Fundamentals of Nursing
closed drainage system
-Jackson-pratt drain -hemovac drain may be connected to an electrical suction or built-in reservoir
color classification of open wounds
-R: red-protect -Y: yellow-cleanse -B: black-debride -mixed wound: contains components of RY&B wounds
water
-accounts for between 50% and 60% of adults total weight -2/3 of body water is contained within the cells (ICF) -the remainder of body water is extracellular fluid, body fluids -acts as solvent, aids digestion
factors affecting body temp
-circadian rhythms -age and gender -physical activity -state of health -environmental temperature
Nurse Practice Acts
-define legal scope of nursing practice -create state board of nursing to make and enforce rules and regulation -define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - established criteria for the education and licensure of nurses
phases of wound healing
-hemostasis-vessels constrict and clotting begins -inflammatory-white blood cells move to wound -proliferation-granulation tissue is formed -maturation-collagen is remodeled, forms scar
goals of nursing research
-improve care in clinical setting -study ppl and nurse process: education, policy development, ethics, nursing history -develop greater autonomy and strength as a profession -provide evidence-based nursing practice
wound complications
-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation
minerals
-inorganic elements found in all body fluids and tissues -some function to provide structure in the body, others help regulate body processes -contained in ash that remains after digestion -macrominerals include calcium, phosphorus, magnesium -microminerals include iron, zinc, manganese, and iodine
fats
-insoluble in water and blood -composed of carbon, hydrogen, and oxygen - 95% of lipids in diet are triglycerides -most animal fats are saturated -most vegetable fats are unsaturated -digestion occurs largely in small intestine -most concentrated source of energy in diet -RDA not established, 20-35% total calorie intake
nursing process for bowels
-inspection -auscultation -percussion -palpation (deep palpation is performed by advanced medical personal)
assessing blood pressure
-listening for korotkoff sounds w/ stethoscope -first sound is systolic -change or cessation of sound occurs: diastolic pressure - brachial artery and popliteal artery are commonly used
The Nursing Process
-one of major guidelines for nursing practice -helps nurses implement their roles -integrates art and science of nursing -allows nurses to use critical thinking and clinical reasoning -defines the areas of care that are within the domain of nursing
Vitamins
-organic compounds needed by the body in small amounts -most are active in form of coenzymes -classified as water soluble or fat soluble -absorbed through intestinal wall (small intestine) directly into bloodstream -needed for metablolism
major classifications of hypertension
-primary (essential): characterized by an increase above normal in both systolic and diastolic pressures -secondary : caused by another disease condition like kidney disease, aorta disorders, or adrenal cortex disorders
heat production
-primary source is metabolism -hormones, muscle movements, exercise increase metabolism -thyroid hormone and shivering also increase heat production - energy production decreases and heat production increases
establishing an effective nurse-patient relationship
-reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all aspects of care
protein
-required for formation of all body structures -based on amino acid composition -animal proteins are complete, plant proteins are incomplete -RDA for adults is 0.8g/kg
types of knowledge
-science (observing, identifying, describing, investigating, and explaining events and occurences that are perceived in world) -philosophy (the study of wisdom, fundamental knowledge, and the processes used to develop and construct on perception on life) -process (a series of actions, changes, or functions intended to bring about a desired result)
measurement of pressure ulcer
-size of wound -depth of wound -presence of undermining, tunneling, or sinus tract(all on wound bed)
stages of pressure ulcers
-stage1: nonblanchable erythema of intact skin -stage2: partial-thickness skin loss -stage3: full-thickness skin loss; not involving underlying fascia( epidermis and dermis) -stage4: full-thickness skin loss with extensive destruction (epidermis, dermis, and subcutaneous) -unstageable: base of ulcer covered by slough and/or eschar in wound bed
carbs
-sugars and starches -organic compounds composed of carbon, hydrogen, and oxygen -lactose is an animal source -most abundant and least expensive -classified as simple or complex sugars -converted to glucose for transport through blood -50-100g needed daily to prevent ketosis
sources of knowledge
-traditional ( passed down from generation to generation) -authoritative- comes from an expert, accepted as truth based on person's perceived expertise -scientific (obtained through the scientific method-research)
Nursing is recognized as profession based on what criteria
-well defined body specific and unique knowledge -strong service orientation -recognized authority by a professional group (ANA) -code of ethics -professional organization that sets standards -ongoing research -autonomy and self-regulation
Aims of Nursing
1. To promote health 2. To prevent illness 3. To restore health 4. To facilitate coping with disability or death
respirations for healthy adult
12 to 20 breaths/min
average blood pressure for healthy adult
120/80
anuria
24-hour urine output is less than 50mL; complete kidney shut down or renal failure
albumin normal lab values
3.5-5
forehead temp
34.4 C, 94.0 F
axillary temp
36.5 C, 97.7 F
oral temperature for healthy adult
37.0 C, 98.6 F
rectal temp
37.5 C, 99.5 F
tympanic temp
37.5 C, 99.5 F
pulse rate for healthy adult
60-100 (80 average)
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound
afferent nervous system conveys info to the
CNS; going to your brain
To restore health
Nurse's responsibility to assess & teach levels of prevention
To facilitate coping w/ disability or death
Nurse's role to provide "comfort" care
RACE
R: rescue anyone in immediate danger A: activate the fire code and notify appropriate person C: confine the fire by closing doors and windows E: evacuate patients and other people to a safe area
stages-of-illness behaviors
Stage 1: experiencing symptoms Stage 2: assuming the sick role Stage 3: assuming a dependent role Stage 4: achieving recovery and rehabilitation
To promote health
State of optimal functioning or wellbeing. not just absence of disease
steps in implementing EBP
Step 1: ask a question about a clinical area of interest or an intervention Step 2: collect the most relevant and best evidence Step 3: Critically appraise the evidence Step 4: integrate the evidence w/ clinical expertise, patient preferences, and values in making a decision to change Step 5: evaluate the practice decision or change
wound
a break or disruption in the normal integrity of the skin and tissues
sinus tract
a cavity or channel underneath the wound that has the potential for infection
suppository
a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature
total incontinence
a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation
dialysis
a mechanical way of filtering waste from the blood
evidence-based practice (EBP)
a problem-solving approach to making clinical decisions, using the best evidence available; blends both science and art of nursing so best outcomes are achieved; may consist of specific nursing interventions or use guidelines established for the care of patients
health
a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
paralysis
absence of strength secondary to nervous impairment
Maslows level 5: Self-Actualization
acceptance of self and others as they are; each lower level must be met; focus of interest on problems outside oneself; respect for all people; focus on strengths and possibilities vs problems
tertiary health promotion
after an illness is diagnosed and treated; example: teaching a patient with diabetes how to recognize and prevent complications, refer woman to support group after removal of breast due to cancer
ileostomy
allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma
wellness
an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health
fistula
and abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another
unintentional wound
are accidental; occur from unexpected trauma
when does discharge planning start?
as soon as the patient comes in the door
pulse is regulated by what?
autonomic nervous system through cardiac sinoatrial node
nonmaleficence
avoid causing harm
nocturia
awakening at night to urinate
proliferation phase
begins 2-3 days of injury and may last up to 2-3 weeks, new tissue is built to fill wound space through action of fibroblasts, capillaries grow across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop
beneficence
benefit the patient; balance benefits against risks and harms
sanguineous drainage
blood cells present; looks like blood
occult blood in stool
blood that is hidden in the specimen or cannot be seen on gross examination
Maslows level 2: safety and security needs
both physical and emotional components; being protected from potential or actual harm
scale used for predicting pressure sore risk
braden scale
orthopnea
changes in breathing when sitting or standing
overflow incontinence
chronic retention of urine, the involuntary loss of urine associated
cleaning a pressure ulcer
clean w/ each dressing change, gentle motions (patting), use 0.9% normal saline solution to irrigate and clean, report any drainage or necrotic tissue
serous drainage
clear and watery
subjective
coming from that subject
psoriasis
common skin condition that speeds up the life cycle of skin cells, cells build up rapidly on surface of skin and extra skin cells form scales and red patches that are itchy and sometimes painful; chronic, comes and goes
indirect studies
commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema
Interrelated roles of nurses
communicator, teacher, counselor, leader, researcher, advocate, collaborator
efferent
creates effect and goes to body part from brain
necrosis
death of tissue
bradypnea
decreased respiratory rate; occurs in some pathologic conditions
parasympathetic stimulation on pulse
decreases heart rate
ischemia
deficiency of blood in a particular area
Florence Nightingale
defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing
desiccation
dehydration
nursing theory
differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices
dyspnea
difficult or labored breathing
radiation
diffusion of heat by electromagnetic waves (such as an uncovered head)
primary health promotion
directed towards PROMOTING health and PREVENTING the development of disease processes or injury; example: immunization clinic, family planning services, accident prevention education
chronic wound
do not progress through stages of healing; healing impeded
laxatives
drugs that induce emptying of the intestinal tract
constipation
dry, hard stool; persistently difficult passage of stool; incomplete passage of stool
nurse practice acts
each state has its own; protects public with legal scope of nursing practice
Clara Barton
established red cross; volunteered to care for wounds and feed union soldiers during civil war; served as supervisor of nurses for the army of James
deductive reasoning
examines a general idea and then considers specific actions or ideas
polyuria
excessive output of urine (diuresis)
perfusion
exchange of oxygen and carbon dioxide between circulating blood and tissue cells
diffusion
exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood
reflex incontinence
experience emptying of the bladder w/o sensation of the need to void
pronation
face down; laying on your stomach
supination
face up; laying on your back (spine)
maturation phase
final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line
secondary health promotion
focus on SCREENING for early detection of disease with prompt diagnosis and treatment of any found; example: assessing children for normal growth and development and encourage regular medical, dental and vision exams
inflammatory phase
follows hemostasis and lasts 4-6 days, white blood cells move to wound, macrophages enter wound and remain extended time, they ingest debris and release growth factors, pt has generalized body repsonse
origination of the word "nurse"
from the latin word "nutrix" meaning to nourish
direct studies
going inside the body ex. colonoscopy, sigmoidoscopy
paresis
impaired muscle strength or weakness
vitamin c and zinc
important in wound healing
hypoxia
inadequate amount of oxygen available to cells
physiological measures that indicate pain
increased blood pressure and pulse
frequency
increased incidence of voiding
tachypnea
increased respiratory rate; may occur in response to increased metabolic rate
sympathetic stimulation on pulse
increases heart rate
urinary incontinence
involuntary loss of urine
when measuring a wound
measure from left to right and then top to bottom
meaning of healing
mending and getting better from disease
serosanguineous drainage
mix of serum and blood cells; light pink to blood tinged
pulmonary ventilation
movement of air in and out of lungs
isokinetic exercise
muscle contraction with resistance
isometric exercise
muscle contraction without shortening
isotonic exercises
muscle shortening and active movement
Maslows level 4: self-esteem needs
need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments; positive self-esteem facilitates the person's confidence and independence
eupnea
normal, unlabored breathing, one respiration to four heartbeats
coping with disability and death
nurses use optimal function of maximum strengths and potentials, refer to community support systems; provide care to families and patients during end-of-life care, hospice
open wound
occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms
hemostasis
occurs immediately after intial injury, blood vessels constrict and clotting begins, exudate(drainage) forms and causes swelling and pain, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to injury to participate in phases of healing
friction
occurs when two surfaces rub against each other
Maslows level 3: love and belonging needs
often called higher-level needs; understanding and acceptance of others in both giving and receiving love; feeling of belonging; unmet needs produce loneliness and isolation
inductive reasoning
one builds from specific ideas or actions to conclusions about general ideas
maceration
overhydration
Maslows level 1: physiologic needs
oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority
chronic pain
pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period
dysuria
painful or difficult urination
paraplegia
paralysis both legs
quadriplegia
paralysis of both arms and both legs
hemiplegia
paralysis one half of the body
sims position
patient again lies on the side but the lower arm is behind the patient and the upper are is flexed at both the shoulder and the elbow
supine or dorsal recumbent position
patient lies flat on the back with the head and shoulders slightly elevated w/ a pillow
side-lying or lateral position
patient lies on the side and the main weight of the body is borne by the lateral aspect of the lower scapula and the lateral aspect of the lower ilium
open drainage system
penrose drain; promotes drainage passively
apnea
periods when no breathing occurs
colostomy
permits formed feces in the colon to exit through the stoma
prone position
person lies on the abdomen with the head turned to the side; the body is straight in the prone position because shoulders, head, and neck are in erect position, arms are easily placed in correct alignment w/ the shoulder girdle, hips, knees can be prevented from flexing or hyperextending
trauma
physical injury
human dimensions that compose the whole person
physical, intellectual, environmental, spiritual, sociocultural, and emotional
glycosuria
presence of sugar in the urine
negative-pressure wound therapy
promotes wound healing and wound closure through the application of uniform negative pressure on wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment; results in mechanical tension on wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels
proteinurea
protein in the urine; indication of kidney disease
maslow hierarchy of needs
provides a framework for nursing assessment and for understanding the needs of patients at all levels; many nursing interventions are aimed at meeting patients' basic human needs
pyuria
pus in the urine; urine appears cloudy
acute pain
rapid in onset, varies in intensity and duration, protective in nature
acute illness
rapid onset of symptoms and lasts only a short time; examples: cold, diarrhea, pneumonia, appendicitis
normal stoma
red and moist
eczema
red, itchy inflammation of the skin; usually develops in early childhood, more common in people w/ family history; treatment involves avoiding soap and other irritants and applying creams or ointments if prescribed
To prevent illness
reduce risk for illness. promote good health habits, maintain optimal functioning
debridement
removal of devitalized tissue and foreign material
autonomy
respect rights of patients to make health care decisions
5 vital signs
respirations, pulse rate, blood pressure, temperature, and pain
closed wound
results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash
negative nitrogen balance
results in muscle wasting and decreased physical energy for movement and work; caused by diseases that are characterized by a larger breakdown of protein than that which is manufactured
shear
results when one layer of tissue slides over another layer
oliguria
scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL
fowlers position
semi-sitting position; head of bed elevated 45 to 60 degrees; used to promote cardiac and respiratory functioning; provides max space in thoracic cavity; high fowlers the bed is elevated to 90 degrees
pale stoma
shows signs of anemia
sources of heat loss
skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces
chronic illness
slow onset, characteristics: permanent change, caused by change in anatomy, requires special patient education, long period of care or support; examples: heart disease, diabetes, lung diseases, and arthritis
the efferent system conveys via
somatic nervous system
when listening to bowel sounds
start lower right and go up, across and down
suppression
stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h
urgency
strong desire to void
6 classes of nutrients
supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water
ostomy
surgical opening from the inside of an organ to the outside
edema
swelling caused by excess fluid trapped in your body's tissues
sustained or continuous fever
temp remains above normal with minimal variations
relapsing or recurrent fever
temp returns to normal for one or more days with one or more episodes of fever, each as long as several days
remittent fever
temperature does not return to normal and fluctuates a few degrees up and down
intermittent fever
temperature returns to normal at least once every 24 hours
places you can record a pulse
temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
footdrop
the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, and patient experiences extreme difficulty in walking; caused by patients feet being in planter flexion position over extended time
enema
the introduction of a solution into the large intestine, usually to remove feces
pain threshold
the level at which a person experiences pain
pain tolerance
the maximum level of pain that a person is able to tolerate
pulse rate
the number of contractions over a peripheral artery in 1 minute
stoma
the part of the ostomy that is attached to the skin
active exercise
the patient independently moves joints through their full range of motion (isotonic exercise)
passive exercise
the patient is unable to move independently, the nurse moves each joint through its range of motion
intentional wound
the result of planned invasive therapy or treatment ex. surgery, intravenous procedure
illness
the unique response of a person to a disease; an abnormal process involving changed level of functioning
body mechanics
the use of proper body positions to provide protection from the stress of movement and activity
eschar
thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately
purulent drainage
thick, musty or foul odor, varies in color
proprioceptor or kinesthetic sense
this informs the brain of the location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendons, and fascia
beta-adrenergic blockers
to block sympathetic stimulation and decrease cardiac output
ACE inhibitors
to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production
vasodilators and calcium channel blockers
to relax smooth muscles of arterioles and decrease peripheral vascular resistance
inversion
turning foot inward
eversion
turning foot outward
functional incontinence
urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation
standards
used as guidelines for peer review (ANA)
diuretics
used to increase urinary output
acute wound
usually heal within days to weeks
visual or optic reflexes
visual impressions contribute to posture by alerting the person to spatial relationships with the environment
hemiparesis
weakness of half of the body
extensor or stretch reflexes
when extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture
pressure ulcer
wound with localized area of injury to the skin and/or underlying tissue
jaundice causes
yellowish, itchy skin; bilirubin problem and liver not functioning properly
objective
you can see the object