)

Safety hazards in the home - Firearm injuries

Youth suicides; domestic violence Prevention: -firearms safety education for parents and children -proper locked storage, keep ammunition separate

joint and connective tissue dz: gout

ac accumulation of uric acid deposits in the joints results from the body inability to metabolize purine foods causes of attacks- fad starvation diets, stress, illness

Immobility Interventions - Assessment (immobility)

aca Asses ability to walk - assess environment at home Complete assessment of ROM, muscle strength, pain, fatigue, etc. Assess ability to carry out functional activities (ADLS, etc)

skeletal disease osteoporosis tx and safety

aka u deann avoid throw rugs keep areas free from clutter adequate lighting use app. assistive devices diet-- high in ca- vit d- fiber- protein Exercise - walking, swimming, and water aerobics are recommended to increase muscle avoid alcohol n smoking note** excessive caffeine can cause excretion of ca through the urine non-skid socks n shoes meds: bed n bm vc boniva estrogen for post-menopausal women didronel NSAIDS for discomfort/pain biophosphonates aka fosamax muscle relaxers vit d supplements Calcium supplements (1000 mg to 1500 mg daily) foods high in ca: camms bsb cac cereal apricots molasses milk dairy esp yogurt spinach breads sardines beans carrots asparagus collard greens

celiacxl dz

multi-system-autoimmune GI disorder where when gluten is ingested it damages the villi in small intestine----CD is a chronic inflammation of the small intestinal mucosa that can cause bowel wall atrophy, malabsorption, and diarrhea. mall gluten- sensitive enteropathy- an immune reaction to eating gluten, a protein found in wheat, barley, rye, damages small intestine lining and prevents absortion of some nutrient *malabsorption* *celiaccause* diarrhea, fatigue, weight loss, anemia, bloating, *celiacs/s* anemia, Abdominal distention, vomiting, loss of bone density, itching,blistering, skin rash, damage to dental enemel, mouth ulcers, h/a, fatigue, nervous system injuries, joint pain, decrease spleen fx, heartburn, irritability, edema----In a celiac crisis, severe diarrhea and dehydration ensue; electrolyte imbalances and metabolic acidosis can create life-threatening disease---- kids vomiting, chronic diarrhea, swollen belly, ftt, decrease appietiate, muscle wasting Patients who have other autoimmune diseases, such as rheumatoid arthritis and diabetes mellitus type 1, are at the highest risk for the disease. *malabsorption* *body cant break down gliadin: wheat prolamin: plant storage protein that is high in amino acid gives protein structure reacts to tTg, iGa, EMA------Gliadin is a wheat prolamin, which is a plant storage protein that is high in the amino acids particularly PROLINE and GLUTAMINE.* - genetic,immunologic, and environmental factors occurs in adults and kids no cure- follow gluten free diet celiacs/s- *malnourished*- acronym mouth/lip ulcers anemia low rbc - cant absorb vitamins- need vitamin b12, folic acid, iron Lactose intolerance- no diary n/v osteo/bone changes- thinning,fx unexplained slow growth *puberty in kids*- no menses in girls/ not in percentile in height and weight loss in adults, -Growth retardation with lack of fat deposits and muscle wasting-----after age 5 rashes-dermatitis- herpetiformis/blisters- knees, elbow,backside,hairline- itchy Irreg periods---irritable: low in vitamins can cause depression and mental health problems stools greasy/oily and odorous Hair loss Enamel changes on teeth- yellow/brown spots or defomed enamel diarrhea varying signs and symptoms with cycles of remission and exacerbation (flare-up), usually related to how well they monitor their diet. Classic symptoms include anorexia, diarrhea and/or constipation, *steatorrhea (fatty stools)*, abdominal pain, abdominal bloating and distention, and weight loss. Some patients have no symptoms. Still others have atypical symptoms that affect every body system s/s bloating, stomach pain, gas, fatigue, low blood count -anemia Symptoms typically appear within 3-6 months after introduction of gluten (usually in form of grains) into child's diet objective: diarrhea, constipation, *sateorea: fatty bowel movement bc of malabsorption bc the small intestine is damaged* Atypical Symptoms • Osteoporosis • Joint pain and inflammation • Lactose intolerance • Iron deficiency anemia • Depression • Migraines • Epilepsy • Autoimmune disorders • Stomatitis • Early menopause • Protein-calorie malnutrition • Infertility Celiacdx screening blood test and endoscopy 72-hour fecal fat analysis, biopsy of small intestine, serum IgA antiendomysial antibodies and IgA antitissue transglutaminase antibodies Antibodies- blood test: tTg, iga serum, ema endoscopy: biospsy of villi is flat/abnormal? celeiaccomplications: malnourished affects every body system, bones-skin-mental health,growth, reproductive problems cancer/lymphoma-The primary complication of CD is cancer, specifically non-Hodgkin's lymphoma or GI cancers and NUTRITION deficiencies. villi never heal back: Refractory celiac dz cant absorb nutrients from food, will need iv nutrients dx: biopsy- identify gluten foods- dx: endoscopy, bld test-biopsy- identify gluten foods celiacni Monitor I&O, assess skin turgor, mucous membranes, and urine specific gravity assessing s/s: ask patient when noticed s/s, abdominal bloating, diarrhea, mental fog keep food diary- no pizza, sandwhich bc high in wheat, assess skin(herpetiformis/blisters- knees, elbow,backside,hairline) teeth mouth(sores) family hz? knowledge on celiac dz, gluten ability to read food labels/ingredients and what contains gluten educate must avoid all foods with gluten, so those villi can grow back and feel better celiacfoods *gluten free diet* plain meats- fish, poultry/chicken, beef **Grains-rice,corn** soy, millet,tapoica**chia buckwheat**fruits and veges**nuts,beans,legumes-dairy *no malt*Cornflakes,Milk, cream, cheese, puffed rice, cornmeal *foods w/ gluten* croissant, graham crackers, anything with wheat, barley,malt, beer, ale, rye, pasta noodles, seasonings, canned soup, breaded foods, bread type: crouton/crackers/cookies/bread/dough/cereals/oats/ *processed foods contain gluten*pizza, sandwich,Oatmeal,bread, rolls, cookies, cakes, crackers, cereal, spaghetti, macaroni, Ovaltine, instant tea mix, commercially prepared ice cream, prepared puddings, Salad dressings and mayonnaise, ketchup, gravy, Inability to tolerate dairy products Dietary management is the only available treatment for achieving disease remission. In most cases, a gluten-free diet (GFD) results in healing the intestinal mucosa after about 2 years celiacteach gluten free diet- to allow villi to heal-Teach patients to carefully check for hidden sources of gluten that are in foods, food additives, drugs, and cosmetics. Written and verbal instructions on gluten-free diet Urgency of seeking medical care in the event of celiac crisis Importance of lifelong adherence to dietary modifications and follow-up health care ****** Acute episodes of celiac disease called celiac crises are characterized by bulky, frothy stools with fat. Anorexia would be expected rather than increased appetite. Pain does not occur in waves prior to mealtimes. Stools are not soft and formed Acute episodes (called celiac crises) are characterized by a general flare-up of symptoms; may be precipitated by infections, prolonged fasting, ingestion of gluten, or anticholinergic drugs; can lead to electrolyte imbalance, rapid dehydration, and severe acidosis very different from a wheat allergy, or a gluten sensitivity sn n.i- patients will have to read food labels and identify foods with gluten vitamins- make up for the nutrients they miss out on immune rx to gluten, gluten is a protein found in wheat barely and rye dr will have them eat gluten foods, then do a blood test states that they're positive for celiac dz, then they go further and do a endoscopy

Renal Calculi renal xl

ashlii Kidney stones. Cause is unknown, but greater incidence in males. Most stones are calcium oxalate but can also be composed of calcium phosphate, uric acid, struvite, and cystine. ashlii manifistations -Severe pain (renal colic). Pain intensifies as the stone moves through the ureter. Flank pain suggests the stone is located in the kidney or ureter. Flank pain that radiates to the abdomen, scrotum, testes, or vulva suggest the stone is in the ureter or bladder. Renal calculi cause renal colic on affected side; originates in lumbar region and radiates around side to groin -Frequency -Fever -Diaphoresis -Pallor -Nausea -Vomiting -Tachycardia, tachypnea, increased BP (pain) -Decreased BP (shock) -Hematuria -Other symptoms: possible dull ache in kidney, abdominal distention, fever, and chills -Oliguira/anuria occurs with stones that obstruct urinary flow. This is a medical emergency and needs to be treated to preserve kidney function.---Urinalysis may reveal hematuria, pyuria, and crystal fragments Twenty-four-hour urine levels may reveal high calcium, uric acid, and/or oxalate *Medication therapy*: calcdrugs antimicrobial therapy for infection, analgesics for pain, and diuretics to prevent urine stasis *ashlii n.i* calcni -Increase fluid intake to 3L/day -Administer IV fluids, analgesics and antibiotics as prescribed -Strain all urine to check for passage of stone, and save to send to lab for analysis -Monitor pain, I&O, urinary pH-------=======Stones that are too large to pass spontaneously ( diameter > 5 mm ) , (diameter >5 mm), multiple stones, and those that obstruct urinary tract usually require surgery-----=====Strain all urine and save stones or stone fragments for analysis *rf* calcrf More common among whites than African americans Family history Dehydration: concentrates calculus-forming substances Urinary stasis, infection, or obstruction (allows solid materials or bacteria to collect and form nucleus of calculus) Metabolic factors: hyperparathyroidism, renal tubular acidosis, elevated uric acid levels (gout), defective oxalate metabolism Diet high in vitamin D or calcium, purines, oxalates, protein, or alkali *pt teaching* calcteach Treatment for calcium phosphate and/or oxalate stones Acid-ash diet with limitations of foods high in calcium and oxalates Treatment for struvite stones: acid-ash diet Treatment for uric acid stones: alkaline-ash and low-purine diet; increase hydration Treatment for cystine stones: alkaline-ash diet; increase hydration *DIET* calcdiet Acid-ash foods: Cranberries, plums, grapes, and prunes; tomatoes; eggs and cheese; whole grains; meat and poultry Alkaline-ash foods: Legumes, milk and milk products, green vegetables, rhubarb, fruits except those acid-ash fruits noted above Foods high in calcium: Milk and other dairy products, beans and lentils, dried fruits, canned or smoked fish (except tuna), flour, chocolate, and cocoa Foods high in oxalates: Asparagus, beets, celery, cabbage, dark green leafy vegetables, fruits, tomatoes, green beans, chocolate and cocoa, beer, cola beverages, nuts, and tea Foods high in purines: Organ meats, sardines, salmon, herring, venison, and goose; other meats (beef, chicken, pork, veal) also contain purines and should be limited in quantity *pt teaching* Dietary alterations to prevent recurrence of stones; teach dietary needs related to type of calculus Increase fluid intake to 2500-3500 mL/day Maintain activity at level that will prevent urinary stasis and resorption of calcium from bone If discharged prior to stone passage, collect and strain all urine and bring stones to follow-up visit; observe urine amount and characteristics and report to healthcare provider at follow-up visit also Report increased pain, persistent blood in urine, inability to void, significant decrease in UO Report signs of infection: burning with urination, cloudy urine, or fever Review specific drug information and procedures for self-administration Increase hydration and exercise

muscle fibromyalgia

au hs A clinical syndrome or condition involving chronic widespread diffuse musculoskeletal pain, stiffness, and tenderness. usually affects women of child-bearing age and has no known cause healthcare provider will rule out everything else first syndrome of fatigue and chronic pain

skeletal disease osteoporosis s&S

bdd f cd back pain Decrease in height accompanied by kyphosis dowagers hump- hump back Fractures: forearm, femur, ribs, and spine constipation decreased bone mass

Postoperativexl phase Postopxl

begins with client's admission to PACU and ends with a follow-up evaluation in either a clinical setting or home; general nursing activities include: Assessing for physical adaptation following anesthesia and surgical intervention Assisting in orienting client who is regaining consciousness Providing continuity of information between nursing units about client progress after surgery

skeletal disease kyphosis tx

braces and spinal infusion if cardiopulmonary problems or pain occur

Lyme disease

bm Bacterial infection that occurs after the bite of an infected deer tick, once the tick is attached it must remain in place for 36-48 hours for the infection to be transmitted Multisystem inflammatory process with devastating long-term effects if left untreated

Bone marrow aspiration and biopsy

butt Bone marrow is aspirated using a needle that is inserted into the cancellous bone. Used to examine the bone marrow for abnormal tissue growth or to monitor the progress of bone marrow disease. This procedure is performed under local anesthesia. The aspiration can be performed at the ILIAC CREST or the STERNUM.

skeletal disease osteomalacia dx procedures

bx cvs bp bone densitometry x-ray creatinine vit d serum ca bun phosphate

emergency and disaster preparedness multi- casualty

can be managed by a hospital using local resources

skeletal disease pagets dz

chronic bone disorder that begins with an increase in bone absorption, in compensating for this bone formation increases along with bone remodeling leading to deformities and fractures

psychogenic pain

chronic pain depression, bi-polar, ocd, panic attack *meds* nsaids, antidepressants, narcotics book Psychogenic pain refers to pain that is believed to arise from the mind. The patient perceives the pain despite the fact that no physical cause can be identified. Psychogenic pain can be just as severe as pain from a physical cause.

safety** nurses attend to safety needs of

clients in all healthcare settings healthcare workers, including themselves safety is a basic human need

arthritis dz: osteoarthritis

cn changes are associated with increasing age and trauma nonsystemic, non inflammatory progressive disorder of movable joints

Nerve conduction studies

ene Electromyography (EMG) measures electrical activity of skeletal muscle at rest and during voluntary muscle contraction. Needles are inserted into the muscle to detect electrical activity, which is printed as a graph. This procedure may be uncomfortable for the patient. EMG is used to diagnose neuromuscular diseases and nerve damage. The EMG can be used to differentiate between muscle and nerve damage.

eat

evaluate assess teach

emergency and disaster preparedness disaster

event in which illness or injuries exceed resource capabilities of a health care facility or community due to destruction and devastation

safety hazard - community pollution

example/ cause air, water, noise, soil prevention- c pe pe car pool public transportation ear plugs proper disposal and recycling of solid waste environmental safe products

safety hazard - community mva

example/ cause fan-p failure to use seat belts alcohol non-deployment of airbags pedestrian accidents prevention-- pauu proper age- dependent restraints for children avoid distractions in cars-- cell phone txt message- loud music use designated driver use seat belts, proper age-dependent restraints for children

joint and connective tissue dz: gout foods high in purine

fl loop pads fish esp sardines liver lobster oatmeal oyster peas poultry asparagus dried beans spinach

PN concepts

he c healthcare organization/disparaties ethics clinical judgement

identify the common causes of patient falls

hss tl high bed slippery floors stairs tubs low toilet seat

skeletal disease pagets dz dx procedure

increase in serum- alkaline phosphate is the first indicator x-ray bone scan

skeletal disease osteomylitis

infection has invaded bone area

joint and connective tissue dz: gout foods low in purine

megn mc sicc f milk eggs gelatin nuts most veges citrus juice sugar increase fluids cheese cherries fats

skeletal disease scoliosis tx

mild curvature- exercise and braces sx is needed for curvature greater than 40 degrees

older adult factors affecting safety impaired mobility

need to focus on functional ability

radiating pain radiatingxl

nerves on nerve root under pressure numbness sharp tingling pain muscle weakness chest pain *ex* sciatica, MI in arm, jaw book Radiating pain starts at the origin but extends to other locations. For instance, the pain of a severe sore throat may extend to the ears and head. Or the pain of gastroesophageal reflux ("heartburn") may radiate outward from the sternum to involve the entire upper thorax.

older adult factors affecting safety.. test types of abuse

physical- use of physical force that results in bodily injury financial- mismanagement or misuse of property or resource emotional- intentional use of threats, humiliation, intimidation, isolation

skeletal disease osteomylitis at risk

pico rem poor blood supply Injection/needle drug use chronic illness- diabetes, cardio-vascular dz overweight recent trauma elderly Malnourished patients

muscle fibromyalgia s&s

pif pain- increase with stress- weather conditions insomnia fatigue

Major complications of immobility

po padd pk Pressure ulcers Orthostatic intolerance (postural or orthostatic hypotension) Psychological effects: powerlessness and possible reduced self-esteem Atrophy and contractures Disuse osteoporosis Deep vein thrombosis Pneumonia 8. Decrease in peristalsis (paralytic ileus) Kidney stones

case management

provides quality and cost effective services and resources to achieve positive pt outcome ex- The nurse and case manager coordinate *in-patient* and community- based care before discharge from facility in order to prevent readmission

skeletal disease osteomylitis s&s

ps fmp tt purulent drainage from infected site swelling fever malaise pain of affected area tenderness of infected area tachycardia

Nursing Process - Goals and outcomes related to immobility

ridi -Report more control over muscles during ambulation -Increase ambulation (distance and time) daily -Describe modifications to daily routine to reduce stress and promote relaxation -Identify ways to conserve energy to manage fatigue

scrub nurse

sets up the sterile field prepares the surgical instruments assists with the sterile draping for the pt anticipates and responds to the surgeons needs maintains the integrity of the sterile field

acutexl glomerulonephritis-

strep throat causes glomerulonephritis-- not really strep, but the immune system complexes inflammation of the filtering structure of the nephron; antigen-antibody complexes collect in the glomeruli n cause inflammation mall *glomeruli become injured d/t infection (viral,bacterial, fungal or parasitic)-Any systemic bacterial, parasitic, fungal, or viral infection (potentially). Prompt antimicrobial and anti-inflammatory treatment reduces the risk for acute glomerulonephritis becoming a chronic condition. *smoky, rusty, cola, reddish- brown colored urine, fatigue, lack of energy, anoxeria dx/labs ua for hematuria and proteinuria, A 24-hour urine collection for total protein assay is obtained, renal biospy- Other tests for indicators of IMMUNITY problems include antistreptolysin-O titers, C3 complement levels, cryoglobulins, antinuclear antibodies (ANAs), and circulating immune complexes. Testing for human immune deficiency virus (HIV) is recommended. Blood, skin, or throat cultures may be obtained. Antistreptolysin-O titers are increased after group A beta-hemolytic Streptococcus infections. Complement levels are decreased when the complement system is activated. Type III cryoglobulins may be found during acute illness. ANAs suggest an IMMUNITY excess (autoimmune response), and systemic lupus erythematosus (SLE) is just one possibility. Serum immune complexes containing IgG and C3 are often detected. interventions-managing infection pcn,erythromycin, or azithromycin,stress personal hygiene and hand washing-Medication therapy: antimicrobials (such as penicillin) for infection; prednisone and aggressive immunosuppressive therapy; analgesics for pain relief; and vitamin and electrolyte replacement as needed sara n.i what is going on? fluid overload, htn, renal impairment monitor fluid status very closely, maybe prescribed diuretics daily weight- earliest sign of fluid retention- standing scale strict calculation of I&O low uop, monitor hyperkalemia- no k rich foods, assess urine color, bun n creatine monitor edema. lung sounds any crackles which indicates pulmonary edema, esp vital signs- bp bed rest for acute phase- antihypertensives-Monitor VS every 4 hours (tachycardia, hypertension) no sodium fluid until recovered prevention of complications diuretics, sodium and water restriction for htn, edema, fluid overload, dialysis maybe necessary if fluid access and uremic symptoms cannot be controlled, Plasmapheresis (removal and filtering of the plasma to eliminate antibodies) also may be used ,conserve patient energy and balance activity with rest to maintain function. Relaxation techniques and diversional activities can reduce emotional stress. pt education drug education, ensure they understand dietary or fluid restrictions, weigh daily and bp daily at the sametime each day. strep infections can reoccur, get strep culture rapidly progressive glomerulonephritis - fluid volume excess, htn, oliguria, electrolite imbalances, and urinary symptoms may have previous infections or systemic dz, the renal decline often progresses to end-stage kidney dz-*Evaluate for signs of renal failure: oliguria, azotemia, and acidosis* Serum albumin levels are decreased because this protein is lost in the urine and fluid retention causes dilution. nephrotic syndrome are massive proteinuria, hypoalbuminemia, and edema s/s book Inspect the patient's skin for lesions or recent incisions, including body piercings, because these may be the source of organisms causing GN had strep hypertension aso antistreplysin + titer decreased gfr dec uop swelling face/eyes/mild in the morning tea/cola colored urine-hematuria recent strep elevated bun n creatine proteinuria-mild Ask about any difficulty breathing or shortness of breath. Assess for crackles in the lung fields, an S3 heart sound (gallop rhythm), and neck vein distention. The patient may have fatigue, a lack of energy, anorexia, nausea, and/or vomiting if uremia(abnormally high levels of waste products in the blood) from severe kidney impairment is present.

safety definition

the ability to keep the client and staff free from harm and minimize errors in care prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors.

patient- centered care

the patient- designee is the source of cntrl and full partner in providing compassionate coordinated care based on respect for pts needs, preferences, values nurse culturally competent joint commission family- centered care right of pt and family to make informed decisions

clinical judgement

the process that nurses and other members of the interprofessional team use to make decision based on interpretation of the patient's needs or problems. critical thinking skills and the nursing process - tanner - - assessment- noticing - analysis- interpreting - planning and implementation - responding - evaluation- reflection *rapid response teams*: save lives and decrease the risk for harm by providing care before a medical emergency occurs by intervention rapidly when needed for patients who are beginning to clinically decline who is rapid response?

joint and connective tissue dz: gout dx procedure

uu less Urine albumin will be greater than 100 mg/24 hours Urinary uric acid will be elevated Leukocytosis will be present ESR will be elevated serum uric acid greater than 7mg/dl synovial fluid analysis- will show uric acid crystals

Treatment of complications of anesthesia complicationxl

watkins 1 Establish open airway FIRST 2 Give oxygen 3 Notify surgeon Fast-acting barbiturate is usual treatment Epinephrine for unexplained bradycardia

Hallmark of respiratory acidosis:

watkins give o2 2 make it go up Decreased PaO2 with rising PaCO2

skeletal disease osteomylitis tx

wip wound debridement IV antibiotic therapy for 4-6 weeks- type depends on culture pain meds

Artificial passive IMMUNITY

would be used to present disease or death from rabies, tetanus, and poisonous snakebites.

key points Chapter 14: Care of Preoperative Patients

• Advances in surgical techniques, anesthesia, pharmacology, medical devices, and supportive interventions have provided many benefits to perioperative patients. • Surgical procedures are categorized by the purpose, body location, extent, and degree of urgency. Nursing care is directed toward protecting the patient from injury (SAFETY), prevention of serious cardiac events, prevention of DVTs, and maintaining normothermia. • Patient SAFETY throughout the perioperative period is the number one priority and requires TEAMWORK and INTERPROFESSIONAL COLLABORATION and the use of professional ETHICS. • Quality measures such as wrong-site surgery, patient falls, hospital-acquired pressure ulcers, and vascular catheter associated infections must now be reported to the Centers for Medicare and Medicaid Services (CMS). postoperative periods is known as the perioperative experience. • Preoperative education may begin in the surgeon's office for planned or elective surgery using pamphlets, written instructions, and DVDs. • Information about informed consent, dietary restrictions, bowel and skin preparations, exercises after surgery, and plans for pain management promote patients' participation and help achieve the desired outcome. • Education should be documented in the patient record, including who was involved in teaching, what was taught, and the educational materials given to the patient. • Ask the patient to explain in his or her own words what surgical procedure is being done and why. • If the patient's explanation of the scheduled surgery is not consistent with the documentation, notify the surgeon and request that he or she speak to the patient. • Surgery of any type requires informed consent from the patient or legal guardian. • Surgical procedures that are site specific, such as left, right, or bilateral, require patient identification before surgery. o Patient or staff marks the site to ensure the correct site is used. o Check that documentation for any procedure to be performed on one of a paired organ or extremity clearly indicates which organ or extremity is involved. • Patients have the right to have or to initiate advance directives, such as a living will or durable power of attorney. Ask the patient if an advance directive has been completed. • Preoperative drugs may be prescribed to reduce anxiety, promote relaxation, reduce nasal and oral secretions, prevent laryngospasm, reduce vagal-induced bradycardia, inhibit gastric secretions, and decrease the amount of anesthetic needed for the induction and maintenance of anesthesia. Skin preparation before surgery is the first step to reduce the risk for surgical site infection. Any break in skin, especially for older adult, increases the risk for infection. • Ensure patient SAFETY by assessing the patient's risk for falling, especially older patients. • On the day of surgery, the patient's usual drug schedule may need to be altered in consultation with the medical physician and anesthesia provider. • Report any abnormal assessment findings to the surgeon and to anesthesia personnel; this demonstrates being a proactive advocate using professional legal and ETHICAL responsibility. • The Joint Commission's NPSGs require the patient receives information about informed consent, dietary restrictions, specific preparation for surgery, and exercises after surgery, and plans for pain management to promote patients' participation and help achieve the expected outcome. • Ensure that dentures and any other personal items are removed from the patient before the patient is transferred to the surgical suite. • Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria when a patient is having major abdominal, pelvic, perineal, or perianal surgery. • Prepare the patient for possible postoperative placement of tubes, drains, and vascular access devices. o Follow physician's orders for proper care of these devices. o Monitor proper positioning of patient to maintain patency of tubes, drains, and vascular access devices. • In some cases, a urinary catheter is inserted to prevent injury to bladder and to measure accurate output. • The patient may receive a prophylactic antibiotic to reduce the risk for a surgical site infection, which is given within 60 minutes before the incision is made. • Teach the patient and family members about exercises and procedures that will be performed after surgery. o Family members can be helpful in reminding patients to perform these exercises. o Teaching before surgery reduces apprehension and fear for patients and families. o Teach patients about dietary restrictions and preoperative preparations. o Teach the patient-specific interventions to perform after surgery to prevent complications, such as incision splinting, deep-breathing exercises, and range-ofmotion exercises. o Discussion, demonstration with return demonstration, and practice by the patient aid in the ability to perform various breathing and leg exercises, including incentive spirometry, coughing, and splinting. • Careful assessment for deep vein thrombosis before surgery and timely intervention may prevent the fatal complication of pulmonary embolism. o Devices may be used during and after surgery, along with leg exercises and early ambulation, to promote venous return. • Mobility soon after surgery stimulates intestinal motility, enhances lung expansion, mobilizes secretions, promotes venous return, prevents joint rigidity, and relieves pressure.

key points Chapter 16: Care of Postoperative Patients

• The postoperative period starts at the completion of surgery and transfer of the patient to either the postanesthesia care unit (PACU), same-day surgery unit, or intensive care unit (ICU). • The actual time spent away from home after surgery varies according to age, physical health, self-care ability, support systems, type and length of surgical procedure, anesthesia, any complications, and community resources. • The purpose of a PACU is the ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery, including impaired GAS EXCHANGE, PAIN, CLOTTING, INFECTION, and impaired TISSUE INTEGRITY. • After the surgery is completed, the circulating nurse and the anesthesia provider accompany the patient to the PACU. • When the patient is in critical condition with impaired GAS EXCHANGE, transfer may be directly from the operating room to the ICU. In such cases, a call should be made to the ICU if equipment such as a ventilator is needed. • On arrival, the anesthesia provider and the circulating nurse give the PACU or ICU nurse a verbal "hand-off" report to communicate the patient's condition and care needs. This is done per the Joint Commission's National Patient Safety Goals which requires effective communication between health care professionals. • The PACU nurse is skilled in the care of patients with multiple medical and surgical problems immediately after a surgical procedure. • PACU nurses require in-depth knowledge of anatomy and physiology, anesthetic agents, pharmacology, PAIN management, airway management, surgical procedures, and advanced cardiac life support. • The PACU nurse is skilled in assessment and can make quick decisions if emergencies or complications occur. INTERPROFESSIONAL COLLABORATIVE CARE • After receiving the surgical team's hand-off verbal report and assessing the patient, the PACU nurse reviews the electronic medical record for information about the patient's history, presurgical physical condition, and emotional status. • The patient is assessed and data are recorded on a PACU flow chart record. • Assessment data include level of consciousness, temperature, pulse, respirations, oxygen saturation, blood pressure, and evaluation of the surgical area for bleeding (CLOTTING). • Vital signs and heart sounds are assessed on admission to the PACU and then at least every 15 minutes until stable, or more often if the patient's condition warrants or the surgeon prescribes. • Compare vital signs to those taken before surgery. • The most important assessment is respiratory. When the patient is admitted to the PACU, immediately assess for a patent airway and adequate GAS EXCHANGE. • Begin every subsequent assessment of the patient by checking the airway and breathing effectiveness. • Monitor the patient's oxygen saturation with pulse oximetry at least every hour or more often, according to the patient's condition. • Recognize and respond if the patient's oxygen saturation drops below 95% (or below presurgery baseline), immediately notifying the surgeon or anesthesia provider. • Keep suction equipment, oxygen, and artificial breathing equipment near the patient in the PACU. • Peripheral vascular assessment needs to be performed because anesthesia and positioning during surgery may impair the peripheral circulation and contribute to CLOTTING and venous thromboembolism. • Cerebral functioning and the level of consciousness or awareness must be assessed in all patients who have received general anesthesia or any type of sedation. • Observe for lethargy, restlessness, or irritability, and test coherence and orientation. • Motor and sensory function is assessed for all patients who received general or regional anesthesia since both may alter the motor and sensory function. • Fluid volume deficit, fluid volume overload, or electrolyte imbalances may occur after surgery. • Fasting before and during surgery and the loss of fluid and blood during the procedure affect the patient's fluid and electrolyte balance. • Acid-base balance is affected by the patient's respiratory status before and during surgery, metabolic changes during surgery, and losses of acids or bases in drainage. • Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. • Nausea and vomiting are among the most common reactions after surgery, although preventive drug therapy is effective in reducing the incidence. • Hypothermia after surgery causes shivering that increases oxygen demand and can induce hypoxemia. o Many rewarming methods can be used, although prevention is more important. o The highest incidence of hypoxemia after surgery occurs on the second postoperative day. • Assess the incision site in the PACU and each shift on the medical-surgical nursing unit. • A clean surgical wound heals at skin level in about 2 weeks in the absence of trauma, connective tissue disease, malnutrition, infection, or the use of some drugs, such as steroids. o Smokers, older patients, obese patients, diabetic patients, and those with reduced immunity are at risk of impaired TISSUE INTEGRITY and delayed wound healing and infection. o Complete healing of all tissue layers within the wound may take 6 months to 2 years. • The surgeon usually performs the first dressing change to assess the wound, remove any packing, and advance or remove drains. • Use aseptic technique during all dressing changes. • The use of drains helps prevent deep infection and abscess formation. Monitor drainage, maintain sterile technique when removing drainage from a reservoir, and protect the underlying skin from maceration from drainage. • Patients frequently have PAIN or discomfort after surgery. • PAIN is a subjective experience and may be more intense than the health care professional can appreciate. • PAIN after surgery is related to the surgical wound, tissue manipulation, drains, positioning during surgery, presence of an endotracheal tube, and the patient's experience with pain. • Priority nursing diagnoses after surgery include impaired GAS EXCHANGE, impaired skin (TISSUE) INTEGRITY, acute PAIN, and potential for hypoxemia. • Wound infection is a major complication after surgery resulting from contamination during surgery, preoperative infection, debilitation, or immunosuppression. • Dehiscence or evisceration with protrusion of internal contents is a surgical emergency. o Notify the surgeon and remain with the patient if wound dehiscence or evisceration occurs. o Have the patient lie flat (supine) with knees bent to reduce intra-abdominal pressure. o Apply sterile, nonadherent, or saline dressing materials to the wound. • Use established criteria to determine when a patient is ready to leave the PACU for discharge to home or a medical-surgical nursing unit. o The health care team determines the patient's readiness for discharge from the PACU by a recovery score rating of at least 10 on the recovery scale. o Other criteria for discharge that are organization specific may include stable vital signs; normal body temperature; no overt bleeding (CLOTTING); return of gag, cough, and swallow reflexes; and the ability to take liquids. o Once the patient is discharged from the PACU, vital signs are often measured every 15 minutes for four times, every 30 minutes for four times, every 2 hours for four times, and then every 4 hours for 24 to 48 hours. • During the postoperative period, as part of the critical rescue management for patient SAFETY and quality care, the nurse notices all patients remain at risk for pneumonia, shock, cardiac arrest, respiratory arrest, CLOTTING and venous thromboembolism (VTE), and GI bleeding. • Assess the TISSUE INTEGRITY of the incision site each shift (on the medical-surgical nursing unit) or at least every 8 hours and monitor for signs of infection. • Prevention and early recognition of pressure ulcers due to positioning during surgery are important. Collaborate with the Wound Ostomy Continence Nurse for prevention and management of hospital-acquired pressure ulcers. • Nursing observations and interventions are part of critical rescue management for patient safety and quality to reduce the risk for adverse patient outcomes. • For patients discharged directly to home, assess the home environment for safety, cleanliness, and availability of caregivers to determine the patient's needs. • The patient is usually concerned about complications, PAIN, changes in the usual activity level, or payment of the hospital bill. • The teaching plan for the patient and family after surgery includes PAIN management, drug therapy with reconciliation of post-operative drugs, SAFETY (e.g., understanding whom to contact in case of complications, progressive increase in activity, needed assistive devices), prevention of infection with care and assessment of the surgical wound, management of drains or catheters, nutrition therapy, follow-up with the surgeon, and progressive increase in activity schedule. • Instruct the patient and family about the clinical manifestations of complications and when to seek assistance. • Reinforce to the patient after surgery the specific interventions to use to prevent complications, such as incision splinting, deep-breathing exercises, and range-of-motion exercises. • Encourage early ambulation when appropriate, but stress the need for following the activity restrictions prescribed by the surgeon. • Allow the patient to verbalize feelings about any change in physical appearance or lifestyle as a result of surgery. • Teach the patient about any drugs to be continued after discharge from the facility. • Reassure patients that taking PAIN medication when needed, even opioids, does not make them drug abusers. • Offer alternative therapies for relaxation, pain reduction, and distraction, such as massage, music therapy, and guided imagery.

Body Fluid Compartments

*Intracellular* Within the cells *Extracellular* Interstitial Intravascular Transcellular

Intravenous Solutions

*Isotonic Infusate* Water does not move into or out of body's cells Risk for fluid overload, especially older adults *Hypertonic Infusate* Corrects fluid, electrolyte, and acid-base imbalances by moving water out of body's cells, into bloodstream Parenteral nutrition is example *Hypotonic Infusate* Moves water into cells and expands them

Osteoporosis screening

-What are the national guidelines for screening? **Women 65 and older AND/OR younger who have increased fracture risk -Test? DEXA of the hip and spine

Bone marrow

1. Soft, spongy, highly cellular blood-forming tissue that fills cavities of bones and is site for hematopoiesis (red blood cell or RBC production) and storage of RBCs. 2. Responsible also for production of white blood cells (WBCs), and platelets. 3. Becomes predominantly fatty with age, particularly in long bones of limb.

Passive ROM

Accomplished with assistance of a caregiver who supports client's body part while moving it

Introduction to Acid-Base Chemistry

Acids - release hydrogen ions when dissolved in water Bases - bind with hydrogen ions in solutions Buffers - critical in maintaining normal body fluid pH Body fluid chemistry: Bicarbonate ions (HCO3) Relationship between CO2 and hydrogen ions Calculation of free hydrogen ion level

MALIGNANT HYPERTHERMIA

Acute, life-threatening complication May be genetic Begins with skeletal muscle exposed to specific agent Causes increased metabolism, calcium levels in muscle cells Leads to acidosis, high temperatures, dysrhythmias

Phychosocial Assessment

All pain holds significant meaning for the person experiencing it • Be aware that some nurses and physicians have biases about pain assessment and management. Be objective when caring for any patient in PAIN. Remain objective; advocate for proper pain control

circulating nurse

An RN who applies the nursing process to coordinate all activities in the operating room. She is a client advocate who continuously monitors the client and the sterile field maintains a safe, comfortable environment; communicates with appropriate personnel outside the operating room; responds to emergencies; and, in some cases, administers sedation to the patient. An important aspect of the circulating nurse's role is to attend to the patient during the induction of anesthesia.

Idiosyncratic reaction

An unusual response to a drug that may be unrelated to dose; reaction may or may not reoccur if medication is given again

Postop: Laboratory assessment labxl

Analysis of electrolytes CBC "Left-shift" (bandemia) Specimens for C&S ABGs Urine and renal laboratory tests Other (e.g., serum amylase, blood glucose)

COMPLICATIONS OF LOCAL OR REGIONAL ANESTHESIA

Anaphylaxis Incorrect delivery technique Systemic absorption Overdose Local complications

somatic pain Nociceptive pain somaticxl

Ankylosing spondylitis Cancer pain (tumor growth) and pain associated with bony metastases Labor pain (cervical changes and uterine contractions) Osteoarthritis pain Osteoporosis pain Pain of Ehlers-Danlos syndrome Rheumatoid arthritis pain Surgical trauma Wound and burn pain Cutaneous or superficial: skin and subcutaneous tissues Well localized Sharp, throbbing Incisional pain, pain at insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms throbbing/ dull, chronic pain, superficial/deep, bones, connective tissue, sob, fatigue, weakness, Bony metastases, osteoarthritis and rheumatoid arthritis, low back pain, peripheral vascular diseases ------- Deep somatic: bone, muscle, blood vessels, connective tissues Dull, aching, cramping Incisional pain, pain at insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms Bony metastases, osteoarthritis and rheumatoid arthritis, low back pain, peripheral vascular diseases *meds* analgesics, stress management *ex* 1. pressure ulcer bc bones slow everything down. 2. IMMOBILITY 3. dvt risk 4. pneumonia in lungs 5. arthritis book Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. Deep somatic pain is more diffuse than cutaneous pain and tends to last longer. A fracture or sprain, arthritis, and bone cancer can cause deep somatic pain.

Immobility related to perfusion

Are less able to be mobile because of reduced oxygenated blood reaching peripheral tissues Those who are immobile, perfusion is less effective because of reduced venous return

Considerations for Older Adults

At risk for most electrolyte imbalances from age-related organ changes Have less total body water than younger adults; more at risk for fluid imbalances; more likely to be taking drugs affecting fluid or electrolyte balance

FEDERAL LAWS

Bill of Rights Social Security Act of 1965 Consolidated Omnibus Budget Reconciliation Act Emergency Medical Treatment and Active Labor Act of 1986 American with Disabilities Act Patient Self-Determination Act of 1991 Health Insurance Portability and Accountability Act of 1996 Patient Protection and Affordable Care Act of 2010

BIOETHICS, CLINICAL ETHICS, RESEARCH ETHICS

Bioethics: Ethical questions surrounding biological sciences and technology Clinical ethics: Decisions made at the bedside Research ethics: Conduct of research using humans and animals.

chronic pain persistent pain chronicxl

By Duration Non-cancer- • The veterans of recent wars can have chronic non-cancer pain, mostly due to musculoskeletal disorders (MSD) from either trauma or arthritis which causes depression, post-traumatic stress disorder (PTSD), and a decreased sense of well-being. Some of these patients are managed within the VA system. Some are jobless and homeless, and therefore, receive no care to manage their physical or psychological health problems. Persists or recurs for indefinite period (usually longer than 3 - 6 months) Onset is gradual Poorly localized (hard to pinpoint) Often accompanied by depression Psychological implications Difficult to treat ------------------------- Cancer (malignancy) Caused by cancer/side effects of treatment Persistent pain Breakthrough pain (BTP) "Breaks through" medication treatment Episodic • Chronic PAIN can last a person's lifetime • Chronic PAIN is the most common cause of long-term disability, affecting millions of Americans and others throughout the world. Usually lasts longer than 3 months migraine headache use a dim light, no bright lights ex -edema - depression- intractable pain. -NO change in vitals - change in the quality of life, NO ADL/ interferes w/ adl - tired all the time - strain on the family- stress on caregiver, kids, fighting - arthritis - fibromyalgia -guided imagery -PREVENTION METHODS- BIG ONE - CANCER - bulging/ herniated disc •May or may not have well-defined cause • Usually begins gradually and persists • Serves no useful purpose • Ranges from mild-to-severe intensity • Often accompanied by multiple quality-of-life and functional adverse effects, including depression; fatigue; financial burden; and increased dependence on family, friends, and the health care system • Can impact the quality of life of family members and friends know meds for the dz process • Three major types of pain have been identified—acute, chronic cancer, and chronic noncancer. • Chronic pain or persistent pain is further divided into two subtypes. o Chronic Cancer Pain—patients with cancer are often inadequately treated for what can be persistent, excruciating pain and suffering. Most cancer pain is the result of tumor growth, including nerve compression, invasion of tissue, and/or bone metastasis, an extremely painful condition. Cancer treatments also can cause acute pain. o Chronic Non-Cancer pain, most often in older adults, is often associated with tissue injury that has healed or is not associated with cancer, such as arthritis or chronic back pain. This type of pain is the most common. book related to a progressive disorder, or it can occur when there is no current tissue injury, as in neuropathic pain. Patients with chronic pain may experience periods of remission and exacerbation. Unlike acute pain, chronic pain is often viewed as insignificant by family and care providers. It may lead to patient withdrawal, depression, anger, frustration, and dependence. Next to incurability, chronic pain is the most feared aspect of contracting cancer or other progressive diseases. Chronic pain (also called persistent pain) is often defined as pain that lasts or recurs for an indefinite period, usually for more than 3 months. The onset is gradual, and the character and quality of the pain often change over time. Chronic pain serves no biologic purpose. Because it persists for an extended period, it can interfere with personal relationships and performance of ADLs. Chronic pain can also result in emotional and financial burdens, depression, and hopelessness for patients and their families. It is important to remember that the body adapts to persistent pain; thus vital signs such as pulse and blood pressure may actually be lower than normal in people with chronic pain. Although many characteristics of chronic pain are similar in different patients, be aware that each patient is unique and requires a highly individualized plan of care. Chronic Cancer Pain. Many patients with cancer report pain at the time of diagnosis, which increases in advanced stages of the disease. Most cancer pain can be managed successfully by giving adequate amounts of oral opioids around the clock, yet patients with cancer are often treated inadequately for what can be persistent, excruciating pain and suffering. Most cancer pain is the result of tumor growth, including nerve compression; invasion of tissue; and/or bone metastasis, an extremely painful condition. Cancer treatments also can cause acute pain (e.g., from repetitive blood draws and other procedures, surgery, and toxicities from chemotherapy and radiation therapy). Patients with cancer pain generally have pain in two or more areas of the body but usually talk about only the primary area. Be sure to perform a complete pain assessment to ensure an effective plan of care. Chronic Noncancer Pain. Chronic noncancer pain is a global health problem, occurring most often in people older than 65 years. This type of pain was formerly called chronic nonmalignant pain. However, most experts, and certainly patients who suffer daily, believe that all pain is malignant. There are many sources and types of chronic noncancer pain. Among the most common are neck, shoulder, and low back pain following injury. Chronic conditions such as diabetes, rheumatoid arthritis, Crohn's disease, and interstitial cystitis often are associated with chronic pain. People who have had a stroke or trauma or are paralyzed may report persistent pain as a result of central nervous system (CNS) damage. Sometimes the exact cause of the pain is unclear, as with fibromyalgia.

REVIEW OF IMMUNE RESPONSE 2

Cells associated with immune response All cells are derived from stem cells in the bone marrow and begin as either myeloid progenitor or lymphoid progenitor cells Myeloid - neutrophils, monocytes, eosinophils, basophils, and mast cells Lymphoid -B lymphocytes, mature T lymphocytes, and natural killer cells B and T lymphocytes As person is challenged by foreign antigens during life, specifity of lymphocytes to a specific antigen emerges process called "clonal selection" Re-exposure to same antigen the person will have more rapid and efficient immune reponse indicating a "memory" capacity for the immune system During fetal development produced in large numbers B-lymphocytes - Preprocessing and maturation occurs in the liver T-lymphocytes - maturation occurs in the thymus gland

Postop: Neurological assessment. Postopxl

Cerebral functioning Motor and sensory assessment after epidural or spinal anesthesia

Remember...

Change lipid tubing every 24 hr Change blood tubing within 4 hr Change propofol (Diprovan) tubing every 6 to 12 hr *Check facility protocol for possible deviations

BALANCED ANESTHESIA

Combination of IV drugs and inhalation agents used to obtain specific effects Example: -thiopental for induction -nitrous oxide for amnesia -morphine for analgesia -pancuronium for muscle relaxation

Skeleton

Consists of bones, joints, and cartilage; provides framework for body and protects soft tissue and vital organs Composed primarily of calcium (as Ca++ phosphate and Ca++ carbonate) Provides points of attachment for muscles

Infusion System

Containers - plastic (PVC-free or DEHP-free), glass Administration sets—secondary, intermittent Add-on systems Needleless connection devices Rate-controlling infusion devices

PERSONAL ETHICS

Continuously intersect with other categories of ethics. Do not overlap perfectly; consequently, a potential for conflict exists. Sources of ethics are not static and change over time.

TYPES OF CIVIL LAW

Contract law Dealing with agreements between individuals Explicit or implicit -- Tort law Dealing with duties and rights among individuals Involves claims for damages

Clinical Nursing Skills for Thermoregulation Cooling measures

Cool water bath Cool intravenous fluids Cool fluid lavage Cooling blankets

Infusion Therapy

Delivery of medications in solutions and fluids by parenteral route IV therapy most common route IV therapy most common invasive therapy administered to hospitalized patients

Safety hazards in the home - Suffocation/Asphyxiation

Drowning, choking, smoke/gas inhalation Children 0-4 years old high risk Prevention -Watch for small, removable parts -Cut food into tiny pieces -Pay attention to mobiles, strings, cords, plastic bags -Apply a barrier to pool -Know Heimlich maneuver

Dual Energy X-ray Absorptiometry Scan (DEXA)

Dual energy X-ray absorptiometry (DEXA) scans measure bone density. These scans assist in the early diagnosis of osteoporosis. Using a computer analysis, the scans can determine size, thickness, and mineral content of the bone.

NURSING ETHICS

Ethical questions that arise out of nursing practice -What will your level of participation be in a given ethically challenging situation? -Can you support clients'decisions based on their ethical beliefs? -What are your feelings about the results of decisions made by others?

PROFESSIONAL ETHICS

Ethical standards and expectations of a particular profession Held to a higher standard because of privileged role in society Code of conduct Aimed at the highest ideals of practice

COMPLEXITY OF ETHICS

Ethics encompasses many different dimensions of a person's life.

Tendons

Fibrous tissue that attaches muscle to bone *book* tendons (bands of tough, fibrous tissue that attach muscles to bones)

TRADITIONAL LEGAL DISCIPLINES

Five traditional legal disciplines: Tort law Contract law Property law Constitutional law Criminal law ***All legal disciplines have shaped health care law to some degree, but most health care laws are derived from constitutional law and tort law.

ORGANIZATIONAL ETHICS

Formal and informal principles and values guide the behavior, decisions, and actions taken by members of an organization. Directs all aspects of an organization.

Clinical Significance: Diffusion

Free movement of particles (solute) across permeable membrane from area of higher to lower concentration Important in transport of most electrolytes; other particles diffuse through cell membranes Sodium pumps Glucose cannot enter most cell membranes without help of insulin

Hypotonic Solutions D2.5W, ½ NS, 0.33% NS aka 1/3

Go into the vascular space then shift out into the cells to replace cellular fluid (solutions cause fluid to move into the cells, leading to swelling and in some instances, bursting of cells). **ADMINISTER SLOWLY TO PREVENT CELLULAR EDEMA!! They rehydrate the client without causing HTN *Examples*: D2.5W, ½ NS, 0.33% NS aka 1/3 (**Hypo=hippo = solution >30%**) *Uses*: Client with HTN, cardiac or renal disease and needs fluid replacement due to N/V, burns, hemorrhage, etc. Also, for dilution when a client has hypernatremia( excessive na) or cellular dehydration-shrunk, so we need increase the volume inside of the cell. **Alert**: Watch for cellular edema find balance

Safety hazards in the home - Scalds & burns

Hot water, grease, sunburn, cigarettes Prevention: -Guardrails by fireplace -Turning pot handles -Care with candles -Sunscreen -Care when warming food in microwave

Safety hazards at home - Poisoning

Household chemicals, lead, medicines, cosmetics Prevention: cabinet locks, store poison high, keep Poison Control telephone number available Treat: depends on type of poison ingested; antidotes, charcoal, etc.

Pain Assessment

How does the nurse assess for breakthrough pain? How does the nurse conduct a pain reassessment? What are common challenges with pain assessment? When does the nurse use a surrogate to facilitate pain assessment?

WHISTLEBLOWING

Identification of an unethical or illegal situation Can involve one person or an entire organization Reporting such an action to someone in authority Need accurate information Be aware of the consequences ANA working to protect whistleblowers

nursing responsibilities during postoperativexl period postopxl

Immediate care Assess effects of anesthetic agents and surgical procedure Monitor vital functions Provide comfort and pain relief NCLEX® Ongoing care Assess for client adaptation to effects of surgery Provide pain management Position client appropriately Promote use of incentive spirometry Assist with postoperative exercises Maintain hydration Promote urinary elimination Maintain suction to devices as needed Provide wound care Continue client teaching and discharge planning

Synarthroses

Immovable joints (e.g. the sutures between cranial bones). In youth these joints have some flexibility to allow growth but they gradually become rigid.

INFECTIOUS PROCESS

Immune responses to bacterial invasion: B lymphocytes are activated, resulting in the production of antibodies. T lymphocytes are activated, resulting in phagocytosis. Complement system is activated to enhance overall response. Bacteria release endotoxins or exotoxins, which damage the cells of the host and initiate an inflammatory response.

CLINICAL MANAGEMENT: PRIMARY PREVENTION

Immunizations Avoid high-risk behaviors Adequate nutrition Exercise Infection control measures

COLLABORATIVE CARE: EXAGGERATED IMMUNE RESPONSE 2

Immunosuppression Pharmacotherapy Corticosteroids Chemotherapeutic agents NSAIDs immunomodulators Pain Management Pharmacotherapy NSAIDs corticosteroids Hypothermia or hyperthermia treatments as appropriate Maintenance of mobility and physical activity

STAGES OF INFECTION

Incubation: from time of infection until manifestation of symptoms; can infect others book Incubation is the stage between successful invasion of the pathogen into the body and the first appearance of symp- toms. In this stage, the person does not suspect that he has been infected but may be capable of infecting others. This stage may last only a day, as with the influenza virus, or as long as several months or even years, as with tuberculosis. Prodromal: appearance of vague symptoms; not all diseases have this stage book The prodromal stage is characterized by the first appearance of vague symptoms. For example, a person infected with a cold virus may experience a mild throat irritation. Not all infections have a prodromal stage. Illness: signs and symptoms present book Illness is the stage marked by the appearance of the signs and symptoms characteristic of the disease. If the patient's immune defenses and medical treatments (if any) are inef- fective, this stage can end in the death of the patient. Decline: number of pathogens decline book Decline is the stage during which the patient's immune defenses, along with any medical therapies, successfully reduce the number of pathogenic microbes. As a result, the signs and symptoms of the infection begin to fade. Convalescence: tissue repair, return to health book Convalescence is characterized by tissue repair and a return to health as the remaining number of microorganisms approaches zero. Convalescence may require only a day or two or, for severe infections, as long as a year or more.

In your learning group, discuss common examples of situations leading to thermoregulation problems by age-group. How are they different, and how are they similar?

Infants and children Adolescents Adults Older adults

DEFINE AND DESCRIBE THE CONCEPT OF INFECTION.

Infection is the invasion and multiplication of microorganisms in body tissues, which may be unapparent or the result of local cellular injury caused by competitive metabolism, toxins, intracellular replication, or antigen-antibody response. Simply put... When microorganisms capable of producing disease invade the body

DEFINE AND DESCRIBE THE CONCEPT OF INFLAMMATION

Inflammation is an immunologic defense against tissue injury, infection, or allergy.

NURSING RESPONSE: INFLAMMATION

Ineffective thermoregulation Assess and document temperature Antipyretic drug use Cooling measures Acute pain Heat and cold therapies ■Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel, or fitted sleeve. ■Apply hot or cold intermittently, leaving it on for no more than 15 minutes at a time in an area.This precaution helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing rebound phenome- non: At the time the heat or cold reaches maximum therapeu- tic effect, the opposite effect begins. ■ Check the skin frequently for extreme redness, blistering, cyanosis (blueness), or blanching. When heat or cold is first applied, the thermal receptors react strongly, and the person feels the temperature intensely. Over about a 15-minute period, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because doing so can cause tissue injury. *Applying Heat Therapy* Local application of heat is used to relieve stiffness and dis- comfort associated with musculoskeletal problems. It may also be used for patients with wounds. Heat increases blood flow to an area through vasodilatation, increased capillary permeability, and reduced blood viscosity. Increased blood flow brings oxygen and white blood cells to the wound and aids in the healing process. Heat promotes the delivery of nu- trients and removal of waste products from the tissue, pro- motes relaxation, and decreases stiffness and muscle tension. -When heat is applied to a large area of the body, vasodilata- tion may cause a drop in blood pressure and a feeling of faint- ness. Warn patients to be alert for this effect if they will be administering heat at home. *Applying Cold Therapy* The application of moist or dry cold causes vasoconstriction and decreases capillary permeability. It produces local anesthesia, re- duces cell metabolism, increases blood viscosity, and decreases muscle tension. It also slows bacterial growth. Applications of cold are used to prevent or limit edema and reduce inflamma- tion, pain, oxygen requirements, and bleeding. Cold therapy is often used to treat fevers and sports injuries (e.g., sprains, strains, fractures, and contusions), and to prevent swelling after surgery (e.g., an ice bag may be applied to the perineum after childbirth; an ice collar may be applied to the throat after a ton- sillectomy). Cold applications have the following side effects: ■Elevated blood pressure. Because cold causes vasoconstriction, it may increase the patient's blood pressure. ■Shivering. Prolonged cold may cause shivering, a normal response as the body attempts to produce heat. ■Tissue damage. Prolonged exposure to cold may cause tissue damage due to impaired circulation. Cooling Baths A cooling bath is often used to treat a high fever (above 104°F [40°C]). It promotes heat loss through conduction and vaporization. Elevation Rest, immobilization, and medications

UTIxl

Infection found within the urinary system caused by bacteria , virus ,fungal Inflammation of the urinary tract due to bacterial infection (E. coli) LUTS: Urethritis &; Cystitits Upper urinary system: Ureteritis &; pyelonephritis ashlii An infection involving the kidneys, ureters, bladder, or urethra. Often caused by E.Coli. A UTI is labeled according to the region of infection. In general terms, reference is made to lower urinary tract (e.g., urethra, bladder, or prostate) and upper urinary tract infections (e.g., ureters or kidney). rf/causes hard to void H: Hormones changes: pregnancy, menopause, birth control A: antibiotics: changes normal flora R: Renal stones: prevent urine from draining D: Diabetes: compromised circulation, decreased immune system, glucose in urine, urinary retention T:Toiletries: excessive bubble baths, powders, perfumes, scented tampon/sanitary pads O: obstructive Prosthetic hypertrophy : BPH (seen in males): urinary retention, decrease antimicrobial fluid V: Vesicouretal reflux (vur) happens in peds population- urine back flow from bladder to kidney, valve defect O: overextended bladder: bladder not emptied regular (immobile) weak bladder leading to urinary retention I: Indwelling catheter(foley): invasive procedures, intercourse spemacide D: Decreased immune system: viral and fungal utis/s *pain/burning when voiding*,*Dysuria no pee*, frequent urination, but nothing is coming out (more than every 2hrs, urgency, Nocturia, Incontinence, Pyuria, Bacteriuria, Retention, suprapubic discomfort, pressure or fullness, Feeling of incomplete bladder emptying, *odorous, dark cloudy*, pain with costal vertebral angle (*cva tenderness) which is associated with kidney infection*, spasms of the bladder/urethra, fever, increased wbc on ua. ashlii s/s *Symptoms of upper UTI* -Fairly high fever (higher than 38.3° C [101° F]) -Shaking chills -Nausea -Vomiting -Flank pain - Malaise ureters-ureteritis, kidneys- pyelonephritis *Symptoms of lower UTI* Dysuria Frequency Urgency Hesitancy or difficulty in initiating urine stream Cloudy, foul smelling urine Hematuria-blood tinged Bladder spasms Lower abdominal/back pain Mild fever (less than 38.3° C [101° F]) Chills Not feeling well (malaise) uti starts in lower region of uti, urethra-urethritis, bladder-cystitis utiOLDER ADULTS will appear confused, have a loss of appetite, (hypotension, tachycardia, tachypnea, and fever are symptoms of urpsepsis), *agitated*, *falling alot*, A sudden onset of incontinence or a worsening of incontinence may be the only symptom of an early urinary tract infection (UTI). nocturia, and dysuria are common indications,lethargy, or anorexia utidrugs sulfumamide, bactrim, take the sametime everyday. take all antibiotics bc of resistence antimicrobials to eradicate bacteria; antispasmodics and analgesics to relieve pain, frequency, and burning The three most common drug treatment regimens are (1) one low-dose tablet of trimethoprim (Proloprim, Trimpex), (2) sulfamethoxazole/trimethoprim (single-strength Bactrim, Cotrim), or (3) nitrofurantoin (Macrodantin, Nephronex , Novo Furantoin ). Trimethoprim*/sulfamethoxazole (Bactrim DS, Septra DS,trimethoprim/sulfamethoxazole orally)-Teach patients to drink a full glass of water with each dose and to have an overall fluid intake of 3 L daily because these drugs can form crystals-Teach patients to keep out of the sun or to wear protective clothing outdoors and use a sunscreen because these drugs increase sun sensitivity and can lead to severe sunburn. Ciprofloxacin (Cipro, ProQuin) Levofloxacin (Levaquin) Ofloxacin (Floxin)-Teach patients how to take their pulse, to monitor it twice daily while on this drug, and to notify the primary health care provider if new-onset irregular heartbeats occur to identify serious drug-induced dysrhythmias. Amoxicillin (Amoxil) Amoxicillin/clavulanate (Augmentin, Clavulin)-Teach patients to take the drug with food to reduce the risk for GI upset. Cefdinir, cefaclor, or cefpodoxime-Instruct patients to mix the contents of a package in about cup of cold water, stir well, and drink all the liquid to ensure that all granules are dissolved and the correct dose is taken. Phenazopyridine (Azo-Dine, Prodium, Pyridiate, Pyridium, Uristat, Phenazo)*-*Remind patients that this drug will not treat an infection, only the symptoms because these drugs have no antibacterial activity.*-*Teach patients to take the drug with or immediately after a meal to reduce the risk for GI upset.*-*Warn patients that urine will turn red or orange to reduce anxiety about this change. *-*Hyoscyamine (Anaspaz, Cystospaz, many others)*-**Trimethoprim can be given alone to patients with a sulfa allergy utidx *Urinalysis: WBC and bacteria- best to collect when urine is concentrated* for 2-3 hours- what pt will do is wipe with an antiseptic wipe to clean area, then have pt void small amount in the toilet, they will stop and within midstream theyre going to void into cup, few inches away from urethra. utidx pelvic ultrasound or CT may be needed to locate the site of obstruction or the presence of calculi. Voiding cystourethrography is needed when urine reflux is suspected. Cystoscopy may be performed when the patient has recurrent UTIs (more than three or four a year). utidx Nurse's role *(clean catch concentrated specimen*)If the patient cannot produce a clean-catch specimen, obtain the specimen with a small-diameter (6 Fr) catheter. *Foley use: use the access port NOT from the collection bag* A urine culture and Gram stain confirms the type of organism and the number of colonies. takes 48 hrs/2days for results Cystoscopy: assess inside of bladder and urethra (recurrent uti) Collect urine culture (FIRST) before giving antibiotic utini Assess for signs and symptom of uti, maintain fluid status (I/O>30ml/hr), *control pain administer meds* per md order Take all antibiotics, wipe front to back *Encourage 2.5-3L/3000 mL/ 8-10 glasses per day or more of fluid per day FLUSH KIDNEYS KEEP PEE DILUTED * *Encourage voiding 2-3/4 hrs*- Monitor I&O and observe urine characteristics [For both women and men] Gently wash the perineal area before intercourse ashlii n.i Promote fluid intake up to 3 liters daily Administer antibiotics as prescribed Encourage to urinate every 3-4 hours Encourage to shower daily Recommend warm sitz bath for comfort Avoid use of indwelling catheters Advise to urinate before and after sex Advise to drink cranberry juice to reduce risk Comfort Measures. A warm sitz bath two or three times a day for 20 minutes may provide COMFORT and some relief of local symptoms. If burning with urination is severe or urinary retention occurs, teach the patient to sit in the sitz bath and urinate into the warm water. Urinary tract analgesics or antispasmodics may also provide comfort Applying topical estrogen to the perineal area, if postmenopausal. Topical estrogen normalizes vaginal flora. Oral estrogens are not effective. utiPain: warm sitz bath, heating pads Phenazopyridine Common (orange urine) which is normal, FINISH ANTIBIOTICS-Stress the need for correct spacing of doses throughout the day and the need to complete all of the prescribed antibiotics. PATIENT & CAREGIVER TEACHING utie Take all antibiotics Empty the bladder regularly and completely, evacuating the bowel regularly, wipe front to back Wipe from front to back Void AFTER sexual intercourse- keep perineum clean and dry- Take showers rather than baths if recurrent infection is a problem AVOID tight underwear, Wear loose cotton underwear AVOID bubble baths, perfumes, vaginal douches, harsh soaps, powders, sprays due to irritating the urethra Change sanitary pads often, AVOID tampons AVOID caffeine and alcohol Void every 2-3 hrs Encourage drinking unsweetened cranberry juice (8oz TID or taking cranberry extract tablets Maintain acidic urine with acid-ash diet, which may include cranberry juice or ascorbic acid daily (helps prevent bacteria from clinging to bladder wall)

Remember...

Interventions to reduce infection risk: Clean needleless system connections before use with antimicrobial for 30 seconds Do not tape connections between tubing sets Use evidence-based hand hygiene guidelines from CDC and OSHA

ATTRIBUTES OF CLINICAL JUDGMENT

Involves a holistic view of the patient situation. Is a process orientation a circular process Requires reasoning and the interpretation of data.

PROFESSIONAL NURSING PRACTICE

Is regulated by the states; nurses must hold a state-issued license to practice nursing. Details of the practice of nursing are found in the scope of practice for each state. Practice can vary from state to state; for this reason, nurses should be familiar with the nursing practice act and scope of practice in the state in which they work.

Factors affecting mobility and activity

Lifespan Nutrition Lifestyle Stress External environment Disease

Immobility related to tissue integrity

May have diminished tissue integrity or be at risk of experiencing such problems, like skin breakdown

Practical Nurses (PNs) lpnxl

Monitoring findings (as input to the RN's ongoing assessment) Reinforce client teaching from a standard care plan Performing tracheostomy care Suctioning Checking NG tube patency Administering enteral feedings Inserting a urinary catheter Administering medications

WOUNDS wz Classification of Wounds

Open- open if there is a break in the skin or mucous membranes. Open wounds include abrasions, lacerations, puncture wounds, compound fractures (projection of bone through the skin), and surgical incisions. closed- If there are no breaks in the skin, the wound is de- scribed as closed. Contusions (bruises) or tissue swelling from fractures are common closed wounds. Acute- Acute wounds are expected to be of short duration. In a healthy person, these wounds heal spontaneously without complications through the three phases of wound healing (inflammation, proliferation, and maturation). chronic- Wounds that exceed the expected length of recovery are classified as chronic wounds. The natural healing progression has been interrupted or stalled because of infection, continued trauma, ischemia, or edema. Chronic wounds include pres- sure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with 7rl types of bacteria, and healing is slow because of the underlying disease process. Unless the wound is properly diagnosed and the underly- ing disease treated, a chronic wound may linger for months or years Clean Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacte- ria). There is little risk of infection for a clean wound. Clean/contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. contaminated- include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds. infected- Wounds are considered infected when bacteria counts in the wound tis- sues are above 100,000 organisms per gram of tissue. How- ever, the presence of beta-hemolytic streptococci, in any number, is considered an infection. Signs of wound infection include erythema and swelling around the wound, fever, foul odor, se- vere or increasing pain, a large amount of drainage, or warmth of the surrounding soft tissue. Superficial- Superficial wounds involve only the epidermal layer of the skin. The injury is usually the result of friction, shearing, or burning. partial- extend through the epidermis but not through the dermis. full-thickness extend into the subcutaneous tissue and beyond Penetrating- The descriptor penetrating is sometimes added to indi- cate that the wound involves internal organs. Wound depth is a major determinant of healing time: The deeper the wound, the longer the healing time. Types of Wound Drainage Serous exudate: straw-colored book Clean wounds typically drain serous exu- date. It is watery in consistency and contains very little cellu- lar matter. Serous exudate consists of serum, the straw-colored fluid that separates out of blood when a clot is formed. Sanguineous: bloody drainage book You will often see sanguineous exu- date (bloody drainage) with deep wounds or wounds in highly vascular areas. It indicates damage to capillaries. Fresh bleeding produces bright red drainage, whereas older, dried blood is a dark, red-brown color. Serosanguineous: mix of bloody and straw-colored fluid book In new wounds, you will most commonly see serosanguineous drainage, a combination of bloody and serous drainage. Purulent: yellow, contains pus book The thick, often malodorous, drainage that is seen in infected wounds is called purulent exudate. It contains pus, a protein-rich fluid filled with WBCs, bacteria, and cellular debris. It is commonly caused by infection from pyogenic (pus-forming) bacteria, such as streptococci or staphylococci. Normally, pus is yellow in color, although it may take on a blue-green color if the bacterium Pseudomonas aeruginosa is present. ■Purosanguineous Exudate. Red-tinged pus is called purosanguineous exudate. It indicates that small vessels in the wound area have ruptured.

Diarthroses

Or synovial joints. Freely movable because of the amount of space between the articulating bones.

Post-op: Gastrointestinal assessment postopxl

Postoperative nausea/vomiting common 30% of patients experience nausea or vomiting after general anesthesia Peristalsis may be delayed up to 24 hours Monitor for bowel sounds ashlii Postoperative nausea/vomiting common 30% of patients experience nausea or vomiting after general anesthesia Peristalsis may be delayed up to 24 hours Monitor for bowel sounds **Absent bowel sounds common due to meds that decrease peristalsis, not a big concern immediately after surgery

Lines of defense against infection

Primary Defenses Anatomical features, limit pathogen entry Intact skin Mucous membranes Tears Normal flora in GI tract Normal flora in urinary tract Secondary Defenses Biochemical processes activated by chemicals released by pathogens Phagocytosis Complement cascade Inflammation Fever Tertiary Defenses Humoral immunity B-cell production of antibodies in response to an antigen Cell-mediated immunity Direct destruction of infected cells by T cells CONSEQUENCE OF UNCONTROLLED INFECTION Once the body's compensatory mechanisms (e.g., vascular, renal, nervous, respiratory) are overcome, the following process occurs.

Pain Pharmacologic Therapy Classification: Opioids

Pure agonists Morphine (MS Contin) Morphine is the standard against which all other opioid drugs are compared. It is the most widely used opioid throughout the world, particularly for cancer pain, and its use is established by extensive research and clinical experience. Morphine is a hydrophilic drug (readily absorbed in aqueous solution), which accounts for its slow onset and long duration of action when compared with other opioid analgesics. It is available in a wide variety of short-acting and modified-release oral formulations and is given by multiple other routes of administration, including rectal, subcutaneous, and IV. oxycodone (OxyContin) Oxycodone is available in the United States for administration by the oral route only and is used to treat all types of pain. In combination with acetaminophen or ibuprofen, it is appropriate for mild-to-some moderate pain. Single-entity, short-acting (OxyIR) and modified-release (OxyContin) oxycodone formulations are used in patients with moderate-to-severe chronic pain. It has been used successfully as part of a multimodal treatment plan for postoperative pain as well. Like morphine, it is available in liquid form for patients who are unable to swallow tablets. methadone Methadone (Dolophine) is a unique opioid analgesic that may have advantages over other opioids in carefully selected patients. In addition to being a mu opioid, it is an antagonist at the NMDA (N-methyl-D-aspartate) receptor site and thus has the potential to produce analgesic effects as a second- or third-line option for some neuropathic pain states. codeine Codeine in combination with nonopioids (e.g., with acetaminophen in Tylenol No. 3) has been used for many years for the management of mild-to-moderate pain; however, it has largely been replaced by analgesics that are more efficacious and better tolerated (e.g., Percocet, Vicodin). Research has shown that codeine/acetaminophen is less effective and associated with more adverse effects than NSAIDs such as ibuprofen and naproxen for acute pain. Block release of neurotransmitters in spinal cord Can be administered by every route PRN range orders Patient-controlled analgesia (PCA) (PCA) is an interactive method of management that allows patients to treat their pain by self-administering doses of analgesics. It is used to manage all types of pain and given by multiple routes of administration, including IV, subcutaneous, epidural, and perineural. A PCA infusion device ("pump") is used when PCA is delivered by invasive routes of administration and is programmed so the patient can press a button ("pendant") to self-administer a set dose of analgesic ("PCA dose") at a set time interval ("demand" or "lockout") as needed. Patients who use PCA must be able to understand the relationships among pain, pressing the PCA button and taking the analgesic, and pain relief. They must also be cognitively and physically able to use any equipment that is used to administer the therapy. PCA may be given with or without a basal rate (continuous infusion). The use of a basal rate is common when patient-controlled epidural analgesia (PCEA) is used. For IV PCA, a basal rate may be added for opioid-tolerant patients to replace their home analgesic regimen. Basal rates should be used with great caution and only in special circumstances for opioid-naïve patients receiving IV PCA. Remember that the patient has no control over the delivery of a continuous infusion. Essential to the safe use of a basal rate is prompt discontinuation of the basal rate if increased sedation or respiratory depression occurs. The primary benefit of PCA is that it recognizes that only the patient can feel the pain and only the patient knows how much analgesic will relieve it. This fact reinforces that PCA is for patient use only and that unauthorized activation of the PCA button (called "PCA by proxy") can be very dangerous. Instruct staff, family, and other visitors to contact the nurse if they have concerns about pain control rather than pressing the PCA button for the patient.

CLINICAL MANAGEMENT: COLLABORATIVE INTERVENTIONS

Rest, ice, compression, elevation (RICE) Most helpful after sprain, strain, or trauma Helps minimize swelling Most beneficial for the first 24 to 48 hours after injury

ATI - NCLEX - QSEN 2

Safety Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance Targeted KSAs (Knowledge, Skills, Attitudes K: Discuss potential and actual impact of national patient safety resources, initiatives, and regulations S: Use national patient safety resources for own professional development and to focus attention on safety in care settings A: Value relationship between national safety campaigns and implementation in local practices and practice settings

Immobility Interventions - Decreases stressors / strengthen lines of defense

Set up consultation with multidisciplinary care team (PT, OT, social worker, etc) Perform ROM (passive, passive/active, active, etc) Work with PT to recover body rhythm and muscle control (lessens fatigue)

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress in 1996 to protect patients: ■ Protect health insurance benefits for workers who lose or change their jobs. ■ Protect coverage to persons with preexisting medical conditions. ■ Establish standards to protect the privacy of personal health information.

drugs to treat or prevent osteoporosis

The evidence shows that drug therapy should be used for postmenopausal women and men age 50 and older when the BMD T-score for the hip or lumbar spine is below or equal to −2.5 with no other risk factors, or when the T-score is below −1.5 with risk factors or previous fracture. Anyone age 50 or older who had a hip or vertebral fracture should also be treated (NOF, 2017). The health care provider may prescribe calcium and vitamin D3 supplements, bisphosphonates, estrogen agonist/antagonists (formerly called selective estrogen receptor modulators), parathyroid hormone, RANKL inhibitor, or a combination of several drugs to treat or prevent osteoporosis (Chart 50-2). In addition, calcitonin may be used for some patients. Estrogen and combination hormone therapy are not used solely for osteoporosis prevention or management because they can increase other health risks such as breast cancer and myocardial infarction.

Mandatory reporting laws

The law in various states requires healthcare workers to report communicable diseases. You also have a duty to report physical, sexual, or emotional abuse or neglect of children, older adults, or the mentally ill, whether you suspect it or have actual evidence of it.

DEFINE AND DESCRIBE THE CONCEPT OF IMMUNITY

The normal physiologic response to microorganisms and proteins as well as conditions associated with an inadequate or excessive immune response. Lets look deeper in to immunity definitions...

Fecal Impaction

The presence of a hardened fecal mass in the rectum. The impaction often blocks the passage of normal stool and sets up further hardening. ashlii manifistations Liquid stool may leak, seeping around the hardened mass, and the patient may report feelings of fullness, bloating, constipation, diminished appetite, and a change in bowel habits. You can detect fecal impaction by digital examination of the rectum. ashlii- Nursing management of fecal impaction -Prevention is the best treatment -Determine presence: digital examination -Enemas *Oil retention to soften *Tap water or Fleet enemas to remove and cleanse -Manual/digital removal: dysimpacting -Establish bowel program to prevent recurrence dx You can detect fecal impaction by digital examination of the rectum NURSING INTERVENTIONS Use enemas or digital removal of stool, once the impaction has been removed, establish a bowel regimen to prevent recurrence of impactions DRUG THERAPY Prevention is the best treatment Determine prescence: digital examination Enemas : oil retention to soften, tap water or fleet enemas to remove and cleanse Manual/digital removal: dysimpacting Establish bowel program to prevent recurrence

SURGICAL SCRUB, GOWNING, AND GLOVING

The scrubbing, gowning, and gloving process. A, The surgical scrub. B, Rinsing. Note the water falling off the hands and arms. Also note the foot-operated handle that controls the water flow. (After scrubbing and rinsing, the scrub nurse dries his hands and arms with a sterile towel inside the operating room and then is assisted into a sterile gown.) C, The scrub nurse prepares sterile gloves. Note that the scrub nurse's hands are inside the sleeve of the gown and that he is touching the sterile gloves only with the sterile sleeve. D, The scrub nurse puts on his first sterile glove while the sterile gown is being tied in the back. Note again that his hand never emerges from under the sterile sleeve. E, The scrub nurse puts on his second sterile glove.

Acid-Base Control Action& Mechanisms: Kidneys

Third line of defense against pH changes Stronger for regulating acid-base balance; take longer than chemical and respiratory Kidney movement of bicarbonate, kidney is seen by ct scan. Formation of acids Formation of ammonium

Post-op: Drug therapy to reduce nausea/vomiting

To reduce nausea/vomiting: Ondansetron (Zofran) Meclizine (Antivert, Dramamine)

Skeletal Disease: Osteoporosis Treatment

Treatment: Exercise - walking, swimming, and water aerobics are recommended to increase muscle Diet - high in calcium, Vitamin D, fiber, & protein Examples of foods high in calcium: breads cereals, apricots, molasses, milk, dairy products (especially yogurt), spinach, sardines, beans, carrots, asparagus, & collard greens Avoid alcohol & smoking NOTE: excessive caffeine can cause excretion of calcium through the urine Safety: avoid the use of throw rugs, use of appropriate assistive devices, keep areas free of clutter, adequate lighting, non-skid socks/shoes Medications: Biophosphonates (i.e. Fosamax, Boniva, Didronel), Calcium supplements, Vitamin D supplements, Estrogen (for post menopausal women), muscle relaxers, NSAIDS

PATIENT & FAMILY TEACHING

Tubes -Urinary catheter -NG Drains -Penrose -JP -Hemovac Vascular access -PIV -Central Line

Pre-op Labs preopxl

Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT) Electrolyte levels Serum creatinine level Pregnancy test

Urge Incontinence- overactive bladder urgexl

Urge incontinence is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate.-----due to decreased bladder capacity, bladder spasms, diet, and neurologic impairment ashlii The involuntary loss of larger amounts of urine accompanied by a strong urge to void. It is often referred to as OVERACTIVE BLADDER. book The involuntary loss of urine associated with a strong desire to urinate. Patients cannot suppress the signal from the bladder muscle to the brain that it is time to urinate. patients cannot suppress the signal from the bladder muscle to the brain that it is time to urinate *-cause * Idiopathic. Brain and nerve disorders. Bladder inflammation or infection. Bladder cancer. -clinical manifestations an abrupt and strong urge to void. may have loss of large amounts of urine with each occurence - include stroke neurologic problems, irritation from concentrated urine or artificial sweeteners, caffeine, alcohol, citric intake, drugs such as diuretics and nicotine *urges/s* Urinating more than 8 times a day--- frequent urge to urinate, frequent urination, bedwetting, bladder spasm, or leaking of urine *urgedx dx: * bladder log when they got the urge, or didnt go, how many times they wet the bed, leaked for themselves *urgeni n.i* Treatment of underlying cause, bladder retraining with urge suppression (schedule toileting with progressive voiding intervals) , decrease in dietary irritants, bowel regularity, pelvic floor muscle exercises, anticholinergic drugs, calcium channel blockers, These include bladder training and drug therapy if bladder training is not successful Neuromodulation therapy, which involves stimulation of the nerves to the bladder, can be used to manage urge incontinence. Occurs randomly when involuntary urination is preceded by urinary urgency Leakage is periodic but frequent and usually in large amounts Nocturnal frequency and incontinence are common Caused by uncontrolled contraction or overactive detrusor muscle urgedrugs *meds*: anticholinergics aka antimuscarinics DEA VP/ bladder training, leaking, bed wetting- bladder log,kegal pelvic comb 2 stop urine-onabutulinumtoxinA (Botox) darifenacin (Enablex), fesoterodine (Toviaz), oxybutynin (Ditropan and Ditropan XL), propiverdine (Detrunorm), solifenacin (VESIcare), tolterodine (Detrol and Detrol LA), and trospium (Sanctura). Some of these drugs are available over-the-counter. This class of drugs has serious side effects, particularly for older adults, and is used along with behavioral interventions. T Tricyclic antidepressants with anticholinergic and alpha-adrenergic agonist activity, such as imipramine (Tofranil, Novopramine), have been used successfully in younger patients. *urgerf rf* Nervous system disorders stroke, Alzheimer's, brain tumor, Parkinson's disease, Interstitial cystitis, ------ sn alot of the pts get the urge to urinate, but when try to it goes away. subjective: urge to go really bad, and then it goes away. objective: leaking out if they cough, bed wetting --------- urgeteaching *pt education*: kegals, bladder/ pelvic comb, bladder retrainig, so try to hold it for awhile to strengthen the pelvic muscle urinary tract problems; and irritation from concentrated urine, artificial sweeteners, caffeine, alcohol, and citric intake. Drugs, such as diuretics, and nicotine can also irritate the bladder. Often urine loss is related to both stress and urge incontinence, and symptoms mimic more than one subtype. This category is more common in older women. • Responds to urge in a timely manner • Gets to toilet between urge and passage of urine • Avoids substances that stimulate the bladder (e.g., caffeine, alcohol) avoid foods that irritate the bladder such as caffeine and alcohol. Spacing fluids at regular intervals throughout the day (e.g., 120 mL every hour or 240 mL every 2 hours) and limiting fluids after the dinner hour (e.g., only 120 mL at bedtime) help avoid fluid overload on the bladder and allow urine to collect at a steady pace. Remind patients that maintaining an ideal body weight

ATI - NCLEX - QSEN Psychosocial Integrity

Use effective communication when teaching patients and family members about what to expect during the surgical experience. Act as a patient advocate with regard to patients' rights, informed consent, and advance directives. Identify learning needs for the patient preparing for surgery.

ATI - NCLEX - QSEN Physiological Integrity

Use knowledge of physiology and behavioral principles to describe an accurate and complete preoperative assessment. Evaluate personal factors that increase the patient's risk for complications during and immediately after surgery. Evaluate laboratory values for changes that may affect the patient's response to drugs, anesthesia, and surgery. Explain the purposes and techniques commonly used for patient preoperative preparation. Apply anti-embolic stockings, sequential compression boots, or other devices to reduce or prevent vascular complications.

Pharmacologic agents

ana Anti-inflammatory agents Nutrition supplementation Analgesics

older adult factors affecting safety skin break down

anni rc avoid friction and shearing national patient safety goal: must have program to prevent agency associated pressure injuries nutrition support: protein- zinc- vitamin a&c increase mobility and activity when appropriate reposition and provide support surfaces clean skin use moisture barriers

CLINICAL MANIFESTATIONS OF MALIGNANT HYPERTHERMIA malixl

dantrolene is the antidote up to 10/mg/kg watkins: skeletal muscle exposed, increase metabolism, calcium levels in muscle cells, acidosis, high temp, dysrythmias s/s Tachycardia Skin mottling Cyanosis Myoglobinuria Rise in end tidal carbon dioxide Elevated temperature ashlii -Tachycardia -Tachypnea -Skin initially appears flushed, then becomes mottled and cyanotic -Myoglobinuria -Rise in end tidal carbon dioxide -Rapid rise in body temperature -Respiratory and metabolic acidosis

delegation

definition- the process of transferring to a competent person the authority to perform a selected nursing task or activity in a selected client care situation the nurse is always accountable for the task or activity that is delegated! 5 rights of delegation right task right circumstance right person right communication right supervision --> supervision is guidance or direction, evaluation, and follow-up by the nurse to ensure that the task or activity is performed appr.

safety hazard - community electrical storms

example/ cause lightning prevention-- dd s during a storm seek lowest point possible do not use metal objects seek shelter in a large building away from water

Elements of a musculoskeletal assessment

far pp los pfc rfr Fatigue Altered gait or imbalance Reduced functional ability Problem-based history Pain (0-10) Lifestyle behaviors Occupation Social environment Past medical history Family history Current medications Reduced joint movement Falls (history of) Reduced sensation or loss of sensation

Clinical Management: Primary Prevention

for p Fall prevention measures -Optimal nutrition -Regular physical activity -Protection against injury

teamwork & interprofessional collaboration

in order to provide patient and family centered care, the nurse functions effectively within nursing & interprofessional teams, fostering open communication mutual respect shared decision-making to achieve quality patient care *interprofessional education collaborative competencies* tire teams and teamwork interprofessional communication role- responsibilities ethics/ values for interprofessional practice

Hyperthermia

is a body temperature above 37.6 C

Hyperpyrexia

is an extremely high body temperature (above 41.5 C)

walker

is most often used by the older patient who needs additional support for balance. The physical therapist assesses the strength of the upper extremities and the unaffected leg. Strength is improved with prescribed exercises as needed.

Health care law

is the collection of laws that have a direct impact on the delivery of health care or on the relationships among those in the business of health care or between the providers and the recipients of health care. Fundamental concept for all health care professionals and health care-related entities

Infection Infectionxl

is the invasion and multiplication of microorganisms in body tissues, which may be unapparent or the result of local cellular injury caused by competitive metabolism, toxins, intracellular replication, or antigen-antibody response. Simply put... When microorganisms capable of producing disease invade the body

cronsxl dz

mall an inflammatory dz that can occur anywhere in the gi tract, but most often effects the terminal ileum and leads to thickening, scarring, a narrowed lumen, fistulas, ulcerations and abscess, remissions and exacerbation's a type of ibd that causes inflammation and ulcer formation in the GI tract. crons is found in the large and small intestine- mainly in the terminal/end of the ileum in the start of the colon, crons can be in the mouth and the anus- it affects all layers of the bowel----found in scattered patches throughout the GI tract, *cobble-stone appearance* *causes of crons* is UNKNOWN, but it is due to a FAULTY IMMUNE SYSTEM not doing its job and causing inflammation throughout the body *triggered by the environment-Food, stress, viral/bacteria illness, smoking, *genetic* periods of flare-ups and remissions- scarring leading to obstruction NO CURE!!! what we can do is a bowel resection, it can managed with medications and diet *cronscomplication* acronym- *abscessing fistulas may form sepsis* abscess- pockets of infection form w/in intestinal wall & burst forming fistulas fistulas- ulcer/absess form deep in intestine wall creating an opening channel/passage from intestine to another intestine; from an intestine to an organ; from an intestine to a skin surface leading to SEPSIS!!! malnourishment- small intestine inflamed, and doesnt work; seen more in crons fissure: tears mainly anal & gi lining stricture/obstruction- common complication stricture- major narrowing of the intestinal wall due to chronic inflammation which causes SCARRING *s/s---mall assessments* cronss/s fever, cramp-like, colicky, pain after meals, diarrhea with mucus and pus and blood, ab distention, anorexia, nlv, weight loss, anemia, dehydration, electrolyte imbalance, malnutrition, athritis,stones,gallbladder, peritonitis Most patients report diarrhea, abdominal pain, and *low-grade fever*. Fever is common with fistulas, abscesses, and severe inflammation. If the disease occurs in only the ileum, *diarrhea occurs five or six times per day, often with a soft, loose stool*. Steatorrhea (fatty diarrheal stools) is common. Stools may contain bright red blood. The patient who has Crohn's disease (CD) needs a complete psychosocial assessment. cronss/s abdominal pain, inflammation of the *right lower side* or pass stenosis/stricture, *ulcer in mouth and GI tract* weight loss, malnourishment, electrolyte issues, fissures (anal) that bleeds, bloating,h/a ashlii-Clinical presentations of Crohn's disease Typically, abdominal pain (RLQ) and tenderness accompanies the disorder. Often the pain is relieved temporarily with defecation. In addition, eating can initiate the abdominal discomfort, and patients may consequently limit their food intake. This lends them to have nutritional deficits, and weight loss, and experience malnutrition and even secondary conditions. Diarrhea is common and not necessarily positive for occult bleeding. There may be a palpable mass in the RLQ. Steatorrhea is also a common finding with the stool (pale appearance, presence of fat and mucous) GI assessment: freq bm. bowel sounds, -------- cronsfood diet NO high fiber, raw veges/fruit, spicy, fatty, allergen types-wheat,gluten,fish,nuts,popcorn are hard to digest FOOD THEY CAN EAT low in fiber- white rice, fruits/veges cooked w/ skin removed. high in protein basically foods that are easy to digest cronsdrugs 5- aminosalicytes sulfasalizine(antiinflammatory), corticosteroid prednisone--- not long term....mercaptopurine (Purinethol), Methotrexate mild to severe drug immunosupressar/ modulators drug/azathioprine/imuran, but this causes infection/CANCER/ NO LIVE VACCINE W/ THIS DRUG infliximab/ remicade/adimumab/hurnia/ antibiotics cipro/ antidiarrhea/ pain meds but NO NSAIDDSSS!!! Common antidiarrheal drugs include diphenoxylate hydrochloride and atropine sulfate (Lomotil) and loperamide (Imodium). ------ cronsdx: endoscopy, lab cc, blood test- iron, mineral, protein test, X-rays, MRE, An abdominal ultrasound or CT scan, If the patient has lower GI bleeding of more than 0.5 mL per minute, a GI bleeding scan may be useful to localize the site of the bleeding *Location-Most often in the terminal ileum, with patchy involvement through all layers of the bowel *Etiology- Unknown *Peak incidence at age-15-40 yr *Number of stools- 5-6 soft, loose stools per day, nonbloody *Complications- Fistulas (common) Nutritional deficiencies *Need for surgery- Frequent ----------- cronsteach Teach patients to take a folic acid supplement, because sulfa decreases its absorption. Teach patients that carbonated beverages, pepper, nuts and corn, dried fruits, and smoking are common GI stimulants that could cause discomfort. Ensure that the patient has easy access to a bedpan, bedside commode, or bathroom in case of urgency or tenesmus. Serum levels of folic acid and vitamin B12 are generally low because of malabsorption, further contributing to anemia. Ensure or Sustacal can be given to provide nutrients and more calories. Teach the patient to avoid GI stimulants, such as caffeinated beverages and alcohol. cronsni goals: help pt understand diet; NO CURE, medications, diet, *sx stirctoplasty* bowel resiction, partial or total removal of the colon ileostomy, ostomy care if present, *smoking cessation* severe crons pts have bowel rest where nothing enters the gi tract TPN NO FOOD- imbalanced nutrition *ashlii- n.i* Provide prescribed diet: usually high-calorie, high-protein; involve client in making appropriate menu choices. Weigh daily, maintain calorie count, and monitor I&O. TPN may be ordered during periods of severe exacerbation to provide total bowel rest. *mall ni* sx is avoided because of the increase likelyhood of this condition reoccuring in the same region *npo*, admin fluid and electrolyte if needed, gi assess monitor stools, decrease fiber, increase protein diet, vitamins, and iron. no smoking ashlii--cm Chronic inflammatory bowel disorder with a relapsing and remitting course. Once remission is achieved, the main aim of the management of Crohn's disease is maintenance of that remission. Usually begins with a small inflammatory lesion of the intestinal mucosa. Eventually, the inflammation continues and progression through all layers of tissue is seen. Deeper ulcerations, fissures, and granulomatous lesions persist into the deeper layers of the bowel wall. As the disease progresses, the inflammation causes the bowel wall to thicken and become fibrotic, and a narrowing of the intestinal lumen occurs. Fistulas are common between loops of bowel, as are adhesions of the diseased bowel areas. The absorption of nutrients is impaired as the jejunum and ileum are affected. sn chronic lining of the digestive tract life-threatening, no cure, ab pain, diarrhea, fatigue, weight loss, anemia, loss of appetite, no spicy foods- meds immunosapressant comfort measures, anti-inflammatory: suflanalazine, trasomi no nsaids bc bleeding can increase increase fluid, caffeine, alcohol, ----- cronstypes dz ileocolitis- inflammation found in the ileum and found in parts of the colon gastroduadenum- found in stomach and duodenum jejunulitis- found in the jejunum iletis- found in the ileum granulomateus colitis: found only in colon ----- *types of fistulas* enteroenteric- intestine to intestine perianal- due to anal abscess enterovisecal- intestine to bladder enterovaginal- intesine to vagina enterocutaneous- intestine to skin surface

skeletal disease osteomalacia

metabolic dz that causes poor and delayed mineralization of the bone cells in mature bones main cause is a vitamin d deficiency *book* Osteomalacia is loss of bone related to lack of vitamin D, which causes bone softening. Vitamin D is needed for calcium absorption in the small intestines. As a result of vitamin D deficiency, normal bone building is disrupted, and calcification does not occur to harden the bone. Table 50-1 compares these two bone diseases caused by impaired cellular regulation.

Procedure for incident reporting

pits pin dd bfd person filing report may or may not be the person responsible for or involved in incident Identify client, visitor, employee, and all witnesses to event The policy for incident reporting is unique to each health care agency; review and follow specific agency policy for incident reporting State objective facts of incident Prevent further injury and provide care for client, visitor, or employee Is an agency record of an accident or other event in the health care agency that is not consistent with hospital policy; may also be called unusual occurrence report or variance report. Notify health care provider immediately and take orders for interventions that may limit further harm Document facts of incident in client's record do not document in client record that an incident report was filed Be specific—list name of medication or equipment involved File report as soon as possible do not draw conclusions or lay blame

Scope of errors - Active

pm cdif -Prevention of decubitus ulcers -Medication administration: *10 Rights *Components of an physician med order -Diagnostic workup -Invasive procedures -Fall prevention -Recognition of/action on adverse events -Communication

skeletal disease osteomalacia tx

prevention sunlight exposure vit d supplements when dx- ERGOCALCIFEROL and ca is prescribed

skeletal disease scoliosis dx procedures

standing spinal x-ray curvature measured

THE SPREAD OF INFECTION: SIX LINKS

watkins: 2chains infectious agent can be infected by different things. bacteria,virus,fungi and thats going to determine how we tx them. they all do not get antibiotics! I will do a culture, to see what kind of drug. like a broad spectrum antibiotics to make sure were getting the right thing for that agent *INFECTIOUS AGENTS* Pathogens Normal flora that become pathogenic book-Infectious Agent Some microorganisms live on or in the human body without causing harm. For instance, the Staphylococcus bacteria growing on human skin are usually harmless. Other microorgan- isms are beneficial or even essential for human health and well-being. They are referred to as normal flora. *Normal flora* in the intestine aid in digestion; synthesize vitamin K; and release vitamin B12, thiamine, and riboflavin when they die. In addition, they limit the growth of harmful bacteria by compet- ing with them for available nutrients. There are two types of normal flora: transient and resident. *Transient flora* are normal microbes that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand- washing. *Resident flora* live and multiply harmlessly deep in skin layers. They are permanent inhabitants of the skin, and cannot usually be removed with routine handwashing. *Pathogens* are microorganisms capable of causing disease. In fact, the precise accepted definition of the term *infection* is successful invasion of and multiplication in the body by a pathogen). The largest groups of pathogenic microorganisms are bacteria, viruses, and fungi (which include yeasts and molds). Less common pathogens are protozoa, *helminths* (commonly called worms), and *prions*, which are infectious protein particles that cause certain neurological diseases. In addition, normal flora may become pathogenic when a patient is especially vulnerable to disease, or if they enter the deep tissues or body regions they do not normally inhabit. For instance, rupture of the bowel through trauma or disease allows intestinal microbes to enter the abdominal cavity or bloodstream, where they cause infection. Once a pathogen gains entry into a host, four factors determine whether the person develops infection: ■*Virulence* of the organism (its power to cause disease) ■Ability of the organism to survive in the host environment ■Number of organisms (the greater the number, the more likely they are to cause disease) ■Ability of the host's defenses to prevent infection --------------------- watkins: 2chains the Susceptible host is going to pick on people that have a poor immune system. our post-op, age (very young/old/premature babies) immune suppressed. chemo pts, our hiv, diabetes, dialysis, steroid use, disease processes esp ppl who have chronic dz. stress, lack of sleep, nutrition-protein, vitamin c, zinc *Susceptible Host* Person with inadequate defense Four determining factors Virulence Organism's ability to survive in the host's environment Number of organisms Host's defenses book Susceptible Host A susceptible (or compromised) host is a person who is at risk for infection because of inadequate defenses against the invading pathogen. Various factors can increase susceptibility to infection, among them: age (the very young or very old), compromised immune system (as in those receiving immune suppression for organ transplantation or treatment of cancer or chronic illness), and immune deficiency conditions (e.g., HIV, leukemia). -------------------- watkins: 2chains incision wound-pressure ulcer iv site Foley catheter/jp drains-tubes inhalation ingestion membranes- mouth,nose,mouth *Portal of Entry* Eye, nares, mouth, vagina, cuts, scrapes Wounds, surgical sites, IV or drainage tube sites Bite from a vector book Portal of Entry Pathogens can enter the body through various portals of entry. Normal body openings, such as the conjunctiva of the eye, the nares (nostrils), mouth, urethra, vagina, and anus are potential portals of entry, as are abnormal openings, such as cuts, scrapes, and surgical incisions. Vectors, such as mosqui- toes, create portals of entry when they bite through the skin. In healthcare settings, common portals of entry include wounds, surgical sites, and insertion sites for tubes or needles. ------------------- watkins 2chains how it gets from one place to another vectors-animals that carry it; tick(lyme disease), mosquito fomite- inanimate objects. doorknob, money, stethoscope, scrubs, shoes, cellphone, pens, tables, countertop direct contact- something on my hands and i touch somebody indirect contact- airborne, droplet 2chains *Mode of Transmission* Contact Direct - touching, kissing, sexual contact Indirect - contact with a fomite Droplet: cough, sneeze Airborne: via air conditioning, sweeping book Mode of Transmission Contact, either direct or indirect, is the most frequent mode of transmission of infection. *Direct contact* between two people usually involves touching, kissing, or sexual intercourse. Animals commonly transmit infection via scratching and biting as well. *Indirect contact* involves contact with a *fomite*, a contaminated object that transfers a pathogen. For example, suppose that while you are charting you begin to sneeze or cough. If you cover your nose and mouth with your hand and then resume charting, you may transmit pathogens to the pen, paper, and chart (or keyboard). Shoes, eyeglasses, stetho- scopes, and other items we wear also commonly serve as fomites, as do contaminated needles. Some microbes can live only a few seconds on fomites; others can live for years. It depends on the type of microorganism and the environment. *Droplet transmission* occurs when the pathogen travels in water droplets expelled as an infected person exhales, coughs, sneezes, or talks. It may also occur during suctioning and oral care. The usual method of transmission is for the droplet to be inhaled or enter the eye of a susceptible person. Although droplets can travel only a few feet from the infectious person, within that distance they may readily contaminate fomites that then transmit the organism by contact. *Airborne transmission* occurs with much smaller organ- isms that can float considerable distances on air currents. Airborne pathogens can travel through heating and air condi- tioning systems to infect large numbers of people. Sweeping a floor or shaking out contaminated bed linens can stir up air- borne microorganisms and launch them on air currents—think of a flying magic carpet (of pathogens). The agents of measles and tuberculosis, as well as many fungal infections, are com- monly transmitted in this manner. A *vector* is an organism that carries a pathogen to a suscep- tible host, typically by biting or stinging, creating another portal of entry into the body. The mosquito is a common vec- tor for diseases, including malaria, yellow fever, and the West Nile virus. Ticks, fleas, mites, and other insects also carry various diseases. ------------------- watkins 2chains how does it get out of a person. ex- coughing, sneezing, emesis, bm, urine, semen, blood *Portal of Exit* Via Bodily fluids Coughing, sneezing, diarrhea Seeping wounds Tubes, IV lines book Portal of Exit A contained reservoir is only a potential source of infection. For infection to spread, a pathogen must exit the reservoir. In the case of human or animal reservoirs, the most frequent portal of exit is through body fluids, including blood, mucus, saliva, breast milk, urine, feces, vomitus, semen, or other secretions. The body's natural response to foreign materials, including pathogens, is to try to expel them. If you have a pathogen in the respiratory system, you cough and sneeze. If it is in the gastrointestinal system, you vomit or experience intestinal cramping and diarrhea. Microbes responsible for sexually transmitted infections can exit via semen, vaginal secretions, or blood that is present during sex. Cuts, bites, and abrasions also provide an exit for body fluid. Blood and pus seeping from a wound help transport pathogens away from the broken skin but become a portal by which infection may be transmitted to others. In healthcare- related infections, puncture sites, drainage tubes, feeding tubes, and intravenous lines commonly serve as routes for pathogens to exit the body. -------------------- watkins 2chains bacteria like to grow in warm, dark, moist, ex- stagnant water has bacteria *RESERVOIR* Where pathogens live and multiply May be living Humans, animals, insects May be nonliving Food, floors, equipment, contaminated water Most pathogens prefer a warm, moist, dark environment. book A reservoir is a source of infection: a place where pathogens survive and multiply. The human body is the most common reservoir for pathogens. Animals and insects are other living reservoirs. Nonliving reservoirs include soil, water, food, and environmental surfaces. Examples include con- taminated water, garbage, soiled diapers, and wound dressings. In healthcare facilities, many surfaces act as reser- voirs. Microorganisms have mass, and they eventually fall to the floor or onto bedside tables, chairs, or equipment. Other surfaces, such as sinks, toilets, bed rails, and bed linens, may also become reservoirs because of their proximity to patients, family members, and healthcare providers harbor- ing pathogens. carriers are capable of defending themselves from active disease but harbor the pathogenic organisms within their bodies. They have no symptoms, yet they serve as reservoirs and can pass the disease to others

Considerations for Older Adults

• Consider the special needs of older adults when assessing and managing their pain. Greater risk for undertreated pain Undertreatment of cancer pain due to inappropriate beliefs about pain sensitivity, tolerance, and ability to take opioids • Pain is inadequately treated in all health care settings. High-risk populations and lack of adequate staffing are factors in pain management.

qsen comp

pets IQ patient centered care evidence based practice teamwork and interprofessional collaboration safety informatics quality improvement

muscle fibromyalgia tx

pf pt- exercise with swimming & water exercises being recommended focus on clients symptoms

define and describe actions to prevent falls from occurring

pg nn proper lighting grab bars/rails *no scatter rugs* non-skid shoes

emergency and disaster preparedness

* nursing role in healthcare facility* pcpcp prior to disaster- contribute to developing internal and external emergency response plans collaborate with medical command physician to meet patients needs personal emergency preparedness plan creativity and flexibility are essential personal readiness supplies " go bag" * nursing role in the community* test- f triage emergency response shelter assistance teaching first aid

HEALTHCARE-RELATED INFECTION

*An infection acquired as a result of healthcare* Cost to the healthcare system = $4.5 billion/year Leading cause of death Preventable with use of aseptic principles/techniques *Exogenous Healthcare-Related Infection:* Pathogen acquired from healthcare environment *Endogenous Healthcare-Related Infection: * Normal flora multiply and cause infection as a result of treatment book (e.g., chemotherapy or antibiotics) causes the normally harmless microbe to multiply and cause infec- tion. For example, candidal vaginitis (yeast infection) may develop in a client receiving antibiotics after surgery.

QSEN COMPETENCIES 2

-Safety Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance -Targeted KSAs (Knowledge, Skills, Attitudes K: Discuss potential and actual impact of national patient safety resources, initiatives, and regulations S: Use national patient safety resources for own professional development and to focus attention on safety in care settings A: Value the relationship between national safety campaigns and implementation in local practices and practice settings

SKIN PREPARATION

-Skin is first line of defense - break in barrier can lead to infection -1st step in reducing surgical site infection -Can start 1-2 days before surgery with Antiseptic solutions with shower -Removal of hair Do not shave - clip

Fall assessment screening

-What are common screening tools? **Morse Falls Score sheet When should these be used? **Upon admission - meeting **Ongoing as conditions change

Mobility screening

-What are common screening tools? **Timed Get-up-and Go test **Performance-oriented mobility assessment

Muscles

1. Primarily function as a source of power and pull against bones to move body 2. Three primary types of muscle: -skeletal muscle (striated, voluntary) moves extremities and external areas of body -cardiac muscle (striated, involuntary) is found in heart -smooth muscle (nonstriated, involuntary) is found in walls of arteries and bowel

Joint articulations

1. Result when two bones are joined together; categorized according to type of motion 2. Composed of fibrous connective tissue and cartilage (dense avascular connective tissue) that covers ends of bones making movement smooth 3. Joint cavity secretes synovial fluid, which lubricates joint and reduces friction *book* A joint is a space in which two or more bones come together. This is also referred to as articulation of the joint. The major function of a joint is to provide movement and flexibility in the body. There are three types of joints in the body: • Synarthrodial, or completely immovable, joints (e.g., in the cranium) • Amphiarthrodial, or slightly movable, joints (e.g., in the pelvis) • Diarthrodial (synovial), or freely movable, joints (e.g., the elbow and knee) Although any of these joints can be affected by disease or injury, the synovial joints are most commonly involved

Midline Catheter

3 to 8" long, 3 to 5 Fr, double or single lumen Inserted through vein in upper arm Used for therapies lasting 1 to 4 wk Do not use for vesicant drugs; can cause tissue damage if extravasation occurs Do not use to draw blood

Muscle: Fibromyalgia

A syndrome that is characterized by fatigue and chronic pain Healthcare provider will rule everything else out first Usually affects women of childbearing age & has no known cause S&S: Pain (increases with stress &/or weather conditions), fatigue, insomnia Treatment: (focuses on client's symptoms), physical therapy, exercise with swimming & water exercises being recommended Medications: antidepressants, NSAIDS (ibuprofen), skeletal muscle relaxants (cyclobenzaprine), for fibromyalgia treatment - pregabalin (Lyrica)

OBJECTIVES - ATI - NCLEX Psychosocial Integrity

Apply nursing interventions to reduce patient and family anxiety. Explain procedures to ensure the identity of the patient and the accuracy of the planned surgical procedure. Act as a patient advocate with regard to patients' rights, informed consent, and advance directives. Apply interventions to ensure the patient's safety and dignity during an operative procedure

Postop: Renal/urinary system assessment postopxl

Check for urine retention Consider other sources of output (e.g., sweat, vomitus, diarrhea stools) Report urine output of < 30 mL/hr

Pain Mechanisms and Pathways Transduction activation of nociceptors to:

Chemical stimulus Electrical charge Mechanical stimulus Pressure Thermal stimulus Transduction is the first process of nociception and refers to the means by which noxious events activate neurons that exist throughout the body (skin, subcutaneous tissue, and visceral [or somatic] structures) and have the ability to respond selectively to specific noxious stimuli. These neurons are called nociceptors. When they are stimulated directly, a number of excitatory compounds (e.g., serotonin, bradykinin, histamine, substance P, and prostaglandins) are released that further activate more nociceptors

APPLICATION

Clinical judgment is an aspect of nursing in all settings. Clinical judgment is not required in all patient interactions. What is an example of a patient interaction that does not require critical thinking?

COLLABORATIVE CARE: SUPPRESSED IMMUNE RESPONSE

Clinical outcomes: Normal GI transit time Resolution of infection Adequate hydration Adequate nutrition Resolution of skin rash Restoration of adequate nutrition, body weight, and BMI

Implanted Port

Consists of portal body, dense septum over a reservoir, and catheter Single or double Surgically created subcutaneous pocket houses the port body Usually placed in upper chest/extremity Not visible externally Flushing after each use and at least once per month between therapies prevents clot formation in internal chamber

OBJECTIVES - ATI - NCLEX Health Promotion and Maintenance

Evaluate patient risk for complications of wound healing. Provide postoperative education for patients and family members after surgery

Clinical Significance: Blood Pressure

Example of hydrostatic filtering forces, moving whole blood from the heart to capillaries where filtration occurs to exchange water, nutrients, and waste products between the blood and tissues

Treatment of Osteoarthritis

I 2 tan w If function is completely lost joint replacement surgery would then have to be explored *2 main goals are to provide comfort & maintain function/mobility TENS unit Application of heat Nonpharmacological techniques for pain relief Weight loss

Nontunneled Percutaneous Central Venous Catheter

Inserted through subclavian vein in upper chest or jugular veins in neck May require insertion in femoral vein—rate of infection is high 7 to 10 inches (15 to 25 cm) long; up to 5 lumens Tip resides in superior vena cava Chest x-ray confirms placement

Safety hazards in the home - Take-home toxins

Pathogenic microorganisms, asbestos, lead, mercury, arsenic Prevention: -Be aware of workplace preventive measures -Remove work clothing -Shower if appropriate -Use gloves

INFORMED CONSENT

Patients may sign with "X" In emergency, telephone authorization is acceptable Special permits required for some procedures

ENVIRONMENT OF THE OPERATING ROOM

Preparation of surgical suite, team safety Layout Health and hygiene of surgical team Surgical attire Surgical scrub Remember!!! People are a source of bacteria in the surgical setting! Special health care standards, dress are needed Watch for nosocomial infections, identify source of pathogens

Principles of body mechanics To move your body without causing injury

Proper alignment Wide base of support Avoid bending and twisting Squat to lift Keep objects close when lifting Raise beds Push vs. lift Get help

CLINICAL MANAGEMENT: COLLABORATIVE INTERVENTIONS

Rest, ice, compression, elevation (RICE) Most helpful after sprain, strain, or trauma- Wounds caused by trauma have a greater risk of infections and slower healing Helps minimize swelling Most beneficial for the first 24 to 48 hours after injury General discussion questions What is the best method for applying ice? What should the nurse monitor? After applying a compression device, the nurse should monitor for what developments? How high is "high enough" when elevating an extremity?

Electrolytes normal lab labsxl values

Sodium 136-145 mEq/L Potassium 3.5-5.0 mEq/L Calcium 9.0-10.5 mg/dL Magnesium 1.3-2.1 mEq/L Chloride 96-106 mEq/L Phosphate 3.0-4.5 mg/dL

skeletal disease osteoporosis at risk

access A = alcohol use C = corticosteroid use C = calcium is low E = estrogen is low (especially postmenopausal) S = smoking S = sedentary lifestyle *book* People with eating disorders such as anorexia nervosa and bulimia nervosa are also at risk for osteoporosis related to decreased intake of calcium and vitamin D.

ethics 1536

according to the american nurses association ANA, ethics is a theoretical and reflective domain of human knowledge that address issues and questions about mortality in human choices, actions, character, and ends ana code of ethics 6 essential ethical prinipiles that nurses and health care professional should use as a guide for clinical decision making 1533/34 Autonomy- self-determination- person's right to choose and ability to act on that choice. right to make own decisions 1534 beneficence- duty to do or promote good. benefit to others 1534 nonmaleficence- twofold duty to do no harm and to prevent harm. Respect for Dignity 1535 fidelity- Fidelity (faithfulness) is the duty to keep promises. The duty to keep a promise is the same regardless of its level of importance. keeping promises 1535 veracity- Veracity is the duty to tell the truth. be culturally sensitive in order to act on the family's values, not the dominant cultural values. Key Point: Always consider the context. 1536-1543 social justice- is the obligation to be fair. equal treatment of all patients.

Diarrhea diaxl

ashlii ni Increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort, and possibly incontinence. *ni* diani Monitor stools to quantify diarrhea Assess and monitor fluid imbalance Monitor for alterations in perineal skin integrity ashlii- Nursing management of diarrhea -Monitor stools to quantify diarrhea -Assess and monitor for fluid imbalance -Monitor for alterations in perineal skin integrity -Proper dietary teaching *Clear liquid *Bananas, rice, applesauce, toast (BRAT) *Foods to avoid -Antidiarrheal medications ***Not recommended for acute diarrhea Lomotil, immodium -Teach clients about over-the-counter aids DRUG THERAPY Antidiarrheal medications: not recommended for acute diarrhea Chlordiazepoxide/ Diphenoxylate (Librium) Immodium Teach clients OTC aids PATIENT TEACHING Proper dietary teaching Clear liquid Bananas, rice, applesauce, toast (BRAT) Foods to avoid

skeletal disease pagets dz s&s

cv he is bb mm ss check for family occurrence and hz of previous fractures- disease is genetic vision hearing enlarged scalp- The skull is often enlarged with the bone becoming soft and thick. in advanced cases may see khyphosis or scoliosis skin over affected area maybe warm to touch balance deficiencies Bowing of the long bones of the arms and legs. most common symptom is pain the hips and pelvis which is often described as deep aching pain that worsens with weight bearing movement of the eye and facial muscle swallowing speech

safety hazard - community community- acquired pathogens

example/ cause food-borne prevention: c-pap cleaning cooking surfaces proper storage attention to folk remedies?? proper cooking and cleaning of foods Vector-borne Prevention: drain standing water; insect repellents; protect skin contact with insects; wipe out breeding areas

older adult factors affecting safety substance abuse

excessive use alcohol and illicit drugs impairs cognition isolation depression delirium can result *** national institute on alcohol abuse and alcoholism recommends no more than 1 drink per day, or 7 drinks per week for people over 65 short Michigan alcohol screening test cage test???

emergency and disaster preparedness hospital incident command system

fd remi ht facility- level organizational model for disaster management debriefing- critical incident stress debriefing and administrative review roles- formally structured under hospital or long term care facility incident commander with clear lines of authority and accountability for specific resources emergency operations systems medical command physician incident commander determines when to *stand down* hospital incident commander triage officer

skeletal disease osteomalacia s&s

generalized skeletal pain and tenderness without a hz of injury *hips are the most common site* reluctant to walk low back pain pain in the ribs, feet, and other areas waddling gate

Accident prevention - Infant

i c bp in pr hl Infants may be trapped by crib slats spaced too far apart Carefully select infant furniture paying special attention to current safety standards Because of their inability to communicate, infants are at risk for burns from applications of heat to skin, such as from a hot water bottle or other heated device Place infants riding in a car in a rear-facing car restraint system in back seat; use a rear-facing restraint system until child is 1 year old and at least 20 pounds Infants or young children may be poisoned by lead paint on antique furniture normal serum lead level is < 10 mg/dL Place infants on back after eating and while sleeping; this will not increase risk of aspiration and will reduce risk of sudden infant death syndrome (SIDS) Rapid changes in development and acquisition of new motor skills put infants at increased risk for injury from falls from tables, beds, high chairs, infant seats, and so on higher levels require treatment to reduce or prevent neurological deficits lead level 10-19 mg requires environmental history

Nursing interventions for impaired mobility - Explain benefits of exercise

i dip Improves tone and strength of muscles, joint flexibility and range of motion (ROM) Decreases bone loss of calcium, which helps maintain acidic urine to decrease risk for renal calculi Improves GI motility and tone, thereby improving digestion and elimination Promotes good pulmonary ventilation, which prevents pooling of secretions in lungs and reduces risk of pneumonia

safety hazard: healthcare facility

in case of fire race (R)emove clients from danger. (A)ctivate the fire alarm. (C)ontain the fire. (E)vacuate the area (horizontal evacuation should be done before vertical evacuation if possible). to use fire extinguisher: pull pin aim hose squeeze handle sweep from side to side

EMTALA

is a federal law that requires hospital emergency departments to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay — this law has been an unfunded mandate since it was enacted in 1986.

cane

is sometimes used if the patient needs only minimal support for an affected leg. The straight cane offers the least support. A hemi-cane or quad-cane provides a broader base for the cane and therefore more support. The cane is placed on the unaffected side and should create no more than 30 degrees of flexion of the elbow. The top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist.

developmental factors affecting safety preschool 3-5 years

leading cause of death/ accidents mva, drowning, fires, poisoning *falls are the primary cause of non-fatal injuries* risk factors play extends to outdoors more adventurous

skeletal disease pagets dz tx

lmn pwp Limiting disability Meds- calcitonin & biophoshonates- analgesics No cure, so focus is aimed at *symptom management* prevent complication Worst cases: Surgery pt- weight bearing exercises

Consequences of immobility

mj pu pigs radd cov Muscle atrophy Joint dysfunction Paralytic ileus Urinary tract infection Pressure ulcers Increased coagulability Glucose intolerance Sleep disturbances Renal calculi Atelectasis/pneumonia Depression Disorientation Constipation Orthostatic hypotension Venous stasis

Isometric exercise

ms tm Muscle tension or resistance is produced without a change in muscle length Strengthen muscle groups that will be used later in ambulation Teach client to push or pull against a stationary object Muscles exercised are abdominal, gluteus, and quadriceps

Laboratory Assessment: metabolic acidosis

pH < 7.35 Bicarbonate < 21 mEq/L PaO2 normal PaCO2 normal or slightly decreased Serum potassium high

skeletal disease osteomylitis nursing interventions

pad pait perform sterile dressing changes admen pain meds diet high in protein and vit c *perform neurovascular checks* antibiotics ASAP immobilize the body part teach importance of antibiotics completion

Patient teaching regarding Lyme disease

pd dl t Properly using insect repellents containing DEET is recommended *Daily tick checks* should be conducted after coming in from the outdoors. *If found, the tick should be properly removed by using fine-point tweezers to take away the ENTIRE creature.* *Dress appropriately for the outdoors when going out in a tick-laden environment*: Light-colored clothing should be worn to make ticks more visible. Tuck pants into socks when going into areas that could harbor ticks.

attributes of patient- centered care

pita rice physical comfort information, communication, education transitional and continuity access to healthcare respect for patients values preferences needs involvement of family and friends coordination and integration of care emotional support- free from fear and anxiety

quality improvement

process in which nurses and the interprofessional healthcare team use indicators --data-- to monitor care outcomes and develop solutions to change and improve care

skeletal disease osteomylitis prevention

prophylactic antibiotics and sterile technique during and after sx

Nursing Process - Nursing diagnoses (related to immobility)

sari rari Self-care deficit (bathing/hygiene, feeding, dressing/grooming, toileting Acute pain / chronic pain Risk for disuse syndrome Ineffective health maintenance Risk for ineffective peripheral tissue perfusion Activity intolerance Risk for injury / risk for falls Impaired physical mobility

Skeletal Disease: Scoliosis

spinal deformity that is characterized by a lateral curve, spinal rotation causing asymmetry, and less than normal curvature in the thoracic spine S&S: uneven pant or shirt length, pain is usually not an issue until the deformity has progressed, Adams Bending Forward Test (test used in the schools to help with observing curvature in the spine) Diagnostic Procedures: standing spinal x-rays and curvature measured Treatment: mild curvature - exercises and braces, surgery is recommended for curves greater than 40 degrees

Emergency response - Secondary survey

td mira The secondary survey is initiated after initiating lifesaving interventions Do a complete health history and physical examination Measure and record a full set of vital signs Identify family members Remove all of client's clothing Administer comfort measures or pain medication if appropriate

Accident prevention - Adolescent

tease ra Teach adolescents dangers of alcohol and substance use Encourage courses in driver's education Adolescents may be injured in sports-related accidents seatbelt regulations should be role modeled and enforced by parents encourage protective sporting gear for organized and impromptu sporting events Review water safety principles because adolescents can overestimate endurance when swimming Adolescents benefit from information about sexual health, including information about sexually transmitted infections and pregnancy prevention birth control

Somatosensory Evoked Potentials (Evoked Potentials)

u tiie Used to measure time in meters per second from the stimulation of a peripheral nerve through the response. This measurement documents axonal continuity when sensory potential cannot be measured due to nerve trauma. **It is used when EMG is not appropriate. It is useful in the evaluation of radiculopathies and peripheral nerve function and the diagnosis of Charcot-Marie-Tooth disease. Electrodes are placed on the skin, stimulus is applied, and time intervals are calculated based on the time it takes from the stimulus to be given at one electrode and reach the next electrode along the peripheral nerve pathway.

chain of infection

watkins: 2chains infectious agent can be infected by different things. bacteria,virus,fungi and thats going to determine how we tx them. they all do not get antibiotics! I will do a culture, to see what kind of drug. like a broad spectrum antibiotics to make sure were getting the right thing for that agent INFECTIOUS AGENTS Pathogens Normal flora that become pathogenic book-Infectious Agent Some microorganisms live on or in the human body without causing harm. For instance, the Staphylococcus bacteria growing on human skin are usually harmless. Other microorgan- isms are beneficial or even essential for human health and well-being. They are referred to as normal flora. Normal flora in the intestine aid in digestion; synthesize vitamin K; and release vitamin B12, thiamine, and riboflavin when they die. In addition, they limit the growth of harmful bacteria by compet- ing with them for available nutrients. There are two types of normal flora: transient and resident. Transient flora are normal microbes that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand- washing. Resident flora live and multiply harmlessly deep in skin layers. They are permanent inhabitants of the skin, and cannot usually be removed with routine handwashing. Pathogens are microorganisms capable of causing disease. In fact, the precise accepted definition of the term infection is successful invasion of and multiplication in the body by a pathogen). The largest groups of pathogenic microorganisms are bacteria, viruses, and fungi (which include yeasts and molds). Less common pathogens are protozoa, helminths (commonly called worms), and prions, which are infectious protein particles that cause certain neurological diseases. In addition, normal flora may become pathogenic when a patient is especially vulnerable to disease, or if they enter the deep tissues or body regions they do not normally inhabit. For instance, rupture of the bowel through trauma or disease allows intestinal microbes to enter the abdominal cavity or bloodstream, where they cause infection. Once a pathogen gains entry into a host, four factors determine whether the person develops infection: ■Virulence of the organism (its power to cause disease) ■Ability of the organism to survive in the host environment ■Number of organisms (the greater the number, the more likely they are to cause disease) ■Ability of the host's defenses to prevent infection --------------------- watkins: 2chains the Susceptible host is going to pick on people that have a poor immune system. our post-op, age (very young/old/premature babies) immune suppressed. chemo pts, our hiv, diabetes, dialysis, steroid use, disease processes esp ppl who have chronic dz. stress, lack of sleep, nutrition-protein, vitamin c, zinc Susceptible Host Person with inadequate defense Four determining factors Virulence • Virulence is a term for pathogenicity. o Virulence is related more to the frequency with which a pathogen causes disease and its ability to invade and damage a host. o Virulence can also indicate the severity of the disease. Organism's ability to survive in the host's environment Number of organisms Host's defenses book Susceptible Host A susceptible (or compromised) host is a person who is at risk for infection because of inadequate defenses against the invading pathogen. Various factors can increase susceptibility to infection, among them: age (the very young or very old), compromised immune system (as in those receiving immune suppression for organ transplantation or treatment of cancer or chronic illness), and immune deficiency conditions (e.g., HIV, leukemia). -------------------- watkins: 2chains incision wound-pressure ulcer iv site Foley catheter/jp drains-tubes inhalation ingestion membranes- mouth,nose,mouth Portal of Entry Eye, nares, mouth, vagina, cuts, scrapes Wounds, surgical sites, IV or drainage tube sites Bite from a vector book Portal of Entry Pathogens can enter the body through various portals of entry. Normal body openings, such as the conjunctiva of the eye, the nares (nostrils), mouth, urethra, vagina, and anus are potential portals of entry, as are abnormal openings, such as cuts, scrapes, and surgical incisions. Vectors, such as mosqui- toes, create portals of entry when they bite through the skin. In healthcare settings, common portals of entry include wounds, surgical sites, and insertion sites for tubes or needles. ------------------- watkins 2chains how it gets from one place to another vectors-animals that carry it; tick(lyme disease), mosquito fomite- inanimate objects. doorknob, money, stethoscope, scrubs, shoes, cellphone, pens, tables, countertop direct contact- something on my hands and i touch somebody indirect contact- airborne, droplet 2chains Mode of Transmission Contact Direct - touching, kissing, sexual contact Indirect - contact with a fomite Droplet: cough, sneeze Airborne: via air conditioning, sweeping book Mode of Transmission Contact, either direct or indirect, is the most frequent mode of transmission of infection. Direct contact between two people usually involves touching, kissing, or sexual intercourse. Animals commonly transmit infection via scratching and biting as well. Indirect contact involves contact with a fomite, a contaminated object that transfers a pathogen. For example, suppose that while you are charting you begin to sneeze or cough. If you cover your nose and mouth with your hand and then resume charting, you may transmit pathogens to the pen, paper, and chart (or keyboard). Shoes, eyeglasses, stetho- scopes, and other items we wear also commonly serve as fomites, as do contaminated needles. Some microbes can live only a few seconds on fomites; others can live for years. It depends on the type of microorganism and the environment. Droplet transmission occurs when the pathogen travels in water droplets expelled as an infected person exhales, coughs, sneezes, or talks. It may also occur during suctioning and oral care. The usual method of transmission is for the droplet to be inhaled or enter the eye of a susceptible person. Although droplets can travel only a few feet from the infectious person, within that distance they may readily contaminate fomites that then transmit the organism by contact. Airborne transmission occurs with much smaller organ- isms that can float considerable distances on air currents. Airborne pathogens can travel through heating and air condi- tioning systems to infect large numbers of people. Sweeping a floor or shaking out contaminated bed linens can stir up air- borne microorganisms and launch them on air currents—think of a flying magic carpet (of pathogens). The agents of measles and tuberculosis, as well as many fungal infections, are com- monly transmitted in this manner. A vector is an organism that carries a pathogen to a suscep- tible host, typically by biting or stinging, creating another portal of entry into the body. The mosquito is a common vec- tor for diseases, including malaria, yellow fever, and the West Nile virus. Ticks, fleas, mites, and other insects also carry various diseases. ------------------- watkins 2chains how does it get out of a person. ex- coughing, sneezing, emesis, bm, urine, semen, blood Portal of Exit Via Bodily fluids Coughing, sneezing, diarrhea Seeping wounds Tubes, IV lines book Portal of Exit A contained reservoir is only a potential source of infection. For infection to spread, a pathogen must exit the reservoir. In the case of human or animal reservoirs, the most frequent portal of exit is through body fluids, including blood, mucus, saliva, breast milk, urine, feces, vomitus, semen, or other secretions. The body's natural response to foreign materials, including pathogens, is to try to expel them. If you have a pathogen in the respiratory system, you cough and sneeze. If it is in the gastrointestinal system, you vomit or experience intestinal cramping and diarrhea. Microbes responsible for sexually transmitted infections can exit via semen, vaginal secretions, or blood that is present during sex. Cuts, bites, and abrasions also provide an exit for body fluid. Blood and pus seeping from a wound help transport pathogens away from the broken skin but become a portal by which infection may be transmitted to others. In healthcare- related infections, puncture sites, drainage tubes, feeding tubes, and intravenous lines commonly serve as routes for pathogens to exit the body. -------------------- watkins 2chains bacteria like to grow in warm, dark, moist, ex- stagnant water has bacteria RESERVOIR Where pathogens live and multiply May be living Humans, animals, insects May be nonliving Food, floors, equipment, contaminated water Most pathogens prefer a warm, moist, dark environment. • A pathogen or an agent is any microorganism capable of producing disease. book A reservoir is a source of infection: a place where pathogens survive and multiply. The human body is the most common reservoir for pathogens. Animals and insects are other living reservoirs. Nonliving reservoirs include soil, water, food, and environmental surfaces. Examples include con- taminated water, garbage, soiled diapers, and wound dressings. In healthcare facilities, many surfaces act as reser- voirs. Microorganisms have mass, and they eventually fall to the floor or onto bedside tables, chairs, or equipment. Other surfaces, such as sinks, toilets, bed rails, and bed linens, may also become reservoirs because of their proximity to patients, family members, and healthcare providers harbor- ing pathogens. carriers are capable of defending themselves from active disease but harbor the pathogenic organisms within their bodies. They have no symptoms, yet they serve as reservoirs and can pass the disease to others

Pyelonephritis- kidneys piexl

watkins: if a uti is really bad and not tx it backs up into the bladder then up to the *kidneys* bacterial infection tx with antibiotics, if infection is in kidneys we flush kidney out Drink water to flush if hospitalized do iv fluids if the oral doesn't work depends on the severity *A bacterial infection in the kidney and renal pelvis (the upper urinary tract).* Pyelonephritis is a bacterial infection in the kidney and renal pelvis (McCance et al., 2014). It can be acute or chronic. Pyelonephritis interferes with urinary ELIMINATION, which is the excretion of waste from the body by the urinary system (as urine). Chapter 2 provides a summary of the concept of elimination in more detail. pyelonephritis (upper urinary tract infection); postdelivery urinary tract infections are usually caused by E. coli bacteria and generally occur soon after vaginal delivery sn bacterial infection renal pelvis tubule institional tissue in 1 or both kidneys, can be caused by uti, severe pain in kidney that radiates to your groin during urination, hot/ cold flashes, objective data: pyuria aka puss in the urine discharge foul smelling and cloudy with hematuria (bld in urine), every once in awhile the pt will be asymptomatic mall bacterial infection in the kidney and renal pelvis the increase urinary tract, can be acute/chronic- most common bacteria e.coli *acute*- bacteria during pregnancy, obstruction or reflux *chronic*- structural deformities, obestruction or reflex *acute s/s*- fever, chills, increased hr, flank pain, loin pain, tender cva, abd (colicky) discomfort, n/v, malaise,fatigue,nocturia, burning,urgency, or frequency of urination *chronic s/s* pies/s - htn, inability to conserve sodium, decreased urine concentrativy ability (nocturia), often develop hyperkalemia and acidosis *ashlii s/s* -Bacteruria -Flank pain at the costovertebral angle (CVA) -Fever -Chills -Colicky abdominal pain -Nausea -Vomiting -Dysuria -Frequency -Nocturia *s/s* Elevated temperature; low-grade temperature occurs with cystitis, higher fever occurs with pyelonephritis Flank pain, costovertebral angle tenderness, chills, nausea and vomiting (N/V) with pyelonephritis *manage pain, nonsurgical- drug theraphy (ABTs), nutrition theraphy 2-3 l/daily, balanced adequat diet, surgical mangement- pyelolithotomy, nephrectomy ureteral diversion Inflammation( usually caused by infection) of the renal parenchyma and collecting system Acute Pyelonephritis: ashlii An infection of the UPPER urinary tract. It may involve the ureters, renal pelvis, and papillary tips of the collecting ducts. Unchecked, it can extend into the tubules of the nephron, creating a potential for renal failure. Filtration, re absorption and secretion are impaired. *ashlii dx* piedx Urinalysis and urine culture may be sufficient in mild, initial cases of pyelonephritis in an uncomplicated presentation. -----renal scan Computed tomography (CT) is the standard diagnostic tool for pyelonephritis unresponsive to 72 hours of antibiotic therapy. Ultrasound is used when CT scanning is contraindicated, such as in pregnancy or in pre-existing renal compromise. *ashlii n.i* pieni Assess and monitor: Nutritional status I&O Fluid & Electrolytes BUN/Creatnine WBC's Temp Pain Increase fluid intake to at least 2L/day Administer acetaminophen for fever Administer opiods for pain Assist with hygiene *piedrugs* DRUGS • Uses pharmacologic relief measures • Uses NSAIDs appropriately -----====Acetaminophen is preferred over NSAIDs because it does not interfere with kidney autoregulation of blood flow.-----opioids in the short term for pain control.=====first the antibiotics are broad spectrum.-----=====usually IV in hospitalized patients; orally in community-dwelling patients *Administer prescribed antibiotics*; commonly sulfamethoxazole/trimethoprim, nitrofurantoin, or, in case of sulfa allergy, amoxicillin or axoxicillin-clavulanate • Uses best practices for catheter replacement when chronic catheter use is indicated • Reports pain controlled *rf* pierf Predisposing factors: retention of residual urine, bacteria introduced during catheterization, and bladder traumatized by childbirth *pt teaching* pieteach Teach patients on antibiotic therapy for a UTI (pyelonephritis) to complete the drug regimen. Promote nutrition and hydration; increase oral fluids to at least 8-10 8-ounce glasses daily, especially water Acidify urine with low-sugar juices (such as cranberry, plum, apricot, and prune) and vitamin C; *AVOID foods* and beverages that alkalinize urine, such as carbonated beverages, coffee, citrus fruits, tomatoes, and chocolate Encourage voiding at first urge and at least every 2-4 hours while awake; wear underwear with a cotton panel to facilitate air circulation Teach preventive measures: use underwear with cotton crotch to facilitate air circulation; avoid fabrics such as nylon that retain moisture and heat; when intercourse is resumed, void beforehand (to prevent bladder trauma) and after (to wash contaminants from area of urinary meatus)

appendicitis penxl

watkins: mc burneys point- flank pain, right lower quadrant- when you push on it, going to have rebound tenderness called mc burneys point ashlii pathology An inflammation of the vermiform appendix, which is a small finger-like appendage just below the ileocecal valve. the fx of the appendix is STORES good bacteria in the GI tract after diarrhea illness to help maintain gut flora. Treatment: Appendectomy is the most common emergency abdominal *surgery* will be needed in the United States.-----NPO-----NO HEAT, ENEMAS, LAXATIVE for ruptured appendix-----IV antibiotics if rupture PRE_OP NURSING CARE: monitor VS; looking for s/s of *perfiration(rupture) & peritonitis*-----semi-Fowler or right side-lying position to help localize and prevent spread of any infection POST-OP monitor vs temp, sx for infection, Ambulating, Incentive spirometer, cough/deep breathing to prevent PNEMONIA----MONITOR BOWEL SOUNDS---- MAKE SURE PASS GASS/bOWELmovement 2-3days penfood hight fiber diet monitor pain level labs penlabs moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm3 with a "shift to the left" (an increased number of immature WBCs). A WBC elevation to greater than 20,000/mm3 may indicate a perforated appendix. An ultrasound study may show the presence of an enlarged appendix. If symptoms are recurrent or prolonged, a CT scan can be used for diagnosis and may reveal the presence of a fecaloma (a small "stone" of feces). Apply cold packs to client's abdomen to help relieve discomfort dx pendx: physical exam- ct, ultrasound, abdominal x-ray, urine test to rule out uti------A laparoscopy is a minimally invasive surgery (MIS) with one or more small incisions near the umbilicus through which a small endoscope is placed.-----laparotomy:for complicated or atypical appendicitis or peritonitis pens/s *Appendix* acroymn s/s *a*bdominal pain- dull around the belly button and radiates to rlq *p*oint of mcBurneys-most pain. rebound tenderness- *p*oor appietiete *e*levated temp *n*/v *d*esire to be in fetal position *i*ncreased wbc *i*nnability to pass gas/stool--- constipation or diarrhea *e*xperience rebound tenderness, abdominal rigidity s/s--- n/v, bloating- loss of appetite- fever Signs of ruptured appendix include sudden relief of pain, fever, chills, elevated WBC count (15,000-20,000 cells / mm 3 cells/mm3), guarding, abdominal distention, rapid shallow breathing, irritability, and restlessness *causes* OBSTRUCTION, fecali aka hard stool, worms parasites, foreign body(ingested), swollen lymph nodes, TRAUMA/INJURY fecala hard stools lead to increased pressure inside stools builds- 48-72 hrs MAJOR RISK FOR PERIFICATION!!! RUPTURES!!!!!----venous obstruction----BOT CLOT=*ISCEMIA* appendix starts to die leading to *peritonitis* leading to shock/death sn inflammation of appendix removal of appendix- antibiotics pt teaching-- monitor pt for infection and wound, make sure the pt walks 6-8 hours after surgery, have pt cough after sx----avoid lifting, stretching, and strenuous activities until all follow-up care is completed

Medications that may affect surgery, therefore are a risk

-Antibiotics - may potentiate the action of anesthetic agents -Anticoagulants - increase risk for bleeding -Antidysrhythmics - may impair cardiac function during anesthesia -Antihypertensives - increase the risk for hypotension during surgery; may interact with anesthetic agents to cause bradycardia and impaired circulation -Aspirin - increase risk for bleeding -Corticosteroids - delay wound healing and increase risk for infection -Diuretics - alter fluid and electrolyte balance (especially potassium balance) -Opiods - increase the risk of respiratory depression -NSAID's - inhibit platelet aggregation, increasing the risk for bleeding -Tranquilizers - increase the risk of respiratory depression

QSEN COMPETENCIES

-Teamwork and Collaboration Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care -Targeted KSAs (Knowledge, Skills, Attitudes K: Discuss effective strategies for communicating and resolving conflict S: Choose communication styles that diminish the risks associated with authority gradients among team members A: Contribute to resolution of conflict and disagreement

RECOGNIZE WHEN AN INDIVIDUAL HAS ALTERED IMMUNITY

Assessment of immune disorders and dysfunction begins with a thorough health history and physical examination Basic laboratory and diagnostic testing procedures Followed by more specific tests depending on the individual's history and current s/s Genetic testing may also be important to confirm a diagnosis Determine appropriate counseling concerning a persons prognosis Make reproduction recommendations

Ligaments

Bands of rigid connective tissue that HOLD JOINTS TOGETHER, allowing for movement and stability Have a relatively poor blood supply, which significantly prolongs healing process after injury *book* ligaments, which attach bones to other bones at joints.

Skeletal Disease: Paget's Disease

Chronic bone disorder that begins with an increase in bone absorption, in compensating for this bone formation increases along with bone remodeling leading to deformities and fractures S&S: (check for family occurrence and previous factures), most common symptom is pain in the hips and pelvis which is often described as deep aching that worsens with weight bearing, hearing, vision, swallowing, speech, movement of the eye and facial muscles, and balance deficiencies, bowing of long bones, enlarged scalp, in advance cases may see kyphosis or scoliosis, skin over affected areas may be warm to touch Diagnostic Procedure: increase in serum alkaline phosphate (ALP) is the first indicator, x-ray, bone scan Treatment: no cure so focus is aimed at symptom management, limiting disability, and complication prevention Physical therapy (weight-bearing exercises), pharmacological therapy (Calcitonin & Biophosphonates), analgesics, & surgery

REVIEW OF IMMUNE RESPONSE 7

Dendritic cell function in an immune response Discovered 35 years ago; recognized as potent cells in asserting control from initiation to termination of the immune response; have "sentinel" function throughout the body as they look for foreign antigens and alert lymphocytes to the presence of injury or infection; they bind to antigens and then process and present them to both B and T Lymphocytes in an immune response. Found to directly activate helper and killer T cells Present cancer cells to cytotoxic T cells

ETHICAL THEORY

Ethics of Duty -Is the right thing to do. Ethics of Consequence -Is the greatest good for the greatest number. Ethics of Character -Is based on life experiences and a willingness to reflect on our actions. Ethics of Relationship -Is the nature and obligation inherent in human relationships.

RISK FACTORS 3

Exaggerated immune response Gender, race, ethnicity SLE occurs more often in women than men by a 10:1 ratio and African Americans are 8 times more likely to contract the disease tan Caucasians/non-Hispanics Genetics May be minor and just an annoyance or may lead to destruction of normal tissue, loss of organ function, or death Environmental or food allergies (minor to severe) Environmental or medication exposure Foods, drugs, pollens, dust, molds, bee venom, vaccines, or serum may evoke a reaction (types I, II, or III) Generally does not happen with first exposure but with re-exposure However genetic predisposition by exposure by mother during fetal development may cause an exaggerated response on first exposure

Isotonic Solutions NS, LR, D5W, D5 ¼ NS

Goes into the vascular space and stays there Solution causes no fluid shift between compartments but rather expands circulating volume in the body. *Examples*: NS, LR, D5W, D5 ¼ NS *Uses*: Client has lost fluids through N/V, burns, sweating, trauma NS is the basic solution when administering blood products ***Alert*: DO NOT use these solutions in clients with HTN, cardiac disease, or renal disease ***Alert*These solutions can cause increase NA levels (when administering solutions that contain NA) and fluid volume excess--more fluid volume, that would increase our bp, which will increase the cardiac workload if they have renal dz and we are already retaining fluid on the body theyre not going to be able to get that fluid out

Attitudes & Practices Related to Pain

Health care provider and nurse attitudes affect interaction with patients experiencing pain Many patients reluctant to report pain Desire to be "good" patient Fear of addiction

CONFRONTED WITH DIFFICULT CHOICES

How we act ethically in practice -or- Why we falter ethically when confronted with difficult choices. The nurse has to make certain decisions that are critical to an ethical practice.

EXAGGERATED IMMUNE RESPONSE exxl

Individuals who have a "hyper" or exaggerated immune response range from: Allergic reactions Autoimmune reactions Critical point to immune system: Differentiate between self and non-self Accomplished by presence of unique proteins on surface of every cell When system fails to recognize "self" - system begins to attack host cells Cytotoxic reactions This process leads to autoimmune diseases and disorders Examples: Rheumatoid arthritis or systemic lupus erythematosus

SUPPRESSED IMMUNE RESPONSE

Individuals who have a "hypo" or suppressed immune system are referred to as: Immunocompromised In a state of immunodeficiency Types of immunodeficiency primary - occurs as a results of improperly developed cells or an absence of cells required to execute immune responses Secondary - loss of immune functioning as a result of an illness or treatment Individuals are unable to provide adequate immune defense against invasion Leaves them at significant risk for infection Leaves them at risk for cancer if immunosuppression occurs over time due to loss or removal of mutating cells

ANESTHESIA

Induced state of partial or total loss of sensation, occurring with or without loss of consciousness Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, achieve controlled level of unconsciousness (in some cases)

OPTIMAL IMMUNE RESPONSE

Involves the three protective functions: Protects the body from invasion of microorganisms and other antigens Removes dead or damaged tissue and cells Recognizes and removes cell mutations that have demonstrated abnormal cell growth and development To accomplish these functions system reacts with three lines of defense First: skin boundary surface includes (mucous membranes, enzymes, natural microbial flora, and complement proteins.) Second: activities of phagocytes, natural killer T lymphocytes, granulocytes, and macrophages Third: antibodies derived from B lymphocytes and the T lymphocytes

Osmosis

Is the movement of water only through a selectively permeable (semipermeable) membrane. In order for osmosis to occur, a membrane must separate two fluid spaces and one space must have particles that cannot move through the membrane (this membrane is impermeable to these particles). Isotonic fluids Hypertonic fluids Hypotonic fluids

COMMON DIAGNOSTIC TESTS

Laboratory tests Complete Blood Count (with WBC differential) Culture and sensitivity C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serologic tests to detect specific antibodies or viruses Radiographic studies X-rays MRI CAT PET and indium scans

STATE LAWS

Licensing of professionals—scope of practice -Credentialing -Discipline Licensing of health care institutions Laws relating to public health and disease prevention and control (mandatory reporting laws) -Communicable disease -Abuse Consent Advanced directives Physician-assisted suicide

Electrolytes lab values rhyme

Little Maggie is 1.3 to 2.1 years old (Mg+). She ate 3.5 - 5.0 bananas (K+) and drank 9.0 - 10.5 oz. milk (Ca+). Then she took an 136 - 145 hour nap after swimming in the ocean (Na+).

REVIEW OF IMMUNE RESPONSE 6

Lymphocyte function in an immune response B Lymphocyte response Plasma cells Memory cells Ig cells Immunoglobulins are primarily responsible for the body's response to invading bacteria and viruses and provide the humoral immunity component of an immune response T Lymphocyte response Undergo differentiation on exposure to a foreign antigen, developing into subtypes of cells that may directly attack the antigen or stimulate the activation of other leukocytes Cytotoxic T lymphocytes attack and kill antigens directly with preference for viruses or mutated cells that have become cancerous This process is termed "cellular or cell-mediated immunity" 7rl types of T lymphocytes (T cells) - 3 primary groups Helper T cells - (CD4) - helps in functions of the immune system by regulating most of the system's functions via the protein mediators, lymphokines. They direct and encourage other T cells and also help to activate B lymphocytes Cytotoxic T cells - "killer cells" - directly kill foreign antigens and may kill cells of the self supxl Suppressor T cells - suppress the function of both helper and cytotoxic T cells in order to prevent hyperimmune responses evolve Suppressor T-cells prevent hypersensitivity (allergy) (IMMUNITY overreactions) on exposure to non-self cells or proteins preventing the formation of antibodies directed against healthy self cells, which is the basis for many autoimmune diseases. Complement system response 25 primary proteins Amplifying and increasing the efficiency and efficacy of the other components of the immune system Contributes to the inflammatory response

Vascular Access Devices

Major types: Short peripheral catheters Midline catheters Peripherally inserted central catheters (PICC) Nontunneled percutaneous central venous catheters (CVC) Tunneled catheters Implanted ports Hemodialysis catheters

Arthrometry

Measures and documents cruciate ligament laxity of the knee both passively and actively. The arthrometer measures the distraction forces on the knee. These measurements are taken passively, actively, and manually. Measurements are taken on both the noninjured and injured knee. **Surgeons use this method to diagnose anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) tears.

Pain Mechanisms and Pathways Modulation

Mechanisms that influence perception Natural analgesic system Neuroreceptors Opioid peptides Endorphins Enkephalins Dynorphin Modulation of afferent input generated in response to noxious stimuli happens at every level from the periphery to the cortex The neurochemistry of modulation is complex and not yet fully understood, but it is known that multiple peripheral and central systems and dozens of neurochemicals are involved. For example, the endogenous opioids (endorphins) are found throughout the peripheral nervous system (PNS) and CNS and, like the exogenous opioids administered therapeutically, they inhibit neuronal activity by binding to opioid receptors. Other central inhibitory neurotransmitters important in the modulation of pain include serotonin and norepinephrine, which are released in the spinal cord and brainstem by the descending fibers of the modulatory system to inhibit pain.

MORAL ETHICS

Morals Private, personal, or group standards of right and wrong Moral behavior; in accordance with custom; reflects personal moral beliefs Ethics Systematic study of right and wrong conduct Formal process for making consistent moral decisions

CLINICAL MANAGEMENT: SCREENING

Most common infection screening: Sexually transmitted infection in high-risk groups Tuberculosis screening in high-risk groups General question: How do you determine who is in a "high-risk" group?

PAO2

Normal PaO2 range is 80-100 mmHg This value may or may not be given to you when for interpretation of blood gas values on exams, but are apart of the lab result. The easiest way to think about the PaO2 is that it is like the O2 Saturation for ABGs. Therefore, if the value is below 80 they would be considered to be hypoxic.

Post-op: Skin/incision assessment

Normal wound healing *draining wound does not mean infected wound* Impaired wound healing - seen most often between 5th and 10th days after surgery -Dehiscence- WOUND RUPTURES ALONG A SURGICAL INCISION is a surgical complication in which a wound ruptures along a surgical incision. -*Evisceration- ORGAN PROTRUDE THROUGH SURGICAL OPENING surgical incision opens (dehiscence) and the abdominal organs then protrude or come out of the incision--- intestine coming out- cover w/ sterile soaked gause saline then dry dressing over it* *Marking post op drainage:* How: Any drainage is on the dressing, the nurse circles the area and marks it with a time and date. Provides a gauge how much seepage is occurring. When to notify surgeon: When excessive bleeding or hematoma formation has occurred, the surgeon should be notified right away so that the wound site assessment can be performed.

Skeletal Disease: Osteomyelitis

Occurs when an infection has invaded the bone area At risk: malnourished, elderly, overweight, injection drug use, poor blood supply, recent trauma & those with a chronic illness (ie. Cardiovascular disease, Diabetics) S&S: fever, malaise, swelling &/or tenderness of the affected area, purulent drainage from the affected site, pain in the affected area, tachycardia Diagnostic Procedures: Bone biopsy/culture, bone scan, bone x-ray, CBC, Needle aspiration of the affected area, CRP, ESR Treatment: antibiotic therapy for 4-6 weeks (type depends on culture), pain medication, wound debridement Nursing interventions: immobilize the body part, administer pain medications, perform neurovascular checks, perform sterile dressing changes, provide diet high in protein & vitamin C, initiate antibiotics a.s.a.p. & teach the importance of completion Prevention: prophylactic antibiotics and sterile technique during and after surgery

Factors that Influence Pain

Past experience with pain Emotions Developmental stage Communication skills Cognitive impairments Other illnesses contributing to pain • Factors that affect pain and its management include age, gender, genetics, and culture. Sociocultural influences Stoicism valued by many cultures Age Misconception that children feel less pain Many elderly experience chronic pain Gender differences ------------------- culture- "stoic" age "children" The most common kind of pain children experience is acute pain, usually resulting from injury, illness, or necessary medical procedures.---assess pain in children through self-report, behavioral observation, or physiological measures. • Acupuncture, magnet therapy, and herbal supplements are examples of other complementary and alternative therapies used for chronic pain management. 2/3 pain scale bc of previous experience to pain- start of with one pain med

Evaluation of Outcomes

Potential nursing diagnoses Impaired comfort • Pain causes impaired COMFORT and can lead to poor health for many millions of people. Unrelieved pain can alter or diminish quality of life more than any other single healthrelated problem. Anxiety Potential outcomes Use effective coping mechanisms Vital signs reflect decrease in pain

SUPPRESSED IMMUNE RESPONSE 2

Primary immunodeficiency (PI) Situation wherein the entire immune defense system is inadequate and the individual is missing some or all of the components necessary for a complete immune response NIH identified 70 types of immunodeficiencies 10 warning signs - consider PI if 2 or more are present 4 or more new ear infections w/in 1 year 2 or more serious sinus infections w/in 1 year 2 or more months taking antibiotics with little effect 2 or more pneumonias w/in 1 year Failure of an infant to gain weight or grow normally Recurrent, deep skin or organ abscesses Persistent thrush in mouth or fungal infection on skin Need for IV antibiotics to clear infections 2 or more deep-seated infections including septicemia Secondary immunodeficiency Other health problems develop for immunocompromised patients Increase in incidence of infection by bacteria and viruses Development of super-infections (MRSA, C-Diff) Development of treatment-resistant fungal infections secondary to antibiotic treatment for primary bacterial infections

NURSING RESPONSE: INFLAMMATION

Risk for infection Lab values Assessment of site Monitoring Documentation Standard precautions

DRUGS FOR PREOPERATIVE PREPARATION preopmeds

Sedatives/Antihistamines - provide sedation and antiemetic effects -hydroxyzine (Vistaril) -diphenhydramine (Benadryl) Hypnotics - provide sedation and increase the duration of sleep -lorazepam (Ativan) -temazapam (Restoril) Anxiolytics - control anxiety, calming -midazolam (Versed) -diazepam (Valium) Opioid analgesics - provide pain relief and sedation; induce anesthesia -morphine (Duramorph) -fentanyl (Sublimaze) Anticholinergic agents - reduce oral and pulmonary secretions, prevent laryngospasms, prevent bradycardia -atropine (Atropisol) -scopolamine (Maldemar) H2 histamine blockers - reduce gastric acidity and reflux -ranitidine (Zantac) -cimetidine (Tagamet)

Older Adult Care

Skin care Vein and catheter selection Cardiac and renal changes

EBP

Star model Definition of knowledge transformation Underlying premises of knowledge transformation ashlii ACE Star Model of Knowledge Transformation The core concept of the ACE Star Model is knowledge transformation; this is defined as the conversion of research findings from primary research results through a series of stages and forms to have an impact on health outcomes by way of evidence-based care. Each of the five points of the star focuses on a sequential cognitive activity. In the model the stages progress clockwise from discovery to evaluation. Stages Point 1: Discovery- Primary research. It is the approach with which nurses are familiar, i.e., single reports of research studies. Point 2: Evidence Summary-All primary research on a given clinical topic is gathered and summarized into a single statement about the state of the science. Point 3: Translation- Experts are called on to consider the evidence summary, fill in gaps, and merge research knowledge with expertise to produce clinical practice guidelines (CPGs). Clinical practice guidelines are commonly produced and sponsored by a clinical specialty organization. The aim of translation is to provide a useful and relevant package of screened, summarized, and interpreted evidence to clinicians and patients in a form that suits the time, cost, and care standard. Point 4: Integration- Perhaps the most familiar stage of knowledge transformation in health care because of society's longstanding expectation that health care be based on the most current knowledge, thus requiring implementation of innovations. Once guidelines are produced, implementation plans are put into action to change the individual clinician practices, organizational practices, and environmental policies. Point 5: Evaluation-A broad array of endpoints and outcomes are evaluated. These include evaluation of the impact of EBP on patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic analysis, and the health status of a population. As new knowledge is transformed through the five stages, the final outcome is evidence-based quality improvement of health care.

Transplant Rejection

Transplant rejection is caused by general and specific immunity functions of a host directed against tissues and organs transplanted from other people. Host natural killer (NK) cells and cytotoxic/cytolytic T-cells are the major cells responsible for the destructive attacks on transplanted organs (grafts) leading to host rejection of these helpful tissues. Because the solid organ transplanted into the recipient (host) is seldom a perfectly identical match of human leukocyte antigens (HLAs) (unless the organ is obtained from an identical sibling) between the donated organ and the recipient host, the patient's immune system cells recognize a newly transplanted organ as non-self. Without intervention, the recipient's immune system starts immunologic actions that destroy these non-self cells, leading to rejection of the transplanted organ. Rejection is a complex series of responses that change over time and involve different components of IMMUNITY. Rejection can be hyperacute, acute, or chronic.

Advanced directives

Two common forms of advance directives are a living will or health care proxy (POA) -Living will outlines medical treatment client wishes to refuse (ex: intubation) if client unable to communicate wishes at that time -Health care proxy (also called durable power of attorney for health care) appoints someone (usually family or trusted friend) to make health care decisions if client unable to do so

Combined Metabolic & Respiratory Acidosis

Uncorrected respiratory acidosis leads to poor oxygenation and lactic acidosis More severe than metabolic or respiratory acidosis alone Combined problem of DKA and COPD lead to this

Collaborative Management Principles

Underlying cause must be identified; treatment depends on the underlying cause, core temperature, age of the patient, and overall patient condition Overall goal is to bring body temperature into the normal temperature range before long-term effects occur

ALTERED IMMUNITY

What is meant by "altered" immunity? Conditions in which immune responses are either suppressed or exaggerated Suppressed responses are referred to as immunocompromised or immunodeficiency Exaggerated responses are referred to as hypersensitive

Hyperthermia

body temp > 104 f clinical findings s/s heat syncope, heat rash, heat cramps, heat edema, heat exhaustion, heat stroke, severe thirst, weakness rapid pulse nursing intervention remove clothing/ blankets hydrate with cool fluids cold blanket/ cool lavage adjust room temp education avoid extreme temp dress app. for the temp maintain normal home temp risk very young, elderly, poor ppl, living in hot climate rationale

Isotonic exercise

iee Increase muscle tone and maintain joint flexibility Exercises that shorten muscle to produce contraction and active movement with no significant change in resistance, so force of contraction stays stable Examples are using a trapeze to lift body or pushing body into a sitting position

older adult factors affecting safety impaired cognition

if an older adult is not legally competent, a guardian may be appointed examples: depression ptsd dementia delirium

The pQUS

is an effective and low-cost screening tool that can detect osteoporosis and predict risk for hip fracture. The heel, tibia, and patella are most commonly tested. This procedure requires no special preparation, is quick, and has no radiation exposure or specific follow-up care (Pagana et al., 2017). Both tests are commonly used for screening at community health fairs, skilled nursing facilities, and women's health centers.

Thermoregulation

is the process of maintaining the core body temperature at a nearly constant value

joint and connective tissue dz: gout s&s

k rr s tp kidney stones Rapid development (within hours) of pain and edema in the one affected joint. renal abnormalities Swelling, pain, and decreased range of motion in the affected joint Tophi- growths of urate crystals- Tophi may be seen on external ears, hands, feet, the olecranon process, and prepatellar bursas. progressive joint damage n deformaties

Accident prevention - Toddler

kd bats kua paw h keep handles of pans on stove tops facing inward *Drowning is a leading cause of death in toddlers* Burns in toddlers occur because of chewing on electrical wires, pulling hot liquids from tables or stove tops, and touching space heaters assess toys for small parts Toddlers explore all objects with their mouths Store medications, cleaning supplies, and poisons in locked cabinets to prevent poisonings in a curious toddler keep electrical outlets covered use car restraint systems until child's shoulders are above the harness or ears have reached top of seat accompany children at all times when in and around water in bathtub, wading pool, or swimming pool Place car restraint systems for toddlers in back seat and may be forward-facing after toddler has reached 1 year of age and 20 pounds avoid giving foods such as hard candy, peanuts, and chewing gum to prevent choking and aspiration when a child outgrows system, a booster seat with a lap/shoulder belt is required have poison control phone number readily available to caregiver and posted on telephone

older adults 65 +

leading cause of death/ accidents is fam br jss falls are the most common cause of accidental deaths ** all of which place them at risk for falls mva burns risk factors loss of muscle strength joint mobility sensory lossess slowing reflexes

polycystic kidney dz aka pkd 60+

mall an inherited disorder of fluid filled cysts that develop in the nephrons- dominant form, increase in 30's... recessive form from birth (kidney becomes enlarged) causes htn, no way to prevent teach early detection s/s- abdominal, flank pain, increased htn, nocturia, increased abd girth, constipation, bloody or cloudy urine, kidney stones interventions acute/chronic pain management, cyst infection tx, (antibiotics therapy- bactrim,septia,cipro), constipation tx and prevention, htn and renal failure, low sodium diet, psychosocial assessment student: inherited genetically; cluster of cyst on kidney dx: mri, ultrasound, or ct,pilogram-xray recurrent uti, back and side pain heaviness, headache, blood in stools, stress management, kidney failure leading cause,

skeletal disease osteoporosis

mc mostly affects wrist- hip- vertebral column chronic dz in which bone loss causes decreased density and fracture. *book* The patient may have back pain, which often occurs after lifting, bending, or stooping. The pain may be sharp and acute in onset. Pain is worse with activity and is relieved by rest. Back pain accompanied by tenderness and voluntary restriction of spinal movement suggests one or more compression vertebral fractures (i.e., the most common type of osteoporotic or fragility fracture). Movement restriction and spinal deformity may result in constipation, abdominal distention, reflux esophagitis, and respiratory compromise in severe cases. The most likely area for spinal fracture is between T8 and L3, the most movable part of the vertebral column. Fractures are also common in the distal end of the radius (wrist) and the upper third of the femur (hip). Ask the patient to locate all areas that are painful and observe for signs and symptoms of fractures, such as swelling and malalignment. Pathophysiology Osteoporosis is a chronic disease of CELLULAR REGULATION in which bone loss causes significant decreased density and possible fracture. (See Chapter 2 for a concept review of cellular regulation.) It is often referred to as a silent disease or silent thief because the first sign of osteoporosis in most people follows some kind of a fracture. The spine, hip, and wrist are most often at risk, although any bone can fracture. Euro-American postmenopausal women have a 50% chance of having an osteoporotic-related (fragility) fracture in their lifetime (National Osteoporosis Foundation [NOF], 2017). A woman who experiences a hip fracture has a four times greater risk for a second fracture. Fractures as a result of osteoporosis and falling can decrease a patient's MOBILITY and quality of life. The mortality rate for older patients with hip fractures is very high, especially within the first 6 to 12 months, and the debilitating effects can be devastating (Fitton et al., 2015). Osteoporosis is a major global health problem. In less affluent or famine countries, many individuals have both osteoporosis and osteomalacia as a result of dietary deficiencies.

phantom pain

perception of limb/ organ no longer there itching, shooting, stabbing, burning, *treatment* acupuncture biofeedback mirror box therapy- psychological scratch other leg to relieve itching if they had pain before amputation, amputee pain increases book Phantom pain is pain that is perceived to originate from an area that has been surgically removed. Patients with amputated limbs may still perceive that the limb exists and experience burning, itching, and deep pain in that area.

Mu agonist

opioids stimulate mu receptors and are used for acute, chronic, and cancer pain. They include codeine, morphine, hydromorphone (Dilaudid), fentanyl, methadone, and oxycodone. These are excellent medications for break- through pain—pain that "breaks through" relief provided by analgesics. Breakthrough analgesia refers to a rescue, or extra, dose. Drugs used for breakthrough pain should have a rapid onset and short duration. Whenever possible, use the same drug as that given for ongoing pain relief. There is no maxi- mum daily dose limit and no "ceiling" to the level of analge- sia from mu agonists. You can steadily increase the dose to relieve pain. • The opioid full agonists are most effective for both acute and chronic pain management. They bind to mu receptors and block pain transmission. o Equianalgesic charts are useful when changing from one opioid to another. A morphine dose of 10 mg is the standard dose against which other opioids are measured. o Morphine and similar mu agonists are the gold standard drugs for both acute and chronic pain and are available in many forms, both short acting and long acting. o Other commonly used mu agonists include oxycodone, hydromorphone, and fentanyl. o Meperidine is an outdated drug and is rarely used. Its toxic metabolite (normeperidine) can accumulate, especially in the older adult or someone with decreased renal clearance, and can cause seizures and confusion.- If prescribed, meperidine should not be used for more than 48 hours or at doses exceeding 600 mg/24 hours. o Observe for and prevent common side effects of opioids, including nausea and vomiting, constipation, sedation, and respiratory depression. Full or mu agonists ("morphine-like") bind primarily to the mu-type opioid receptors in the CNS and, among other actions, block the release of the neurotransmitter substance P, which prevents the opening of calcium channels and the transmission of pain (Wright, 2015). A major benefit of the mu opioid agonists is that they have no ceiling on analgesia. This means that increases in dose produce increases in pain relief and that there is no maximum dose . This property makes the mu opioid agonists the first-line opioid analgesics for moderate-to-severe nociceptive pain. Examples are morphine, fentanyl, hydromorphone, oxycodone, oxymorphone, and hydrocodone.

Joint aspiration

ptt Performed to examine the synovial fluid in the joint cavity. It is also used to relieve pain in the joint resulting from edema and effusion. The procedure involves inserting a needle into the joint space and withdrawing fluid using a syringe. The fluid is then sent to the laboratory to be analyzed for infection or abnormal cells. The procedure is generally done under local anesthetic in the health care provider's office.

LOCAL ANESTHESIA localxl

stitches, numbs specific area Briefly disrupts sensory nerve impulse transmission from specific body area/region Delivered topically and by local infiltration Patient remains conscious, able to follow instructions

Nursing interventions to prevent medication errors

u's bad bk vcr Use standard hours and times for medication administration Stop and double- check medication if client questions appearance or dose Be familiar with side effects or possible adverse reactions; observe for these on an ongoing basis Ask a nurse colleague to double-check complex dosage calculations Do not interrupt nurses giving medications, which can lead to errors during administration Be familiar with medication resources at agency c. ensure client information e.g., height, weight, allergies is accessible to healthcare providers, clinicians, and pharmacists Know agency medication administration system; follow protocols Verify medication orders; do not transcribe orders that contain unapproved or nonstandard abbreviations until clarified Check client identification bracelet before administering medication; ask client to verbalize name and date of birth (or other method of checking two unique identifiers) according to agency policy; additional measures are needed with blood administration Report and document any error or variation in medication administration process

OPTIMAL IMMUNE FUNCTIONING optxl

watkins: what does it mean to have an optimal immune function? it protects the body from invasion of microorganisms abnormal cell growth is cancer which is not the optimal response ---------- Clinical indicators of optimal immune functioning reveal an individual who: Generally appears well - and well nourished Vital signs WNP for age Lymph nodes are soft, movable, non-tender Older adults may not have palpable ones Wounds are healing within a timeframe of "normal" for type of wound

irritable bowel syndrome ibsxl

*watkins; diarrhea and or constipation bc no fiber/fluids, balance for diarrhea and constipation c/b stress like divorce-personalized- esp in females over 50+, manage symptoms* mall functional GI disorder that causes recurrent diarrhea, abdominal pain, constipation, bloating aka spastic colon, mucous colon, or nervous colon- believed to be d/t impairment in the motor or sensory function of the GI tract changes bowel elimination with out pathophysiologic bowel changes the mucosal lining stays the same factors diverticulitis dx, coffee and GI stimulants, smoking, nsaid, increased dietary fat intake, sulfur intake, milk allergy increase *most common digestive disorder seen in clinical practice* s/s manning criteria abdominal pain, relieved by sleep, defecation. abdominal pain r/t stool frequency/ consistency. abdominal distension, incomplete defecation sensation, mucous in stool ashlii s/s Recurrent abdominal pain or discomfort at least three days per month in the last three months associated with two or more of the following: 1. Improvement with defecation 2. Onset associated with a change in frequency of stool 3. Onset associated with a change in form (appearance) of stool *flare-up* abdominal pain, cramps, diarrhea, constipation *the common s/s* LLQ pain of the abdomin n.i health teaching, drug therapy, stress management, teach avoid proplem stimulants, increase intake of calcium rich food, lactose free food, calcium supplements d/t increased risk of osteoporosis drugs bulk forming laxative (metamucil), imodium, paxil-antidepressants, muscurinic (m3)- receptor antagonists ashlii A relatively common functional disorder characterized by abdominal pain and altered bowel habits in the absence of structural or biochemical explanations for the symptoms. The cause of IBS is unknown, although there may be a genetic propensity to the disorder. In addition, stress exacerbates the manifestations, as does a diet high in fat, irritating foods, alcohol, and smoking. *ashlii Health promotion and disease prevention* for IBS Avoid foods that trigger exacerbation, such as dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspertame. Avoid alcoholic and caffeinated beverages, and other fluids containing fructose and sorbitol. Consume 2-3L/day from food and fluid sources Increase fiber intake (approx 30-40g/day) sn changes in weight fatigue, malaise, mucus; increase fluids, pain in ab, diarrhea, constipation/alternating pattern, mucus?, cause is unknown 2ndary, whats there diet. find out what meds there on meds: antidiarretic, laxatives, bulk forming if there having constipation drink water, if there having diarrhea bulk-up diet irritable; fiber, fluid, no sugar, dx: colonoscopy, endoscopy, hydrogen test

INFLAMMATORY DISEASE

*Diseases that result in inflammatory process* Viruses Bacteria Pneumonia fungi Protozoa Others *Diseases that produce inflammatory effect* Antibiotic-resistant organisms Asthma Allergic disease Response to allergens and irritants *Diseases caused by inflammatory effect* Self-induced inflammatory reaction Arthritis Myocardial infarction Obesity

hemmoroids inflamed and itchy hemoxl

*Watkins*; lifting heavy objects- how to care for them, stool softener, fiber, fluid, so they are not straining when they go; sitz bath, witch hazel goes on top of hydrocortisone helps with inflammation and itching lidocaine has hydrocortisone in them *mall* dilated varicose veins of the anal canal, maybe external, internal, or prolapse *internal* lie above the anal sphincter and cannot be seen on inspection *external* lie below the anal sphincter and cannot be seen on inspection *prolapsed* can be become thrombosed or inflamed caused by portal hypertension, straining,irritation, increase venous or abdominal pressure *assessment* bright red bleeding w/ defecation, rectal pain/itching *interventions* apply cold packs to anal rectal area followed by sitz bath, witch hazel soaks, topical anesthetics, increased fiber diet and fluids to promote bm w/ straining, administer stool softeners. *sn* inside/outside the rectum, pressure from pregnancy- vericose vein s/s constipation, itch, painful, cant sit bc inflamed

Scope of Concept

*acidotic* pH < 7.35 *optimal* pH 7.35-7.45 PaCO2 HCO3 normal *alkalotic* pH> 7.45 Acid-base balance can be viewed as on a continuum; optimal balance is seen in the middle and extremes of imbalance are on each end of the spectrum.

PREVENTION OF RESPIRATORY COMPLICATIONS

-Breathing exercises Deep (diaphragmatic) Expansion -Incentive spirometry- deep breathing and coughing exercises every 2 hours while awake to prevent atelectasis and pneumonia. -Coughing and splinting o Pulmonary complications, including atelectasis and pneumonia, are more likely to occur in older patients, those with chronic respiratory problems, and smokers. o Sensitivities or allergies to certain substances, especially latex, may cause reactions to anesthetic agents or to perioperative substances. o Laboratory tests before surgery provide baseline data about the patient's health and help predict potential complications. o Monitor complete blood count and white blood cell differential for signs of infection.

Joint & Connective Tissue Disease: Gout

Accumulation of uric acid deposits in the joints, results from the body's inability to metabolize purine foods Causes of Attacks: fad starvation diets, stress, illness S&S: painful small joints (warm & red), kidney stones &/or renal abnormalities, tophi (growths of urate crystals), progressive joint damage and deformities Diagnostic Procedures: serum uric acid greater than 7mg/dL, ESR, synovial fluid analysis (will show uric acid crystals) Foods Low in Purine: cheese, eggs, fats, gelatin, milk, most vegetables, nuts, sugar, increase fluids, citrus juices, cherries Foods High in Purine: dried beans, fish (especially sardines), liver, lobster, oatmeal, oyster, peas, asparagus, poultry, spinach Medications - used to decrease the production of uric acid and promote the production of it Acute - Colchicine (Colsalide) and an NSAID, such as ibuprofen (Motrin) Chronic - Allopurinol (Zyloprim)

Acid-Base Imbalances (cont'd)

Alkalosis Serum pH above 7.45 Respiratory cause: blowing off CO2 Metabolic cause: increase in bicarbonate

Circulating nurse

An RN who applies the nursing process to coordinate all activities in the operating room. She is a client advocate who continuously monitors the client and the sterile field maintains a safe, comfortable environment; communicates with appropriate personnel outside the operating room; responds to emergencies; and, in some cases, administers sedation to the patient. An important aspect of the circulating nurse's role is to attend to the patient during the induction of anesthesia.

POSTOPERATIVE PERIOD postopxl

Begins with completion of surgery and transfer to PACU, ambulatory care unit, or ICU by the circulating nurse and give a FACE to FACE report 1st thing you do is ASSESS THE AIRWAY!!!! if pt doesn't have an airway, nothing else matters. *PATENT* airway, then you could monitor the rest of their vital signs, loc pt had anestia, so may not be fully alert, so ORIENT THEM TO WHERE THEYRE look at sx site to assess dressing, if serosangiuouns bld...mark that area with time date and initials, want to see if thryre continuing to bleed, want to monitor that area NORMAL FINDINGS Anestial slows everything in the body down, low respirs, hypoactive bowel sounds, no bowel sounds lung sounds have to listen! diminished breath sounds are normal after anesthesia abnormal diminished breath sounds w. respirs of 6 is abnormal *uop should never be less than 30 ml per hour LESS THAN 30ML IS A PROBLEM!!!!* needs to be reported imm!!!

REVIEW OF IMMUNE RESPONSE 5

Complement system Works to enhance the immune response and help rid the body of antibody-antigen complexes Comprised of 25 proteins - circulate in an inactive form in the blood Engage in a cascade of interactions when the first protein molecule (C1) encounters an antigen-antibody complex Cascade is responsible for the dilation and ultimate leaking of fluid from the vascular system, leading to the redness and swelling during the inflammatory process

Planning and Implementation

Contemporary pain management measures Intractable pain Interventions for management of acute pain Interventions for management of chronic pain Physical care of patients with pain Pharmacology Non-opioid/opioid analgesics Drug forms and routes of administration of analgesics ----------------------- Side effects of opioids Geriatric considerations affecting administration of analgesics Contraindications for opioid analgesics Alternative therapy for pain relief Psychological counseling, support groups, exercise, and physical therapy Therapeutic touch

NURSING ASSESSMENT: SKIN AND WOUNDS

Focused skin assessment *Braden scale* (based on sensory perception, moisture, activity, mobility, nutrition, and friction or shear) Numeric value for six risk factors related to impaired skin integrity Total score <18 = risk book n scales. The Braden scale is used to identify persons at risk for developing pressure ulcers. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer (see the Focused Assessment box, The Braden Scale for Predicting Pressure Sore Risk). The final score reflects the patient's risk; the lower the score, the more likely the patient will develop a pressure ulcer. A score of 18 or less for hospitalized patients indicates risk. Interventions should be based on the individ- ual risk factors, as well as the total score. You should use this scale to assess the patient on admission to the facility and again in 48 to 72 hours. Studies have shown the second score to be more predictive, probably related to increased aware- ness of the patient's status. The Braden Q is a modified scale used in children. *Wound assessment* Location Size Appearance Drainage Redness Swelling

anesthesiologist or nurse anesthetist crna

Induces amnesia, analgesia, and muscle relaxation or paralysis with anesthesia. Their role is to continuously monitor and evaluate the patient's responses to the anesthetic agent and the surgical procedure. CRNAs administer more than half of all anesthetics in the United States.

REVIEW OF IMMUNE SYSTEM ANATOMY AND PHYSIOLOGY

Lymphoid tissues Leukocytes (WBCs) Neutrophils-.62% is a normal segmented neutrophil- 55%-70% of total WBCs- and refers to mature neutrophils, which, along with macrophages, eliminate invaders (infection) by phagocytosis. *function*Phagocytize pathogens- *Granular WBCs* Monocytes-3%-8% of total WBCs- *function* Able to phagocytize directly as well as to differentiate into macrophages, which help clean up damaged tissue, infection, and cellular debris. Percentage increases in tuberculosis, protozoal, and rickettsial infections. *Agranular WBCs* Eosinophils-1%-3% of total WBCs- most active against infestations of parasitic larvae and also limits inflammatory reactions. Some eosinophil granules contain enzymes that degrade the vasoactive chemicals released by other leukocytes. This is why the number of circulating eosinophils increases during an allergic response. *function* Bind to helminthes and release toxins to destroy them; mediate allergic reactions; have limited role in phagocytosis. Percentage increases in parasitic infections. *Granular WBCs* Basophils- 0.5%-1% of total WBCs; an elevated count indicates inflammation--cause the signs and symptoms of inflammation.---Basophil function acts on blood vessels with heparin, histamine, serotonin, kinins, and leukotrienes. *** *function* Release histamine and heparin granules as part of the inflammatory response. Percentage normal during infections.---*Granular WBCs* Lymphocytes-28% is a normal count in the differential-Lymphocytes are the cells needed for long-lasting antibody-mediated immunity (AMI) and cell-mediated immunity (CMI).- 20%-35% of total WBCs *function* T cells—responsible for cell-mediated immunity; recognize, attack, and destroy antigens. B cells—responsible for humoral immunity; produce immunoglobulins to attack and destroy antigens. Percentage of total lymphocytes increases in viral infection and chronic bacterial infection; decreases in sepsis.---*Agranular WBCs* Immune response Types of immunity evolve For bands, 4% is a normal count. Bands are elevated only when an infection is present and the bone marrow cannot keep up with mature segmented neutrophils.

COMPROMISED ETHICAL AGENCY

Moral Distress Inability to carry out a moral decision Perceived constraints Physicians; nurse administrators; other nurses The law; threat of lawsuit ------- Moral Outrage Belief that others are acting immorally. Similar to moral distress, except that in cases of moral outrage, nurses do not participate in the act. Therefore, they do not believe that they are responsible for doing wrong, but that they are powerless to prevent the wrongdoing. Powerlessness Cannot prevent a "wrong" Respond with "whistleblowing" ------- Moral distress occurs when a person is unable to act on what he or she believes is the morally appropriate action to take or when a person acts in a manner contrary to his or her personal and professional values.

Angiogram

Most often used after trauma or surgery to confirm a diagnosis of a DVT or a pulmonary embolism or to assess damage in an injured area. An angiogram is an invasive procedure that can have serious complications. A catheter is inserted in the femoral, brachial, subclavian, or carotid artery and a contrast dye is injected to visualize the vessels. The most serious complication is an embolus forming due to catheter clot formation.

Inflammatory/Auto-Immune Disease: Lyme Disease

Multisystem inflammatory process with devastating long-term effects if left untreated Bacterial infection that occurs after the bite of an infected deer tick, once the tick is attached it must remain in place for 36-48 hours for the infection to be transmitted S&S: symptoms can begin as soon as three days after the bite or as late as 30 days, flu-like symptoms (low grade fever, fatigue, muscle and bone aches, chills, and malaise), patient usually reports being active outside in the last 2-4 weeks, may or may not report bite, 90% of cases report erythema migrans (which is the circular rash that continues to grow often resembling a bullseye) Diagnostic Procedures: western blot test to confirm positive ELISA (enzyme-linked immunosorbent assay) test Treatment: antibiotics (type and route are dependent on the stage), vaccine is no longer available, when synovitis accompanies arthritic symptoms then surgery is performed to reduce edema and pain in the joint Teaching: dress appropriately in the outdoors, daily checking for ticks, how to remove ticks Properly using insect repellents containing DEET is recommended Daily tick checks should be conducted after coming in from the outdoors. If found, the tick should be properly removed by using fine-point tweezers to take away the ENTIRE creature. Dress appropriately for the outdoors when going out in a tick-laden environment: Light-colored clothing should be worn to make ticks more visible. Tuck pants into socks when going into areas that could harbor ticks.

Nociceptive

Nociceptive pain is the result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral. Somatic pain arises from the skin and musculoskeletal structures, and visceral pain arises from organs. Examples include pain-associated trauma, surgery, burns, and tumor growth. • Nociceptive Pain o Normal pain processing, believed to be sustained by tissue damage or inflammation. Duration can be acute and/or chronic. o The gate control theory involves a gating mechanism in the spinal cord. When the gate is opened, pain impulses ascend to the brain; when closed, the impulses do not get through and PAIN is not perceived. By cause Somatic E.g., rheumatoid arthritis Referred E.g., myocardial infarction

What to do if a doctor becomes hypoglycemic during a procedure? impairedxl

Nurse has the duty to report impaired practice.

nursing responsibilities during intraoperativexl period intraopxl

Participate with rest of surgical team in protocol to prevent "wrong site, wrong procedure, wrong patient" surgery; includes verification of correct client, marking of operative site, and a final "time-out" before procedure begins to perform final verification of correct client, procedure, and site Administer IV infusions and medications as needed NCLEX® Provide safe, effective care Position client to ensure functional alignment and exposure of surgical site Apply grounding device Provide emotional and physical support if awake Account for all equipment and supplies Maintain aseptic environment Perform physiological monitoring Assess fluid loss or gain Monitor cardiac, respiratory, and neurologic status Monitor client response to preoperative medications Nursing roles during surgery Circulating nurse assists scrub nurses and surgeons; sterile scrubbing and gloving not necessary Scrub nurses assist surgeons; maintain sterile gowns, gloves, shoe covers; wear eye protection and caps Circulating nurse and scrub nurse account for used sponges, needles, and instruments during case

Myelogram

Used to diagnose defects in and around the spinal column. Using fluoroscopy and radiography, a contrast dye is injected into the subarachnoid space of the spinal canal. Defects are revealed when a smooth flow of contrast is not seen. Herniated discs, tumors, and spinal nerve root injury are examples of defects that may be seen.

Invasive Techniques for Chronic Pain

Used when drugs/other methods ineffective Nerve blocks (temporary/permanent) Spinal cord stimulation Spinal cord stimulation is an invasive stimulation technique that provides pain control by applying an electrical field over the spinal cord. A trial with a percutaneous epidural stimulator is conducted to determine whether permanent placement of the device is appropriate. If the trial is successful, electrodes are surgically placed in the epidural space and connected to an external or implanted programmable generator. The patient is taught to program and adjust the device to maximize comfort. Spinal cord stimulation can be extremely effective in selected patients but is reserved for intractable neuropathic pain syndromes that have been unresponsive to less invasive methods. Care for the patient with an implanted spinal cord stimulator is the same as that for anyone who has back surgery and epidural anesthesia.

developmental factors affecting safety adults 18-65

leading cause of death/ accidents is 35 mw sl 35-54 leading cause of death is unintentional poising mva workplace injury risk factors some decline in strength and stamina-others maintain fitness lifestyle choices impact health

developmental factors affecting safety adolescents 13-18

leading cause of death/ accidents is --hams-- homicide alcohol and drug use mva sports and recreational injuries risk factors false confidence feel industructable risk-taking behaviors most lack adult adult judgement

PHYSIOLOGIC PROCESSES AND CONSEQUENCES

OVERVIEW OF IMMUNE RESPONSE pp chart pp20

key points Chapter 23: Care of Patients with Infection

OVERVIEW OF THE INFECTIOUS PROCESS • The human body has many protective systems that promote homeostasis. • Physiologic mechanisms provide structural and functional defenses that maintain IMMUNITY and protect people from stressors such as infection. • When these mechanisms fail to work properly or are overcome with microbes, infection can result. • Infections and infectious diseases have been the major cause of millions of deaths worldwide for centuries. • Bioterrorism threats have added to the concerns about multidrug-resistant and emerging infections. • Global travel and migration have increased exposure to a wider variety of infectious agents than in the past. • Advancing technology and invasive procedures also introduce microorganisms into the body, often resulting in infection, even though in other environments these microorganisms are harmless. --------------------------------------------- • A pathogen or an agent is any microorganism capable of producing disease. • Infections can be communicable or transmitted from person to person, such as influenza, or not communicable. • Microorganisms with differing levels of pathogenicity or the ability to cause disease surround everyone. -------------------------------------------------- • A current issue in health care, IMMUNITY, and genomics is the microbiome. Many microorganisms live in or on the human host without causing disease; in fact, some microbes are beneficial. • Each body location harbors its own characteristic bacteria, or normal flora. o Normal flora often competes with and prevents infection by unfamiliar agents attempting to invade a body site. • In some instances, microorganisms that are often pathogenic may be present in the tissues of the host and yet not cause symptomatic disease; this process is called colonization. --------------------------------------------------- HEALTH PROMOTION AND MAINTENANCE • Infection acquired in the inpatient health care setting (not present or incubating at admission) is termed a health care-associated infection (HAI). • Urinary tract infection is one of the most common HAIs, especially in the older adult, indwelling urinary catheters a primary cause of catheter-associated urinary tract infections (CAUTIs). • Central venous catheters are a primary cause of bloodstream infections. • These infections tend to occur most often because health care workers do not follow basic infection control principles, especially aseptic technique. • A medical procedure can cause impaired TISSUE INTEGRITY or a break in mucous membranes, as in catheter-acquired bacteremia and surgical-site infections. • Fragile skin of older patients and of those receiving prolonged steroid therapy increases infection risk. ----------------------------------------------- Centers for Disease Control and Prevention Transmission-Based Guidelines • The Centers for Disease Control and Prevention (CDC) collects information about the occurrence and nature of infections and infectious diseases. • The CDC recommends guidelines to health care agencies for infection control and prevention. • Certain diseases, such as tuberculosis, must be reported to health departments and the CDC by the health care provider. • A health care professional certified in infection control is responsible for tracking infections through surveillance and ensuring compliance with federal, state, and local requirements. • Infections can be prevented or controlled through hand hygiene, disinfection/sterilization, personal protective equipment, patient placement, and adequate staffing. Proper hand hygiene and gloves are the most important intervention because health care workers' hands are the primary way in which disease is transmitted from patient to patient. • Handwashing and alcohol-based hand rubs are two methods of hand hygiene. • The CDC recommends a ban on artificial fingernails for health care professionals when they are caring for patients at high risk for infection. • Standard precautions are used with all patients in health care settings, assuming that all body excretions and secretions are potentially infectious. • Airborne precautions are used for patients who have infections transmitted through the air, such as tuberculosis. • Droplet precautions are used for patients who have infections transmitted by droplets, such as influenza and certain types of meningitis. • Contact precautions are used for patients who have infections transmitted by direct contact or contact with items in the patient's environment. ------------------------------------------------ MULTIDRUG-RESISTANT ORGANISM INFECTIONS AND COLONIZATIONS • Examples of multidrug-resistant organisms include MRSA and vancomycin-resistant Enterococcus and carbapenem-resistant Enterococcus organisms. • Patients most at risk for health care-associated MRSA are older adults and those who have suppressed IMMUNITY have a long history of antibiotic therapy, have invasive tubes or lines, or are intensive care unit patients. • One of the newest discoveries to explain the increase in HAIs, especially the rise in drugresistant infections, is the formation of biofilms. o A biofilm, also called glycocalyx, is a complex group of microorganisms that functions within a "slimy" gel coating on medical devices, such as urinary catheters, orthopedic implants, and enteral feeding tubes; on parts of the body, such as the teeth (plaque) and tonsils; and in chronic wounds. o Biofilms are extremely difficult to treat, and mechanical disruption strategies are the mainstay of management and research. o Antibiotic therapy may increase the growth of microbes within biofilms ------------------------------------------- OCCUPATIONAL AND ENVIRONMENTAL EXPOSURE TO SOURCES OF INFECTION • The Occupational Safety and Health Administration (OSHA) is a federal agency that protects workers from injury or illness at their place of employment. • Reduction of skin and soft tissue injuries (e.g., needle sticks) is essential to reduce bloodborne pathogen transmission to health care personnel. • OSHA mandates that sharp objects (sharps) and needles be handled with care. PROBLEMS FROM INADEQUATE ANTIMICROBIAL THERAPY • If infections are not treated or are inadequately treated, systemic sepsis (septicemia), septic shock, and disseminated intravascular coagulation may result. • Inadequate antimicrobial therapy may range from an incorrect choice of drug to poor patient adherence. Some infections relapse in a subtle fashion. • Drug regimen noncompliance (deliberate failure to take the drug) or nonadherence (accidental failure to take the drug) prevents contact of harmful microorganisms with sufficient concentrations of the drug and contributes to resistant organism development. ----------------------------------------------- Interprofessional Collaborative Care • Notice patients with impaired IMMUNITY as a result of disease or therapies such as chemotherapy and radiation are also at a high risk for infection. • Wounds can easily become infected when TISSUE INTEGRITY is impaired. • Patients who have transmission precautions may feel isolated, anxious, depressed, neglected, and dissatisfied with their care. • Help isolated patients cope with these feelings through verbalization and collaboration with the health care team. • A culture is the most definitive way to confirm and identify microorganisms. • Sensitivity testing determines which antibiotics will destroy the identified microbes. • The differential count usually shows a shift to the left, meaning an increased number of immature neutrophils (bands), during active infections. • Antimicrobials and antipyretics are the most common types of drugs used when infection is accompanied by fever. • Antipyretics are used only when the fever presents a significant risk or the patient is very uncomfortable, because antipyretics may mask the disease. • Other nursing interventions may be helpful for fever management, including external cooling and fluid administration. • Perform a thorough assessment before and after interventions are implemented. -------------------------------------------------- o External cooling by hypothermia blankets or ice bags or packs, sponging the patient's body with tepid water, or applying cool compresses to the skin and pulse points may be used. o Teach unlicensed assistive personnel to report shivering during any form of external cooling, which indicates a too-rapid decrease in body temperature. o In patients with fever, fluid volume loss is increased from rapid evaporation of body fluids and increased perspiration. As body temperature increases, fluid volume loss increases. --------------------------------------------- • Some organisms are resistant to commonly used antimicrobial agents. • Health teaching about clinical manifestations of infection and drug therapy is important for the patient with an infection being managed at home; some patients may need health care nursing services for IV antimicrobial therapy. • Teach patients about antimicrobial therapy and protective measures to prevent infection transmission. Teach patients how to avoid community-acquired methicillin-resistant Staphylococcus aureus (MRSA) by performing frequent hand hygiene, and avoiding crowds and direct contact with others who have INFECTIONS. ------------------------------------------------------- CRITICAL ISSUES: EMERGING INFECTIONS AND BIOTERRORISM • Current concerns related to infection and infection control include the risk of global bioterrorism, emerging infectious diseases, and multidrug-resistant organisms. • Preparation for and education about bioterrorism has been a major focus of the U.S. government since September 11, 2001. • Sources of infection with Escherichia coli O157:H7 include contamination of food or water. Common sources include spinach, ground beef, lettuce, strawberries, unpasteurized milk or apple cider, and soft cheeses made from raw milk. • Other ways for contamination to occur include working with dairy animals, changing diapers, swallowing lake water, touching the environment after touching animals, and eating food prepared by those with E. coli on their hands. • Anthrax and smallpox both have a high fatality rate in humans and are agents that could be used in bioterrorism. • The federal government and health care agencies around the United States include the risk of pandemic disease in their disaster planning.

FACTORS AFFECTING SKIN INTEGRITY

*Impaired circulation* Negatively affects tissue metabolism book The vascular system brings oxygen-rich blood to the tissues and removes metabolic waste products. Circulatory impairment interferes with tissue metabolism. Impaired arterial circulation restricts activity, produces pain, and leads to muscle atrophy and thin tissue that is prone to ischemia and necrosis. Impaired venous circulation results in engorged tissues with high levels of meta- bolic waste products, thereby increasing the risk for edema, ul- ceration, and breakdown. Both forms of circulatory impairment delay wound healing, and may lead to chronic wounds. *Medications* Side effects: itching, rashes book Side effects and idiosyncratic reactions to medications can affect skin integrity and wound healing. Any medication that causes pruritus (itching), dermatoses (rashes), photosensitivity, alope- cia, or pigmentation changes can result in changes that impair skin integrity or delay healing. The following are examples: ■ Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. ■ Anti-inflammatory medications, such as over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids, inhibit wound healing. ■ Anticoagulants (e.g., heparin, warfarin) can lead to extrava- sation of blood into subcutaneous tissue. As a result, even minimal pressure or injury can cause a hematoma. ■ Chemotherapeutic agents delay wound healing because of their cellular toxicity. ■ Certain antibiotics, psychotherapeutic drugs, and chemotherapy agents for cancer increase sensitivity to sunlight, increasing the risk for sunburn. ■ Several herbal products, such as those containing lavender and tea tree oil, have a drying effect on the skin. *Moisture* Leads to maceration book Moisture leads to maceration (softening of the skin) and in- creases the likelihood of skin breakdown. Incontinence and fever are the most common sources of moisture. Bowel in- continence is particularly troublesome because feces contain digestive enzymes and microorganisms that readily lead to excoriation (denuding) of superficial skin layers, placing such a patient at risk for moisture-associated skin damage (MASD), dermatitis (inflammation of the skin), pressure ulcers, and infection. *Fever* Depletes moisture Increases metabolic rate book Fever leads to sweating, which can cause maceration. In addi- tion, it increases the metabolic rate, thereby raising the tissue demand for oxygen. An increased demand for oxygen is diffi- cult to meet if there is any circulatory impairment or tissue compression from immobility. *Infection* delay/impede healing book Contamination of a wound refers to the presence of microor- ganisms in the wound. All chronic wounds are contaminated. As bacteria begin to increase in number, a wound is said to be *colonized*, though the microorganisms are causing no harm. Wounds are colonized from the surrounding skin and local skin organisms, the external environment, and internal sources, usually from the mucous membranes of the gastroin- testinal system. A wound becomes *critically colonized* when the bacteria begin to overwhelm the body's defenses. Critical colonization may be detected by subtle signs, such as an in- crease in drainage, or by more pronounced signs such as a new foul odor, a change in color of the wound bed, new tunneling of the wound, or absent or friable granulation tissue. An *infection* implies the microorganisms are causing harm by releasing toxins, invading body tissues, and increasing the metabolic demand of the tissue. Infection of the skin makes it more vulnerable to breakdown and impedes healing of open wounds. If not stopped, bacteria can then gain access to the systemic circulation. *Lifestyle* Tanning, bathing, piercings, tattoos book The following are some lifestyle habits that affect skin integrity: ■ Tanning exposes the skin to ultraviolet radiation, thereby increasing the risk for skin cancer. ■ Hygiene habits involving either excessive or insufficient skin hygiene are not healthy for skin integrity. Frequent bathing and use of soap remove skin oils and may lead to drying, which jeopardizes the skin's barrier function. Infrequent cleansing of the skin contributes to excessive oiliness, clogged sebaceous glands, and inadequate removal of microbes on the skin, which can infect a wound or lesion. ■ Regular exercise improves circulation. ■ A nutritious diet provides the nutrients needed to maintain skin integrity. ■ Smoking compromises the oxygen supply to the tissues, mak- ing skin more prone to breakdown and delaying wound healing. It also interferes with vitamin C absorption, which is needed for collagen formation. ■ Body piercings and tattoos present a risk for infection and scar- ring. Complications, which occur in about 20% of piercings, include local infections, sepsis, endocarditis, hepatitis, and toxic shock syndrome. Intraoral and perioral piercings can result in gingivitis, damage to teeth and gums, and choking. Advise patients to become informed about the procedure and about aftercare and to find reputable piercers.

note Cutaneous/ superficial Stimulation Cutaneousxl

30-60 min for pain meds if sleeping need to document sleeping- pt is resting w/ eyes closed, cut on forehead- child book pain arises in the skin or the subcutaneous tissue. If you have ever touched a hot object or received a paper cut, you have experienced superficial pain. Although the injury is superficial, it may cause significant short-term pain. Application of Heat and Cold. The application of cold causes vasoconstriction and can help prevent swelling and bleeding. Cold can be especially effective in reducing the amount of pain that occurs during procedures. Apply a cold pack to the site before and after a procedure to reduce pain. Heat promotes circulation, which speeds healing. Use caution with these methods, however, because the skin may be injured by extremes of either hot or cold. Also, because the addition of moisture to heat or cold amplifies the intensity of the treatment, take extra precautions when applying moist heat or cold. yoga ti-chi TENS Units. A transcutaneous electrical nerve stimula- tor (TENS) is a battery-powered device about the size of a pager that is worn externally. TENS units consist of electrode pads, connecting wire, and the stimulator. The pads are directly applied to the painful area. Once activated, the unit stimulates A-delta sensory fibers. A TENS unit can be worn intermittently or for long periods of time, depending on the patient's pain. Guided Imagery. The use of auditory and imaginary processes to affect emotions and help calm and relax is called guided imagery. Acute and chronic pain, both physical and psychological, may respond to guided imagery; however, it is more effective for chronic pain. Audio media featuring guided imagery can help patients use their imagination to create images of temporary escape that will elicit a sense of well-being chiropractor

INTESTINAL PREPARATION

Performed to prevent injury to colon; reduce number of intestinal bacteria Enema or laxative

Accident prevention - Adult

emt hearr fame Encourage working adults to participate in occupational health programs offered in workplace musculoskeletal injury is most frequent workplace injury teach that homes should have smoke detectors, a fire extinguisher in the kitchen, and a fire evacuation plan Hazardous conditions and toxic substances may occur in workplace educate employees in OSHA (Occupational Safety and Health Administration) regulations and guidelines for use of safety devices and handling hazardous substances Alcohol consumption is involved in 40% of deaths from motor vehicle accidents Residents in some neighborhoods may be at risk for crime and injury Residential fires account for the majority of fire-related injuries Firearms in the home may lead to accidental injury or death assess for access to police and fire services making it important to have community education programs about hazards of drinking and driving; other drugs that cause impairment pose similar risks encourage owners to attend firearm safety class and store all firearms and ammunition in a locked cabinet

Clinical judgement

is "an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response." (Tanner, 2006*) *C.A. Tanner: Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 45(6), 2006, 204-211. ashlii An interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response. Related terms: Inference Interpretation Decision Clinical reasoning Critical thinking

Hypothermia

is a body temperature below 36.2 C Hypothermia • Hypothermia is a core body temperature less than 95° F, or 35° C. An environmental temperature below 82° F (28° C) can produce impaired thermoregulation and hypothermia in any susceptible person, especially older adults. Brain injury Environmental exposure Frostbite Another significant cold-related injury that may or may not be associated with hypothermia is frostbite. The main risk factor is inadequate insulation against cold weather (i.e., either the skin is exposed to the cold, or the person's clothing offers insufficient protection, leading to injury). Wet clothing in particular is a poor insulator and facilitates the development of frostbite. Fatigue, dehydration, and poor nutrition are other contributing factors. People who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite. Any previous history of frostbite further increases a person's susceptibility. Frostbite occurs when body tissue freezes and causes damage to TISSUE INTEGRITY. Like burns, frostbite injuries can be superficial, partial, or full thickness. By contrast, frostnip is a type of superficial cold injury that may produce pain, numbness, and pallor or a waxy appearance of the affected area but is easily relieved by applying warmth; it does not cause tissue damage (impaired TISSUE INTEGRITY). Frostnip typically develops on skin areas such as the face, nose, finger, or toes. Untreated, it is a precursor to more severe forms of frostbite. First-degree frostbite, the least severe type of frostbite, involves hyperemia (increased blood flow) of the involved area and edema formation. In second-degree frostbite, large clear-to-milky fluid-filled blisters develop with partial-thickness skin necrosis (Fig. 9-7). Third-degree frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch. Full-thickness and subcutaneous tissue necrosis occurs and requires débridement. In fourth-degree frostbite, the most severe form, there are no blisters or edema; the part is numb, cold, and bloodless. The full-thickness necrosis extends into the muscle and bone. At this stage, gangrene develops, which may require amputation of the affected part. Of note, except for frostnip, other degrees of frostbite may all have the same general appearance while the body part is frozen; the differentiating features of each degree of frostbite only become apparent after the part is thawed. Gangrene may evolve over days to weeks after injury. • Frostbite results from inadequate insulation against cold weather and, like burns, frostbite injuries can be superficial, partial thickness, or full thickness. • Frostbite can be mild (frostnip) to serious (fourth degree). • Frostnip is a type of superficial cold injury that may produce initial pain, numbness, and pallor of the affected area, but is easily remedied with application of warmth and does not cause impaired TISSUE INTEGRITY. • First-degree frostbite, the least severe type of frostbite, involves hyperemia of the involved area and edema formation. • Second-degree frostbite is characterized by the development of large fluid-filled blisters with partial-thickness skin necrosis. • Third-degree frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch. • Fourth-degree frostbite, the most severe form, has no blisters or edema. The body part is numb, cold, and bloodless. At this stage, gangrene develops, which may necessitate amputation of the affected part. Preterm infant • Cold-water immersion • Acute illness (e.g., sepsis) • Traumatic injury • Shock states • Immobilization • Cold weather (especially for the homeless and people working outdoors) • Advanced age • Selected medications (e.g., phenothiazines, barbiturates) • Alcohol intoxication and substance abuse • Malnutrition • Hypothyroidism • Inadequate clothing or shelter (e.g., the homeless population) An environmental temperature below 82° F (28° C) can produce impaired thermoregulation and hypothermia in any susceptible person. Therefore people, especially older adults, are actually at risk on a year-round basis in most areas of the world. Wind chill is a significant factor: heat loss increases as wind speed rises. Wet conditions further increase heat loss through evaporation. Weather is the most common cause of hypothermia for outdoor sports enthusiasts and for those with inadequate clothing or shelter. It is also a problem for the older adult, the homeless, and the poor who cannot afford heating. mild hypothermic- mild (90° to 95° F [32° to 35° C]) • Shivering • Dysarthria (slurred speech) • Decreased muscle coordination • Impaired cognition ("mental slowness") • cold Diuresis (caused by shunting of blood to major organs) moderate hypothermic- (82.4° to 90° F [28° to 32° C]) • Muscle weakness • Increased loss of coordination • Acute confusion • Apathy • Incoherence • Possible stupor • Decreased clotting (caused by impaired platelet aggregation and thrombocytopenia) Patients with moderate to severe hypothermia have obvious motor impairment and weakness. severe hypothermic- (below 82.4° F [28° C]) • Bradycardia • Severe hypotension • Decreased respiratory rate • Cardiac dysrhythmias, including possible ventricular fibrillation or asystole • Decreased neurologic reflexes • Decreased pain responsiveness • Acid-base imbalance • In moderate to severe cases of hypothermia, coagulopathy (abnormal clotting) or cardiac failure can occur. • General management principles apply to both moderate and severe hypothermia. o Protect patients from further heat loss and handle them gently to prevent ventricular fibrillation. o Position the patient in the supine position to prevent orthostatic changes in blood pressure from cardiovascular instability. o Follow standard resuscitation efforts.

METABOLIC ACIDOSIS

• Four processes can result in metabolic acidosis: overproduction of hydrogen ions, underelimination of hydrogen ions, underproduction of bicarbonate ions, and overelimination of bicarbonate ions Causes Renal Failure Severe Diarrhea Cells are starving for glucose, therefore the body will break down protein and fat, produce ketones, ketones are acids DKA, starvation Signs & Symptoms Depend on the cause Hyperkalemia Muscle twitching, muscle weakness, flaccid paralysis, arrhythmias Increased respiratory rate Treatments Treat the cause • Patients with metabolic acidosis problems include hypotension and decreased perfusion, impaired memory and cognition, and increased risk for falls. • Interventions to respond to metabolic acidosis include hydration and drugs or treatments to control the problem causing the acidosis.

Chapter 13: Concepts of Infusion Therapy

• Infusion therapy is the delivery of medications in solution and fluids by the parenteral (piercing of skin or mucous membranes) route through a wide variety of catheter types and locations using multiple procedures. • Intravenous (IV) therapy is the most common route for infusion therapy. • Infusion therapy is used for maintaining or correcting FLUID AND ELECTROLYTE BALANCE, maintaining ACID-BASE BALANCE, administering medications, and replacing blood or blood products. • A specialized team of infusion nurses often initiates and maintains infusion therapy to reduce complications of therapy. • Infusion nurses may develop evidence-based policies and procedures; insert several types of peripheral and central venous catheters; provide therapies, including blood withdrawal, hypodermoclysis, intraosseous infusions, and administering medications, including chemotherapy; monitor patient outcomes; educate staff, patients, and families; and consult on product selection and purchasing decisions. Orders for infusion fluids should include the specific type of fluid; rate of administration written in milliliters per hour, or the total amount of fluid and the total number of hours for infusion; drugs; and the specific dose to be added to the solution, such as electrolytes or vitamins. • Nurses are responsible for determining that the correct device is used and the order is appropriate for the patient, and for clarifying any questions before administration. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks. ---------------------------------------------- TYPES OF INFUSION THERAPY FLUIDS • Intravenous fluids are categorized according to osmolarity and tonicity as isotonic, hypertonic, and hypotonic. o Only isotonic normal saline solution (0.9%) is given with blood products. o Although dextrose 5% in water (D5W) is considered isotonic, it quickly becomes hypotonic as the dextrose is taken up by the cells. o Because the isotonic infusate stays in the vascular space, monitor for signs of fluid overload, especially with the very young and very old. o Because of its high osmolarity, total parenteral nutrition, a hypertonic solution, is best infused into a central line for rapid dilution in a high-volume vein. o Hypertonic solutions are used to promote FLUID AND ELECTROLYTE BALANCE by moving water out of the body's cells and into the bloodstream. o Always observe the fluid for turbidity (cloudiness) or any unusual color that could indicate contamination and infection, especially with a glucose packed solution like TPN. o Instead of moving water out of cells like hypertonic solutions, hypotonic solutions move water into cells to expand them. --------------------------------------------- • Blood and Blood Components o Whole blood, packed red blood cells, platelets, fresh-frozen plasma, albumin, and clotting factors can be transfused via the blood. o To ensure that the right blood products are given to the right patient, the patient is identified using two identifiers by two qualified health care professionals to ensure patient safety. o The International Society of Blood Transfusion system requires four components to be verified: the unique facility identifier, donor lot number, product code, and ABO group, and Rh type of donor. o An acute hemolytic transfusion reaction caused by an incompatible blood transfusion is called a "sentinel event." ---------------------------------------------------- PERIPHERAL IV THERAPY • Use best practice for placement of short peripheral vascular access devices (VADs), including avoiding the small veins of the hands. • TPN should not be infused in peripheral circulation because it can damage blood cells and the endothelial lining of the veins and decrease PERFUSION. • Choose the appropriate peripheral catheter gauge size of the VAD depending on its purpose. ---------------------------------------------------- CENTRAL IV THERAPY • Peripherally inserted central catheters (PICCs), tunneled central venous catheters, and implanted ports are commonly used for long-term infusion therapy. -------------------------------------------------------- INFUSION SYSTEMS • Vascular access devices (VADs) are catheters that are used to deliver fluids, electrolytes, and medications into the intravascular space. • The type of VAD that is used depends on the reason for infusion therapy, the patient's condition, and the length of therapy. • Common types of VADs include short peripheral catheters, midline catheters, peripherally inserted central catheters (PICCs), nontunneled percutaneous central venous catheters (CVCs) and tunneled central venous catheters, implanted ports, and hemodialysis catheters. • Document care for the patient receiving IV therapy, including the type of VAD inserted. • Infusion controllers and pumps are electronic devices used to regulate the flow of infusion fluids and medications, but be sure to monitor the infusion rate. -------------------------------------------------------- NURSING CARE FOR PATIENTS RECEIVING IV THERAPY • Use best practice for administering intermittent IV medications by either of the two methods of piggybacking or backpriming. • Nursing assessment for all types of infusion systems should be systematic, beginning with the insertion site and working up toward the tubing. • Nursing care for patients receiving IV therapy includes using sterile technique when starting the therapy and when changing components of the infusion system, changing and securing the site dressing, and assessing the site for local complications. • Use normal saline to flush IV catheters on a periodic basis per organizational policy. • Assess, prevent, and manage systemic complications related to intravenous therapy, which can cause infection and reduce PERFUSION. • Older adults present special challenges when infusion therapy is used—physiologic changes of the skin (TISSUE INTEGRITY) and cardiac/renal systems must be considered. • Use small IV catheters for older adults and insert using a 10- to 15-degree angle to prevent rolling of the vein. • Check intravenous administration orders for accuracy and completeness before implementing them. • Prevent IV administration errors by using smart pumps and other safety infusion systems. • Devices engineered with safety mechanisms are required by the Occupational Safety and Health Administration to prevent staff injuries from needles by preventing bloodborne pathogen hazards. • Conscientiously document care for the patient receiving IV therapy, before and after VAD insertion and during the course of IV therapy. • No specific time frame is recommended for dwell time of short peripheral catheters. Recommendations for catheter removal or relocation are based on clinical indications (e.g., signs of phlebitis, infection, or malfunction). • Teach the patient and family about care of the patient receiving infusion therapy, including purpose and safety precautions. ---------------------------------------- COMPLICATIONS OF IV THERAPY • Use the evidence-based catheter-related bloodstream infection (CR-BSI) prevention bundle during insertion and care of central lines. • Assess and document the presence of phlebitis using the Infusion Nurses Society Phlebitis Scale. • Assess, prevent, and manage systemic complications related to IV therapy, including infection. • Assess for common complications associated with central VAD insertion. • Assess, prevent, and manage complications during the course of central IV therapy. Particularly in the older adult, maintain skin integrity (TISSUE INTEGRITY) when applying and removing adhesive tape or dressings. --------------------------------------------------- ALTERNATIVE SITES FOR INFUSION • Arterial therapy is used primarily for the administration of chemotherapy agents directly into a tumor site; the liver is the most common arterial site for this purpose. • Intraperitoneal (IP) infusion therapy is used for antineoplastic agent administration into the peritoneal cavity, especially for ovarian and gastrointestinal tumors that have metastasized into the peritoneum. • Subcutaneous infusion therapy with fluids (hypodermoclysis) involves a slow infusion for a short time; the thighs, hips, and abdomen are commonly used sites. • Epidural and intrathecal administration of medications is the common use for intraspinal infusion. o Epidural infusions are usually for pain management. o Intrathecal infusions are usually for antineoplastic agents used for cancers that cross the blood-brain barrier into the central nervous system. • Intraosseous (IO) therapy allows fluids and medications to be absorbed by the rich vascular network of the long bones; it is used for both children and adults, particularly in emergency situations.

RESPIRATORY ACIDOSIS

• Respiratory acidosis results when any area of respiratory function is impaired, reducing the exchange of oxygen and carbon dioxide, causing CO2 retention. • Respiratory acidosis results from only one process: retention of CO2, causing increased production of free hydrogen ions. • Respiratory acidosis is caused by four types of problems: respiratory depression, inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion. -------------------------------------------- THINK-----HYPOVENTILATION Causes Retain CO2 Mid abdominal incision, narcotics, sleeping pills, pneumothorax, collapsed lung, pneumonia Signs & Symptoms Confusion, headache, sleepiness If problem is not fixed then it could lead to a coma Early signs and symptoms of hypoxia - tachycardia & restlesness

PROTECTIVE ISOLATION

"Protective Environment" Patients who are immunosuppressed (e.g., receiving chemotherapy) are sometimes placed in a special form of isolation, called protective isolation or reverse isolation. However, the CDC states that standard and transmission- based precautions are adequate protection for most of those patients. They recommend a "protective environment" only for a special class of stem cell-transplant patients, who are neutropenic (have a low white blood cell count) secondary to chemotherapy. Most of the recommendations are engineering and environmental services rather than nursing measures. Protects the client from organisms Used in special situations with immune-compromised client population Precautions include Room with special ventilation and air filters; no carpeting; daily wet-dusting Avoiding standing water in the room (e.g., humidifier) Nurse not assigned to other clients with active infection Standard and transmission-based precautions, plus mask and other PPE (to protect patient) The CDC recommends and the United States Occupational Safety and Health Adminis- tration requires employers to provide personal protective equipment (PPE) for healthcare workers (e.g., gloves, gowns, face masks, and eye protection *protective isolation* being used for clients with low WBC counts, clients undergoing chemotherapy, or clients with large open wounds or weak immune systems. Protective isolation usually includes following standard precautions; placing the patient in a private room; restricting visitors; wearing a mask, gown, and gloves for patient care; and special cleaning or disposal of the patient's equipment and supplies. Some units, such as neonatal intensive care units, burn units, and labor and delivery suites, may follow some aspects of protective isolation all the time.

COMMON DIAGNOSTIC TESTS 2

*Laboratory tests* CBC WBC with differential CRP ESR Serologic tests to detect specific antibodies or viruses *Radiographic studies* MRI CAT PET scans colonoscopy

Major Electrolytes (cont'd)

*Calcium* Bone health; neuromuscular function; cardiac function Insufficiency leads to osteoporosis Absorption requires active form of vitamin D Stored in bones Influenced by hormones: Parathyroid hormone Thyrocalcitonin *Magnesium* ICF; bone; many cellular functions Alcoholism leads to low levels Critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation , cell growth *Chloride* ECF; bound to other ions Imbalance occurs resulting from other electrolyte imbalances Treat underlying electrolyte imbalance or acid-base problem

STRUCTURE OF THE SKIN skinxl

*Epidermis* The epidermis is the outer portion of the skin Stratum corneum: the outermost layer, is composed of numerous thicknesses of dead cells. Functioning as a barrier, it restricts water loss and prevents fluids, pathogens, and chemicals from entering the body Stratum germinativum- The sratum germinativum, the innermost layer, continu- ally produces new cells, pushing the older cells toward the skin surface. *Keratinocytes* are protein-containing cells that give the skin strength and elasticity. Deeper in the epi- dermis are *melanocytes*, which produce *melanin*, a pig- ment that gives skin its color and provides protection from ultraviolet light. *Langerhans cells* are mobile. Their func- tion is to phagocytize (engulf) foreign material and trigger an immune response. *Dermis*- The dermis lies below the epidermis and above the subcutaneous tissue. It is made of irregular fibrous con- nective tissue that provides strength and elasticity to the skin and is generously supplied with blood vessels. Within the dermis are sweat glands, sebaceous (oil) glands, ceruminous (wax) glands, hair and nail follicles, sensory receptors, elastin, and collagen. *Subcutaneous layer* - The subcutaneous layer is com- posed primarily of connective and adipose tissue. It provides insulation, protection, and a reserve of calories in the event of severe malnutrition. This layer varies in thickness in different body sites. Sex hormones, genetics, age, and nutrition also influence the distribution of subcutaneous tissue

Fluid Imbalances dehydrationxl fluidxl

*Fluid Volume Deficit* Hypovolemia *Dehydration* Dry skin, mucous membranes blood pressure q 15 mins place 2 18-gauge iv lines WITH NS o2 at 3l via nasal cannula Nonelastic skin turgor Decreased urine output and blood pressure (hypotension); increased heart rate (tachycardia); rise in temperature *Weight loss* interventions urine output= 400-600ml if lower call dr clients need 2000ml of fluid drink 2-3l of water

Calcium (9.0-10.5 mg/dL)

*Hypercalcemia* *Causes*: hyperparathyroidism, thiazides, immobilization *S&S*: bones are brittle, kidney stones (majority made of calcium) muscle weakness, constipation, anorexia, nausea, vomiting, polyuria, polydipsia, bizarre behaviors, bradycardia *Treatment*: MOVE!, fluids, Phospho Soda ® & Fleet ® enema (↑PO4, Ca will ↓), steroids, add PO4 to diet, safety precautions, must have vitamin D to use Ca Phosphorus foods are protein foods avoid hctz *Hypocalcemia* *Hint*: Think muscles first *Causes*: hypoparathyroidism, radical neck, thyroidectomy *S&S*: (Same as Hypomagnesemia) Rigid muscle tone, seizures, muscle twitching, stridor/laryngospasms, + Chvostek's, + Trousseau's, Arrhythmias, ↑ DTRs, minds changes, swallowing changes (aspiration)-- cardiac dysrhythmias, increased neuromuscular excitability, muscle cramps, twitching, hyperactive reflexes, carpal and pedal spasms, tetany *Treatment*: Vitamin D, phosphate binders, Ca pills like ca citrate pill every morning, needs dairy, broccoli, spinach Food sources of calcium Milk Milk products Dark green leafy vegetables Salmon Calcium-fortified foods such as breads and cereals.

COMMON DIAGNOSTIC TESTS

*Laboratory tests* Complete Blood Count (with WBC differential) Culture and sensitivity C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serologic tests to detect specific antibodies or viruses *Radiographic studies* X-rays MRI CAT PET and indium scans

Potassium (3.5-5.0 mEq/L) Excreted by the Kidneys; if the kidneys are not working well then the serum K+ will ↑

*Hyperkalemia* *Hint*: Can cause life-threatening arrhythmias *Causes*: Kidney problems, Aldactone: Diuretic It can treat high blood pressure. It can also treat fluid retention (edema) and high levels of the hormone aldosterone *S&S*: Begins with muscle twitching → then proceeds to muscle weakness → then flaccid paralysis *Treatment*: Dialysis, Ca Gluconate (↓ arrhythmias), glucose & insulin, ***Kayexalate*****antidote --------------------- *Hypokalemia* *Hint*: Can cause life-threatening arrhythmias *Causes*: Vomiting, NG suctioning, diuretics, not eating *S&S*: muscle cramps, weakness---poor muscle contraction, FLACCID MUSCLE WEAKNESS, fatigue, skeletal muscle weakness, poor muscle tone, hyporeflexia, possibly paralysis, weakening of the respiratory muscles, decreased GI motility, anorexia, nausea, vomiting, ileus with decreased bowel sounds, parathesias, confusion, lethargy, DYSRHYTHMIAS, flattened T wave. *Treatment*: Give K+, Aldactone, eat more K+ Food sources of potassium kxl Bananas Oranges Apricots Figs Dates Carrots Potatoes Tomatoes Spinach Dairy products Meats

Magnesium (1.3-2.1 mEq/L) Excreted by kidneys and can be lost other ways (GI tract)

*Hypermagnesemia* (TOO MUCH SEDATIVE) *Hint*: Think muscles first *Causes*: Renal failure, antacids *S&S*: ↓ DTRs, ↓ muscle tone, ↓ LOC, ↓ pulse, ↓ respirations, arrhythmias, flushing, warmth, mg makes you calm & prevent seizures *Treatment*: Ventilator, Dialysis, Safety precautions *Antidote*: Calcium Gluconate (will increase respirations) *Hypomagnesemia* (NOT ENOUGH SEDATIVE) *Hint*: Think muscles first *Causes*: Diarrhea, alcoholism *S&S*: Rigid muscle tone, seizures, stridor/laryngospasms, + Chvostek's, + Trousseau's, Arrhythmias, ↑ DTRs, minds changes, swallowing changes (aspiration), low blood calcium, muscle cramps, spasms, nausea, weakness, irritability, and confusion. chxl *Treatment*: Give Mg, √ kidney fx, seizure precautions, eat magnesium

RISK FACTORS: PRESSURE ULCER DEVELOPMENT

*INTRINSIC FACTORS* • Circulation • Underlying health status *Immobility *Impaired sensation *Malnourishment/ Nutrition *Aging *Fever *EXTRINIC FACTORS* Friction Friction damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions *Pressure*- (formerly called decubitus ulcers, pressure sores, and bedsores) are localized areas of injury to the skin, and possibly the underlying tissue, usually over a bony prominence. They are caused by unrelieved pressure, or pressure in combination with shearing forces, which compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying Tissue ischemia leads to tissue anoxia (lack of oxygen) and cell death. The key variables in ischemia are time and pressure. Small amounts of pressure over an extended period of time or a large amount of pressure for a short period of time results in tissue ischemia. Pressure ulcers can occur in as little time as 2 hours, though it may take as long as 5 days for the full extent of tissue damage to be known. When ischemia first occurs, the skin over the area is pale and cool. When you relieve the pressure (e.g., by turning the patient), vasodilation occurs, and extra blood rushes to the area to compensate for the ischemic period. The area flushes bright red (*reactive hyperemia*). If the redness does not disap- pear quickly, tissue damage has occurred. The redness should last about half as long as the duration of the ischemia. For example, if the tissue was compressed for an hour, reactive hyperemia should not last more than about 30 minutes. Although time and pressure are the key variables, several other factors predict the likelihood of pressure ulcer formation (Fig. 36-7). Some factors are intrinsic and some are extrinsic. *Shearing* Shearing occurs when the epidermal layer slides over the dermis, causing damage to the vascular bed. It most com- monly occurs when the head of the bed is elevated and the patient slides downward, causing shear to develop in the sacral area. When shearing occurs, the amount of pressure needed to occlude circulation is cut in half. ----*Exposure to moisture* especially in the form of urine or feces, macerates the skin and also decreases the amount of pressure required to produce ulceration.

STAGES OF INFECTION

*Incubation*: from time of infection until manifestation of symptoms; can infect others book Incubation is the stage between successful invasion of the pathogen into the body and the first appearance of symp- toms. In this stage, the person does not suspect that he has been infected but may be capable of infecting others. This stage may last only a day, as with the influenza virus, or as long as several months or even years, as with tuberculosis. *Prodromal*: appearance of vague symptoms; not all diseases have this stage book The prodromal stage is characterized by the first appearance of vague symptoms. For example, a person infected with a cold virus may experience a mild throat irritation. Not all infections have a prodromal stage. *Illness*: signs and symptoms present book Illness is the stage marked by the appearance of the signs and symptoms characteristic of the disease. If the patient's immune defenses and medical treatments (if any) are inef- fective, this stage can end in the death of the patient. *Decline*: number of pathogens decline book Decline is the stage during which the patient's immune defenses, along with any medical therapies, successfully reduce the number of pathogenic microbes. As a result, the signs and symptoms of the infection begin to fade. *Convalescence*: tissue repair, return to health book Convalescence is characterized by tissue repair and a return to health as the remaining number of microorganisms approaches zero. Convalescence may require only a day or two or, for severe infections, as long as a year or more.

COLLABORATIVE CARE: SUPPRESSED IMMUNE RESPONSE

*Infection* Clinical management of infection and opportunistic diseases are important part of clinical care (antibiotics) - more next week** *Gastrointestinal Dysfunction* Pharmacologic treatment of diarrhea, candidiasis, and fluid and electrolyte loss *Skin Disorders* Pharmacologic treatment of skin rash *Nutrition* Multiple vitamin and mineral supplements Dietary supplements such as Ensure or equivalent Evaluation of weight and BMI

Concept Attributes of Safety

*Knowledge Focus of safety is on the execution of skills, as well as on technology and systems level. *Skills Nurses need to use tools to contribute to safer systems. *Attitudes Nurses and other health care professionals need to value their roles in safety and collaboration.

PREVENTING INFECTION: IMPLEMENTING MEDICAL ASEPSISxl

*MEDICAL ASEPSIS* ("clean technique") "A STATE OF CLEANLINESS THAT DECREASES THE POTENTIAL FOR THE SPREAD OF INFECTIONS" refers to procedures that decrease the potential for the spread of infections. You probably already practice medical asepsis in other settings without realizing it. For example, at home you wash your hands before and after han- dling foods. Before chopping food, you make sure the cutting board and utensils you use are clean. After using it, you wash the board with hot, soapy water. In the healthcare setting, *medical asepsis includes hand hygiene, environmental clean- liness, standard precautions, and protective isolation*. The effectiveness of these measures, and the patient's safety, de- pend on nurses' rigorously and consistently following the principles of asepsis. **Protective Isolation. If a client is in protective isolation, be sure that equipment has been disinfected before it is taken into the room. Take linen and dishes directly to the protec- tive isolation room, and hand them to someone wearing the required protective garb. jargon**Transmission-Based Isolation. If the client is in transmission- based isolation, disinfect the equipment on removal from the room. When removing linen or nondisposable items from a room with contact, droplet, or airborne isolation, place them in special isolation bags.-----This process requires two healthcare workers. The worker inside the room wears protec- tive clothing and handles only contaminated items. The second worker stands at the door and holds the isolation bag open. The first worker places items inside the bag without touching the outside of the bag. If the bag contains linens, the isolation bag is closed and placed in a laundry hamper. Securely close the isolation trash bag, and place it in a special isolation trash container. *PROMOTED THROUGH* Maintaining a clean environment--- A clean environment includes the surfaces in a patient's room, as well as supplies, equipment, and other objects brought into the room. An object is said to be contaminated if it becomes unclean—that is, if you suspect it may contain pathogens. *The floor, soiled dressings, used tissues, sinks, commodes, and bedpans are other examples of contaminated items.* Agency policies determine whether a reusable item is cleaned, disinfected, or sterilized, based on how the item is used. Maintaining clean hands-based on the amount of contact you have with patients or con- taminated objects, as well as the patient's infection status and susceptibility to infection.-- Handwashing involves five key factors: time, water, soap, friction, and drying. Following Centers for Disease Control (CDC) guidelines

CLINICAL JUDGEMENT PROCESS

*Noticing* A nurse notices things about a patient in the context of the nurse's background and experience, context of environment, and knowing the patient. A nurse is looking for patterns that are consistent with previous experiences and uses that information to guide care. *Interpreting* Interpreting is the process of assembling information to make sense of it. Types of reasoning patterns tend to vary with the experience of the nurse. -Novice nurses tend to rely on analytic reasoning. -Expert nurses draw from a variety of reasoning patterns—analytic, intuitive, and narrative. *Responding* Responding is the implementation of actions and interventions, based on patient needs. Depending on the level of expertise, the nurse may or may not be able to judge the effectiveness of the intervention before initiating it. *Reflecting* Reflecting is the process of thinking and learning from experiences. Reflection-in-action happens in real time while care is occurring. Reflection-on-action happens after the patient care occurs. Reflecting is critical for development of knowledge and improvement in reasoning. ashlii- An interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response. Related terms: Inference Interpretation Decision Clinical reasoning Critical thinking

KNOWLEDGE DEFICIT: INTERVENTIONS preopxl

*Preoperative teaching* *Informed consent:* Surgeon obtains signed consent before sedation and/or surgery Nurse clarifies facts and dispels myths about surgery Nurse not responsible for providing detailed information about procedure!

LINES OF DEFENSE AGAINST INFECTION

*Primary Defenses* pg 610 bn Anatomical features, limit pathogen entry and prevent organisms from entering the body. Intact skin- skin surface normal flora The respiratory tree. The nares, trachea, and bronchi are cov- ered with mucous membranes that trap pathogens. The nose contains hairs that filter the upper airway; the nasal pas- sages, sinuses, trachea, and larger bronchi are lined with cilia, tiny hairlike cells that sweep microorganisms upward from the lower airways. Coughing and sneezing forcefully expel organisms from the respiratory tract. Mucous membranes The mouth- contains lysozyme and continually washes microbes from the teeth and gums.---In addition, normal flora of the mouth compete for nutrition with invading organisms, thereby limiting the number of pathogens. eyes- Tears: contain lysozyme, an antimicrobial enzyme. Normal flora in GI tract Normal flora in urinary tract many different white blood cells (WBCs) and their products??? *Secondary Defenses* Biochemical processes activated by chemicals released by pathogens Phagocytosis-Phagocytic WBCs include neu- trophils, monocytes, and eosinophils. Complement cascade- triggers the release of chemicals that attack the cell membranes of pathogens, causing them to rupture. Complement also sig- nals basophils (WBCs), to release histamine, which prompts inflammation. Inflammation-The inflammatory process begins when histamine and other chemicals are released either from dam- aged cells, or from basophils being activated by complement. With inflammation, blood vessels dilate and become more permeable, which increases the flow of phagocytes, antimicro- bial chemicals, oxygen, and nutrients to the affected area. The classic signs and symptoms of inflammation are localized warmth and erythema (redness), which develop as blood flow is increased. In addition, fluid leaking from the more perme- able blood vessels accumulates in the surrounding tissue, causing edema, which in turn prompts pain as pressure is exerted on nerve endings. Fever-many clinicians do not treat a fever unless it's greater than 102°F (38.9°C).

WOUND HEALING PROCESSES wz

*Regeneration* In epidermal wounds No scar book When a wound affects only the epidermis and dermis, regenerative/epithelial heal- ing takes place. No scar forms, and the new (regenerated) epithelial and dermal cells form new skin that cannot be distin- guished from the intact skin. Partial-thickness wounds heal by regeneration. *Primary intention* Clean surgical incision/edges approximated Minimal scarring book When a wound involves minimal or no tissue loss and has edges that are well approxi- mated (closed), primary (first) intention healing takes place (Fig. 36-2A). Little scarring is expected. A clean surgical incision heals by this method. *Secondary intention* Wound edges not approximated -Tissue loss -Heals from inner layer to surface book Healing by secondary (second) intention occurs when a wound (1) involves exten- sive tissue loss, which prevents wound edges from approxi- mating, or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue (a form of connective tissue with an abundant blood supply) (Fig. 36-2B). Epithelial tissue may appear in the wound as small pink or pearl-like areas. Do not mistake this as a sign of infection. Wounds that heal by secondary intention heal more slowly, are more prone to infection, and develop more scar tissue. Pressure ulcers (discussed later) and infected wounds are examples. *Tertiary intention* Granulating tissue brought together -Delayed closure of wound edges book A wound heals by tertiary (third) intention, also called delayed primary closure, when two surfaces of granulation tissue are brought together (Fig. 36-2C). This technique may be used when the wound is clean-contam- inated or contaminated. Initially the wound is allowed to heal by secondary intention. When there is no evidence of edema, infection, or foreign matter, the wound edges are closed by bringing together the granulating tissue and suturing the sur- face. Such wounds require strict aseptic technique during all dressing changes because they are prone to infection. Tertiary intention healing creates less scarring than does secondary, but more than primary intention healing.

Peripheral IV Therapy

*Short peripheral catheters:* Superficial veins of dorsal surface of hand and forearm Dwell for 72 to 96 hr, then require removal and insertion into another site Portable vein transilluminators available ***BD Insyte Autoguard IV catheter. With the push of a button, the needle instantly retracts, reducing the risk for accidental needle stick injuries. Needles and Sharps Do not recap, bend, break, or hand-manipulate used nee- dles. If recapping is necessary, use a one-handed scoop tech- nique. Place used sharps in puncture-resistant containers.

ATI - NCLEX - QSEN

*Teamwork and Collaboration* Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care *Targeted KSAs (Knowledge, Skills, Attitudes* K: Describe examples of the impact of team functioning on safety and quality of care S: Choose communication styles that diminish the risks associated with authority gradients among team members A: Appreciate the risks associated with handoffs among providers and across transitions in care

OSTEOPOROSIS n OSTEOMALACIA defferences

*osteoporosis* Decreased bone mass caused by multiple factors Primary etiology Lack of calcium and estrogen or testosterone Radiographic findings Osteopenia (bone loss), fractures Calcium level Low or normal Phosphate level Normal Parathyroid hormone Normal Alkaline phosphatase Normal *OSTEOMALACIA* Bone softening caused by lack of calcification Primary etiology Lack of vitamin D Radiographic findings Fractures Calcium level Low or normal Phosphate level Low or normal Parathyroid hormone High or normal Alkaline phosphatase High

quality improvement models

*plan do study act (pdsa)* identify and analyze the problem, develop and test an evidence based solution analyze effectivness of the test solution, implement the improved solution to positively impact care *focus-pdca* *f*ind a process to improve *o*rganize a team *c*larify the current process *u*nderstand variations in current process *s*elect the process to improve *p*lan the improvement *d*o the improvement *c*heck for results *a*ct to hold the gain *dmaic* *d*efine the issue/problem *m*easure the key aspects of the current process for the issue --collect data-- *a*nalyze the collected data *i*mprove the current process by implementing and evidence based interventions/solution *c*ontrol the future state of the intervention to ensure continuity of the process

Functional Incontinence funcxl

*watkins*; bedside commode- loose fitting clothing, dresses, elastic clothing-- no overalls-- these people want independence involuntary, unpredictable passage of urine----Functional incontinence due to impaired cognition or neuromuscular limitations ashlii The untimely loss of urine when no urinary or neurological cause is involved. This type of incontinence occurs because of physical disability, immobility, pain, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet. mall *Functional incontinence is incontinence occurring as a result of factors other than the abnormal function of the bladder and urethra.* A common factor is the loss of cognitive function in patients affected by dementia. To maintain continence, an adult must be aware that urination occurs in a socially acceptable place. Patients with dementia may not have that awareness. OLDER ADULTS: Getting out of bed to urinate is a common cause of falls among older adults in the home and other settings *Leakage of urine caused by factors other than disease of the lower urinary tract.* *cause* funccause *Decreased cognition such as with dementia, some central nervous system disorders; inability to walk to the toilet.------common factor- the loss of neurological/ cognitive function in patients affected by dementia---- Loss of urine resulting from cognitive, functional, or environmental factors* *s/s* funcs/s *Quantity and timing of urine leakage vary; patterns are difficult to discern.* Urgency: strong desire to void may be caused by inflammation or infection in bladder or urethra Dysuria: painful or difficult voiding Frequency: voiding that occurs more than usual when compared with client's regular pattern or generally accepted norm of voiding once every 3-6 hours Hesitancy: undue delay and difficulty in initiating voiding Polyuria: a large volume of urine voided at any given time Oliguria: a small volume of urine or output between 100 and 500 mL/24 hr Nocturia: excessive urination at night, interrupting sleep Hematuria: RBCs in urine ---------- *dx* funcdx is # of accidents. bladder training *n.i* funcni Modifications of environment or care plan that facilitates regular, easy access to toilet and promotes patient safety Include better lighting, removal of scatter rugs, ambulatory assistance equipment, clothing alterations, timed voiding, different toileting equipment n.i: keep area clutter free *rf* funcrf Older adults have problems that affect mobility and balance e.g. severe arthritis Cognitive problems: dementia ------ sn student: aware to urinate- physical mental cant go to the bathroom bc of physically arthritis, alzheimers, dementia

DRESSINGS AND DRAINS

--Gravity drains Penrose (A) T-tube (B) drain directly through a tube from the surgical area. ashlii Gravity drains: -Penrose: Short-term drain to give fluids under the wound a channel to drain to the surface; prevents pressure on suture lines -T-tube: Drain directly through a tube from the surgical area --Closed wound drainage systems Jackson-Pratt (C) Hemovac (D)- drainage collects in a collecting vessel by means of compression and re-expansion of the system. -Montgomery straps may be used when frequent dressing changes are anticipated. They help prevent skin irritation from frequent tape removal. -Application of skin staples. The stapler is lightly positioned over everted skin edges. It is not necessary to press the staple, or stapler anvil, into the skin to get a proper "bite" (just "kiss" the skin). Center the staples over the incision line, using the locating arrow or guideline, and place staples approximately ¼ inch apart.

ADMINISTERING REGULARLY SCHEDULED MEDICATIONS

-Consult with physician and anesthesia provider for instructions -Drugs for certain conditions often allowed with a sip of water: Cardiac disease Respiratory disease Seizures Hypertension

POTENTIAL FOR HYPOVENTILATION

-Continuous monitoring of: Breathing Circulation Cardiac rhythms Blood pressure and heart rate -Continuous presence of anesthesia provider

OLDER ADULTS: CHANGES OF AGING AS SURGICAL RISK FACTORS

-Decreased: Cardiac output, peripheral circulation Vital capacity, blood oxygenation Blood flow to kidneys, glomerular filtration rate -Increased: Blood pressure Risk for skin damage, infection Sensory deficits Deformities related to osteoporosis/arthritis

QSEN COMPETENCIES

-Ebpdef *Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care* -Targeted KSAs (Knowledge, Skills, Attitudes K: Describe reliable sources for locating evidence reports and clinical practice guidelines S: Base individualized care plan on patient values, clinical expertise, and evidence A: Value the concept of EBP as integral to determining best clinical practice

QSEN COMPETENCIES 4

-Evidence-Based Practice Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care -Targeted KSAs (Knowledge, Skills, Attitudes K: Describe EBP to include the components of research evidence, clinical expertise, and patient/family values S: Base individualized care plans on patient values, clinical expertise, and evidence A: Value the concept of EBP as integral to determining best clinical practice

ANXIETYxl

-Expected Outcomes Expressed reduction Showing absence of body language indicators -Interventions Preoperative teaching Encouraging communication Promoting rest Distractions Teaching family members

Organizational culture of safety

-Historically, a culture of blame has existed; identify the clinical at fault, followed by disciplinary measures. -Now: the focus is on what when wrong rather than who to blame. -Culture of safety is needed to address errors and to prevent a re-occurrence.

QSEN COMPETENCIES 2

-Patient-Centered Care Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs -Targeted KSAs (Knowledge, Skills, Attitudes K: Describe strategies to empower patients or families in all aspects of the health care process S: Communicate care provided and needed at each transition in care A: Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care K: Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort S: Assess presence and extent of pain and suffering A: Appreciate the role of the nurse in relief of all types and sources of pain or suffering

Crew Resource Management Six critical components:

1. Situational awareness 2. Problem identification 3. Decision making by generating alternative acceptable solutions 4. Appropriate workload distribution 5. Time management 6. Conflict resolution

acute pain acutexl

Acute pain Heat and cold therapies Elevation Rest, immobilization, and medications • Acute pain often results from sudden, accidental trauma (e.g., fractures, burns, lacerations) or from surgery, ischemia, or acute inflammation. As injured tissue heals, SENSORY PERCEPTION changes. • Acute pain serves as a warning to the body, causing sympathetic responses such as increased heart rate, increased blood pressure and pulse, dilated pupils, and sweating. • Acute pain is usually short lived less than 3 months-Brief acute pain serves a biologic purpose in that it acts as a warning signal by activating the sympathetic nervous system and causing various physiologic responses. gall bladder/ gall stones, injury or pain after surgery(most common), anxiety, appendix rupture "fight-or-flight" increase in vitals, sweating, and dilated pupils.- sudden onset/ rapid in onset. ex -inflammation - injury -sprain - trauma Acute pain is usually temporary, has a sudden onset, and is easily localized. The pain is typically confined to the injured area and may subside with or without treatment. As the injured area heals, the SENSORY PERCEPTION of pain changes and, in most cases, diminishes and resolves. Both the caregiver and the patient can see an end to the pain. It is protective in that it indicates potential or actual tissue damage. Although acute pain may absorb a patient's physical and emotional energy for a short time, it is helpful for the patient to know that it will usually dis- appear as the tissues heal. Behavioral signs may include restlessness (especially among cognitively impaired older adults who sometimes fidget and pick at clothing), an inability to concentrate, apprehension, and overall distress of varying degrees.- The absence of the physiologic and behavioral responses does not mean the absence of pain. book • Has short duration • Usually has a well-defined cause • Decreases with healing • Is usually reversible • Initially serves a biologic purpose (warning sign to withdraw from painful stimuli or seek help) • When prolonged, serves no useful purpose • Ranges from mild-to-severe intensity • May be accompanied by anxiety and restlessness • When unrelieved can increase morbidity and mortality and prolong length of hospital stay

IMMUNITYxl

Adaptive internal protection resulting in long-term resistance to effects of invading microorganisms Body must learn to generate specific immune responses when infected by or exposed to specific organisms Book IMMUNITY is protection from illness or disease that is maintained by the body's physiologic defense mechanisms. This protection requires the interaction of immunity and inflammation IMMUNITY with inflammation is critical to maintaining health and preventing disease. immunity plays a role in repair of damaged tissues. evolve is an adaptive internal protection that results in long-term resistance to the effects of invading microorganisms. This means that the responses are not automatic.

FACTORS THAT SUPPORT HOST DEFENSES

Adequate nutrition- To manufacture cells of the immune system-*protein, vitamins, minerals, and water*.-- maintain production of white blood cells, and to repair damaged tissues. Balanced hygiene -Sufficient to decrease skin bacterial count -Not overzealous; causes skin cracking Rest/sleep Rest and sleep conserve energy needed for healing. Sleep needs vary, and there is really no "correct" amount or pattern of sleep. However, sleep of 6 to 9 hours per night is considered fully restorative for most people. Exercise and Activity. Research demonstrates that exer- cise is just as important as rest and sleep. Too little activity causes circulation to slow and the lungs to supply less oxygen. Excessive exercise leads to fatigue and joint injury. Reducing stress Whether physical or mental, stress decreases the body's immune defenses. Numerous studies demonstrate a correlation between stress and disease. Laughing, in contrast, increases oxygenation, promotes body movement, and increases immune responses. Immunization Immunization via vaccination can pro- tect against several infectious diseases (e.g., measles, mumps, and other childhood diseases; pneumonia, influenza, small- pox, and shingles). Unfortunately, some pathogens, such as the virus that causes the common cold, mutate too rapidly for an immunization to be developed. Encourage clients to follow recommendations for immunizations. For most diseases, at least 85% of the population must be immunized in order to protect the entire population from the disease. If you need specific recommended immunizations throughout the life span and their role in health promotion

OBJECTIVES - ATI - NCLEX Safe and Effective Care Environment

Apply concepts of sterile technique, asepsis, and Standard Precautions during wound assessment and dressing changes. Use specific agency criteria for determining readiness of the patient to be discharged from the postanesthesia care unit. Examine individual patient factors for potential threats to safety, especially the risk for surgical site infection and venous thromboembolism.

REGIONAL ANESTHESIA

Administration of spinal and epidural anesthesia. A, Spinal or epidural anesthesia is administered by inserting a spinal needle between the second and third or the third and fourth lumbar vertebrae (L2-3 or L3-4). The patient is placed in the flexed lateral (fetal) position (shown here) or seated on the edge of the operating bed with the back arched and the chin tucked to the chest. B, Spinal anesthesia (viewed from the side). A large needle is inserted to the surface of the dura mater, and a second, smaller needle is passed through the first to penetrate the dura mater and arachnoid mater. An anesthetic is injected, sometimes through an indwelling catheter, directly into the cerebrospinal fluid in the subarachnoid space. C, Epidural anesthesia (viewed from the side). The needle is inserted to the surface of the dura mater, and the anesthetic is injected, usually through an indwelling catheter, into the epidural space.

CIVIL LAW

Allows for resolution of dispute between private parties May result in monetary compensation Plaintiff: person bringing suit Defendant: person being sued

NURSING INTERVENTIONS RELATED TO WOUND CARE

Applying negative pressure wound therapy Dressing a wound Gauze/transparent film Hydrocolloids/hydrogels Supporting/immobilizing a wound Binders Binders may be used to keep a wound closed when there is danger of dehiscence, or to immobilize a body part to aid in the healing process. They are typically used on large areas of the body and are designed for a specific body part. They may be made of cloth or elasticized material and fasten with straps, pins, or Velcro. The most common binders are the following: ■ A triangular arm binder or sling is used to support the upper extremities. Because commercial slings are readily available, you will use the triangular sling infrequently. ■ A T-binder is used to secure dressings or pads in the perineal area. ■ An abdominal binder is used to provide support to the ab- domen. It is often ordered when there is an open abdominal wound that is healing by secondary intention. The binder decreases the risk of dehiscence. Abdominal binders may be straight or multitailed. bandages A bandage is a cloth, gauze, or elastic covering that is wrapped in place. With the exception of a sling, most bandages come in rolls and in various widths, commonly 1.5 to 7.5 cm (0.5 to 3 in.). Use a narrow width on small body parts, such as a finger, and wider bandages on arms and legs. ■Cloth bandages are most commonly used as slings to im- mobilize an upper extremity or to hold large abdominal dressings in place. ■ Gauze is the most frequently used type of bandage. It is available in many sizes and forms and readily conforms to the shape of the body. It may also be impregnated with med- ications for application to the skin or with plaster of Paris, which, when dried, hardens to form a cast. ■ Elastic bandages are used to apply pressure and give support (e.g., to improve venous circulation in the legs). Ace bandages are the most common form of elasticized bandage. ■A rolled bandage is a continuous strip of material (gauze, stretchable gauze, or elastic webbing) that you unroll as you apply it to a body part. To apply a rolled bandage, hold the free end in place with one hand, and use the other hand to pass the roll around the body part. Exert equal tension on each pass (or turn). Each turn should overlap the last one- half to two-thirds the width of the bandage, except for the circular turn. There are five basic turns for rolled bandaging Applying heat and cold Local application of heat or cold has been used for therapeu- tic purposes for centuries. Temperature-sensitive nerve end- ings respond readily to temperatures between 59°F and 113°F (15°C and 45°C). Response to heat or cold depends on the area being treated, the nature of the injury, duration of the treatment, age, physical condition, and the condition of the skin

COLLABORATIVE MANAGEMENT

Assessment Medical record review Allergies and previous reactions to anesthesia or transfusions Autologous blood transfusion • Autologous blood donation for surgery can be made by the patient up to 5 weeks before the scheduled surgery date. The blood donor center gives the patient a matching tag that he or she wears or brings to the surgical area before surgery to help ensure that patients receive only their own donated blood. • Increased use of bloodless surgery and minimally invasive surgery provide alternatives for patients with religious or medical restrictions to blood transfusions. • Discharge planning should be started for all patients before surgery by assessing the patient's home environment, self-care capabilities, and support systems. Laboratory and diagnostic test results Medical history and physical examination findings

Alkalosis: Patient-Centered Collaborative Care

Assessment (same for metabolic and respiratory alkalosis) Hypocalcemia Hypokalemia CNS changes—positive Chvostek's and Trousseau's signs Neuromuscular changes—tetany Cardiovascular changes Respiratory changes

MORAL PRINCIPLES

Autonomy- Patients have the freedom to make decisions for themselves. The client's right to make her own decisions. But the client must accept the consequences of those decisions. The client must also respect the decisions ofothers. example: Rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice. Non-maleficence- To do no harm, either intentional or unintentional Beneficence-To act in the best interest of others; to benefit others The quality of doing good; can be described as charity example: a nurse helps a newly admitted client who has a psychotic disorder to feel safe in the environment of the mental health facility. Fidelity-Duty to keeping commitments and promises Loyalty and faithfulness to the client and to one's duty example: a client asks a nurse to be present when he talks to his mother for the first time in a year. the nurse remains with the client during this interaction. Veracity-To tell the truth, which has an added benefit of promoting trust between client and nurse. Veracity:Honesty when dealing with a client example: a client states, "You and that other staff member were talking about me, weren't you?" the nurse truthfully replies, "We were discussing ways to help you relate to the other clients in a more positive way." Justice- Fair, equitable, and appropriate treatment; resources are distributed equally to all. Fair and equal treatment for all example: during a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally.

Acute acutexl

By Duration Major distinction from chronic pain is the effect on biologic responses Acts as warning sign Activation of sympathetic nervous system Common experience Usually responds to treatment Increased heart rate Increased blood pressure Increased respiratory rate Dilated pupils Sweating

• Neuropathic Pain

By quality Paroxysmal Persists beyond normal healing • Anticonvulsants like the gabapentinoids gabapentin (Neurontin) and pregabalin (Lyrica) are recommended as first-line analgesics for persistent neuropathic pain. o Sustained from abnormal processing of stimuli and can occur in the absence of either tissue damage or inflammation. o Difficult to treat and often resistant to first-line pain agents. o PAIN descriptors include "burning," "shooting," "stabbing," and feeling "pins and needles." • Tolerance implies that the patient has adapted to a drug and, over time, its effects decline. • Tolerance is also a normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid (e.g., decreased analgesia, sedation, or respiratory depression). Like physical dependence, tolerance is not the same as addictive disease. Tolerance to analgesia usually occurs in the first days to 2 weeks of opioid therapy but is uncommon after that. It may be treated with increases in dose or rotation to a different opioid. However, disease progression, not tolerance to analgesia, appears to be the reason for most dose escalations. Stable pain usually results in stable opioid doses. With the exception of constipation, tolerance to the opioid side effects develops with regular daily dosing of opioids over several days. • Physical dependence is manifested by a withdrawal reaction. • Addiction is a primary, chronic disease that occurs over a long period. Behaviors in addiction include craving, compulsive drug use, and continued use despite harm. Neuropathic pain is a descriptive term used to refer to pain that is believed to be sustained by a set of mechanisms driven by damage to or dysfunction of the PNS and/or CNS. In contrast to nociceptive pain, which is sustained by ongoing activation of essentially normal neural systems, neuropathic pain is sustained by the abnormal processing of stimuli. Whereas nociceptive pain involves tissue damage or inflammation, neuropathic pain may occur in the absence of either. It is not clear why noxious stimuli result in neuropathic pain in some people and not in others and why some treatments work in some and not in others. Neuropathic pain is difficult to treat and often resistant to first-line analgesics. Asking patients to describe it is the best way to identify the presence of neuropathic pain. Common distinctive descriptors include "burning," "shooting," "tingling," and "feeling pins and needles." Much is unknown about what causes and maintains neuropathic pain; it is the subject of intense ongoing research.

THERMOREGULATION Objectives

By the end of this module you should be able to: Describe the physiological process involved in the maintenance and restoration of health and wellness. Discuss what a normal body temperature is and how to measure it. Describe the nursing interventions for the patient with temperature alterations. Utilize various forms of technology and professional references to support the care of the patient.

Cell-mediated immunity

Cell-Mediated Immunity Whereas the humoral immune response acts directly against antigenic cells, the cell-mediated immune response destroys microorganisms (usually viruses). Four types of T cells are responsible for the cell-mediated immune response: ■Cytotoxic (killer) T cells directly attack and kill pathogens and infected body cells. ■Helper T cells help regulate the action of cytotoxic T cells, as well as that of B cells in humoral responses. ■Memory T cells. The first time an antigen invades the body, T cells form that respond to that specific antigen. The mem- ory T cells are able to increase the speed and amount of the T-cell response with subsequent invasions by that antigen. ■Suppressor T cells are thought to stop the immune response when the infection has been contained. *Helper/inducer T-lymphocytes (T-cells)-Enhances immune activity of all parts of general and specific immunity through secretion of various factors, cytokines, and lymphokines *Cytotoxic/cytolytic T-cell Selectively attacks and destroys non-self cells, including virally infected cells, grafts, and transplanted organs *Natural killer cell Nonselectively attacks non-self cells, especially body cells that have undergone mutation and become malignant; also attacks grafts and transplanted organs book Cell-mediated IMMUNITY (CMI), or cellular immunity, involves many white blood cell (WBC) actions and interactions. CMI also is adaptive or acquired true immunity that is provided by lymphocyte stem cells that mature in the secondary lymphoid tissues of the thymus and pericortical areas of lymph nodes (see Fig. 17-7). Certain CMI responses influence and regulate the activities of antibody-mediated immunity (AMI) and innate immunity (inflammation) by producing and releasing cytokines. For total or full immunity, CMI must function optimally. Protection Provided by Cell-Mediated Immunity Cell-mediated IMMUNITY (CMI) helps protect the body through the ability to differentiate self from non-self. The non-self cells most easily recognized by CMI are cancer cells and self cells infected by organisms that live within host cells, especially viruses. CMI watches for and rids the body of self cells that might potentially harm the body. CMI is important in preventing the development of cancer and metastasis after exposure to carcinogens.

Skeletal Disease: Osteoporosis

Chronic disease in which bone loss causes decreased density & possible fracture Wrist, hip & vertebral column are the most commonly affected At risk: A = alcohol use C = corticosteroid use C = calcium is low E = estrogen is low (especially postmenopausal) S = smoking S = sedentary lifestyle S&S: back pain, constipation, decrease in height, Dowager's hump (humped back), fractures, decreased bone mass

CLINICAL MANAGEMENT

Clinical management of individuals with immunosuppression or hyper immune conditions varies widely depending on the type of condition, severity, and attributes variables such age: Age Health status Underlying medical conditions

Clinical Management: Nonpharmacologic Interventions Based on "gate control" theory

Complementary and alternative therapies Immobilization and rest Positioning and body alignment Splinting Contralateral stimulation • Nonpharmacologic therapies for pain management may be used in place of or in combination with drug therapy. These therapies are classified as physical modalities or cognitive-behavioral therapies. • Cognitive-behavioral interventions Mind-body therapies- mindfulness Distraction relaxation techniques Progressive muscle relaxation Guided imagery-imagery Hypnosis Humor Journaling ------------------------------------- Cutaneous stimulation Application of heat, cold, pressure Therapeutic touch Massage Vibration Acupuncture Acupressure TENS TENS is used as an adjunctive treatment for pain. Although there are several types of transcutaneous electrical nerve stimulation (TENS) units, each involves the use of a battery-operated device capable of delivering small electrical currents through electrodes applied to the painful area (Fig. 4-5). The voltage or current is regulated by adjusting a dial to the point at which the patient perceives a prickly "pins-and-needles" SENSORY PERCEPTION rather than the pain. The current is adjusted based on the degree of desired relief. Newer, smaller, and less expensive TENS units are easy for anyone to apply and are often used at home or other community-based setting. The cost for a single unit usually ranges between $100 to $300 per unit, depending on the number of settings and leads. PENS • Examples of physical measures to manage pain are transcutaneous electrical nerve stimulation (TENS), heat, cold, massage, and low-impact exercises.

Appendicular section

Connected to axial skeleton by bones of upper and lower extremities a. Shoulder girdle supports arms; humerus is located in upper arm and ulna and radius in forearm b. Each innominate bone (hip bone) consists of 3 parts—ileum, ischium, and pubis; innominate bones unite with sacrum and coccyx of vertebral column to form pelvic girdle, which supports legs

MORAL FRAMEWORKS

Consequentialism: The rightness or wrongness of an action depends on the consequences of the act rather than on the act itself. Theories of this type are also called: Teleology- from the Greek word telos, meaning "end" or the study of ends (also called final causes) . Utilitarianism- the most familiar consequentialist theory, takes the position that the value of an action is determined by its usefulness. The principle of utility states that an act must result in the greatest good (positive benefit) for the greatest number of people. ------ Deontology:Unlike the utilitarian model, considers an action to be right or wrong regardless of its consequences. Formalism-Defines morals based off of logic and reason which says that if something is defined as wrong or right, it is defined as wrong or right all the time. Categorical imperative- One should act only if the action is based on a principle that is universal—or in other words, if you believe that everyone should act in the same way in a similar situation -------- Feminist ethics-Based on the belief that traditional ethical models provide a mostly masculine perspective, and that they devalue the moral experience of women. Uses relationships and stories rather than universal principles. Addresses female perspective of issues. Values relationships/stories Addresses female perspective of issues ---------- Ethics of care-Nursing's responsibility to care in ethical situations. Using an ethics of care perspective, nurses include a responsibility to care as a part of their professional behavior. Some aspects of care include the ability and duty to appreciate, understand, and even share the patient's pain or condition Nursing's responsibility to care in ethical situations Principles + feelings

TRANSMISSION-BASED PRECAUTIONS Contactxl contxl

Contact Precautions Pathogen is spread by direct contact Sources of infection: draining wounds, secretions, supplies Precautions include Possible private room Clean gown and glove use Disposal of contaminated items in room Double-bag linen and mark book When to Use: Use contact precautions when direct contact with the patient or the patient's environment can lead to spread of the pathogen.This is the most common form of transmission. Draining wounds, dressings, patient supplies, and secretions are sources of infection. Indirect contact, or contact with fomites, can also transmit pathogens that spread by this method. *Patient Placement and Transport* ■ Ideally, consult with an infection preventionist for patient placement. ■ Place in a private room, if available. Private room provides the most effective protection. ■ If no private room is available, place patient in a room with a patient with an active infec- tion caused by the same organism and no other infections. ■ When transporting the patient, ensure that infected or colonized areas of the body are contained and covered. ■ Ambulatory care: Place the patient in an exam room or cubicle as soon as possible. Personal *Protective Equipment (PPE)* ppexl ■ Wear clean nonsterile gloves when touching the patient's intact skin. Don gloves on entry to the room. ■ Wear a clean gown if you anticipate your clothing may contact the patient or any contam- inated items in the room. ■ Remove PPE and observe hand hygiene before leaving the room.Take care that your skin and clothing do not contact environmental surfaces on the way out of the room. *Equipment, Supplies, and Environment* ■ Keep contact precaution supplies just outside the patient's room on a cart. ■ Double bag all linen and trash (or use a single waterproof bag), and clearly mark them contaminated. ■ Use disposable equipment (e.g., blood pressure cuffs) if possible; otherwise, clean and disinfect the equipment per institutional policy before removing them from the room and before use on another patient. ■ Ensure that the patient room is cleaned and disinfected at least daily. ■ Home care: Limit the amount of nondisposable equipment brought into the home. If possible, leave the equipment in the home until discharge from home care. ■ Home care: If equipment cannot remain in the home, clean and disinfect items before taking them from the home, or place them in a plastic bag for transport to a reprocessing area.

TORTS AND NURSING PRACTICE Quasi-Intentional Torts

Defamation False communication to a third person Slander Oral defamatory statements Libel Written defamatory statements

Categories of errors

Diagnostic Treatment Preventive Communication

TRANSMISSION-BASED PRECAUTIONS Dropletxl dropxl

Droplet Precautions Pathogen is spread via moist droplets Coughing, sneezing, touching contaminated objects -Precautions include Same as those for contact Addition of mask and eye protection within 3 ft of client book *When to Use*: Use droplet precautions when the pathogen can be spread via moist, large droplets (e.g., sneezing, coughing, talking). Droplets can spread infection by direct contact with mucous membranes or through indirect contact, for example, suctioning or touching a bedside table that was contaminated with moist droplets and then rubbing your eyes. *Patient Placement and Transport* ■ If no private room is available and the patient must be placed with patients who have a different infection, ensure that the patients are physically separated by more than 3 ft. Keep the privacy curtain closed.This minimizes contact between patients. Ideally, consult with an infection preventionist for patient placement.A private room provides the most effective protection. ■ Limit transport outside the room to medically necessary purposes; if transport is neces- sary, the patient should wear a mask.The transporter is not required to mask. *Personal Protective Equipment* ppexl ■ Keep droplet precaution supplies just outside the patient's room on a cart. ■ Wear a mask when working within 3 ft of the patient. Don the mask on entry into the room.Whether to wear goggles is an unresolved issue. Follow agency policy. ■ Change PPE and perform hand hygiene between contact with patients in the same room, regardless of whether one or both patients are on droplet precautions.

MINIMALLY INVASIVE AND ROBOTIC SURGERY (MIS)

Now common practice Preferred technique for many surgery types, including: Cholecystectomy Joint surgery Cardiac surgery Splenectomy Spinal surgery Potential injury Mechanical trauma Thermal injury

A WOUND FOR SPECIAL CONSIDERATION: PRESSURE ULCER

Nurses play a major role in prevention and treatment Pressure ulcers affect 15% of hospitalized clients They are caused by unrelieved pressure to an area, resulting in ischemia

Indwelling catheters

Indwelling catheters (urethral or suprapubic catheters) An indwelling catheter is a catheter that resides in the bladder. ... External catheters (condom catheters) A condom catheter is a catheter placed outside the body. ... Short-term catheters (intermittent catheters) ---------- care One-time use catheters and reusable catheters are available. For reusable catheters, be sure to clean both the catheter and the area where it enters the body with soap and water to reduce the risk of a UTI. One-time use catheters come in sterile packaging, so only your body needs cleaning before inserting the catheter. You should also drink plenty of water to keep your urine clear or only slightly yellow. This will help prevent infection. Empty the drainage bag used to collect the urine at least every eight hours and whenever the bag is full. Use a plastic squirt bottle containing a mixture of vinegar and water or bleach and water to clean the drainage bag. Read more on clean intermittent self-catheterization. Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails. Change the warm water in your container if you are using a container and not a sink. Wet the second washcloth with warm water and soap it up. Gently hold the catheter and begin washing the end near your vagina or penis. Move slowly down the catheter (away from your body) to clean it. NEVER clean from the bottom of the catheter toward your body. Gently dry the tubing with the second clean towel. --------------- rf According to an article in BMC Urology, indwelling urinary catheters are the leading cause of healthcare-associated urinary tract infections (UTIs). Therefore, it's important to routinely clean catheters to prevent infections. The symptoms of a UTI may include: fever chills headache cloudy urine due to pus burning of the urethra or genital area leaking of urine out of the catheter blood in the urine foul-smelling urine low back pain and achiness Other complications from using a urinary catheter include: allergic reaction to the material used in the catheter, such as latex bladder stones blood in the urine injury to the urethra kidney damage (with long-term indwelling catheters) septicemia, or infection of the urinary tract, kidneys, or blood -------------- 24 hour The 24-hour collection should begin by having the patient empty his or her bladder or catheter bag at a fixed time and discard the specimen. Record this start date and time on the collection container and on the laboratory requisition. If a preservative is required, the patient must be advised to collect the urine in a separate clean container and then carefully transfer the urine to the collection container that will be transported to the laboratory. Comment: Assume that all preservatives are hazardous (most are). Instruct the patient (or nurse) to collect all voided urine during the 24-hour collection period and add it to the collection container. The collection should end exactly 24 hours after it began, by having the patient empty his or her bladder, or catheter bag, and adding this specimen to the collection container. Record the ending date and time on the collection container and on the laboratory requisition. Carefully seal the cap tightly so as to avoid leakage.

RISK FACTORS: POPULATIONS AT GREATEST RISK

Infections potentially affect all individuals, regardless of age, gender, race, and socioeconomic status. Populations at greatest risk are the: Very young Poor Uninsured Residents of geographic areas where an infection is prevalent

RISK FACTORS: POPULATIONS AT GREATEST RISK

Inflammation can affect all individuals, regardless of age, gender, race, and socioeconomic status. The populations at risk for a severe or ineffective inflammatory response are the: Very young Very old Uninsured

Infection

Inflammation occurs in response to tissue injury as well as to infection by organisms. Infection is usually accompanied by inflammation; however, inflammation can occur without infection. Inflammation without infection includes joint sprains, myocardial infarction, and blister formation. Inflammation caused by noninfectious invasion includes allergic rhinitis, contact dermatitis, and other allergic reactions. Inflammations from infection include otitis media, appendicitis, and viral hepatitis, among many others. Inflammation does not always mean that an infection is present.

Post-surgical patient education: Activity

Maintain activity restriction if ordered by surgeon Resume activities gradually (all clients) Avoid heavy lifting for 6 weeks after major surgery Avoid lifting more than 10 pounds or performing activities involving pushing or pulling with an abdominal incision Often may return to work in 6 to 8 weeks (depending on surgery and client status preoperatively) • Patients are screened preoperatively for problems that increase the risk for complications during and after surgery. o Identify current health problems, potential complications from anesthesia, and complications that may occur after surgery. o Age, drugs, herbs, and substance use may affect patient responses to anesthesia and pain medication. o Many chronic illnesses increase surgical risks and need to be considered when planning care. o Complications from anesthesia occur more often in patients with cardiac problems. In accordance with The Joint Commission's National Patient Safety Goals (NPSGs), patients with cardiac disease who are prescribed beta-blocking drugs should continue the therapy before surgery and in the immediate postoperative period.

PROFESSIONAL GUIDELINES FOR ETHICAL DECISION MAKING

Nursing Codes of Ethics International Council of Nurses American Nurses Association Standards of Care Patient Care Partnership

PREOPERATIVE PATIENT PREPARATION PREOPxl

Remove most clothing; provide gown Leave valuables with family member or lock up Tape rings in place if cannot be removed Ensure patient is wearing ID band Remove: -Dentures -Prosthetic devices -Hearing aids -Contact lenses -Fingernail polish -Artificial nails -Pierced jewelry

LINES OF DEFENSE AGAINST INFECTION

Tertiary Defenses *specific immunity*: the process by which the body's immune cells "learn" to recognize and destroy pathogens they have encountered before. The cells involved in specific immunity are the *lymphocytes*, WBCs produced from stem cells in the red bone mar- row. B lymphocytes, or B cells, grow to maturity in the bone marrow, whereas T lymphocytes, or T cells, mature in the thy- mus. After maturing, most B cells and T cells travel to the lymph nodes, spleen, and other sites of lymphatic tissue. Some circulate in blood and lymph. From all of these loca- tions, lymphocytes seek out foreign cells and other matter to target for destruction. Lymphocytes recognize foreign substances by the molecules present on their surfaces. These molecules that trigger a specific immune response are called antigens. Humoral immunity- pg 611 bn book Antibody-mediated immunity (AMI) (also known as humoral immunity) can be transferred from one person or animal to another.==Circulating antibodies can be transferred from one adult to another and provide the receiving adult with immediate short-term immunity. B-cell production of antibodies in response to an antigen Cell-mediated immunity The cells and actions of cell-mediated immunity control and coordinate the entire inflammatory and immune responses. Cell-mediated IMMUNITY (CMI) protects the body through differentiation of self from non-self. These are important in preventing the development of cancer and metastasis after exposure to carcinogens. Direct destruction of infected cells by T cells

Pain Transmission

Transmission is the second process involved in nociception. Nociceptors have small-diameter axons—either A-delta or C fibers Effective transduction generates an electric signal (action potential) that is transmitted in these nerve fibers from the periphery toward the CNS. Painful stimuli often originate in extremities If pain not transmitted to the brain, person feels no pain Two specific fibers transmit periphery pain: A delta fibers-are lightly myelinated and conduct faster than unmyelinated C fibers. The endings of A-delta fibers detect thermal and mechanical injury. The SENSORY PERCEPTION accompanying A-delta fiber activation is sharp and well localized and leads to an appropriately rapid protective response such as reflex withdrawal from the painful stimuli. C fibers- C fibers are unmyelinated or poorly myelinated slow conductors and respond to mechanical, thermal, and chemical stimuli. Activation after acute injury yields a poorly localized (more widely distributed) typically aching or burning pain. In contrast to the intermittent nature of A-delta sensations, C fibers usually produce more continuous pain. • Painful stimuli often originate in the periphery of the body. o To be perceived, the stimuli must be transmitted from the periphery to the spinal cord and then to the central areas of the brain.

MRI

Used to confirm the diagnosis of musculoskeletal dysfunction and infection by orthopedic surgeons. Similar to CT images; however, the ability to see tissue is much clearer, without contrast Bone, joint, and soft tissue injuries can be seen without bone artifact and can distinguish whether a tumor is within or adjacent to a bone *book* MRI, with or without the use of contrast media, is commonly used to diagnose musculoskeletal disorders. It is more accurate than CT and myelography for many spinal and knee problems. MRI is most appropriate for joints, soft tissue, and bony tumors that involve soft tissue. CT is still the test of choice for injuries or pathology that involves only bone. The image is produced through the interaction of magnetic fields, radio waves, and atomic nuclei showing hydrogen density. Simply put, the radio waves "bounce" off the body tissues being examined. Because each tissue has its own density, the computer image clearly distinguishes normal and abnormal tissues. For some tissues, the cross-sectional image is better than that produced by radiography or CT. The lack of hydrogen ions in cortical bone makes it easily distinguishable from soft tissues. The test is particularly useful in identifying problems with muscles, tendons, and ligaments. Ensure that the patient removes all metal objects and checks for clothing zippers and metal fasteners. Although joint implants made of titanium or stainless steel are usually safe, depending on the age of the MRI equipment, pacemakers, stents, and surgical clips usually are not. Large facilities and those focused on sports medicine may have orthopedic-type MRI machines that are open design and vertically oriented (upright) to make the examination more comfortable. These machines are most useful for viewing extremity injuries but cannot be used for abdomen, brain, or spine studies because of their size and shape. Chart 49-3 lists questions that the nurse or technician should consider in preparing the patient for MRI.

herniationxl hernxl

Watkins; babies are born with it,some people will get them fixed, some people will not unless symptomatic mall *indirect inguinal hernia* sac formed from the petroleum that contains a portion of the intestine or omentum- most common *direct inguinal hernias* pass through a weak point in the abdominal wall- older adults *femorial hernias* protrude through the femoral ring- obese, pregnant woman) *also caused by- colyhirs, heavy lifting, pregnancy, abdominal distension, ascites, all causes increased abdominal pressure in obese and pregnant women. *umbilical hernias* -congenital is infant -acquired is intra abd pressure, obesity *incisional, ventral hernias* occur at the site of previous sx incision result from inadequate healing of the incision d/t infection, inadequate nutrition, obesity, post-op----- for pts who have undergone abdominal sx a weakness of the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes *reducible*- the contacts of the hernia sac can be placed back into abdominal cavity by gentle pressure *irreducible*- (incarcerated) can not be reduced or placed back into abdominal cavity *requires sx intervention immideatly* *strangulated*- when blood supply to the herniated segment- a bowel is cut off leading to necrosis possible necrosis s/s- abdominal distension, n/v, pain, fever, tachycardia auscultate bowel sounds, never forcefully reduce hernia hernni *herniation n.i*- non surgical- tress pad surgical- Laparoscopy minimally invasive hernia repair remain npo per order, avoid coughing, encourage pt to stand and void, fluid intake to 1500-2500 ml/po daily sn internal organ or tissue, bulges through muscle/ brain, bulging in groin--- laying down, retracts. no bowel sounds for hernia. strangulation no o2 leading to necrosis, sx to fix it, trust pad 7 types of hernia

labsxl--- Common Tests for Evaluating the Presence of or Risk for Infection

White blood cell (WBC) count with differential- 5,000-10,000/mm3. Leukocyte (WBC) count-4,500-11,000/mm3 func Usually done as a part of a complete blood count (CBC) but may be ordered as an independent test.WBCs may increase when a wound develops; continued elevation may signal infection.A lowWBC count may delay wound healing. Leukocytes are responsible for an inflammatory reaction at the wound site, phagocytosis of bacteria and cellular debris, and the creation of antibodies. --Serum protein- 6.0-8.0 g/dL --Serum albumin- 3.4-4.8 g/dL ----Serum prealbumin- 12-42 mg/dL func Low serum levels indicate limited nutritional stores that delay wound healing or place the patient at high risk for pressure ulcers. Serum protein may be monitored as an indicator of the ability to heal a wound or prevent a pressure ulcer. Serum protein and albumin levels are closely related. However, both fluctuate slowly.A more accurate measure of a patient's immediate protein stores is reflected in prealbumin level. Coagulation studies: Partial thromboplastin time, activated (aPTT)- Varies with respect to equipment and reagents used. Critical values: >70 sec or <53 sec Prothrombin time (clotting time)- Critical values: >20 sec (uncoagulated) or 3 times normal control (anticoagulated) International normalized ratio (INR)- < 2.0 for patients not receiving anticoagulation therapy; 2.0-3.0 for those receiving coagulation therapy Blood cultures- A sample of blood placed on culture media and evaluated for growth of pathogens. Normally, should show no growth of infectious microorganisms. Urine cultures- Urine is normally sterile with no microorganism growth. Throat cultures, wound cultures-Presence of microorganisms is normal, but there should be no growth of infectious microorganisms.To yield the most reliable results, blood cultures should be obtained from peripheral sites, using venipuncture by trained phlebotomists, unless a culture is specifically ordered from a central catheter or peripherally inserted central catheter. Disease titers- Blood tests for specific disease immunity (e.g., to rubella) Panels to evaluate specific disease exposure-Blood tests to evaluate exposure to specific diseases (e.g., HIV, hepatitis) Immunoglobulin (IgG, IgM) levels- Blood tests to evaluate humoral immunity status C-reactive protein (CRP)- A blood test to measure inflammatory change or bacterial infection Agglutinins, warm or cold- Used to diagnose atypical infections by detecting antigens in the blood Erythrocyte (red blood cell) sedimentation rate (ESR or sed rate)- A measure of inflammatory changes. Sed rate increases with inflammation. Normally it is at 15 mm/hr for men and < 20 mm/hr for women. Erythrocyte sedimentation rate (ESR) -Younger than 50 yr: 0-15 mm/hr; -older than 50 yr: 0-20 mm/hr Iron level- Normally 60-90 g/100 mg. Lower in chronic infection.

Agonist-antagonists

are another group of opioids. These medications stimulate some opioid receptors but block oth- ers. Commonly used medications include mixed agonist- antagonists, such as pentazocine (Talwin) and nalbuphine (Nubain), and partial agonists, such as buprenorphine (Buprenex). These medications are appropriate for moder- ate to severe acute pain. Agonist-antagonists should not be given to patients taking mu agonists (e.g., morphine) be- cause they may act as antagonists at the mu receptor sites and reduce or reverse the analgesia from the mu agonist. • Mixed agonists antagonists bind to more than one type of opioid receptor. They bind as agonists to the kappa opioid receptors to produce analgesia and other effects and to the mu opioid receptors as antagonists. This antagonistic property explains why these drugs can trigger severe pain and opioid withdrawal syndrome characterized by rhinitis, abdominal cramping, nausea, agitation, and restlessness in patients who have been taking regular daily doses of a mu agonist opioid for several days. Another undesirable effect of these drugs is that they produce a dose-ceiling effect, which means that further increases in dose will not produce further relief. This latter property limits their usefulness in pain management. Occasionally these drugs are used in very low doses to antagonize (in hopes of relieving) opioid-induced side effects such as pruritus. However, this approach risks reversing analgesia; therefore patients must be assessed frequently to ensure that adequate pain control and COMFORT are maintained. Examples are butorphanol (Stadol) and nalbuphine (Nubain). • Partial agonists have some kappa and mu opioid receptor activity but produce an analgesia plateau and are not easily reversed by opioid antagonists such as naloxone (Narcan). These properties limit their role in pain management. Buprenorphine is a partial agonist opioid, available in a transdermal patch (Butrans) for stable pain management. The drug has been formulated alone (Subutex) and with naloxone (Suboxone) for the treatment of the disease of addiction. Opioid antagonists (e.g., naloxone [Narcan], naltrexone [Revia]) are drugs that also bind to opioid receptors but produce no analgesia. If an antagonist is present, it competes with opioid molecules for binding sites on the opioid receptors and has the potential to block analgesia and other effects. They are used most often to reverse opioid effects such as excessive sedation and respiratory depression.

Crutches

are the most commonly used ambulatory aid for many types of lower-extremity musculoskeletal trauma (e.g., fractures, sprains, amputations). In most agencies, the physical therapist or emergency department/ambulatory care nurse fits the patient for crutches and teaches him or her how to ambulate with them. Reinforce those instructions and evaluate whether the patient is using the crutches correctly. Walking with crutches requires strong arm muscles, balance, and coordination. For this reason, crutches are not often used for older adults; walkers and canes are preferred. Crutches can cause upper-extremity bursitis or axillary nerve damage if they are not fitted or used correctly. For that reason, the top of each crutch is padded. To prevent pressure on the axillary nerve, there should be two to three finger-breadths between the axilla and the top of the crutch when the crutch tip is at least 6 inches (15 cm) diagonally in front of the foot. The crutch is adjusted so the elbow is flexed no more than 30 degrees when the palm is on the handle (Fig. 51-7). The distal tips of each crutch are rubber to prevent slipping.

Constipation constixl

ashlii A bowel pattern of difficult and infrequent evacuation of hard, dry feces. The number of bowel movements a patient has is individual, but if a patient has fewer than three bowel movements per week or must vigorously strain, the patient is considered to have constipation. It is due to sedentary lifestyle, poor diets (low in dietary fiber and fluid), frequent use of laxatives, pregnancy, and some medications. ashlii- Nursing management of constipation -Increase intake of high-fiber foods -Increase fluid intake -Increase activity/exercise -Provide privacy -Help client to a position that facilitates defecation -Allow uninterrupted time -Offer laxatives when lifestyle changes are ineffective rf Decreased activity, bedrest, opioids or other medications that slow peristalsis, decreased fluid and fiber intake DRUG THERAPY Increase high fiber intake Increase fluid intake Increase activity/exercise to stimulate peristalsis Provide privacy Help client to a position that facilitates defecation ( in a seated or squatting position whenever possible. Semi-fowlers position is preferred for a client on bedrest. Allow uninterrupted time Offer laxatives when lifestyle changes are ineffective

Accident prevention - Older adult

bo fml cc ss f fb dnh be careful with use of space heaters; be sure older adults have fans or air conditioners in summer heat Older adults may be prey to strangers and criminals who can inflict physical and financial injury frequent assessment of driving ability is required Motor vehicle accidents are of concern for older adults loss of driving privileges can mean a loss of independence Clients taking some medications may have decreased cognitive abilities or impaired judgment; encourage them to ask for assistance with activities of daily living caution them against letting strangers into their homes or responding to telephone calls, e-mails, or letters asking for money or personal information Stairwells should be well lit Small scatter rugs, runners, and mats should not be used Furniture, floors, and passageways should be free of clutter Falls are the leading cause of accidents in older adults Bathrooms and showers/tubs should have grab bars Decrease in temperature regulation may increase risk of hyperthermia or hypothermia Neighbors, police, and fire officials should be made aware of older adults with disabilities living alone Home modifications may be necessary to accommodate safe use of wheelchairs or walkers

Maslow's - Safety and Security Needs

fh perm b pe family health property employment resources morality body Physical safety and security means being protected from potential or actual harm. Emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension.

Nociception Nociceptionxl

has four processes, including SENSORY PERCEPTION (involves the conscious awareness of PAIN). o Somatic PAIN arises from the skin and musculoskeletal structure. o Visceral PAIN arises from organs. is the term that is used to describe how pain becomes a conscious experience. It involves the normal functioning of physiologic systems that process noxious stimuli, with the ultimate result being that the stimuli are perceived to be painful. In short, nociception means "normal" pain transmission and is generally discussed in terms of four processes: transduction, transmission, perception, and modulation (Fig. 4-1). Although it is helpful to consider nociception in the context of these four processes, it is important to understand that they do not occur as four separate and distinct entities. They are continuous, and the processes overlap as they flow from one to another.

detrusor hyperreflexia- reflex incontinence sorxl

involuntary loss of urine at predictable intervals when bladder reaches a specific volume------Reflex incontinence due to neurologic impairment the abnormal detrusor contractions result from neurological abnormalities *cause* cns lesions from stroke, multiple sclerosis, parasacral spinal cord lesions. local irritating factors such as caffeine, meds, or bladder tumor clinical manifistations post void residual < 50 ml *sors/s s/s* Urgency: strong desire to void may be caused by inflammation or infection in bladder or urethra Dysuria: painful or difficult voiding Frequency: voiding that occurs more than usual when compared with client's regular pattern or generally accepted norm of voiding once every 3-6 hours Hesitancy: undue delay and difficulty in initiating voiding Polyuria: a large volume of urine voided at any given time Oliguria: a small volume of urine or output between 100 and 500 mL/24 hr Nocturia: excessive urination at night, interrupting sleep Hematuria: RBCs in urine Detrusor hyperreflexia (DH) is a frequently occurring condition. The symptomatology is characterized by frequency, urgency and urge incontinence. DH is defined as involuntary, uninhibited detrusor contractions. The physiology and pathophysiology of the micturition reflex is reviewed. *sordrugs* These patients complain of urinary frequency and urgency and urge incontinence. First-line treatment for detrusor hyperreflexia includes anticholinergic medication.

analxl fissure

mall a tear in the anal lining small- straining to have bm's, diarrhea, constipation large/deep- chron's dz, tb, leukemia,neoplasm or due to trauma- foreign body, rough anal intercoarse,perirectal sx s/s pain during/after bm, bright red blood in stools, itching, urinary frequency, orientation, dysuria, painful intercoarse tx aimed at local pain relief, and softening stools, warm sitz baths, analgesics, bulk producing agents to minimize pain during bm, topical antiinflammatory sn small tear in thin moist tissue in mucosa that lines the anus. crack- bright red blood, visible lump- skin tag objective pain during bowel movement, itching, irritation around anus, dx: digital rectal exam, colonoscopy, topical cream, Botox to relax sphincter- bp med n.i: increase fluids, fiber, stool softener and exercise to go

analxl fistula

mall abnormal tracts b/t 2 or more body anus (common with acute periods of chron's dz) enterovesical b/t bowel and bladder enteroenteral- b/t 2 segments of bowel entercuteaneous- b/t skin and bowel enterovaginal- b/t bowel and vagina complications systemic infections, skin problems, malnutrition, fluid and electrolyte imbalance * adequate nutrition and fluid/electrolyte balance priorities patient is at high risk for malnutrition, dehydration, hypokalemia, I&O these patients need atleast 3000 calories daily to promote healing of the fistula s/s pruitis(itching), purulent drainage, tenderness/pain that is worsened by bowel movements tx sx is necessary to heal by scondary intention sn infected tunnel b/t skin and anus. s/s: pain in the rectum, swelling, anal discharge of blood and pus in anus sx like fistomy is needed to treat anal fistula dx: mri, colonoscopy pain meds--- antibiotics c/b absess that doesn't heal properly

Urinary Retention- External sphincter doesn't open for release of urine or blockage or urethra urinexl

mall accumulation of urine and inability to urinate Urine is retained in the bladder Lack of ability to urination Common causes(obstructive): BPH, yrethral stricture, phimosis, tumor, stenosis, prostate cancer, kidney stones, prostatitis Non-obstructive causes : nerve dysfunction, decrease sensory input from bladder Constipation UTI DRUG THERAPY urinedrugs Administer analgesic to reduce pain (avoid drug, morphine Urinary catheterization, bladder drainage Anxiety Parkinson's disease Some *drugs*: antidepressants, antihistamines, anticholinergic, opioids Complications; Renal failure, UTI, stone formation, bladder damage, kidney damage Leads to increased urine volume and bladder distention (backflow to the upper urinary tract, dilation of the ureters and renal pelvis, pyelonephritis and renal atrophy) ashlii An inability to empty the bladder completely. Etiologies include obstruction (BPH), inflammation and swelling, neurological problems, medications (anesthesia & opiods), and anxiety. Treatments: Urinary catheterization. ashlii-Managing urinary retention Urinary Catheterization: Introduction of a sterile tube into the bladder -Straight catheter -Indwelling catheter: Foley -Suprapubic catheter *s/s*: urines/s Sense of incomplete voiding High intake of fluid and no output of fluid present Round swelling above the pubic symphysis Edema,restlessness,pain, incontinence, hydroneprosis, discomfort, dysuria,distended bladder *DIAGNOSTICS DX* urinedx H & P physical examination, Cystoscopy, CBC, creatinine and bilirubin levels Bladder scan *n.i* urineni Urinary catheterization: Straight catheter, indwelling catheter (Foley), suprapubic catheter Nursing care( for urinary catheter) Prevent UTI, backflow of urine, encourage fluids, perineal hygiene ashlii n.i Prevent UTI's Prevent backflow of urine Encourage fluids Perineal hygiene

parasitic infection paraxl

mall can invade the GI tract and cause infections via oral fecal route *cause* contaminated food/water/oral/anal sex practices, or contact with contaminated feces handwashing is the best way to prevent infection *bacteria* entamoeba histolytica, giardia lamblia, cryptosporidium, paras/s s/s foul stools with mucus, abdominal cramping, flatulence,fatighue, weight loss *s/s of SEVERE AMEBIC INFECTION* frequent, more liquid, foul smelling stools with mucus and blood, FEVER 104 degrees, urge to defecate, abdominal tenderness, vomiting paradrugs *meds* amebicides FLAGYL, novonidazole, iv fluids, opiates, lomotil to control gi motility tx for GIARDIAS is metronidazole (diflucan), parateaching *pt education* avoid transmitting to others, increase hand hygiene, keep toiletries clean, avoid stool from dogs, beavers sn foot, gi system, loss of appetite, pain ,d/n/v dx: blood test-serology blood test; colonoscopy- high fiber diet- proper hygiene COOK FOODS PROPERLY- counters needs to be clean jargon---ego- on top/ colonoscopy on bottom

chronicxl glomerulonephritis-

mall develops over 20-30 yrs or longer- exact onset rarely defined r/t changes in the lanry tissue from htn, infections, inflammation, or poor blood flow to kidneys *it always lead to kidney failure assess urinary systems, slurred speech,ataxia,tremors, or Asterixis ( flapping tremors of the fingers,or the inability to maintain a fixed posture with arms extended and wrist hyper extended, yellowing of the skin, texture, bruises, rashes, or eruptions dx ua, decrease GFR, bun increased, sodium retention, hyperphosphatemia, decreased calcium, acidosis develops, renal biopsy tx diet changes, sufficient fluid intake, eventually patient requires dialysis or transplantation

intestinal obstruction testxl

mall mechanical- physically blocked bowel outside of the intestinal wall non-mechanical- (paralytic ileus) decrease parialstalsis labs ct, kub, colon/sigmoidoscopy small bowel abdominal discomfort/ pain, increase abdominal distention, n/v with fecal matter, obstipation ( no stool/gas), severe fluid/ electrolyte imbalance, metabolic akalosis large bowel intermittent decrease abdominal cramping, decrease abdominal distension, minimal or no vomiting, obstipation, or ribbon like stools, no major fluid/electrolyte imbalance, metabolic acidosis ( not always seen) sn constipation, can't pass gas, least invasive like increase fluids, use stool softner, laxatives, sx if it gets worst to remove obstruction prevention: high fiber diet, fluid avoid solid food, avoid meds that cause constipation like narcotics, pain meds, opiods

Mixed Incontinence Mixedxl

mall the presence of one or more than 1 type of incontinence often urine is losed related to both stress and urge incontinence stress incontinence and urge incontinence often occur together in women during and after menopause. *combo of stress, urge, overflow incontinence* Total incontinence: continuous and unpredictable involuntary loss of urine

diabetic nephropathy- oxycodone, pregablin

mall vascular complication of dm type 1 and 2 s/s- persistent albuminuria, increased kidney size, increase GFR, decreased hypoglycemia episodes kidneys metabolize and excrete insulin, leads to a more rapid progression to eskd n.i/teach- keep blood glucose levels in normal range. constantly ( may help to delay onset/ prevent it, keeping blood pressure normal, increase cardiovascular health sn nerve pain c/b diabetes, s/s fatigue, increased urine, loss of appetite, objective: pain, protein in urine, swelling in ankles, feet, eyes, bad in bp dx: urine test, glucose blood test, renal function test meds: oxy, tramadol, pregablin pt teaching: sexual dysfunction- feet exams, follow up neurologist

gastroenteritis= stomach flu gastxl

mall an increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucus membranes in the stomach and intestinal tract and transmitted via the oral fecal route and result in increase GI motility ashlii An increase in the frequency and water content of stools and vomiting as a result of inflammation of the mucous membranes of the stomach and intestines, primarily affecting the small bowel. May be viral or bacterial in origin. *viral* rotavines and norwalkvirus *bacterial* ecoli, campylobacter, shigellosis *gasts/s s/s* nlv, myalgia, headache, malaise progressing to poor skin turgor, dry moucus membrane, ortho bp changes, decrease htn, oliguria progressing to dehydration and shock d/t fluid/electrolyte losses ashlii s/s Onset of diarrhea w/ accompanying abdominal cramping or pain, *s/s* fatigue, lack of appetite, n/v/d, drink fluids, cramping Nausea and vomiting Bloody, mucous, or watery, foul smelling stool Possible fever Dehydration Positive stool sample for bacteria *gasttx* fluid replacement (pedialyte) AVOID CAFFIENE, 1/2 normal saline w/ k+ ashlii tx Fluid replacement Diet therapy Drug therapy (antiemetics or anticholinergics) gastdrugs *drugs* immodium if necessary, peptobismal, antibiotics theraphy, norflaxacin,cipro,septra ds, bactrim ds gastteach *pt education* skincare techniques, sitzbaths, increase hand and environment hygiene, prevent transmission to others ashlii pt teaching Replace fluids Follow recommended diet Wash hands Do not share utensils Maintain clean bathroom drink fluids, antibiotics- no alcohol, caffeine, dairy products- no raw fruit or veges, no nsaids or aspirin ---------------- Antimicrobials are given if it is caused by an infecting organism susceptible to therapy sn inflammation of gastrointestinal tract, involving stomach and intestine intestine has a virus or bacteria, rx to meds and food allergies, food or water poising, use of laxatives, alcohol

older adult factors affecting safety restraints

mr. bob jacc jacc jt rap pda but rlr ccccccc must be prescribed by the healthcare provider Reduce risk of injury to others by an agitated client Bedside rails Are considered restraints Order must include reason for restraint and time period; PRN restraint orders are prohibited Bedside rails- Half or three-quarter rails may be better than full length rails for confused or agitated clients who may be injured climbing over rail Jacket, belt, or extremity restraints- Use a half-bow knot for easy release when attaching restraint to bed or chair Assess and document condition of a restrained client HOURLY Creative nursing measures to prevent use of physical or chemical restraints- Orient client to surroundings Creative nursing measures to prevent use of physical or chemical restraints- Encourage family, friends, or a sitter to stay with client Jacket, belt, or extremity restraints- Check for adequate circulation when using restraints; maintain TWO finger widths between client and restraint A nurse may apply physical restraints; however, healthcare provider must evaluate client within an Creative nursing measures to prevent use of physical or chemical restraints- Keep confused clients near nursing station Creative nursing measures to prevent use of physical or chemical restraints- Provide confused clients with diversionary activities Jacket, belt, or extremity restraints- Apply only as specified by manufacturer; never tie them to a movable part of a bed or chair types of chemical restraints-- antipsychotics--antianxiety--antidepressants-- sedative- hypnotics Reduce risk of client injury from falls A written order is needed to restrain a client Prevent interruption of therapy such as traction or IV infusions Prevent a confused or agitated client from removing life support device or drug that prevents the client from moving freely- limit client mobility alternative to restraints should always be used first Bedside rails- Keep bed in lowest position use least restrictive device - turn, reposition, toilet, hydrate/ nutrition - release restraint every 2 hours limit client mobility/freedom remove restraints, assess skin, and allow or assist client to re position per agency policy Can be physical or chemical. check client every 30-60 min. *every 15min for the first hour* check for vitals, skin breakdown, physical comfort, rom Creative nursing measures to prevent use of physical or chemical restraints- Maintain frequent toileting routine Creative nursing measures to prevent use of physical or chemical restraints- Reposition or ambulate frequently if appropriate Creative nursing measures to prevent use of physical or chemical restraints- Evaluate client medications for undesirable effects Creative nursing measures to prevent use of physical or chemical restraints- Use relaxation techniques such as music, aroma therapy, and books on tape

Bone scan

o bat Once the isotope is injected and has been distributed in the body, the body is scanned for hot spots. Dark spots on the scan indicate areas where the radioisotope uptake is greater, usually indicating an abnormality in that region. Bone scans assist in detecting fractures, abnormal healing of fractures, and degenerative bone diseases. A nuclear scan used to detect early bone disease, bone metastasis, and bone response to therapeutic regimens. The patient is injected with the isotope because radioisotopes are used in the bone scan. *book* Nuclear Scans. The bone scan is a radionuclide test in which radioactive material is injected for viewing the entire skeleton. It may be used primarily to detect tumors, arthritis, osteomyelitis, osteoporosis, vertebral compression fractures, and unexplained bone pain. Bone scans are used less commonly today as more sophisticated MRI equipment becomes more available. However, it may be very useful for detecting hairline fractures in patients with unexplained bone pain and diffuse metastatic bone disease.

emergency and disaster preparedness test mass casualty triage

red "CLASS ONE"- emergent needing immediate attention-Priority I or emergent care is needed for victims who need immediate treatment, such as those with cardiac or respiratory distress, trauma and bleeding, or neurological deficits; these victims should be labeled with a RED TAG yellow" CLASS TWO"- can wait short time for care- Priority II or urgent care is needed for victims who need treatment within 2 hours, such as clients with simple fractures, lacerations, or fevers; these victims should be labeled with a YELLOW TAG and reevaluated every 30 to 60 minutes green "CLASS THREE"- non- urgent or "walking- wounded" - Priority III or non-urgent care is needed for victims who need treatment that can wait for hours; those with sprains, rashes, and minor pain should be labeled with a GREEN TAG and reevaluated every 1 to 2 hours ORANGE TAG indicates a client who has a non-emergent PSYCHIATRIC condition black" CLASS FOUR IV"- expected to die or dead

communication

sbar- formal method of hand off communication b/t 2 or more healthcare team members s- situation: describe what is happening at the time to require the communication. b- background: explain any relevant background information that relates to the situation A: assessment: provides an analysis of the problem or client need based on assessment data r: recommendation/ request: state what is needed or what the desired outcome is *team stepps* cus words: state "im concerned: im uncomfortable- I don't feel safe check backs- restate what a person said to verify understanding by everyone call outs- shout out important info for all team members to hear at one time two challenged rule: state a concern twice if needed, if ignored follow facility chain of command

Accident prevention - School age child

sc tbs pi tnt swimming lessons and life jackets are necessary for boating and swimming children should never swim without adult supervision Teach and model pedestrian and bicycle safety to children at this age bicycle helmets can prevent head injury to children biking, rollerblading, or skateboarding school-age children can participate in implementing a school or home fire escape plan; teach to "stop, drop, and roll" if clothing catches fire Place children under 12 years or under 4 feet 9 inches in rear seat of a car with a lap/shoulder seatbelt Include in safety education for children to play in safe areas, avoid strangers, recognize unwelcome touch, and obey traffic signals Teach school-age children principles of fire safety; injury can occur from experimentation with matches, lighters, and fireworks never allow children to ride in the bed of a pickup truck or open, unsecured area of an automobile, such as a station wagon or van Teach school-age children principles of water safety

Risk for falls - Nursing interventions

t u pms gem bt -Transfer the patient to a room near the nurses' station. -Use side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down. Provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors. -Move items used by the patient within easy reach, such as call light, urinal, water, and telephone. -See to it that the beds are at the lowest possible position. If needed, set the patient's sleeping surface as adjacent to the floor as possible. -Guarantee appropriate room lighting, especially during the night. -Encourage the patient to don shoes or slippers with nonskid soles when walking. -Make the primary path for walking clear and as straight as possible. Avoid clutter on the floor surface. -Bed and chair alarms must be secured when patient gets up without support or assistance. -Teach client how to safely ambulate at home, including using safety measures such as handrails in bathroom.

Transient Incontinence

temporary form of incontinence, usually caused by a short-lived medical condition—or the treatment for the condition. Generally a side effect of another medical issue or medication ashlii Short-term incontinence that is expected to resolve spontaneously. Causes include UTI and medications, especially diuretics. *Causes of transient* incontinence include delirium; restricted mobility, retention; infection, inflammation, impaction; polyuria, pharmaceuticals; use the pneumonic DRIP to remember these causes Memory Aid Use DRIP to recall causes of transient incontinence: D—delirium R—restricted mobility, retention I—infection, inflammation, impaction P—polyuria, pharmaceuticals *Transient causes* improve with treatment of the underlying condition. *Reversible loss of cognitive functioning. Loss of awareness that urination is to occur in a socially acceptable place.* *Abnormal openings in the urinary tract, such as a fistula or diverticulum.* *Drugs* transdrugs such as sedatives, hypnotics, diuretics, anticholinergics, decongestants, antihypertensives, and calcium channel blockers. Diabetes insipidus or psychogenic polydipsia. Inability to get to toileting facilities. Direct bladder pressure or urethral obstruction. *transs/s* Altered mental state, as in sedation, delirium, confusion, depression, sepsis, mental illness, or severe psychological stress. Urinary drainage noted from areas other than the urinary meatus. Some drugs cause altered mental state; others cause increased urine production. Increased urine output. Restraints, restricted mobility. Constipation or fecal impaction. *rf* transrf Severe constipation, irritated bladder, urethra, vagina, or who are recovering from surgery or taking medications such as diuretics or sleeping pills

PERIOPERATIVExl nursing everything w/in sx periopxl • Perioperative nurses place special emphasis on SAFETY, advocacy, and patient education, although ensuring a "culture of safety" is the responsibility of all health care team members.

watkins *preoperative preopxl*- from the time they found out they are having sx to the time that they are wheeled into the operating room *days, weeks, months, hours from when the sx is going to occur* *intraoperative intraxl*- the time they enter the operating room until the end of the sx *postoperative postopxl* the end of sx throughout recovery ------------------------------ • Pace the interview to match the learning needs and style of the individual patient. • Encourage the patient to express his or her feelings regarding the surgical procedure or its possible outcome. • Explain and provide written information for all diagnostic procedures, restrictions, and follow-up care to the patient and his or her family. • Communicate any concerns or fears the patient has to the surgeon and anesthesia personnel. • Communicate to the surgeon and anesthesia personnel any physical or laboratory change that may alter the patient's response to drugs, anesthesia, or surgery.

Respiratory Alkalosis

watkins cause of Respiratory Alkalosis is respiratory. *panic attack s/s- anxious* light headed, tingling around there mouth(numb) aka peri-oral numbness, also numbness in finger and feet bc they are not taking in alot of o2, so it goes to the major organs 1st and the furthest away is hands and feet, less oxygenated bld to hands and feet, wants to get oxygenated bld to hand/heart first *Hyperventilation* ct breathing too fast, and removing co2. pts do this when they are having a panic attack. if we start having Respiratory Alkalosis, we have them breath into a paper bag to bring back co2. try and get them to slow down there breathing, good breaths in nose out of mouth to slow it down. if they cant calm down and theyre still hyperventalating, they may have to be sedated. *another cause is acute aspirin overdose/ antidote is acetylsalic acid mucomyst/monitor there abg's* ----------------- *Hyperventilation*—anxiety, fear, improper vent settings, stimulation of central respiratory center due to fever, DNS lesion, salicylates

Respiratory Acidosisxl decrease o2 increased co2 acidxl

watkins cause of respiratory acidosis is respiratory. Respiratory function is impaired, causing problems with O2 and CO2 *hypoventilation* co2 is being RETAINED bc bad lungs bc of pneumonia post-op, pt at risk for pneumonia, we teach them cough and deep breath/ incentive spirometer. if the pt is 2 yrs they can blow bubbles expands lungs. car wreck= collapsed lungs/pneumothorax, pneumothorax treatment is with chest tube put in by physician mid-abdominal incision- shallow breathing, keeping in co2...s/s for retaining co2= lethargic, dizzy, confused, h.a, sleepy, worst case scenario comatose, unconscious. decrease o2 increase co2 leading to unconscious *2 early signs s/s of hypoxia* tachycardia, restlessness,... anxiety ---1st thing we do is assess for a patent airway= give o2. 6 things to do for pneumonia? 1. mucolytics- mucinex 2. deep breathing exercises 3.give fluids/water, 4. postural drainage to put them into position to help drain aka percussion 5. suctioning 6. high fowlers -------------------------- *Retention of CO*: *Respiratory depression bc opiods/narcotics/chronic users of sleeping pills* *air*xl Airway obstruction Inadequate chest expansion Reduced alveolar-capillary diffusion

COLLABORATIVE CARE: EXAGGERATED IMMUNE RESPONSE 1 abc

watkins client is having an anaphylaxis reaction,what would u do 1st? -assess for a patent airway *Anaphylaxis* Support of airway, breathing, and circulation Subcutaneous epinephrine if type 1 reaction Other bronchodilators Intubation and ventilator support Circulatory volume expanders Vasopressors (raises bp) to maintain blood pressure and circulating volume *Pharmacotherapy* Subcutaneous epinephrine if type 1 reaction Other bronchodilators *Education:* Avoiding contact with pathogen initiating anaphylactic response, proper use of an EpiPen for self-administration of epinephrine

laboratory assessment respiratory acidosis

watkins give o2 2 make it go up *ps ps ps* pH < 7.35 Serum potassium levels elevated (if acute acidosis) PaO2 low Serum potassium levels normal or low (if renal compensation present) PaCO2 high Serum bicarbonate variable

Compensation

watkins kidneys remove acid through urine, filter excrete waste and absorb stuff we want. kidneys work slow. hours-days lungs work faster than kidneys ------------------------------- Body attempts to correct blood pH changes pH < 6.9 or >7.8 usually fatal Respiratory system more sensitive to acid-base changes; can begin compensating in seconds to minutes Kidneys more powerful; result in rapid changes in ECF composition; fully triggered for imbalance of several hours to days

CATEGORIES locaxl

watkins systemic- is fever, diaphoresis, chills, body ache, malaise, HIV..... *increased wbc* local- swelling. rash, redness, discharge ------------------ *Local* Some infections cause harm in a limited region of the body, such as the upper respiratory tract, the urethra, or a single bone or joint. Such infections are said to be local.--local infection evidenced by pain, redness, swelling, and warmth. Occurs in a limited region in the body (e.g., urinary tract infection, infected wound, sprained ankle, boil on the hand, an abscess of finger, Increasing or Continual Pain from Wound, pyelonephritis, cellulitis, cystitis *Duration* Acute: rapid onset of short duration (e.g., common cold) Chronic: slow development, long duration (e.g., osteomyelitis)book---, chronic infections (e.g., an abscess) develop slowly and last for weeks, months, or even years. Some chronic infections, such as relapsing fever, recur after periods of remission. Latent: infection present with no discernible symptoms (e.g., HIV/AIDS, Tuberculosis) *Systemic* Spread via blood or lymph and spread throughout the body. Affects many regions (e.g., septicemia, high blood pressure, flu, Systemic lupus erythematosus, Rheumatoid arthritis, Sarcoidosis, meningitis, headache, stiff neck, temperature higher than 101° F (38.3° C) systemic infections occur that require strong antibiotics such as methicillin. *Source* Hospital-acquired/health care-acquired infection versus community-acquired infection Primary infection versus secondary infection book A *primary infection* is the first infection that occurs in a patient. Especially in immunocom- promised patients, one or more *secondary infections* may follow a primary infection. For example, a frail client infected with pneumonia may develop herpes zoster (shingles), a viral infection related to past infection with varicella, secondary to the stress of illness. ------------- *Local Indicators* • Conversion of a partial-thickness injury to a full-thickness injury • Ulceration of healthy skin at the burn site • Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin • Edema of healthy skin surrounding the burn wound • Excessive burn wound drainage • Pale, boggy, dry, or crusted granulation tissue • Sloughing of grafts • Wound breakdown after closure • Odor *Systemic Indicators* • Altered level of consciousness • Changes in vital signs (tachycardia, tachypnea, temperature instability, hypotension) • Increased fluid requirements for maintenance of a normal urine output • Hemodynamic instability • Oliguria • GI dysfunction (diarrhea, vomiting, abdominal distention, paralytic ileus) • Hyperglycemia • Thrombocytopenia • Change in total white blood cell count (above or below normal) • Metabolic acidosis • Hypoxemia

breaking the chain of infection

watkins the biggest way to prevent infection is: 1.educating pts to wash there hands 2. proper ppe 3. keep areas dry and clean ■Reduce exposure to pathogens through the use of aseptic technique (discussed shortly). Make sure your healthcare providers clean their hands before they touch you.This is one of the most important infection prevention and control measures. Wash your hands often with soap and water.Wash for 15 to 30 seconds, or as long as it takes to sing the "Happy Birthday" song. Handwashing involves five key factors: time, water, soap, friction, and drying. Use alcohol-based hand sanitizer if soap and water are not available or hands are not visibly soiled. Sanitizer should contain at least 60% alcohol. ■Maintain skin integrity and support natural defenses against infection. ■Reduce stress. ■Promote immune function through collaborative care. ■Provide supportive measures to decrease the length of time that a patient needs invasive devices, such as intravenous lines and urinary catheters. other stuff Specific nursing activities will be based on the unique situa- tion of the client, as described in the etiology of the diagnostic statement. For example: For clients who have had surgery and general anesthesia or who are at risk for pneumonia, promote coughing and deep breathing on a regular basis *For clients being mechanically ventilated, provide special oral care designed to prevent ventilator-associated pneumonia.* (See the accompanying QSEN box for an example.) *For clients who have breaks in the skin or incision sites, provide regular assessment for infection status* and follow appropriate medical or surgical asepsis guidelines. For all clients at risk for infection, provide care that is based on principles of medical asepsis. For all clients at risk for infection, provide care that is based on principles of medical asepsis Community health nurses can limit disease transmission through surveillance of the community, tracking of disease patterns, and initiation of prompt treatment *For clients who are at risk for disease* based on age, debili- tated state, congregate living arrangement, or employment in healthcare facilities, facilitate participation in *vaccination programs*, which can *help* them *acquire immunity* from some communicable diseases. Other preventive *nursing activities* are discussed in the following sections. They *include providing client teaching, supporting host defenses, and practicing medical and surgical asepsis*.

SUPPRESSED IMMUNE FUNCTIONING * supxl

watkins: which s/s may a ct complain of suppressed immune system? malaise ------------ SYMPTOMS Report of frequent infections Report of poor wound healing Fatigue Malaise Weight loss *CLINICAL FINDINGS* May appear poorly nourished or have wasting syndrome May have chronic wounds May have enlarged lymph nodes Presence of opportunistic infection *Note: Symptoms and clinical findings vary widely based on the severity of the problem.

metabolic acidosis metaxl

watkins think lower gi: renal failure and severe diarrhea/dka *renal failure electrolyte values are high, potassium k+ etc bc kidneys are not fx so there not able to get rid of it, so they go on dialysis, hyperkalemia where going to see: 1.muscle twitching 2. muscle weakness 3. flaccid paralysis 4. arrythmias and seizures= lactic acid 5. at risk for increased respiration rate and depth WHEN YOU SEE potassium think MUSCLES/heart ------------ severe diarrhea like ibs, food poising were going to give omodium, ------------------ *Hydrogen ions* Overproduction Under-elimination *Bicarbonate ions* Under-production Over-elimination

Metabolic Alkalosis alkxl

watkins upper, loss of upper gi content. emesis, irritation from too many antacids/tums. 1. observe for a level of consciousness, 2. throwing up or ng tube ngxl 3. level k+ would be *low*. 4. low potassium causes muscles cramps, 5. arrthymias, 6. charley horse, if potassium is low it needs to be replaced. iv fluids, pills, capsules, --------------- Base excess—excessive intake bicarbonates, carbonates, acetates, citrates Acid deficit—prolonged vomiting, excess cortisol, hyperaldosteronism, thiazide diuretics, prolonged NG suction

REVIEW OF IMMUNE RESPONSE 3 iggxl

watkins which immunogoblin is responsible for allergic symptoms? ige the primary immunogoblin that crosses the placenta barrier is? igg ---------------- *watkins* *Antibody production is Secreted by B lymphocytes* t-helper cells B-lymphocyte-Becomes sensitized to foreign cells and proteins with the assistance of macrophages and helper-inducer T-cells wbc- fight the infection rbc- carry o2 --------------- Antibodies or immunoglobulins (Ig) - formed after encounter and engulfing of an antigen and then interacts with helper T lymphocytes *mega d* *IgM* - remains in the blood and efficiently kill bacteria; largest of the immunoglobulins; first antibody produced with an initial immune response-- ■ IgM is the first antibody to appear when an antigen is encountered. *IgE* - responsible for allergy symptoms and increased in the presence of parasitic worms; normally found in trace amounts- *IgG* - primary immunoglobulin; may enter tissue spaces, selectively crosses the placenta, coats antigen for more effective and effcient presentation for an immune response; *binds to macrophages and neutrophils for increased phagocytosis*- ■ IgG is the most common immunoglobulin in the body. It takes at least 10 days for IgG to be produced in response to an initial infection. *IgA* - protects entrance to the body; found in high concentrations in body fluids (*tears, saliva, secretions of the respiratory and GI tracts*)- IgA antibodies are secreted by mucous membranes around body openings, providing additional protection for these portals of entry. *IgD* - found within the cell membrane of B lymphocytes- IgD antibodies form on the surface of B cells and trap potential pathogens.

RISK FACTORS 2 supxl

watkins which of the following is a genetic rf for having a suppressed immune system? - Fibromyalgia, supress the immune system bc of stress, pain, dx, good/bad days, depression Suppressed immune response...cont. *Medical treatments* May be implemented to specifically inhibit optimal immune response or may lead to immunosuppression as a consequence of treatment Tissue graft or tissue transplantation - need to suppress to avoid rejection Pharmacologic treatments for autoimmune hypersensitivity reactions like SLE and cancer - inhibit the immune response with treatment regimens *Genetics* fat ma Fibromyalgia- genetic Allergies Type I diabetes Multiple sclerosis asthma *High-risk behaviors and substance abuse* HIV - Hepatitis virus - shared needles - high-risk sexual behaviors) Alcoholism - compromised (innate and acquired) immunity *Pregnancy* Creates a situation where the mother is immunocompromised Fetus is in a "privileged" immunity environment

Intraoperativexl phase operating room intraxl

watkins: 1st thing- timeout!!! check name, dob, procedure being done, surgeon doing it, MARKING OF THE SITE, so if the patient ex. right below the knee amputation, surgeon and patient would have checked that in pre-op area both pt and surgeon will initial. Confirms right pt, right site. pt name, dob, right site, right physician, as soon as get into OR room ppl in the room -surgeon -anesthesiologist- monitors bp, puts pt to sleep -circulating nurse- paperwork, not sterile, making sure everyone has everything they need need - scrub nurse/ scrub tech- assisting physician, count for instruments, gauses that nothing stays in the pt OR IS ALWAYS COLD AND STERILE if a pt needs a Foley catheter, they would wait until anesthesia puts them under, then they would put it in. (surgical period) begins when client is transferred to operating table and ends with admission to postanesthesia care unit (PACU); general nursing activities include: Preparing client for induction of anesthesia Maintaining homeostasis and asepsis throughout procedure Assisting surgeon and team as needed by providing an aseptic, hazard-free environment and necessary supplies in a timely manner

ACQUIRED IMMUNITY acqxl

watkins: acquired immunity is gained through? after birth ------------------ *watkins:* passive immunity is gained through? passive meaning passed from one person to another, colustrum is the term for the 1st breast milk that comes in from mom. that is what she is going to pass on that has the most antibodies and pass on to the baby. if a baby is preterm this is where we try to educate moms to really get that colostrum to the babies, so they can breastfeed, or pump and give it in a bottle or syringe *the colostrum is full of antibodies that we want baby to get* -------------- *ACQUIRED IMMUNITY acqxl* Refers to immunity protection that is gained after birth either actively or passively *Actively* actxl Develops after the introduction of a foreign antigen resulting in the formation of antibodies or sensitized T lymphocytes Examples: Immune response to an immunization (artificial) Exposure to infectious pathogens like chicken pox (natural) *Passively* Occurs by the introduction of preformed antibodies either from an artificial or natural routes Examples: Transfusion of immunoglobulin (IgG) From mother to fetus thru placental blood transference or colostrum transfer during breastfeeding book Natural passive IMMUNITY occurs when antibodies are passed from the mother to the fetus via the placenta or to the infant through colostrum and breast milk. evolve With passive IMMUNITY, the body receives antibodies that were developed in another person's body. These antibodies are recognized as foreign and are eliminated quickly. For this reason, *passive immunity is only an immediate, short-term protection* against a specific antigen. book Passive IMMUNITY occurs when the antibodies against an antigen are transferred to a human after first being made in the body of another human or animal. Because these antibodies are foreign to the receiving human, they are recognized as non-self and eliminated quickly. For this reason *passive immunity provides only immediate, short-term protection* against a specific antigen. It is used when an adult is exposed to a serious disease for which he or she has little or no actively acquired immunity. Instead the injected antibodies are expected to inactivate the antigen.

POTENTIAL FOR WOUND INFECTION & DELAYED HEALING woundxl

watkins: monitor bleeding, if sat w. blood, reinforce w. another dressing, but the pysician needs to be called,,,,, HAve to get an order to change 1st dressing. REEDA. Redness, Edema, Ecchymosis, Drainage, Approximation. COCA. color odor consistency amount apx of suture lines--- Interventions: Nursing assessment of surgical area Dressings—first change usually done by surgeon Drains—provide exit route for air, blood, bile; help prevent deep infections, abscess formation during healing Drug therapy, irrigation to treat wound infection Débridement Surgical management required for wound opening

artificial immunity artxl

watkins: artificial immunity is gained through? immunizations immunizations is something that someone does into the lab and makes, so they are artificially gained, but we gain immunity from them ----------- Vaccinations cause artificial active IMMUNITY and require boosters for best long-term effects. Because the antigens used have been processes to make them less likely to grow in the body (attenuated), this exposure usually does not cause the disease. book Artificial active IMMUNITY is the protection developed by vaccination or immunization. This type of immunity is used to prevent serious and potentially deadly illnesses (e.g., *tetanus, diphtheria, polio*). Small amounts of specific antigens are placed as a vaccination into your body. Your immune system then responds by actively making antibodies against the antigen. Because antigens used for this procedure have been specially processed to make them less likely to grow in the body (attenuated), this exposure usually does not cause the disease. Artificial active immunity lasts many years, although repeated but smaller doses of the original antigen are required as a "booster" to retain the protection.

SUPPRESSED IMMUNE RESPONSE 1 supxl

watkins: identify the person at risk for having a suppressed immune function. -older adults, post-op if we have a 22 year old post-op and a 69 marathon runner, my post-op is going to over top my age. *post-op supersedes* Marathon running can suppress immune system and break it down and weaken it. when u get to that point where ur in shape and doing it all the time, when training, it can suppress ur immune system, but it does not precede a post-op pt have to look at what type of sx. laparoscopic sx compared to an open heart sx that going to make a big difference *Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen -------- Inadequately functioning immune system leaves the individual immunocompromised - all body systems are affected The two major types of problems that result from suppressed immune response are Infection Cancer - a depressed immunce system may be created with medications in order to avoid rejection of transplanted tissue or it may be induced as a result of treatment for various types of cancer. Assess client for cancer - use mnemonic CAUTION **'C.A.U.T.I.O.N.' : *C*: Change in bowel or bladder habits. *A*: A sore that does not heal. *U*: Unusual bleeding or discharge. *T*: Thickening or lump in the breast or elsewhere. *I*: Indigestion or difficulty in swallowing. *O*: Obvious change in a wart or mole. *N*: Nagging cough or hoarseness. In treatments of some leukemia: destruction of the bone marrow before healthy stem cells may be reintroduced and a health immune system regrows During process immune system is partially destroyed leaving individual immunocompromised In multiple myeloma, Hodgkin's disease and non-Hodgkin's lymphomas: Directly lead to immune system dysfunction and immunocompromise

INNATExl IMMUNITY innxl

watkins: innate immunity is present at birth innate immunity is what you're born with. so it comes from mom. we do not have alot of immunity when we are first born, someone who is preterm is going to have less immunity than someone who goes to term bc they havent had time to get all of that immunity from mom. *innate immunity is in the womb* Also referred to as natural or native evolve *Natural, active IMMUNITY is the most beneficial and long lasting type of immunity.* book natural active IMMUNITY occurs when an antigen enters your body naturally without human assistance and your body responds by actively making antibodies against that antigen (e.g., influenza A virus). Usually the invasion that triggers antibody production also causes the disease. However, processes occurring in your body at the same time as infection create immunity to that antigen so illness does not occur again after a second exposure to the same antigen. *Natural active immunity is the most effective and the longest lasting*. ---Active immunity occurs when antigens enter a human and he or she responds by making specific antibodies against the antigen. This type of IMMUNITY is active because the body takes an active part in making antibodies. Innate, native IMMUNITY is any natural protective feature of a person. It can be a barrier to prevent organisms from entering the body or can be an attacking force that eliminates organisms that have already entered the body. -- This is immunity present at birth Provides non-specific response not considered antigen specific Any natural protective feature of a person Provides immediate protection against effects of tissue injury and foreign proteins—critical to health and well-being Causes visible symptoms and can rid body of harmful organisms; tissue damage may result from excessive response

General Immunity: Inflammationxl infxl natxl

watkins: natural immunity is gained through? having the disease our body is developing the immunity, we have the disease, ans were naturally making those antibodies, people who had chicken pox, gained natural immunity from chicken pox. people who had the chicken pox vaccine, have artificial immunity having the disease ur making the antibodies urself bc ur exposed to it * placenta is the same as innate means ur getting it from mom*, so u r not making ur own immunity, ur getting what ur mom has, so it comes from mom---> placenta---> to baby ------------------ *The inflammatory responses, the skin, mucosa, antimicrobial chemicals on the skin, complement, and natural killer cells compose general immunity*. *the leukocytes (white blood cells [WBCs]) involved in inflammation are neutrophils, macrophages, eosinophils, and basophils. An additional cell type important in inflammation is the tissue mast cell. Neutrophils and macrophages destroy and eliminate foreign invaders. Basophils, eosinophils, and mast cells release chemicals that act on blood vessels to cause tissue-level responses that help neutrophil and macrophage actions.* ****General immunity is nonspecific and is also called innate-native immunity or natural immunity. With inflammation, general immunity provides immediate protection against the effects of tissue injury and invading foreign proteins. Innate-native immunity is any natural protective feature of a human. It is a barrier to prevent organisms from entering the body and can attack organisms that have already entered the body. This type of IMMUNITY cannot be transferred from one adult to another and is not an adaptive response. *The inflammatory responses, the skin, mucosa, antimicrobial chemicals on the skin, complement, and natural killer cells compose general immunity*. Inflammation is critical for health. General immunity and inflammation differ from specific immunity in two ways: • Inflammatory protection is immediate but short term. It does not provide true immunity on repeated exposure to the same organisms. • Inflammation is a nonspecific body defense to invasion or injury and can be started quickly by almost any event, regardless of where it occurs or what causes it. So inflammation triggered by a scald burn to the hand is the same as inflammation triggered by bacteria in the middle ear. How widespread the symptoms of inflammation are depends on the intensity, severity, and duration of exposure to the initiating event. For example, a splinter in the finger triggers inflammation only at the splinter site, whereas a burn injuring 50% of the skin leads to an inflammatory response involving the entire body. Inflammation starts tissue actions that cause visible and uncomfortable symptoms that are important in ridding the body of harmful organisms. However, if the inflammatory response is excessive, tissue damage may result. Inflammation also helps start both antibody-mediated and cell-mediated actions to activate full IMMUNITY. *The inflammatory responses, the skin, mucosa, antimicrobial chemicals on the skin, complement, and natural killer cells compose general immunity*. *the leukocytes (white blood cells [WBCs]) involved in inflammation are neutrophils, macrophages, eosinophils, and basophils. An additional cell type important in inflammation is the tissue mast cell. Neutrophils and macrophages destroy and eliminate foreign invaders. Basophils, eosinophils, and mast cells release chemicals that act on blood vessels to cause tissue-level responses that help neutrophil and macrophage actions.*

EXAGGERATED IMMUNE RESPONSE / CONSEQUENCES 1 exxl

watkins: what is an ex of an exaggerated immune response? anaphylaxis ------------ Four types of exaggerated immune response - hypersensitivity reactions *Type 1* - IgE-mediated or atopic "allergic" Seasonal allergies rhinitis, bee sting Systemic anaphylactic reactions (bee sting) *Type 2* - tissue-specific or cytotoxic Autoimmune thrombocytopenic purpura, Graves' disease, autoimmune hemolytic anemia *Type 3* - immune complex-mediated Systemic lupus erythematosus *Type 4* - cell-mediated or delayed hypersensitivity Contact sensitivity to poison ivy and metals (jewelry)

Treatment for Lyme disease

wave l When synovitis accompanies arthritic symptoms, a synovectomy aka sx may be used to reduce edema and pain in the joint. Antibiotics (type and route are dependent on the stage). Vaccine is no longer available Early illness is usually treated with oral drugs, for example, doxycycline (Vibramycin), amoxicillin, or cefuroxime axetil. Later illness such as nervous-system disease might require intravenous drugs such as ceftriaxone (Rocephin) and penicillin G.

Hypothermia

when body temp falls below 36.2 97.1 clinical findings s/s shivering, mumbling, shallow breathing, weak pulse nursing intervention removing the person from the cold. provide external warming measures, provide internal warming measures education dress infants and children for the temp, maintain proper heating in your home, stay dry. check temp before going out. layer clothing who at risk old people, homeless, mental or physical illness, lower income, very young. rationale

Routes of Administration for Opioid Analgesics Patient-Controlled Analgesia (PCA).

• Assess sedation level and respiratory status in patients receiving patient-controlled analgesia (PCA) or epidural medication. PCA pumps are a safe way to deliver opioids by IV, epidural, or subcutaneous routes. They provide excellent pain relief and give the patient a sense of control over the pain. The system consists of a pro- grammable infusion pump, a syringe, IV tubing, and a trigger that the patient presses to self-administer a dose. The pump must be programmed so that a dose that can be administered frequently enough to manage the patient's pain effectively. Some providers order a low continuous rate of infusion as a base that can be supplemented with patient-initiated doses. Most PCA pumps can be programmed with 1- or 4-hour max- imum medication limits. If the patient reaches the limit set, the pump will auto- matically trigger a "lockout" even if the patient keeps press- ing the button. Teach patients about this lockout feature; some may not activate the pump enough because they fear overdosing. If you are educating the patient in the postoper- ative period, make sure she is alert enough to understand the directions and has been given a hearing aid or glasses, if needed.

METABOLIC ALKALOSIS

• Metabolic alkalosis is caused by conditions that create the acid-base imbalance through either an increase of bases or a decrease of acids Causes Loss of upper GI contents Too many antacids (tums) Signs & Symptoms Depend on cause Observe LOC K+ level will go down: monitor for muscle cramps & arrhythmias Treatments Fix the problem Replace K+

Spinal Analgesia

• Multimodal (balanced) analgesia for epidural pain management is a combination of opioids, non-opioids, and/or local anesthetics to relieve acute pain, usually postoperative pain. Epidural analgesia Epidural analgesia can be delivered by intermittent bolus technique, continuous infusion, or patient-controlled epidural analgesia (PCEA) with or without continuous infusion. The most commonly administered analgesics by the epidural route are the opioids morphine, hydromorphone, and fentanyl in combination with a long-acting local anesthetic such as bupivacaine (Marcaine) or ropivacaine (Naropin). This multimodal approach allows lower doses of both the opioid and local anesthetic and produces fewer side effects. A single epidural injection of preservative-free morphine (Duramorph) is effective for about 24 hours. An extended-release formulation of preservative-free epidural morphine (DepoDur) is effective for 48 hours. Intrathecal (subarachnoid) analgesia Intrathecal (spinal) analgesia is usually delivered via single bolus technique for patients with acute pain (e.g., hysterectomy) or continuous infusion via an implanted device (pump) for the treatment of chronic pain. Because the drug is delivered directly into the aqueous cerebrospinal fluid (CSF), morphine with its hydrophilic nature is used most often for intrathecal analgesia. Extremely small amounts of drug are administered by the intrathecal route (about 10 times less than by the epidural route) because the drug is so close to the spinal action site. The side effects of intraspinal analgesia depend on the type of drug administered. In other words, if opioids are administered, the same opioid-induced side effects that occur with other routes of administration can occur with intraspinal administration. If local anesthetics are administered, common side effects are urinary retention, hypotension, and numbness and weakness of lower extremities. The latter can occur on a continuum (mild and localized) to a complete block (undesirable and requires prompt anesthesia evaluation). In most cases the side effects that occur during continuous infusion or PCEA can be managed by decreasing the dose. Complications of intraspinal analgesia are rare but can be life threatening. Complications from the intrathecal pump can be surgical, pump related, or catheter related (Textor, 2016). Chart 4-2 summarizes best practices needed when caring for a patient who has an intrathecal pump. Perform frequent neurologic assessments and promptly report abnormal findings to the anesthesiologist or nurse anesthetist.

Pain Pharmacologic Therapy Classification: Non-Opioids

• Non-opioid drugs are the first-line therapy for mild to moderate PAIN. o Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol) are commonly used drugs in this category. o NSAIDs should be used with caution in older adults because of adverse effects, such as GI disturbances, bleeding, and sodium and water retention. o Acetaminophen can cause hepatotoxicity and nephrotoxicity with long-term use. Acetaminophen (Tylenol) NSAIDs (nonselective) Aspirin, ibuprofen (Motrin), naproxen (Naprosyn) NSAIDs (selective) Celecoxib (Celebrex) NOTES: Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) most common Most are NSAIDs, including aspirin COX-2 inhibitors for long-term use

What Is Pain? painxl

• PAIN is a universal, complex, and subjective experience. • The nurse is legally and ethically responsible for acting as an advocate for patients experiencing PAIN. • Pain may be described as localized, projected, radiating, and referred pain. Although physiologic changes occur in response to acute noxious stimuli, these are usually not reliable indicators of pain. Unpleasant sensory/emotional experience associated with actual or potential tissue damage Pain is whatever the experiencing person says it is, existing whenever he says it does The patient report is the most reliable indicator of pain Unpleasant feeling conveyed to brain by sensory neurons Emotional experience Sensitivity and response to pain varies Can have destructive effects Can warn of POTENTIAL INJURY A multidimensional experience Nurse has unique role in managing pain Nurse must advocate for patient by believing reports of pain Nurse must act promptly to relieve pain, but respect patient's preferences and values • Multidisciplinary pain teams, consisting of one or more nurses, pharmacists, case managers, and physicians, consult with staff and prescribers on how best to control the patient's pain. • Coordinate the patient's plan of care as he or she transfers between health care agencies. Be sure that the plan of care is communicated clearly. • Coordinate the patient's plan of care as he or she transfers between health care agencies. Be sure that the plan of care is communicated clearly. • Families and significant others should be included in the information-gathering process. • Provide information to the patient and family about complementary and alternative therapies as needed. These modalities are additions to, not replacements for, the established plan of care. • Provide information to patients who have misperceptions about pain and pain management.

pain assessment cont. Nonverbal signs of pain

• Pain intensity scales assess and measure pain and determine the effectiveness of PAIN relief interventions in the clinical or home setting. Nonverbal, intubated, and cognitively impaired patients do feel PAIN that needs to be managed. • Checklist of Nonverbal Pain Indicators (CNPI) has been tested in the acute care setting in patients with varying levels of cognitive impairment. Each category allows a score of 0 if the behavior is not observed and a 1 if the behavior occurred even briefly during activity or rest: • Facial expression • Verbalizations or vocalizations (e.g., screaming) • Body movements (e.g., restlessness) • Changes in interpersonal interactions • Changes in activity patterns or routines • Mental status changes (e.g., confusion, increased confusion) Elevated pulse/blood pressure Crying, moaning Grimacing Assessment tool • Pain can be managed in any setting, including the home. Some patients require parenteral pain medications at home; therefore, provide health teaching to ensure continuity of care. • Refer patients whose pain is difficult to manage to pain specialists and/or pain centers.

RESPIRATORY ALKALOSIS

• Respiratory alkalosis is usually caused by an excessive loss of CO2 through hyperventilation (rapid respirations). • The hallmark of respiratory alkalosis is an ABG result with an elevated pH coupled with a low carbon dioxide level. • Assist patients who have anxiety-induced respiratory alkalosis to identify causes of anxiety and to use stress management techniques. • Interventions are planned to prevent further losses of hydrogen, potassium, calcium, and chloride ions, to restore fluid balance, and to monitor changes. THINK-------HYPERVENTILATION Causes Situations in which the client is breathing too fast and therefore is removing CO2 Hysterical, acute aspirin overdose Signs & Symptoms Lightheaded, faint peri oral numbness, numbness & tingling in fingers and toes