MCC nursing Block 1 third exam

Establish therapeutic relationships with patients (including impaired verbal patients) assigned to your care.

**BOX 8-6**

Describe ways in which nurses can use complementary health approaches and integrative care in providing patient care.

**TEACHING TIPS 28-1**

Describe treatments for hypertension.

-Weight reduction -DASH diet -Decrease sodium intake -Increase physical activity -Moderate alcohol consumption -Thiazide diuretic (hydrochlorothiazide) -Loop diuretic (Furosemide/lasix) -Beta blockers (metoprolol/lopressor) -vasodilators (hydralazine/apresoline) -ACE inhibitor (benazepril/lotensin) -Angiotensin II (losartan/cozaar) -Calcium channel blocker -Dihydropyridines (amlodipine/norvasc)

Use the nursing process to care for patients with hypertension.

ASSESSMENT: • History and physical examination: Obtain a full cardiac history, and family history of hypertension. The physical exam will focus on the apical pulse rate, rhythm, and character. Assess potential symptoms of target organ damage Personal, social, and financial factors that will influence the condition or its treatment • Laboratory tests Urinalysis Blood chemistry Cholesterol levels • ECG: determine if any arrhythmias present Chart 31-2 has the specifics on how to do a proper blood pressure reading if you want to review that. DIAGNOSIS: • Deficient knowledge regarding the relation between the treatment regimen and control of the disease process. • Noncompliance with therapeutic regimen related to side effects of prescribed therapy. • Collaborative Problems and Potential Complications: o Left ventricular hypertrophy o Myocardial infarction o Heart failure o Transient ischemic attack (TIA) o Cerebrovascular accident (CVA, stroke, or brain attack) o Renal insufficiency and failure o Retinal hemorrhage PLANNING AND GOALS: • Understanding of the disease process and its treatment. • Participation in a self-care program. • Absence of complications. INTERVENTIONS: • Lifestyle modifications Weight reduction DASH diet, decreased Na intake (consult with a dietician if needed) Physical activity Moderate alcohol consumption: limit alcohol intake to 2 or less drinks for men and 1 or less drinks for women a day. Life Long therapy: managed with diet, exercise and medication therapy • Medication therapy Diuretics, beta-blockers, alpha1-blockers, combined alpha- and beta-blockers, vasodilators, ACE inhibitors, ARBs, Ca channel blockers, dihydropyridines, and direct renin inhibitors GERONTOLOGIC CONSIDERS: Consider how to best help older adults how to best know what medications and treatments to follow. Family members and caregivers should be included in the education so they can reinforce it at home. • Medication regimen can be difficult to remember • Expense can be a challenge • Monotherapy, if appropriate, may simplify the medication regimen and make it less expensive • Ensure that older adult patients understand the regimen and can see and read instructions, open medication containers, and get prescriptions refilled. • Include family and caregivers in educational program EVALUATION: • Reports knowledge of disease management sufficient to maintain adequate tissue perfusion Maintains blood pressure at less than 140/90 mm Hg with no symptoms of angina, palpitations, or vision changes; stable BUN and serum creatinine levels; and palpable peripheral pulses • Adheres to the self-care program Reduces calorie, Na, and fat intake; exercises regularly; takes medications as prescribed and reports side effects; measures BP; abstains from tobacco and excessive alcohol intake; keeps appointments • Has no complications Reports no changes in vision; exhibits no retinal damage on vision testing Maintains pulse rate and rhythm and respiratory rate within normal ranges; reports no dyspnea or edema Maintains urine output consistent with intake; has renal function test results within normal range Demonstrates no motor, speech, or sensory deficits Reports no headaches, dizziness, weakness, changes in gait, or falls

(WEEK 7: Chapter 25 (Hinkle Medsurge) Learning Objectives:) Describe the relationship between the anatomic structures and the physiologic function of the cardiovascular system.

Anatomical structures and Physiological functions: 3 LAYERS Endocardium: inner layer, consists of endothelial tissue and lines the inside of the heart and valves. Myocardium: middle layer, is made up of muscle fibers and is responsible for the pumping action. Epicardium: outer layer Pericardium: thin, fibrous sac that encases the heart. Consists of 2 layers: Visceral Pericardium adheres to the epicardium. Parietal Pericardium envelops the Visceral and is a tough fibrous tissue that attaches to great vessels, diaphragm, sternum, and vertebral column and supports the heart in the mediastinum. The space between these two layers (pericardial space) is normally filled with about 20 mL of fluid to lubricate the surface of the heart and reduce friction during systole. diastole: period of ventricular relaxation resulting in ventricular filling systole: period of ventricular contraction resulting in ejection of blood from the ventricles into the pulmonary artery and aorta caused by contraction of the left ventricle; also called the point of maximal impulse The varying thicknesses of the atrial and ventricular walls are due to the workload required by each chamber. The myocardial layer of both atria is much thinner than that of the ventricles because there is little resistance as blood flows out of the atria and into the ventricles during diastole. 4 HEART VALVES: Atrioventricular Valves (separate atria from ventricles; Tricuspid and Mitral valves, open during diastole), Semilunar Valves (Pulmonic (separate right ventricle/pulmonary artery) and Aortic (separate left ventricle/aorta); closed during diastole). CORONARY ARTERIES: As heart rate increases, diastolic time is shortened, which may not allow adequate time for myocardial perfusion. As a result, patients are at risk for myocardial ischemia (inadequate oxygen supply) during tachycardia. cardiac conduction system: specialized heart cells strategically located throughout the heart that are responsible for methodically generating and coordinating the transmission of electrical impulses to the myocardial cells sinoatrial (SA) node: primary pacemaker of the heart, located in the right atrium atrioventricular (AV) node: secondary pacemaker of the heart, located in the right atrial wall near the tricuspid valve baroreceptors: nerve fibers located in the aortic arch and carotid arteries that are responsible for control of the blood pressure Three physiologic characteristics of two types of specialized electrical cells, the nodal cells and the Purkinje cells, provide this synchronization: Automaticity: ability to initiate an electrical impulse Excitability: ability to respond to an electrical impulse Conductivity: ability to transmit an electrical impulse from one cell to another ACTION POTENTIAL Phase 0: Cellular depolarization (-) is initiated as positive ions influx into the cell. During this phase, the atrial and ventricular myocytes rapidly depolarize as sodium moves into the cells through sodium fast channels. The myocytes have a fast response action potential. In contrast, the cells of the SA and AV node depolarize when calcium enters these cells through calcium slow channels. These cells have a slow response action potential. Phase 1: Early cellular repolarization begins during this phase as potassium exits the intracellular space. Phase 2: This phase is called the plateau phase because the rate of repolarization slows. Calcium ions enter the intracellular space. Phase 3: This phase marks the completion of repolarization (+) and return of the cell to its resting state. Phase 4: This phase is considered the resting phase before the next depolarization.

Discuss factors that improve health literacy and promote patient safety.

Ask Me 3 questions are: · What is my main problem? · What do I need to do? · Why is it important for me to do this? The teach-back method assesses health literacy, seeking to confirm that the learner understands the health information received from the health professional. The Understanding Personal Perception (UPP) scale has been suggested as a tool to evaluate the level of a patient's understanding of new health information.

Describe the assessment, diagnosis, and management of patients with heart failure.

Assessment and Diagnosis: • Echocardiogram: performed to determine the EF, identify anatomic features such as ejection fraction percentage, structural abnormalities and valve malfunction, and confirm the diagnosis of HF. • Radionuclide ventriculography: noninvasive, injecting a contrast dye and evaluating the flow through the heart. • Ventriculography during cardiac catheterization: invasive. • Chest X-ray: performed to determine the size of the heart. • 12 lead ECG: performed to determine heart rhythm. • Lab values: electrolytes, blood urea nitrogen, creatinine, liver enzymes, thyroid hormones, CBC, and BNP. BNP levels: key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure and can aid in both the diagnosis and management of HF • Urinalysis Medical Management: • Goal is to improve functional status and quality of life and extend life • Supplemental O2: support tissue oxygenation • Cardiac devices (possibly): pacemaker or implantable cardiac defibrillator • Nutritional therapy: low sodium diet, usually under 2 grams a day, and should avoid excessive fluid intake • Major lifestyle changes ↓ Na+, no smoking, ↓ excessive fluid intake, ↓ alcohol Weight reduction, regular exercise • Medications: (WILL COVER IN MEDICATIONS DOCUMENT) Gerontologic Considerations: • May present with atypical signs and symptoms such as fatigue, weakness, and somnolence • Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume • Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland • Stress from urinary frequency and urgency from diuretics may occur in patients with arthritis or limited mobility

Use the nursing process to care for patients with heart failure.

Assessment: • Focus: Effectiveness of therapy Patient's self-management: diet, medications, and life style Signs & Symptoms if increased HF Emotional or psychosocial response: often results in the patient developing depression. • Health history: thorough, focused on the signs and symptoms of HF, history of sleep problems, fatigue, and activities of daily living. • Physical Exam: respiratory rate and depth, breath sounds, O2 saturations, blood pressure, heart tones, heart rate and rhythm, the presence of JVD with the patient sitting at a 45-degree angle, peripheral pulses, skin temperature and color, dependent and sacral edema, abdominal tenderness and girth, urine output, and daily weight. Weigh the patient at the same time, with the same amount of clothes on, with the same scale. A significant weight gain would be considered 2-3 pounds in one day, or 5 pounds in a week, as this is water weight signaling a need to adjust treatment. Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and Input & Output; assess responses to medications Diagnosis: • Activity intolerance related to decreased CO • Excess fluid volume related to the HF syndrome • Anxiety-related symptoms related to complexity of the therapeutic regimen • Powerlessness related to chronic illness and hospitalizations • Ineffective family therapeutic regimen management Planning: • Goals Promote activity and reduce fatigue Relieve fluid overload symptoms Decrease anxiety or increase the patient's ability to manage anxiety Encourage the patient to verbalize his or her ability to make decisions and influence outcomes Educate the patient and family about management of the therapeutic regimen Implementation and Interventions: • Activity Intolerance Bed rest for acute exacerbations Encourage regular physical activity; 30-45 minutes daily Exercise training Pacing of activities Avoid activities in extreme hot, cold, or humid weather Modify activities to conserve energy (sit instead of stand) Positioning; elevation of the HOB to facilitate breathing and rest, support of arms Supervised programs may be beneficial as well • Fluid Volume Excess Assessment for symptoms of fluid overload Daily weight Input & Output: assess lung sounds Diuretic therapy; timing of meds Fluid intake; fluid restriction Maintenance of sodium restriction Assess bony prominences for skin breakdown and teach what positions used (sitting, bed). • Controlling Anxiety Promote physical comfort Provide psychological support Supplemental O2 Family member for support Identify triggers Relaxation techniques • Minimizing Powerlessness Active listening Provide for decision making opportunities Identify factors they can control Screen for depression • Assist Patients and Family to Effectively Manage Health Patient and family make significant lifestyle changes. Lack of coordination of care and clinical follow-up contribute to poor outcomes and rehospitalization. A number of programs and interventions are available to assist patients and families to effectively manage the HF regimen and to prevent hospitalizations and the associated increased costs and decreased quality of life. • Managing Potential Complications Hypokalemia (low potassium) due to excessive and repeated diuresis. Signs include ventricular dysrhythmias, hypotension, muscle weakness, and generalized weakness. Hyperkalemia (high potassium) with the use of ACE inhibitors, ARBs, or spironolactone. Can lead to profound bradycardia and other dysrhythmias. Hyponatremia (sodium deficiency in blood) due to prolonged diuretic therapy. Can result in disorientation, weakness, muscle cramps, and anorexia. Dehydration: Volume depletion from excessive fluid loss Hypotension: Volume depletion from excessive fluid loss; ACE inhibitors and beta-blockers may contribute to the hypotension. ↑ serum creatinine (indicative of renal dysfunction) Hyperuricemia (excessive uric acid in the blood), which leads to gout. Evaluation: Expected patient outcomes may include: Demonstrates tolerance for desired activity Maintains fluid balance Decreased anxiety Makes sound decisions regarding care and treatment Patients and family members adhere to healthy regimen

Describe how ineffective communication hinders communication.

Blocks to Communication: • Failure to perceive the patient as a human being • Failure to listen • Asking too many questions: Avoid asking your patients "why?" as it immediately puts them on the defensive. • Nontherapeutic comments and questions: Most health care clichés suggest that there is no cause for anxiety or concern, or they offer false assurance. Patients tend to interpret them as a lack of real interest in what they have said. • Changing the subject • Using closed questions: cut off the discussion. • Offering personal advice: offer them information to make their own decisions. • Giving false assurance: honest and accurate with your information. • Using questions containing the words "why" and "how" • Stereotyping or talking "down" to your patients

Explain the pathophysiology and the significance of hypertension.

Blood pressure is the product of cardiac output multiplied by peripheral resistance. Cardiac output is the product of the heart rate multiplied by the stroke volume. Each time the heart contracts, pressure is transferred from the contraction of the heart muscle to the blood and then pressure is exerted by the blood as it flows through the blood vessels. Hypertension can result from increases in cardiac output, increases in peripheral resistance (constriction of the blood vessels), or both. Increases in cardiac output are often related to an expansion in vascular volume. Although no precise cause can be identified for most cases of hypertension, it is understood that hypertension is a multifactorial condition. For hypertension to occur there must be a change in one or more factors affecting peripheral resistance or cardiac output and there is a problem with the body's blood pressure control systems that monitor blood pressure. The tendency for hypertension is often GENETIC.

Perform a cardiac assessment.

CARDIAC ASSESSMENT • Medications • Nutrition • Elimination • Activity, exercise • Sleep, rest • Vital signs • Self-perception, self-concept • Roles, relationships • Sexuality, reproduction • Coping, stress tolerance • Prevention strategies PHYSICAL ASSESSMENT • General Survey: Level of consciousness (alert, lethargic, stuporous, comatose) and mental status (oriented to person, place, time; coherence). Changes in level of consciousness and mental status may be attributed to inadequate perfusion of the brain from a compromised cardiac output or thromboembolic event (stroke). • Skin & Extremities: Skin color, temperature, and texture are assessed for acute and chronic problems with arterial or venous circulation. Signs and symptoms of acute obstruction of arterial blood flow in the extremities, referred to as the 6 P's, are pain, pallor, pulselessness, paresthesia, poikilothermia (coldness), and paralysis. Lower extremities, edema (peripheral if in legs, ankles, feet), capillary refill time (inadequate arterial perfusion), clubbing (chronic hemoglobin desaturation which is associated with chronic heart disease). Hair loss, brittle nails, dry or scaling skin, atrophy of the skin, skin color changes, and ulcerations are indicative of chronically reduced oxygen and nutrient supply to the skin observed in patients with arterial or venous insufficiency • Blood Pressure Pulse pressure: The difference between the systolic and the diastolic pressures; how well the patient maintains cardiac output. This increases in conditions that elevate the stroke volume (anxiety, exercise, bradycardia), reduce systemic vascular resistance (fever), or reduce distensibility of the arteries (atherosclerosis, aging, hypertension). Decreased pulse pressure reflects reduced stroke volume and ejection velocity (shock, HF, hypovolemia, mitral regurgitation) or obstruction to blood flow during systole (mitral or aortic stenosis). Normal pulse pressure is 30-40 mm Hg. A pulse pressure of less than 30 mm Hg signifies a serious reduction in cardiac output and requires further cardiovascular assessment. Done in laying or sitting position. Postural (orthostatic) changes: There is a gravitational redistribution of approximately 300 to 800 mL of blood into the lower extremities and the gastrointestinal system immediately upon standing. These changes reduce venous return to the heart, compromising preload that ultimately reduces stroke volume and cardiac output. Normal postural responses that occur when a person moves from a lying to a standing position include (1) a heart rate increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure. postural (orthostatic) hypotension: a significant drop in blood pressure (20 mm Hg systolic or more or 10 mm Hg diastolic or more) after an upright posture is assumed The following is an example of BP and heart rate measurements in a patient with postural hypotension: Supine: BP 120/70 mm Hg, heart rate 70 bpm Sitting: BP 100/55 mm Hg, heart rate 90 bpm Standing: BP 98/52 mm Hg, heart rate 94 bpm • Arterial Pulses Rate: varies from a low of 50 bpm in healthy, athletic young adults to rates well in excess of 100 bpm after exercise or during times of excitement. Anxiety frequently raises the pulse rate during the physical examination. Rhythm: The pulse rate may increase during inhalation and slow during exhalation due to changes in blood flow to the heart during the respiratory cycle. Disturbances of rhythm (dysrhythmias) often result in a pulse deficit, which is a difference between the apical and radial pulse rates. Pulse deficits commonly occur with atrial fibrillation, atrial flutter, and premature ventricular contractions. Amplitude: Assess peripheral arterial circulation 0: Not palpable or absent +1: Diminished—weak, thready pulse; difficult to palpate; obliterated with pressure +2: Normal—cannot be obliterated +3: Moderately increased—easy to palpate, full pulse; cannot be obliterated +4: Markedly increased—strong, bounding pulse; may be abnormal • Jugular Venous Pulsations: Right-sided heart function can be estimated by observing the pulsations of the jugular veins of the neck, which reflects central venous pressure (CVP). CVP is the pressure in the right atria or the right ventricle at the end of diastole. Patient will be elevated 45 to 90°. • Heart inspection, palpation, auscultation Aortic area—second intercostal space to the right of the sternum. To determine the correct intercostal space, the nurse first finds the angle of Louis by locating the bony ridge near the top of the sternum, at the junction of the sternum and the manubrium. From this angle, the second intercostal space is located by sliding one finger to the left or right of the sternum. Subsequent intercostal spaces are located from this reference point by palpating down the rib cage. Pulmonic area—second intercostal space to the left of the sternum Erb point—third intercostal space to the left of the sternum Tricuspid area—fourth and fifth intercostal spaces to the left of the sternum Mitral (apical) area—left fifth intercostal space at the midclavicular line Epigastric area—below the xiphoid process normal heart sounds: sounds produced when the valves close; normal heart sounds are S1 (atrioventricular valves) and S2 (semilunar valves) S1: the first heart sound produced by closure of the atrioventricular (mitral and tricuspid) valves S2: the second heart sound produced by closure of the semilunar (aortic and pulmonic) valves S3: an abnormal heart sound detected early in diastole as resistance is met to blood entering either ventricle; most often due to volume overload associated with heart failure S4: an abnormal heart sound detected late in diastole as resistance is met to blood entering either ventricle during atrial contraction; most often caused by hypertrophy of the ventricle

Evaluate yourself in terms of interpersonal communication competency.

Developing Conversation Skills: • Control the tone of your voice, includes pitch and volume. • Be knowledgeable about the topic of conversation and know the resources to tap into if you need to research a topic more. • Be flexible. • Be clear and concise. • Avoid words that might have different interpretations, use layman's terms. • Be truthful. • Keep an open mind. • Take advantage of available opportunities. Developing Listening Skills: • Sit when communicating with a patient. • Be alert and relaxed and take your time. • Keep the conversation as natural as possible. • Maintain eye contact if appropriate. • Use appropriate facial expressions and body gestures. • Think before responding to the patient. • Do not pretend to listen. • Listen for themes in the patient's comments. • Use silence, therapeutic touch, and humor appropriately. Interview Questions: Active listening involves giving your full attention to the person speaking and not thinking ahead of a response and not interrupting them. • Comfortable, private environment, minimal distractions • Open-ended questions or comments: Allow the patient a wide range of possible responses. It allows patients to express what they understand to be true, yet is specific enough to prevent digressing from the issue at hand. • Assertiveness & confidence: Deal directly with the issue at hand. • Validating questions or comments: Make sure nurse interpreted the meaning of the message correctly • Clarifying questions or comments: Restating in your own words allow the patient to acknowledge that you received their message correctly. • Reflective questions or comments: Share any observations with the patient; repeating what the person has said or describing the person's feelings. • Silence: Conveys acceptance of the message and allows the patient to continue discussing the matter at hand. • Sequencing questions or comments: To place events in a chronologic order or to investigate a possible cause-and-effect relationship between events. • Summarizing: When teaching a patient about something make sure to summarize your conversation at the end so that they know and you know that the teaching has been effective and conveyed the right message Characteristics of the Assertive Nurse's Self-Presentation: • Confident; open body posture • Use of clear, concise "I" statements means owning the conversation and not placing the burden or direction on the other person. • Ability to share effectively one's thoughts, feelings, and emotions • Working to capacity with or without supervision • Remaining calm under supervision • Asking for help when necessary • Giving and accepting compliments • Admitting mistakes and taking responsibility for them assertive behavior: ability to stand up for oneself and others using open, honest, and direct communication. aggressive behavior: standing up for one's rights in a negative manner that violates the rights of others. Aggressive Behavior: • Involves asserting one's rights in a negative manner that violates the rights of others. • Can be verbal or physical. • Communication is marked by tension and anger, inhibiting the formation of good relationships and collaboration. • Characteristics include using an angry tone of voice, making accusations, and demonstrating belligerence and intolerance. • Focus is usually "winning at all costs."

Use effective communication with patients from different cultures.

Dispositional Traits: • Warmth and friendliness • Openness and respect • Empathy: (1) objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting oneself in another person's circumstances and imagining what it would be like to share that person's feelings; (2) intellectually identifying with the way another person feels • Honesty, authenticity, trust • Caring • Competence Rapport Builders: • Specific objectives • Comfortable environment: Is patient in pain? • Privacy • Confidentiality • Patient vs. task focus • Utilization of nursing observations: non-verbal gestures, activing listening, and demonstrate interest in what is going on with patient • Optimal pacing RELATING TO PATIENTS OF DIFFERENT CULTURES (BOX 8-4) Assess your personal beliefs surrounding people from different cultures. Review your personal beliefs and past experiences. Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect care. Assess communication variables from a cultural perspective. Determine the ethnic identity of the patient, including generation in the United States. Use the patient as a source of information when possible. Assess cultural factors that may affect your relationship with the patient and respond appropriately. Plan care based on the communicated needs and cultural background. Learn as much as possible about the patient's cultural customs and beliefs. Encourage the patient to reveal cultural interpretation of health, illness, and health care. Be sensitive to the uniqueness of the patient. Identify sources of discrepancy between the patient's and your own concepts of health and illness. Communicate at the patient's personal level of functioning. Evaluate effectiveness of nursing actions and modify nursing care plan when necessary. Modify communication approaches to meet cultural needs. Be attentive to signs of fear, anxiety, and confusion in the patient. Respond in a reassuring manner in keeping with the patient's cultural orientation. Be aware that in some cultural groups, discussion concerning the patient with others may be offensive and may impede the nursing process. Understand that respect for the patient and communicated needs is central to the therapeutic relationship. Communicate respect by using a kind and attentive approach. Learn how listening is communicated in the patient's culture. Use appropriate active listening techniques. Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture. Communicate in a nonthreatening manner. Conduct the interview in an unhurried manner. Follow acceptable social and cultural amenities. Ask general questions during the information-gathering stage. Be patient with a respondent who gives information that may seem unrelated to the patient's health problem. Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attention. Use validating techniques in communication. Be alert for feedback that the patient does not understand. Do not assume meaning is interpreted without distortion. Be considerate of reluctance to talk when the subject involves sexual matters. Be aware that in some cultures, sexual matters are not discussed freely with members of the opposite sex. Adopt special approaches when the patient speaks a different language. Use a caring tone of voice and facial expression to help alleviate the patient's fears. Speak slowly and distinctly, but not loudly. Use gestures, pictures, and play acting to help the patient understand. Repeat the message in different ways if necessary. Be alert to words the patient seems to understand and use them frequently. Keep messages simple and repeat them frequently. Avoid using medical terms and abbreviations that the patient may not understand. Use an appropriate language dictionary. Use interpreters to improve communication. Ask the interpreter to translate the message, not just the individual words. Obtain feedback to confirm understanding. Use an interpreter who is culturally sensitive.

Accurately document the nurse/patient teaching-learning process.

Documentation of the Teaching-Learning Process: document our summary of the teaching needs for the patient, the teaching plan that was done, the patient's responses and learning, and any need for revisions. • Summary of the learning need • The plan • The implementation of the plan • Evaluation results

Develop nursing diagnoses that identify hygiene problems amenable to nursing intervention.

Each nursing diagnosis statement identifies a patient problem and suggests expected patient outcomes. The etiology of the problem directs nursing interventions. Problems concerning deficient hygiene are categorized as self-care deficits. Self-Care Deficit diagnoses address specific activities necessary to meet daily needs: feeding, bathing, dressing, and toileting. • Bathing self-care deficit • Impaired oral mucous membranes • Impaired Social Interaction • Impaired physical mobility • Risk for impaired skin integrity

Describe the priorities of scheduled hygiene care.

Early Morning: shortly after the patient awakes and before breakfast. • Assist patient with toileting. • Provide comfort measures to refresh patient to prepare for day. • Wash face and hands. • Provide mouth care. Morning Care (A.M. Care): After breakfast, nurse or delegated assistant completes morning care. Have the patient feel refreshed and comfortable. • Toileting • Oral care • Bathing • Back massage: Reasons include the following to help promote health, sleep, etc. o Acts as a general body conditioner o Relieves muscle tension and promotes relaxation o Provides opportunity for nurse to observe skin for signs of breakdowns o Improves circulation o May decrease pain, distress, and anxiety o May improve sleep quality • Special skin measures • Hair care, cosmetics • Dressing • Positioning for comfort • Refreshing or changing bed linens • Tidying up bedside Afternoon Care (P.M. Care): Ensures patient's comfort so can receive visitors or rest. • Offer assistance with toileting, handwashing, oral care. • Straighten bed linens. • Help patient with mobility to reposition self. Hours of Sleep Care: Before patient retires. • Offer assistance with toileting, washing, and oral care. • Offer a back massage. • Change any soiled bed linens or clothing. • Position patient comfortably. • Ensure that call light and other objects patient requires are within reach. As Needed Care (PRN Care): Specific problem or potential problem. • Offer individual hygiene measures as needed. • Change clothing and bed linens of diaphoretic patients. • Provide oral care every 2 hours if indicated.

Describe three methods to evaluate learning.

Evaluating Learning and Obtaining Feedback about Learning: • Reinforcing and Return Demonstration Positive reinforcement to affirm the efforts of patients who have mastered new knowledge, attitudes, or skills. Reinforcement may be as simple as a few words of acknowledgment ("You've mastered this diet quickly"), as spontaneous as a warm hug, or as planned as the entire staff joining to celebrate a patient's independent ambulation Negative Reinforcement—criticism or punishment—is generally ineffective; undesirable behavior is usually best ignored. • Celebrating learning • Evaluating teaching • Revising the plan

Discuss the role of the nurse as a "counselor" to motivate the patient in health promotion.

Guidelines to Patient Counsel: help the patients make informed decisions, and help them work through the decision-making process. • May address an immediate concern • Make everyone feel comfortable in the situation and surroundings. • Counseling may be formal or informal. • Use interpersonal skills of warmth, friendliness, openness, and empathy - Table 9-1 • Caring is fundamental in the counseling role. Types of Counseling: • Short-term: for situational crisis; immediate problem • Long-term: for developmental crisis; continue counsel over time • Motivational interviewing: discussing the patient's feelings and any incentives with the patient • Referrals: social work, psychiatric or mental health professionals, clergy, or a sex therapist may be indicated and the nurse should initiate that if the patient could benefit from their expertise. Make sure that there are no barriers that exist like transportation problems, or timing that can affect the patient following through on the referral.

(Chapter 29 (Hinkle Medsurge) Learning Objectives:) Describe the process of heart failure.

HEART FAILURE: • The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Most common in people older than 75 years. • A syndrome characterized by fluid overload or inadequate tissue perfusion • The term heart failure indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure: alteration in ventricular contraction, weakened heart muscle; most common) or filling of the heart (diastolic failure: stiff and noncompliant heart muscle, making it difficult for the ventricle to fill). • Some cases are reversible. • Most HF is a progressive, lifelong disorder managed with lifestyle changes and medications. • Ejection fraction (EF): percentage of blood volume in the ventricles at the end of diastole that is ejected during systole; a measurement of contractility. Assessed by performing echocardiogram to assist in determining the type of HF. EF is calculated by subtracting amount of blood present in the left ventricle at end of systole from the amount present at end of diastole and calculating the percentage of blood that is ejected. A normal EF is 55% to 65% of the ventricular volume; the ventricle does not completely empty between contractions. ETIOLOGY: • Coronary Artery Disease (CAD) Atherosclerosis of the coronary arteries is the primary cause of HF. Resulting ischemia results in the death of the myocardial cells. • Hypertension (HTN) increases afterload (resistance to ejection), which increases cardiac workload and leads to hypertrophy of myocardial muscle fibers. Sustained hypertension eventually leads to changes that impair the heart's ability to fill properly during diastole, and the hypertrophied ventricles may dilate and fail. • Cardiomyopathy: disease of the myocardium; leads to HF and dysrhythmias, causes necrosis and fibrosis of the heart which is usually chronic and progressive. • Valvular disorders: valves leak blood back into the heart increasing the pressure in the heart and increasing cardiac workload. • Renal dysfunction: cardiorenal syndrome describes how dysfunction in one of these systems leads to dysfunction in the other. • Diabetes PATHOPHYSIOLOGY: · As HF develops, the body activates neurohormonal compensatory mechanisms. These mechanisms represent the body's attempt to cope with the HF and are responsible for the signs and symptoms that develop. · Systolic HF has decreased blood coming from the ventricle. The baroreceptors in the heart sense this change. This stimulates the sympathetic nervous system to release epinephrine and norepinephrine causing increased heart rate and contractility but also vasoconstriction in the skin, GI tract, and kidneys. The decrease in the blood flow to the kidneys cause the kidneys to release renin. Renin converts angiotensinogen to angiotensin 1, which circulates to the lungs. The pulmonary blood vessels then release angiotensin converting enzymes which is another vasoconstrictor that increases blood pressure and afterload. Aldosterone is also triggered to be released by the angiotensin, which leads to an increase of pre-load and afterload to the heart causing the cardiac workload to increase. The over-distended cardiac tissue tries to counteract this by releasing natriuretic peptides. These peptides, ANP and BNP, promote vasodilation and diuresis. But their effect is not enough to overcome all the other vasoconstricting mechanisms at work in the body. · Decreased contractility of the heart leads to increased blood volume in the heart, thus stretching the fibers and increasing the size of the ventricle. The heart tries to compensate for the extra workload by increasing the thickness of the heart muscle. Enlarged heart cells eventually become dysfunctional and die off early. As cardiac cells die then the heart becomes fibrotic and diastolic HF can develop leaving the patient with further dysfunction.

Describe factors that should be assessed in the learning process.

Factors Affecting Learning: • Age and developmental level: Perceive a need to learn something in order to become engaged and actually learn. For older adults nurses must assess if they have any communication or sensory deficits like vision or hearing impairments, mobility problems, or impaired cognition, as all of these will require the nurse to modify the teaching plan. • Family support networks- COPE Model: Coping and support mechanisms. • Financial resources • Cultural influences • Language deficits • Health literacy level

Describe gerontological and gender considerations in the cardiac system.

Gerontological: • Slower conduction: loss of function of the cells throughout the conduction system • Hypertrophy (thickening of heart walls thus decreasing the volume of blood that the chambers of the heart can hold and changing heart structure and decreasing strength of heart contraction). o ↓ Cardiac Output (CO) • Stiffening of valves o Back flow of blood causing heart murmurs. • Decreased compensation adjustments: The heart cannot respond as quickly to increased demands due to stress, exercise or illness. Resulting fatigue, shortness of breath, and palpitations may be present. Gender: • Women heart size smaller than men • Coronary arteries smaller also • Female hormones protect: 3 Major effects of Estrogen o ↑ high-density lipoprotein (HDL) that transports cholesterol out of arteries. o ↓ low-density lipoprotein (LDL) that deposits cholesterol in the artery. o Dilation of blood vessels enhances blood flow to the heart.

Describe hypertensive crisis and treatment.

HYPERTENSIVE CRISIS: Hypertensive crisis requires immediate intervention. There are 2 classes of hypertensive crisis, hypertensive emergency and hypertensive urgency. • Hypertensive emergency Blood pressure >180/120 mm Hg and must be lowered immediately to prevent damage to target organs • Hypertensive urgency Blood pressure is very high but no evidence of immediate or progressive target organ damage HYPERTENSIVE EMERGENCY: Goal to get the blood pressure down quickly with the threat of those life-threatening complications occurring. • Reduce blood pressure 25% in first hour. IV vasodilators like sodium nitroprusside, are used initially to get the quick reduction. • Reduce to 160/100 over 6 hours. • Then gradual reduction to normal over a period of days. • Exceptions are ischemic stroke and aortic dissection. • Medications: IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin • Need very frequent monitoring of BP and cardiovascular status. • Before discharge the patient will be given oral medications to take at home and followed up closely the first week, then at routine intervals after that. HYPERTENSIVE URGENCY: When the pressure is highly elevated, but not to the extreme of hypertensive emergency. Often times the patient will report a headache, or nosebleeds, or anxiety along with presenting with an elevated BP. • Patient requires close monitoring of blood pressure and cardiovascular status. • Assess for potential evidence of target organ damage. • Medications: Patient given oral fast-acting anti-hypertensive medications and possibly diuretics with a goal of getting the BP back to normal in 24-48 hours. Fast-acting oral agents: beta-adrenergic blocker— labetalol; angiotensin-converting enzyme inhibitor— captopril; or alpha2-agonist—clonidine

Utilize SBAR communication technique.

Hand-off Communication: SBAR Performed between nurses and other departments in the facility, during nurse-to-nurse report, or in nurse-to-physician/health care provider discussions. Miscommunication between health care providers during hand-off communication, nurse shift change, or interdepartmental transfers presents sizable risks for adverse patient events, such as preventable patient falls, medication errors and omissions, infections, and pressure-ulcer development. Situation, Background, Assessment, and Recommendations. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. CUS (communication tool): communication tool to assist in effective communication related to patient safety concerns; the acronym CUS stands for I'm Concerned, I'm Uncomfortable, This is unSafe (or This is a Safety issue)

Assess the adequacy of hygiene practices and self-care behaviors using appropriate interview and physical assessment skills.

Hygiene describes activities involved in maintaining personal cleanliness and grooming. Personal hygiene contributes to physical and psychological well-being. ADLs include a bath or shower, washing hair, or brushing and flossing teeth promote comfort, improve self-image, and decrease infection and disease. When healthy, people perform their own personal hygiene; however, some patients need assistance because of illness or injury. As a nurse, you are responsible for providing the necessary assistance to complete hygiene care, and you should promote as much self-care as possible. Self-care in ADLs promotes increased activity, independence, and self-esteem. There are many factors that can affect personal hygiene practices. Good practices include inspection, cleaning and maintaining the skin, hair, nails, mouth, teeth and perineal area.

(Chapter 31 Learning Objectives:) Identify factors affecting personal hygiene.

Identify factors affecting personal hygiene. Culture: affects hygiene preferences, and use of products. This includes the frequency of bathing and how private the bathing is. Socioeconomic class: hygiene options available and affordable to income. Spiritual practices: include a ritual of bathing or cleansing, some practices limit the hygiene facilities in a persons' home. Developmental level: One's family often dictates hygiene habits. Older adults usually bath less often. Health state: Older Adult's skin and hair do not produce the amount of oils as it did when they were young, and often they don't have as much physical exertion, or they may have mobility limitations. Disease, surgery, or injury may reduce a person's ability to perform hygiene measures or motivation to follow usual hygiene habits. Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the lower extremities. Illness may also create a demand for new or modified hygiene measures. Personal preferences

Identify risk factors for hypertension.

Incidence of Hypertension - "The Silent Killer": it is symptom free other than elevated blood pressure and people don't even know they have it. About 40% of people diagnosed with hypertension did not realize they had it. Is a life-long condition that requires constant monitoring to keep it under control. Prolonged uncontrolled hypertension can result in an MI, heart failure, renal failure, strokes, and impaired vision. • Symptoms seen related to organ damage are seen late and are serious Retinal and other eye changes Renal damage Myocardial infarction Cardiac hypertrophy Stroke (Also mentioned on slides: Hypertension, Smoking, Obesity, Physical inactivity, Dyslipidemia, Diabetes mellitus, Microalbuminuria or GFR <60 mL/min, Older age (> 55/men, >65 women), and Family history) Prolonged blood pressure elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. The typical outcomes of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, chronic kidney disease, strokes, and impaired vision. Hypertrophy (enlargement) of the left ventricle of the heart may occur as it works to pump blood against the elevated pressure. • Primary hypertension: Also called essential hypertension, which is defined as high blood pressure from an unidentified cause and in 95% of patients. • Secondary hypertension: Remaining 5% of patients in which cause is known. Causes include chronic kidney disease, renal artery stenosis, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, sleep apnea, dyslipidemia (abnormal lipid levels), and medications like steroids. • About 30% of the adult population of the U.S. has hypertension. • About 54% of adults with HTN do not have it under control. • Highest prevalence in African Americans and Hispanics

Describe strategies that counteract disruptive professional behaviors.

Incivility: rude, intimidating, and undesirable behavior directed at another person. • Bullying: negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility Nurse bullying: include psychological and social harassment. Withholding important information, gossip, starting rumors, humiliating comments, eye rolling and other gestures would all be considered forms of bullying. Negative nurse- physician communication: respond to this behavior immediately with the physician in a private setting, document the occurrence and report it to your nurse manager • Organizational response to disruptive behaviors horizontal violence: anger and aggressive behavior between nurses or nurse-to-nurse hostility

Differentiate between left-side and right-side heart failure.

LEFT SIDE HF: left ventricle cannot pump blood out effectively to the aorta and the systemic circulation which decrease blood flow from the left atrium into the left ventricle during diastole. • Pulmonary congestion, crackles: Pulmonary venous blood flow volume and pressure increase in the lungs forcing fluid from the pulmonary capillaries in the pulmonary tissues and alveoli, causing pulmonary edema and impaired gas exchange. • S3 or "ventricular gallop": caused by abnormal ventricular filling, detected on auscultation. • Dyspnea on exertion (DOE): may be precipitated by minimal to moderate activity. Some patients have sudden attacks of dyspnea at night, a condition known as paroxysmal nocturnal dyspnea (PND). • Orthopnea: difficulty breathing when lying flat • Dry, nonproductive cough initially > wet: The cough can start out as a dry cough, but then progress to producing large amounts of frothy sputum. • Oliguria (urine output drops): The decrease in stroke volume in HF leads the body to release catecholamines which further decreases perfusion to many organs including the kidneys. When lying down, the workload of the heart decreases, improving renal perfusion and increasing urine production and can lead to the patient having nocturia. • Possible altered digestion, lightheadedness, dizziness, confusion, restlessness and anxiety. The skin may appear pale and is usually cool and clammy. The patient may also report tachycardia, possible heart palpitations, and activity intolerance. RIGHT SIDE HF: • Viscera and peripheral congestion: Right side of heart cannot eject blood effectively and cannot accommodate all of the blood that normally returns from the venous circulation. • Jugular venous distention (JVD): Caused by increased venous pressure. • Dependent edema: edema of the lower extremities; affects the feet and ankles and worsens when the patient stands or sits for a long period. • Hepatomegaly: enlargement of the liver; venous engorgement. The increased pressure may interfere with the liver's ability to function (secondary liver dysfunction); may increase pressure on the stomach and intestines and cause gastrointestinal distress, increase pressure on diaphragm causing respiratory distress, may force fluid into abdominal cavity causing ascites. • Ascites: accumulation of fluid in the peritoneal cavity • Weight gain: due to retention of fluid

Discuss the role of nurse as a "coach" in behavior change.

Nursing Coaching Process: • Establishing relationships and identifying readiness for change • Identifying opportunities, issues, and concerns • Establishing patient-centered goals • Creating the structure of the coaching interaction • Empowering and motivating patients to reach goals • Assisting the patient to determine progress toward goals NURSE COACH: Registered nurse who integrates coaching competencies into any setting or specialty area of practice to facilitate a process of change or development that assists individuals or groups to realize their potential. LEADERSHIP.

Describe the most common clinical manifestations of cardiac complications.

· Chest pain, or radiating down the arm, or between the shoulder blades, or jaw pain · Dyspnea · Peripheral edema, weight gain · Fatigue · Dizziness, syncope, changes in level of consciousness

Describe possible diagnostic tests that may be performed for a patient with suspected cardiac conditions.

PRIMARY PURPOSE: check for these enzymes and proteins to determine if there has been damage to the heart muscle. · Lab Tests · Blood Tests · Chest X-Ray: view the size, contour, and position of the heart. It also reveals if there is any cardiac calcifications, and pulmonary circulation. · Fluoroscopy: x-ray imaging technique that allows visualization of the heart on a screen. It shows cardiac and vascular pulsations and unusual cardiac contours. · Lipid profile: Cholesterol (calculated by adding the HDL (transporter of cholesterol and triglycerides into the cell), LDL (transports cholesterol away from the tissue and cells of the arterial wall to the liver), and 20% of the triglyceride level) and triglyceride (free fatty acids and glycerol) levels. · Brain (B-type) Natriuretic Peptide: BNP is a neurohormone that helps regulate BP and fluid volume; primarily secreted from the ventricles in response to increased preload with resulting elevated ventricular pressure. When the ventricle pressure increases in the ventricle of the heart, like during heart failure, the heart muscle releases BNP. Elevations in BNP can occur from a number of other conditions such as pulmonary embolus, MI, and ventricular hypertrophy. A BNP level greater than 100 pg/mL is suggestive of HF. · C-Reactive Protein: produced by the liver in response to systemic inflammation. Inflammation is thought to play a role in the development and progression of atherosclerosis. Risk for CVD. · Homosysteine: Amino acid associated with the development of atherosclerosis by damaging endothelial lining, and thrombus formation. High levels of this leave patients vulnerable to develop CAD, stroke, and peripheral vascular disease. Genetic factors and a diet low in folate, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. Test results are interpreted as optimal (less than 12 mcmol/L), borderline (12 to 15 mcmol/L), and high risk (greater than 15 mcmol/L).

Develop an education plan for patients with heart failure.

Patient Education: You must consider any cultural considerations of the patient and you must assess the patient's willingness to learn and if they have any cognitive impairments due to their illness. It's always good to have family members sit in on the teaching, and of course, provide them with written handouts in their native language so they can refer back to them when they are at home. Make a referral to home care or social services if you feel they may need some assistance at home. • Medications • Diet: low-sodium diet and fluid restriction • Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight • Exercise and activity program • Stress management • Prevention of infection • Know how and when to contact health care provider • Include any family in education • Referrals & resources • End of life care: Because HF is a chronic and often progressive condition, patients and families need to consider issues related to the end of life and when palliative or hospice care should be considered.

(Chapter 9 Learning Objectives:) Describe the teaching-learning process and principles.

Patient education is the process of influencing the patient's behavior to effect changes in knowledge, attitudes, and skills needed to maintain and improve health. Counseling provides the resources and support that patients need to participate actively in self-care and to facilitate their coping with their circumstances. Aims of Teaching and Counseling: goal is to help our patients manage their health. • Maintaining and promoting health • Preventing illness • Restoring health: promote recovery • Facilitating coping: many patients will need to learn to cope with permanent health alterations. Teaching Outcomes: • High-level wellness and related self-care practices • Disease prevention or early detection • Quick recovery from trauma or illness with minimal or no complications • Enhanced ability to adjust to developmental life changes and acute, chronic, and terminal illness • Family acceptance of lifestyle necessitated by illness or disability Focus on Patient Education: • Preparation for receiving care • Preparation before discharge from health care facility • Documentation of patient education activity: includes what you taught, the material you provided them, their response or ability to perform a skill, and any need for further teaching. The Nurse as a Teacher: • T - Tune into the patient. • E - Edit patient information; what is important. • A - Act on every teaching moment. • C - Clarify often. Effective teaching and patient is getting the information they need clearly. • H - Honor the patient as partner in the education process. Teaching-Learning Process (Box 9-2): Assess Learning Needs and Learning Readiness Diagnose the Patient's Learning Needs Develop Learning Outcomes Develop a Teaching Plan Implement Teaching Plan and Strategies Evaluate Learning

Describe ways in which nurses can use selected complementary health approaches for self-care and health promotion.

• Focused Assessment Guide 28-1 Holistic Care Factors to assess Questions and approaches (GUIDE 28-1)

Identify the knowledge the public should possess about complimentary health approaches and integrated health if they wish to be informed consumers.

Please see the previous questions. This explains the risks and central ideas of each CHA and IH.

Demonstrate techniques for assisting patients with hygiene measures, including those used when administering various types of baths and those used in cleaning each part of the body.

Purposes of Bathing: • Cleanses the skin • Acts as a skin conditioner • Helps to relax a person • Promotes circulation • Serves as musculoskeletal exercise • Stimulates the rate and depth of respirations • Promotes comfort through muscle relaxation and skin stimulation • Provides person with sensory input • Helps improve self-image • Strengthens nurse-patient relationship Shower and Tub Baths: Look at facility policy. • Shower: ambulatory and physically able to do the activity • Nursing responsibilities: Clean facility with non-skid mats or strips Provide with wash clothes, soap, shampoo, towels, clean gown Place to sit, and/or hand-held shower heads Assist in and out as needed (Obese patients could need help with thorough cleaning and dementia patients can be given a towel or bag bath to reduce aggressive behaviors and combativeness). Check the water temperature (100-120 degrees) Privacy, unlocked door, instruct in call bell Help to get to unreachable places (Older adults require techniques to prevent skin breakdown, promote comfort, and encourage independence. Bag baths, and a no-rinse pH balanced cleanser are preferred equipment to use. The goal is to protect the barrier function of the skin). Make adjustments to care as needed Providing a Bed Bath or a Bag Bath: Each part of the body is cleaned with a different cloth, no rinsing is required, and the skin air dries quickly with these products. Preferred for people with mild to moderate skin impairments. • Provide articles for bathing on overbed table or bedside stand. • Provide privacy for patient. • Remove top linens and replace with bath blanket. • Place cosmetics in convenient place. Provide a mirror. • Assist patients who cannot bathe themselves completely. Administering Oral Hygiene: Tooth brushing and flossing are recommended to be done twice a day. The patient should use a soft bristled manual or automatic toothbrush with tooth paste. Dentures require special care also. They need to be removed and cleaned twice daily also. • Moistening the mouth • Cleaning the mouth • Caring for dentures (Skill 7-5 in skills book) • Tooth brushing and flossing (45 degree angle) • Using mouthwashes • Dentures: When cleaning dentures, put on gloves and hold them over a basin of water or a sink lined with a washcloth or soft towel so that if they slip from your grasp, they will not fall onto a hard surface and break. Use cool or lukewarm water to cleanse them. • Look at skill 31-2 and 31-3 for oral care of conscious and unconscious patient. Care of Eyes: If someone has eyeglasses we want to make sure care is taken so they are not broken or lost. If possible have the patient wearing contacts remove and replace the lenses themselves. • Clean from inner to outer canthus with wet, warm cloth, cotton ball, or compress. • Use artificial tear solution or normal saline every 4 hours if blink reflex is absent. • Care for eyeglasses, contact lens, or artificial eye if indicated. Standard contact lenses should not be left in the eyes for longer than 16 hours. Extended wear soft lenses can be left in place up to 30 days. Ear and Nose Care: • Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs. • Perform hearing aid teaching and care if indicated. Hearing aids need their batteries checked and changed out often. They should be wiped down daily and have any wax removed. Hearing aids are very expensive and when the patient is not wearing them they should be placed in a denture cup with their name placed on it • Clean nose by having patient blow it if both nares are patent. • Remove crusted secretions around nose by applying warm, moist compress. Providing Hair Care: • Identify patient's usual hair and scalp care practices and styling preferences. • Note any history of hair or scalp problems such as dandruff, hair loss, or baldness. • Treat any infestations, such as pediculosis and ticks. • Groom and shampoo hair. • Care for beards and mustaches. Electric shavers are usually recommended when the patient is receiving anticoagulant therapy or has a bleeding disorder and are especially convenient for ill and bedridden patients. Shaving after a warm bath or shower softens the hair, making the process easier. • Assist with unwanted hair removal. • Skills Book 7-7 & 7-8 Nail and Foot Care: Nail care should be done by filing the nails. Cutting the toenails is not recommended to be done by the nursing staff, this should be done by a podiatrist. • Assess nails for color and shape, intactness and cleanness, and tenderness. • Check for history of nail or foot problems. • Soak nails and feet and assist with cleaning and trimming nails (if not contraindicated). • Massage the feet to promote relaxation and comfort. • Provide diabetic foot care if indicated. Ensuring Bedside Safety and Comfort: care environment is as comfortable as possible and safe. A good habit to get into before you leave the room is to ask "is there anything I can do to make you more comfortable?" • Orientation to the room & equipment and storage • Trash promptly emptied • Good air ventilation & use of room deodorizers • "Is there anything I can do to make you more comfortable?" • The bed is in its lowest position. • The bed position is safe for the patient. • The bed controls are functioning (bed is electrically safe). • Call light is functioning and always within reach • Side rails are raised if indicated. • The wheels or casters are locked. • Linens are clean and free of crumbs and wrinkles. • The patient feels comfortably warm. • Pressure areas are protected from rough sheets and water-repellent materials. This is especially important for patients with a nursing diagnosis of Risk for Impaired Skin Integrity.

Formulate nursing diagnoses for learning needs.

Related nursing diagnoses include the following: Ineffective health management Noncompliance (specify) Self-care deficit (specify)

Assess the condition of the patient's skin, oral cavity, hair, and nails using appropriate interview and physical assessment skills.

SKIN: Assess hygiene Factors to consider: • Cleanliness • Color • Temperature • Turgor • Moisture • Sensation • Vascularity • Evidence of lesions Interview Questions: How long have you had this problem? Does it bother you? How does it bother you? Does it itch? Have you found anything that helps relieve these symptoms? Guidelines for Skin Assessment: • Proceed systematically in head-to-toe sequence. • Use a good source of light, preferably daylight. • Compare bilateral parts for symmetry. • Use standard terminology to report and record findings. • Allow data obtained to direct skin assessment. • Identify variables known to causes skin problems. At Risk for Skin Alteration: • Lifestyle factors • Changes in health state • Illness • Diagnostic measures • Therapeutic measures ORAL CAVITY: related to a person's overall health Assessment: Lips: color, moisture, lumps, ulcers, lesions, and edema Buccal mucosa: color, moisture, lesions, nodules, and bleeding Color of the gums and surface of the gums: lesions, bleeding, and edema Teeth: any loose, missing, or carious (decayed) teeth. Note the presence and condition of dentures or other orthodontic devices Tongue: color, symmetry, movement, texture, and lesions Hard and soft palates: intactness, color, patches, lesions, and petechiae (pinpoint round, red, purple, or brown spots that result from bleeding) Oropharynx: movement of the uvula and condition of tonsils, if present · stomatitis: inflammation of the oral mucosa, numerous causes, such as bacteria, virus, mechanical trauma, irritants, nutritional deficiencies, and systemic infection. · glossitis: inflammation of the tongue, can be caused by deficiencies of vitamin B12, folic acid, and iron. · cheilosis: ulceration of the lips, caused by vitamin B complex deficiencies (especially riboflavin). · periodontitis: marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone · plaque: invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel · tartar: hard deposit on the teeth near the gum line formed by plaque buildup & dead bacteria · caries: cavities of the teeth · gingivitis: inflammation of the gingivae or gums · halitosis: offensive breath At Risk: • Self-care deficits • Poor nutrition • High sugar intake • Family history of periodontal disease • Chemotherapy agents • Seriously ill • Comatose or paralyzed • Dehydration • Confused, Depressed • NG tube insertion • Oral surgery Eyes, Ears, and Nose: For eyes, note the presence of any lesions, nodules, redness, swelling, crusting, excessive tearing, or discharge. For nose, note patency of the nostrils, and any unusual discharge. • Care measures performed • Use of visual aids or prosthetics • Use of hearing aids • Any other problems or treatments uses. • cerumen: wax in the external ear canals, consisting of a heavy oil and brown pigment; can build up in older adults and cause hearing problems. Hair: • Cleansing and scalp care • Any changes in distribution, texture, or amount • Any self-care deficits, immobility, malnutrition, or treatments resulting in hair loss • alopecia: hair loss or baldness • pediculosis: infestation with lice, spread by direct contact with the hair of infested persons, or with contact with items used by the infected person like hats, hair brushes, bedding and clothes. 3 TYPES: Pediculus humanus capitis, which infests the hair and scalp; Pediculus humanus corporis, which infests the body; and Phthirus pubis, which infests the shorter hairs on the body, usually the pubic and axillary hair Nails and Feet: assess the nail base for redness, swelling, bleeding, or discharge. Assess feet for cleanliness and between the toes, and note any swelling, inflammation, lesions, tenderness, or orthopedic problems. • Normal nail & foot practices • Nail or foot problems • Diabetes, peripheral vascular disease, arthritis, obesity • Exposure to chemicals, trauma, ill-fitting shoes Perineal and Vaginal: Examine the male genitalia for lesions, swelling, inflammation, excoriation, tenderness, and discharge. Examine the female genitalia for color, size, lesions, masses, swelling, inflammation, tenderness and any discharge or odor. Inspect the anal area for cracks, nodules, masses, hemorrhoids, or polyps. • Urinary or fecal incontinence • Indwelling catheter • Childbirth • History of douching • Surgery • UTI's, diabetes, STI's

Plan, implement, and evaluate nursing care for common problems of the skin and mucous membranes.

See question 6 and 7.

Create and implement a culturally competent and age-specific teaching plan.

Seek information from a variety of sources, such as the nursing literature and textbooks that describe the health practices and values of other cultures. Identify language deficits or barriers and develop strategies to address them, clearly communicating this in the nursing care plan.

Describe agents commonly used on the skin and scalp, including any precautions necessary for their use.

Skin and scalp Care: • Soaps and detergents • Deodorants and antiperspirants • Cosmetics: may include harmful products. Advise your patient that the FDA is a good source for cosmetic safety. Also, cosmetics pick up bacteria, and should never be shared and should be disposed of after 2-4 months of use • Sunscreen

(WEEK 8: Chapter 8 Learning Objectives:) Describe the communication process, identifying factors that influence communications.

There are two parts, content (message) and process (how it is delivered). Process of Communication: • Stimulus or referent • Sender or source of message (encoder) • Message itself • Medium or channel of communication • Receiver (decoder) noise: factors that distort the quality of a message and interfere with the communication process Factors of Communication: • Intrapersonal o Self-talk; communication within a person • Interpersonal o Occurs between two or more people with a goal to exchange messages • Group o Small-group: communication that occurs when two or more nurses interact with two or more individuals, allowing the members to achieve a goal through communication o Organizational communication: process of communication that involves individuals and groups to achieve established goals o Group dynamics: study of a group's characteristics and ways of functioning Factors Influencing Communication: • Developmental level • Gender: Men have a tendency to be direct, while females may pay more attention to the intention or tone of the communication. • Sociocultural differences • Roles and responsibilities: talents, interests, or economic status • Space and territoriality: • Physical, mental, and emotional state: Most people in the U.S. have about a 2-3 feet of personal space that they are comfortable with. Things like physical impairments or pain can be barriers, along with anxiety and fear. • Values: the way people value themselves, one another, and the purpose of any human interaction. Motivation. • Environment: Eliminate distractions

Describe how to promote patient compliance with treatment plans.

Three Learning Domains • Cognitive: storing and recalling of new knowledge in the brain • Psychomotor: learning a physical skill • Affective: changing attitudes, values, and feelings Teaching Strategies • Lecture: passive learning and not much is retained. • Discussion: effective in an atmosphere of trust with everyone participating with openness to ideas and assuring confidentiality; less effective in larger groups. • Panel discussion • Demonstration: good for psychomotor skills or tasks; time-consuming, labor intensive, not effective in large groups. • Discovery: one-on-one, used in nursing; formulate objectives prior to the learning session and the learner receives printed or audiovisual materials or referrals to web sites for the information; labor intensive but most effective, use of printed material. • Role playing: used to learn in the affective domain, leading by example or demonstrating behaviors that learners should adopt. • Audiovisual materials: many forms including the internet sites, simulating method effective for large groups. • Printed materials • Programmed instruction • Web-based instruction and technology Effective Communication Techniques and Patient Teaching: Genuine interest and respect to patient, be sincere and honest. Be a "cheerleader" for the patient. Avoid lecturing. Assess readiness to learn: physically able to receive the teaching Teach shortly before they need to apply it, good timing Active involvement, ask questions, actively listen Constructive feedback Repetition opportunities Coming prepared Uninterrupted time & good learning environment Include family & caregivers Techniques in Book Ask if the patient has any questions. Avoid giving too much detail; stick to the basics. Use simple words. Vary your tone of voice. Keep the content clear and concise. Listen and do not interrupt when the patient speaks. Ensure that the environment is conducive to learning and free of interruptions. Be sensitive to the timing of teaching sessions. A shorter session is best for a younger child, and an adult may need to choose an opportune time to learn new information. Considerations for Successful Patient Teaching: • Forming contractual agreements: Not legally binding, mutually agreed-on goals • Considering time constraints: prioritize your teaching activities and plan for the time needed to instruct the patient; better for shorter more frequent sessions. • Scheduling • Group vs. individual teaching • Formal vs. informal teaching: Informal teaching can occur anytime you are with a patient and you want them to benefit from your knowledge. Formal teaching is more planned and usually the nurse has outcomes in mind to achieve.

Ask proper questions for health promotion, patient perception, and patient management of cardiac care.

What medications are they taking? Make sure to include all over the counter medications, vitamins, and herbs. What's their diet? Obtain a height and weight on the patient to determine their BMI. What does the patient normally eat and drink in a day? Any particular eating habits? Ask about elimination patterns. Any Nocturia, or problems with constipation? What health behaviors do they have? Do they exercise? How is their sleep? Do they have orthopnea, or paroxysmal nocturnal dyspnea? Do they smoke or use tobacco products? What' s their stress level, and how do they cope?

Describe the components of a comprehensive cardiac health history.

acute coronary syndrome: a constellation of signs and symptoms due to the rupture of atherosclerotic plaque and resultant partial or complete thrombosis within a diseased coronary artery; leads to unstable angina or acute myocardial infarction · Demographic information · Family/genetic history · Cultural/social factors · Medications: complete list; ensure that the patient is safely and effectively taking the prescribed medications. · Risk factors: o Modifiable: Nutrition, Lifestyle (Exercise), Sleep and Rest (OROTHOPNEA: need to sit upright or stand to avoid shortness of breath), Coping and Stress, Bowel and Bladder Habits (NOCTURIA: awakening to urinate at night). o Non-modifiable: Culture, Genetics Cardiac assessment priorities vary depending on the needs of the patient.Is it a life threatening condition, or is it a stable, chronic condition?The acuity and severity of the condition will drive this.We usually start out with a health history.Where do they live?Is there any family history of cardiac disease?If so, have them describe it.What is the ethnicity of the patient?Remember that native Americans have high rates of heart disease.African Americans, Caucasians, and Asians have a high incidence of hypertension. Genetics and ethnicity cannot be modified, but lifestyle and behaviors can be modified, and will need to be part of a teaching plan.

(Chapter 28 Learning Objectives:) Differentiate complementary and integrated health from allopathic/conventional medicine.

complementary health approaches (CHA): interventions that can be used with conventional medical interventions integrative health (IH): combination of complementary health and conventional health approaches in a coordinated way Why Nurses need to Know CHA & IH: • Patients, families, physicians, and institutions increasingly expect practicing nurses to be knowledgeable about CHA & IH. • Many patients use these types of therapies as outpatients and want to continue their use as inpatients. Nurses need to be knowledgeable and aware of the positive and negative outcomes of these therapies. • Many nurses are expanding their clinical practice by incorporating CHA & IH practices. • Nurses play important role in educating the public to use these therapies safely & effectively. • State boards of nursing recognize CHA & IH as a regular part of nursing practice. CHA and IH: • Mind, body, and spirit are integrated and contribute to health and illness. • Health is balance of body systems: mental, social, and spiritual, as well as physical. • Illness is a manifestation of imbalance or disharmony. • Symptoms are a sign or reflection of a deeper instability within the person; restoring physical and mental harmony will alleviate the symptoms. • Emphasis is on health, healing is done by the patient, care is individualized. Allopathic Medicine: traditional medical care or "Biomedicine"; effective with acute issues but not so much with chronic. • Illness occurs in either the mind or body, which are separate entities. • Health is the absence of disease; focus to eliminate disease. • The main causes of illness are pathogens. • Curing seeks to destroy the invading organism or repair the affected part. • Emphasis is on disease and high technology (drugs, surgery, and radiation are key tools). • Dominant for about 100 years. • Spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools. Holism and Integrated Care: • Theory and philosophy that focuses on connections and interactions between parts of the whole; mind, body, emotions, and spirit are all connected to form a whole person. • All living organisms, including humans, are continuously connecting and interacting with their environment. • Parts of the organism, whether they are systems, subsystems, or cells, are also continuously interacting and changing. • This continual interaction and change means that the body is not the sum of its parts (as in reductionism), but that it is a unified, dynamic whole. • Integrated Care: combination of CHA and allopathic approaches- Table 28-2 • Nursing has integrated CHA into our practice holism: theory and philosophy that focuses on connections and interactions between parts of the whole holistic nursing: nursing practice built on a holistic philosophy; heal the whole person Use of CHA in the United States: • Prevalence: more prevalent in women, and adults age 30 to 69 with higher levels of education, people financially well off, people living in the West, former smokers, and adults who were recently hospitalized. Very few people however discuss the use of CHA with their health care provider. • Reasons: to improve health, or resolve symptoms, or wanting to control one's own health. • Most Frequently Used: the use of natural products, deep breathing exercises, meditation, chiropractic care, and yoga. • With Children: Natural products • Growth: Americans have spent over 30 billion dollars a year on CHA products and therapies. • Six tipoffs: One product does it all, Personal testimonials, Quick fixes, All natural, "Miracle Cure", and Conspiracy theories.

Identify patient goals for the phases of the therapeutic relationship.

helping relationship: interaction that sets the climate of movement of the participants toward common goals The Helping Therapeutic Relationship: • Does not occur spontaneously • Characterized by an unequal sharing of information • Built on the patient's needs (Nurse's responsibility to meet those needs). • The nurse is the helper, and the patient is the person being helped. • Communication is the means used to establish rapport and helping-trust relationships. • Dynamic • Purposeful and time limited • Person providing assistance is professionally accountable for the outcomes and the means used to attain them Orientation Phase Goals: First meet the patient and first impression. • Establish tone and guidelines for the relationship. • Identify each other by name. • Clarify roles of both people. • Establish an agreement about the relationship. • Provide the patient with orientation to the health care system, its services, admission routines, and any pertinent information the patient requires to decrease anxiety. The development of a trusting relationship is critical to the development of the nurse-patient relationship. Exhibiting openness and interest in the concerns of the patient paves the way for developing trust and communicating care and respect. Working Phase: bulk of your interactions with the patient. Nurse interactions should include therapeutic communication and building a professional relationship, teaching and giving direct and indirect patient care. • Work together to meet the patient's needs. • Provide whatever assistance is needed to achieve each goal. • Provide teaching and counseling. Termination Phase: can be at the end of a shift, or when the patient is discharged. • Examine goals of helping relationship for attainment. • Make suggestions for future efforts, if necessary. • Encourage patient to express emotions about the termination. • If appropriate, help the patient establish a helping relationship with another nurse. • Assist the patient transferring from one agency to another or from one unit in an agency to another.

Discuss professional responsibilities with electronic communication.

social media: web-based technologies that allow users to create, share, and participate in dialogue in virtual communities and networks Social media networks allow nurses to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Nurses must adhere to Health Insurance Portability and Accountability Act (HIPAA) regulations that protect patient confidentiality and privacy and be aware of their employers' policies about using social media. Nurses are accountable for their use of social media and can be reported to a regulatory authority for an allegation of inappropriate use of social media, reflective of deviation from required professional competencies and standards for practice.

(Chapter 31 (Hinkle Medsurge) Learning Objectives:) Define normal blood pressure and categories of abnormal blood pressure.

• High blood pressure • Defined by the Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg. • Based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider. In table 31-1, people in any of these categories are more at risk for a stroke, heart failure, heart attack and cardiovascular death. People in the pre-hypertension stage should be encouraged to change their nutritional habits and increase their exercise. Stage 1 should be treated with medications and seen by a health care provider every 3-6 months for continued monitoring. Stage 2 will need to be treated more aggressively and seen more often.

Describe ways in which people can communicate non-verbally.

• Verbal (language): Factors include pace (speed of delivery), clarity (right words to convey message), timing (when patient can best receive message). Be careful with humor. • Nonverbal (body language) o Facial expressions, touch, eye contact o Posture, gait, gestures o General physical appearance o Mode of dress and grooming o Sounds, silence o Electronic communication

Compare and contrast the beliefs about the origin of disease and ways to promote health of each of the three main categories of complimentary health approaches.

• Whole medical systems Similar to Allopathic model • Mind-body therapies Relaxation, Meditation, Guided Imagery, Prayer, Aromatherapy • Natural Products Botanicals & Nutritional supplements & therapy Mind-Body Modality: based on awareness of the mind and body being interconnected and that social, familial, and economic factors will affect one's health. • Relaxation: promotes parasympathetic activity to reduce sympathetic activity and balance in the body. Includes mindful breathing, repeating phrases, and meditation. • Meditation: help to quiet and focus the mind and induce relaxation. Two major forms, concentration meditation and mindfulness meditation. In concentration meditation, the focus is on the breath, a sound (mantra), or an object (e.g., a flower). Mindfulness meditation involves directing attention to thoughts, feelings, and sensations—opening up to all stimuli. 4 elements include: Quiet location, Specific comfortable posture, Focus of attention, and Open attitude. • Guided imagery: uses the imagination to create a desired event or scenario. A successful visualization incorporates all five senses to imagine an event or body process unfolding according to a plan, focusing on evoking pleasant images to replace negative or stressful feelings and to promote relaxation. Mind-Body Modalities: Common Types of Yoga: Goal to awaken spiritual identity, and experience peace and happiness. Involves the combination of physical movements, breathing practices, and relaxation practices. • Ashtanga: focuses on synchronizing breath with a fast-paced series of postures • Bikram: is done in a 105-degree studio with 26 set postures • Iyengar: focuses on proper alignment and holding poses for a relatively longer time • Kripaula, or "gentle yoga": focuses on relaxation and coming into balance Qi Gong and Tai Chi: • QI GONG: o System of posture o Exercise—gentle and dynamic o Breathing techniques o Visualization that regulates the qi gong • TAI CHI: o Martial arts o Promotes balance and coordination Acupuncture: Based on Traditional Chinese Medicine (TCM) • Qi flows vertically through body through 12 meridians • Places thin needles at particular acupoints to change flow of energy and restore the balance of yin and yang • Reduces pain, promotes adherence to substance abuse programs, minimizes nausea and vomiting acupuncture: procedure consisting of placing very thin, short, sterile needles at particular acupoints, believed to be centers of nerve and vascular tissue, along a meridian to either increase or decrease the flow of chi along the meridian, restoring the balance of yin and yang, and thereby contributing to healing Chiropractic Medicine Approaches: goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural healing • Spinal adjustment • Heat and ice • Electrical stimulation • Relaxation techniques • Rehabilitative and general exercise • Counseling about diet, weight loss, and other lifestyle factors • Dietary supplements chiropractic health care: profession that focuses on the relationship between the body's structure—mainly the spine—and its functioning; its practitioners primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself Aromatherapy: thought to affect the limbic system in the brain where emotions are stored; must be certified. • Essential Oils • Can also have antibacterial, antifungal, antiviral properties • Must be trained and certified to use with patients aromatherapy: the use of essential oils of plants to treat symptoms Energy Healing Therapies: • Therapeutic touch: A human being is an open energy system. In illness or pain, the free flow of energy is disrupted Anatomically, a human being is bilaterally symmetrical. Illness is an imbalance in an individual's energy field. Human beings have a natural ability to transform and transcend their conditions of living. • Healing touch: goal of restoring wholeness through harmony and balance. • Sound healing or Music therapy: promote wellness, release emotions, manage stress, relieve pain, improve communication, and promote physical rehabilitation. therapeutic touch (TT): an alternative therapy that involves using one's hands to consciously direct an energy exchange from the practitioner to the patient to facilitate healing or pain relief healing touch (HT): uses a collection of energy techniques to assess and treat the human energy system, thereby affecting physical, emotional, mental, and spiritual health and healing Manipulative and Body-Based Practices: Soft tissue and specialized per person. • Therapeutic massage • Goal is to break up tension held in body structures, promote detoxification • Promotes circulation • Requires special training and are used in rehabilitation or health promotion Natural Products: Can be biologically-based, nutritionally-based. NOT monitored by FDA. Non-herbal dietary supplements are not plant products. Examples include hormones, probiotics, vitamins, and minerals. • Botanicals (herbal products) • Nutritional supplements • Nutritional Therapy Whole Medicine Systems: Ayurveda • Originated in Vedic civilization of India • Balance among people, environment, and larger cosmos integral to health, imbalance leads to illness and disease. • Central is patient's basic constitution—dosha Vata (changeable; destruction), pitta (intense; preservation), kapha (relaxed; creation) • Uses nutrition, exercise, herbs, breathing, meditation, massage, aromatherapy, and purification Ayurveda: a science of life that delineates the diet, medicines, and behaviors that are beneficial or harmful for life and considers that balance among people, the environment, and the larger cosmos is integral to human health Key Components of Traditional Chinese Medicine: • Yin-yang theory: the concept of two opposing, yet complementary, forces that shape the world and life Yin: Cool, moist, dark Yang: Hot, dry, light • Qi: a vital energy or life force that circulates in the body through a system of pathways called meridians • Eight principles: cold/heat, interior/exterior, excess/deficiency, and yin/yang (the chief principles) analyze symptoms and categorize conditions • Five elements: fire, earth, metal, water, and wood correspond to organs and tissues and explain how the body works Shamanism: • It is the most widely practiced medical system. • Illness is thought to originate in the spirit world. • The shaman or medicine man/woman accesses the spirit world to obtain information on the proper treatment. • Treatment may consist of retrieving lost soul energy, restoring the individual to right relationship with the spirit world, and treating symptoms. • Healing techniques involve native plants and herbs, animals, rituals, ceremonies, and purification techniques. shamanism: belief that illness originates in the spirit world and usually involves a loss of power; treatment consists of first, restoring the individual's power, and second, treating symptoms Theories of Homeopathy: • "Like cures like": the notion that a disease can be cured by a substance that produces similar symptoms in healthy people • "Law of minimum dose": the notion that the lower the dose of the medication, the greater its effectiveness; many homeopathic remedies are so diluted that no molecules of the original substance remain • "Single Remedy": Treatments are "individualized" or tailored to each person—it is not uncommon for different people with the same condition to receive different treatments. homeopathy: practice of medicine based on the belief of supporting the body while the symptoms are allowed to "run their course" to stimulate and strengthen the immune system and promote healing Principles Underlying Naturopathy: Healing power of nature. • First do no harm • Physician as teacher • Treat the whole person • Prevention • Healing power of nature • Treat the cause