Test 2

Collaborative pathways (critical pathways)

(care maps). specifies the care plan linked to expected outcomes along a timeline. The collaborative pathway is part of a computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each days expected outcomes.

Socioeconomic class

- A persons ___ and financial resources often define the hygiene options available. - lack of funds to obtain toiletries or clean clothing may contribute to inability to maintain personal hygiene Example: • someone renting a room may have limited/no access to a tub/shower and may have limited finances to buy soap shampoo, shaving cream, deodorant • Homeless people (often carry belongings in care/shopping cart) may welcome the warm running water and soap available in roadside/public restrooms.

Functions of the skin: Absorption

- Absorbs substances, such as medications, for local and systemic effects

Functions of the skin: vitamin D production

- Activated by ultraviolet rays from the sun to produce vitamin D

Nursing History: Eyes, Ears, Nose

- Ask to identify any special eye ear or nose care - Address specific care measures related to visual aids or prosthetics (glasses, contacts, artificial eye) and hearing aids. - history of eye ear and nose problems and related treatments

Pressure injury stages

- Blanching (becoming pale and white) of the skin area under pressure may be an early warning sign of potential injury development - when pressure is relieved, blanching, represents ischemia, is rapidly followed by hypermia (reddening of the skin that occurs when pressure is removed) indicating the blood flow to area to nourish and remove waste from the cells. - If the pressure is not removed when ischemia occurs, circulation is further impaired and a pressure injury develops.

Documentation guidelines: Format

- Check to make sure you have the correct chart before writing - Record on the proper form or screen as designated by facility policy - With paper charts, print or write legibly in dark ink to ensure permanence. Use correct grammar and spelling. Use standard terminology, only commonly accepted terms and abbreviations and symbols. alternately, follow computer documentation guidelines - date and time each entry - record nursing interventions chronologically on consecutive lines. never skip lines. draw a single line through blank spaces

Responsibilities

- Check to see that the bathroom is available, clean, and safe. Showers should have mats or nonskid strips to prevent patients from slipping and falling - Ensure that necessary articles- such as skin cleanser, washcloth, towel, and gown- are available for the patient - Provide a place for a weak or physically disabled patient to sit in a shower. Most health facilities have a stool or chair that can be used in the shower, and hand held shower heads may facilitate the process. Some nurses have reported that a commode chair with the pan removed serves effectively as a shower chair and offers the patient more support than a stool or chair - Assist the patient to the shower or bathroom, as indicated. Patients who are beginning ambulation often need assistance to help prevent falling or fainting. - Check to see that the water temperature is safe and comfortable- 100 F to less than 120 to 125. The lower temperature is recommended for children and adults over 65 years of age - Ensure privacy for patients who can safely shower or bathe independently. See that a call device is handy, and make sure the patient knows what the button is for so the patient can obtain help if necessary - Help the patient get in and out of the bathtub, as indicated. Have the patient grasp the handrails at the side of the tub, or place a chair at the side of the tub. The patient sits on the chair as eases to the edge of the tub. After putting both feet into the tub, it is then relatively easy for the patient to reach the opposite side and ease down into the tub. The patient may kneel first in the tub and then sit in it; this process can be reversed when leaving the tub. Use a hydraulic lift, when available, to lower and lift patients who are unable to maneuver safely or completely bear their weight. Some community-based settings have walk-in tubs available. - Keep the bathroom door unlocked. Health personnel should be able to enter with ease if the patient needs help. A sign hung on the door ensures privacy. Never leave children or confused patients alone in the bathroom - Help to wash and dry areas of the body that the patient cannot reach, such as the back - Make any necessary adaptations to achieve person-centered bathing. for example: if the patient is confused and becomes agitated as a result of overstimulation when bathing, reduce the stimuli. Turn down the lights and play soft music and/or warm the room before taking the patient into it. Another alternative is to consider bed bath variations to decrease agitation.

Developmental

- Children learn hygiene practices while growing up. Family practices often dictate hygiene habits, such as morning/evening baths; frequency of shampooing, tooth brushing, clothing changes; feelings about nudity. - Adolescent become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant

Meeting the Oral Hygiene Needs of Patients with Cognitive Impairments

- Choose a time of day when the patient is most calm and accepting of care - Enlist the aid of a family member or significant other. -Break the task into small steps - Provide distraction, such as playing favorite music, while providing care - Allow the patient to participate. The nurse can put a hand over the patient's have to guide the activity. - Start the activity, showing the patient what to do, then let the patient take over. - Withdraw and try again later if the patient strongly refuses - Document effective and ineffective interventions to provide appropriate information for staff to give consistent, person-centered care

Functions of the skin: psychosocial

- Contributes to the external appearance and is a major contributor to self-esteem - Plays an important role in identification and communication

Health state

- 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 tub/shower or from bending to wash lower extremities. - Illness may create a demand for new or modified hygiene measure

Functions of the skin: Temperature Regulation

- Draws heat from the skin as perspiration occurs and evaporates - Dissipates heat as blood vessels in the skin dilate - Compensates for cold conditions with the construction of blood vessels in the skin to diminish heat loss - Compensates for cold through the contraction of pilomotor muscles that cause the hair to stand on end, forming a layer of air on the body for insulation (goosebumps)

Documentation guidelines: Content

- Enter information in a complete, accurate, concise, current, and factual manner - Make sure your documentation reflects the nursing process and your professional responsibilities - Record patient findings (observations and behavior) rather than your interpretation of these findings - avoid words such as "good", "average", "normal" or "sufficient" which may mean different things to different readers - Avoid generalizations such as "seems comfortable today" A better entry would be "On a scale of 1-10 patient rates back pain 2-3 as compared with 7--9 yesterday; VS returned to baseline" - Note problems as they occur in an orderly, sequential manner, record the nursing intervention and the patients response; update problems or delete as appropriate. - Record precautions/preventative measures used - Document in a legally prudent manner. Know and adhere to professional standards and facility/institutional policy for documentation -Document the nursing response to questionable medical records or treatment (for failure to treat). Factually record the date and time the health care provider was notified of the concern and the exact health care provider response. If this occurs by phone, have a second nurse listen to the conversation and cosign the note. If a nurse administrator was contacted, document this. Documentation should give legal protection to the nurse, other caregivers, the health care facility or institution, and the patient - Avoid stereotypes or derogatory terms with charting - Refrain from copying and pasting notes in the EHR, because the data may be outdated or inaccurate

Functions of the skin: Elimination

- Excretes small amounts of water, electrolytes, and nitrogenous waste in sweat

wound healing: proliferation phase

- Fibroblastic, regenerative, or connective tissue phase. - lasts for several week. - New tissue is built to fill the wound space, primarily through the action of fibroblasts- connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. - Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing - Fibroblasts form fibrin that stretched through the clot - A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. - The new tissue, called granulation tissue, forms the foundation for scar development. It is highly vascular, red, and bleeds easily. - In wounds that heal by first intention, epidermal cells seal the wound within 24-48 hours, thus the granulation tissue is not visible - Collagen synthesis and accumulation continue, peaking in 5-7 days. - Depending on the size of the wound, collagen deposit continues for several week or even years - by the end of the second week following injury, the majority of WBC have left the wound area, and the wound is lighter in color, and systemic symptoms typically disappear. During this phase adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care consideration. - Wounds that heal by secondary intention eventually follow the same process but take longer to heal and form more scar tissue. - Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue - Connective tissue healing and repair follow the same phase in healing. However, the differences occur in the length of time required for each phase and in the extent of granulation tissue formed

Nursing History: Oral Cavity

- Identify the patients normal oral hygiene practices and the variables influencing these practices. Note the history of any oral problems and related treatments. - Identify any variables known to cause oral problems, such as deficient self-care abilities, poor nutrition, or excessive intake of refined sugars, family history of periodontal disease, or ingestion of chemotherapeutic agents that produce oral lesions. - Patients at increased risk for oral problems include those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed. Mental health problems are also at risk for alterations in oral health. Mouth breathers, those who can have no oral intake of nutrition or fluids, those with nasogastric tubes or oral airways in place, and those who have had oral surgery are also at increased risk

Nursing History: Hair

- Identify usual hair/scalp practices (styling preference) - History of hair/scalp problems (changes in distribution, texture, amount of hair) - Factors known to cause problems such as deficient self-care, immobility, malnutrition

Developmental Considerations: Skin

- In children younger than 2, the skin is thinner and weaker than it is in adults - An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to and infection of the skin and mucous membranes - A child's skin becomes increasingly resistance to injury and infection - The structure of the skin changes as a person ages. In older adults, the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

Glossitis

- Inflammation of the tongue -can be caused by deficiencies of vitamin b12, folic acid, and iron

Principal of wound healing

- Intact skin is the first line of defense against microorganism. A break in the integrity of the skin increases the risk for infection. Careful hand and hygiene before caring for a wound is probably the single most effective method for preventing wound infections - The body responds systemically to trauma in any of its parts. For example, a surgical incision can cause a variety of systemic reactions, including increased body temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes - An adequate blood supply is essential for the body's normal response to any injury. The blood transports increased numbers of leukocytes, erythrocytes, and platelets to the site of injury. Antibodies are carried by plasma. Increased circulation to the injured part removed toxins and debris and provides nutrients and oxygen. Areas of the body with a good blood supply, such as the head and the neck, heal faster than areas in which the blood supply is not as great, such as the distal part of an extremity - Normal healing is promoted when the wound is free of foreign material, such as excessive exudate, dead or damaged tissue cells, pathogenic organisms, or embedded fragments of bonte, metal, glass, or other substances. In some situations, a collection of pus or foreign body is walled off and healing occurs around it from an abscess - The ability to handle altered skin integrity depends on the extent of the damage and the person's general state of health. The capacity to deal adequately with a wound is limited when a healthy person sustains a massive injury, when the patient has a chronic illness or a depressed immune system, or when the patient is very young or very old - The body's response to a wound is more effective if proper nutrition has been maintained - Undernourished patients are at greater risk fro developing a wound infection because they have difficulty mounting their cell-mediated defense system associated with t-lymphocyte activity, and some leukocytic functions are diminished in the presence of protein deficiency. - Although the role of fatty acids in wound healing is not well understood, certain quantities of glucose are necessary to meet the energy requirements for wound healing - Various vitamins, minerals, and trace amounts of elements are also needed for efficient wound healing. Vitamin A is necessary for collagen synthesis and epithelialization. Vitamin B complex serves as a cofactor of enzyme reactions needed for wound healing.Vitamin C is needed for collagen synthesis, capillary formation, and resistance to infection. Vitamin K is needed for the synthesis of prothrombin. Zinc, Copper, and Iron assist in collagen synthesis. Manganese serves as an enzume activator

Cultural variations

- It is important to identify ___ that could affect a patient's personal hygiene preferences, such as typical bathing habits, and behaviors, such as use of various hygiene-related products. -example: • people from some cultures place a high value on personal cleanliness and feel unclean unless they shower or bathe at least once daily. • many consider bathing incomplete without the use of products to reduce or mask normal body odors. • others may find a weekly bath sufficient and may feel no need to mask normal body odors. • culture may also influence whether bathing is a private or communal activity

Integumentary system

- Largest organ of the body - made up of skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including the hair and nails.

Nursing History: Nails/feet

- Normal nail & footcare practices (footwear worn, history of nail/foot problems and treatments) - Foot problems are common in people with diabetes mellitus and peripheral vascular disease - education can prevent complications (ulcers, lower extremity amputations) - problems known to cause nail and foot problems, deficient self-care, vascular disease, arthritis, diabetes mellitus, history of biting nails/ trimming improperly, frequent/prolonged exposure to chemicals in water, trauma, ill-fitting shoes, obesity

Wound healing: Hemostasis

- Occurs immediately after the initial injury. - Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. - After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming liquid called exudate. - exudate causes swelling and pain - Increases perfusion results in heat and redness - If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury - Platelets are responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing

Factors in Pressure Injury Development

- Pathologic changes at a pressure injury site result from blood vessel collapse caused by pressure, usually from body weight. - Necrosis eventually occurs, leading to the characteristic ulcer. External pressure that compresses blood vessels and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin contribute to pressure injury development External Pressure - Usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue to cushion damage to the skin. - Most occur over the sacrum and coccyx followed by the trochanter and the calcaneus (heel) - The major predisposing factor is external pressure applied over an area, which results in osculated blood capillaries and poor circulation to tissues. Insufficient circulation deprives tissues of oxygen and nutrients, which lead to ischemia-deficiency of blood in a particular area- edema, inflammation, necrosis and ulcer formation. - can occur in as little as 1-2 hours if the patient has not moved or been repositioned to allow circulation to flow to dependent areas. Friction and Shear Friction occurs when 2 surfaces rub against each other. A patient who lies on wrinkled sheets is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often are injured due to friction when patients lift and help move themselves up in bed with the use of their arms and feet. Friction burns can also occur on the back when patients are pulled/slid over sheets while being moved up in bed/transferred onto a stretcher. Shear results when one layer of tissue slides over another layer. Separates the skin from underlying tissues. Small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Patients who are pulled, rather than lifted, when being moved are at risk for injury from shearing force.Patient who is partially sitting up in bed is susceptible when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed.

documentation guidelines: confidentiality

- Patients have a moral and legal right to expect that the information contained in their patient health record will be kept private. Students should be familiar with the facility policy and pertinent legislation about who has access to patient records other than the immediate caregiving team and the process used to obtain access) - Most facilities allow students to access to patient records for educational reasons. Students using patient records are bound professionally and ethically to keep in strict confidence all the information they learn by reading patient records. Actual patient names and other identifiers should not be used in written or oral student reports ?

Personal preferences

- People have different preferences with regard to hygiene practices such as taking a shower vs. tub, using bar vs liquid soap, and washing to wake oneself or relax before sleep - Self-concept and sexuality also influence personal hygiene practices.

Providing Body Piercing Care

- Perform hand hygience before providing care. Explain what you are going to do. Put on gloves - Clean the jewelry and the piercing side of all crust and debris. Rinse the site with warm water and use a cotton swam to gently remove any crusting. Rinse well. Remove gloves. Perform hand hygiene. - Advise patients to avoid the use of alcohol, peroxide, and ointments at the side - Oral piercing aftercare includes rinsing with an antibacterial, alcohol-free mouthwash for 30-60 secs after meals and bedtime. The patient should brush the teeth with a new, soft-bristled toothbrush - Advise patients to avoid oral tobacco use - Most piercings take 6-8 weeks to heal, but some may take several months of a year to heal.

Wound Healing

- Process of tissue response to injury - Injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue. - Fills the gap caused by tissue destruction, restoring the structural integrity of the damaged tissue through the orderly release of growth factors and chemical mediators. This helps to increase the blood supply to the damaged area, wall of and remove cellular and foreign debris, and initiate cellular development - Occurs by primary intention, secondary intention, or tertiary intention. - Wounds healed by primary intention are well approximated (skin edges tightly together) - Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal with secondary intention - If a wound that is healing from primary intention becomes infected, it will heal by secondary intention - secondary intention takes longer to heal and forms more scar tissue - Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed

Scheduled hygiene care

- Provide this care at regular intervals. - In most hospitals and long-term care settings, early morning care, morning care, afternoon care, hour of sleep care, and care as needed are provided

Benefits of an Health Information Exchange

- Provides a vehicle for improving quality and safety of patient care - Provides a basic level of interoperability among EHRs maintained by individual health care providers and organizations - Stimulates consumer education and patients involvement in their own health care. - Helps public health officials meet their commitment to the community - Creates a potential loop for feedback between health-related research and actual practice -Facilitates efficient deployment of emerging technology and health care services - Provides the backbone of technical infrastructure for leverage by national and state-level initiatives

Dermis

- Second layer of skin - Framework of elastic connective tissue comprised primarily of collagen. - Nerves, hair follicles, glands, immune cells, and blood vessels are located in this layer

Hippa, Patients have the right to:

- See and copy their health record - update their health record - get a list of disclosures that a health institution has made independent of disclosures made for the purpose of treatment, payment, and health care operations - request a restriction on certain uses of disclosures - choose how to receive health information

Bathing needs for patients with dementia

- Shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient. Focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness - Individualize patient care. Consult the patient, the patient's record, family members, and other caregivers to determine patient preferences. - Consider what can be learned from the behaviors associated with dementia about the needs and preferences of the patient. A patient's behavior may be an expression of unmet needs; unwillingness to participate may be a response to uncomfortable water temperatures or levels of sound or light in room - Ensure privacy and warmth - Consider the use of music to soothe anxiety and agitation - Consider other methods of bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options - Maintain a relaxed demeanor. Use calming language. Use one-step commands. Try to determine phrases and terms the patient understands in relation to bathing and make use of them. Offer frequent reassurance. - Encourage independence. Use hand-over-hand or a guided hand technique to cue the patient regarding the purpose of the interaction and allow the patient to perform some of the activities independently. - Explore the need for routine analgesia before bathing. Move limbs carefully and be aware of signs of discomfort during bathing. - Wash the face and hair at the end of the bath or a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia.

Skin

- The bodys first line of defense, protecting the underlying structures from invasion by organisms. - Covers the entire body and is continous with mucous membranes at normal body orifices. - Essential for maintaing life.

Reasons why outcomes are not met or only partially emt

- The initial assessment data was incomplete - The outcomes or time frame was not realistic - The outcomes or interventions planned were not appropriate for the patient or the situation

Functions of the skin: Immunologic

- Triggers immunologic responses when broken

Factors affecting skin inegrity

- Unbroken and healthy skin and mucous membranes serve as the first lines of defense against harmful agents - Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person age, the amount of underlying tissue, and illness conditions - Adequately nourished and hydrated body cells are resistant to injury. The better nourished the cell is, the better able it is to resist injury and disease - Adequate circulation is necessary to maintain cell life. When circulation is impaired for any reason, cells receive nourishment and cannot remove wastes effectively

Spiritual Practices

- ___, including religious beliefs, may dictate ceremonial washings and purifications, sometimes as a prelude to prayer or eating. Example: • Orthodox Jewish tradition, ritual baths are required for women after childbirth and menstruation. • some religions, contact with a deceased person or a deceased animal may make a person "unclean" • some dictate that no modern facilities be installed in homes. - prohibiting running water and toilets resulting in bathing infrequently

Functions of the skin: protection

- acts as a barrier to water, microorganisms, and damaging ultraviolet rays of the sun - protects against infection - protects against injury to underlying tissues and organs - prevents loss of moisture from the surface and underlying structures

implementation

- always document the care given as well as the patient's response and involvement in the interventions - Be aware of any new patient problems or safety risks that may arise during the implementation process - prioritize nursing interventions based on patient's well-being, and perform those interventions first - RN's write nursing diagnoses, expected outcomes, and nursing interventions: LPNs may implement the intervention identified by the RN - Be aware of the state and institutional policies for delegation of tasks to unlicensed assistive personnel and LPNs- know what can and cant be delegated

Hair

- an accessory structure of the skin. - good general health is essential for attractive __ and skin, and cleanliness is a positive influence. - Illness affects the __, especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety and worry are present. - Changes in color or condition of the __ shaft are related to changes in hormonal activity or to changes in the blood supply to __ follicles.

Wound

- break or disruption in the normal integrity of the skin and tissues. - may range from a small cut on a finger to a 3rd degree burn covering almost all of the body. -may result from mechanical forces (such as surgical incisions) - physical injury (such as a burn) Classification: intentional or unintentional (based on how they were acquired) open or closed acute or chronic (based on whether the wound follows the normal, timely healing process or not)

Documentation guidelines: Timing

- document in a timely manner. Follow facility policy regarding the frequency of documentation and modify this if changes in the patients status warrant more frequent documentation - If you forget to document something, record it as soon as you can, following the procedures for making late entries. -Indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. This is crucial when a case is being reconstructed for legal purposes - Most facilities use military time, one 24- hour time cycle, to avoid confusion between am and pm - Document nursing interventions as closely as possible to the time of their execution. The more seriously ill the patient, the greater the need to keep documentation current. Never leave the unit for a break when caring for a seriously ill patient until all significant data was recorded - never document interventions before carrying them out - Write a progress note for each of these instances • upon admission, transfer to another unit, and discharge • When a procedure is performed • upon receiving a patient postoperatively or post procedure • upon communicating with health care providers regarding critical patient information • any changes in patient status

Promoting skin health

- easy and effective way to promote the barrier function of the skin and keep the skin healthy is the daily use of soap substitutes, topical moisturizers and emollients and barrier products - Soap cleans the skin, but at the same time it removes dirt from the surface, it affects the lipids that are present on the skin and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. The use of mild cleansers with pH close to skin pH is recommended. - Topical emollient agents (moisturizers) can be applied to the skin as a lotion, cream, gel, or ointment. They act to seal water into the skin and replace lipids in the skin, effectively hydration the skin and recreating its waterproof barrier. - Skin barrier products include breams, ointments, and films. These products are used to protect vulnerable skin and to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces. They are also used to prevent skin breakdown around stomas and wounds with excessive exudate.

Nursing Interventions

- help address the issues related to/causing the "nursing problem" -The treatments/interventions performed by the nurse are to help achieve patient outcomes -are evidence based

Mucous membranes

- line body cavities that open to the outside of the body, joining with the skin. - can be found in the digestive tract, the respiratory passages, and the urinary and reproductive tracts. -Have receptors that offer the body protection - absorb substances from their surface

Integumentary syste

- made up of the skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including glands in the skin, hair, and nails; also includes the blood vessels, nerves and sensory organs of the skin.

Wound healing: Maturation phase

- maturation (remodeling), final stage of healing - Begins about 3 weeks after the injury, possibly continuing for months or years. - collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue. - New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scare eventually becomes a flat, thin line. - Wounds that heal by secondary intention take longer to remodel and form a scar smaller than the original wound

Nursing History: Perineal and Vaginal Areas

- note history of problems - Identify variables known to cause problems such as urinary or fecal incontinence, an indwelling foley catheter, childbirth, douching, rectal or genital surgery, and diseases such as urinary tract infection, diabetes mellitus, STI's

Data collection sources

- patient - Family/caregives/significant others - patient record - other healthcare professional

Dressing purposes

- provide physical, psychological, and aesthetic comfort - prevent, eliminate, or control infection - absorb drainage - Maintain moisture balance of the wound - protect the wound from further injury - protect the skin surround the wound - debride (remove damaged/necrotic tissue), if appropriate - Stimulate and/or optimize the healing process - Consider ease of use and cost effectiveness

Nursing History: Skin

- question the patient about any past or current skin problems and changes in their skin (rashes, lumps, itching, dryness, lesions), as well as recent surgeries, wounds, tattoos, or piercings. When skin problems are present, ask: • 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?

Wound healing: Inflammatory phase

- second phase, following hemostasis and lasts about 2-3 days. - White blood cell,s predominately leukocytes and macrophages, move to the wound. - Leukocytes arrive first to ingest bacteria and cellular debris. - Approx. 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. They are essential to the healing process because they ingest debris and release growth factors that are necessary for the growth of epithelial cells and new blood vessels. - Growth factors produced by the macrophages attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. - Acute inflammation is characterized by pain, heat, redness, and swelling at the side of the injury - During this phase the patient has a generalized body response, including mildly elevated temperature, leukocytosis (increases number of WBC) and general malaise.

Perineal cleaning

- should be performed in a matter-of fact and dignified manner. - Patients with incontinence are at risk for perineal skin damage which is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of perineal skin from friction on moist skin. Skin care should include measures to reduce over-hydration (excess exposure to moisture), contact with ammonia and bacteria, and friction. Remove soil and irritants from the skin during routine hygiene, and clean the area when the skin becomes exposed to irritants. perineal skin cleansers, moisturizers, and barriers is recommended.

documentation guidelines: accountability

- sign your first initial, last name , and the title to each entry. Do not sign notes describing interventions not performed by you that you have no way of verifying - Do not use dittos, erasures, or correcting fluids. Draw a single line through and incorrect entry, and write the words "mistaken entry" or "error in charting" above or beside the entry and sign. Then rewrite the entry correctly - Identify each page of the record with the patient's name and identification number - Recognize that the patient record is permanent. Follow facility policy pertaining to the color of ink and the type of pen or ink to be used. Ensure that the patient record is complete before sending it to medical records

Bed baths

- some patients must remain in bed as part of their therapeutic regimen but can still bathe themselves - Other patients are not on bed rest but require total or partial assistance with bathing in bed due to physical limitations, such as fatigue or limited ROM. Measures to help patients take a bed bath: - Provide the patient with articles for bathing. If using a basin of water for bathing, ensure the water is comfortable and safe temperature. Place these items conveniently for the patient on a bedside stand or overbed table. - Provide privacy for the patient. Make sure the call device is within reach - Place cosmetics in a convenient place for the patient. Provide a mirror, a good light, and hot water for patients who wish to shave with a razor - Assist patients who cannot bathe themselves completely. For example: some patients can wash only the upper parts of the body. Nursing personnel thne completes the remainder of the bath.

nursing process, accomplish:

- systematically collect patient data (assessing) - Clearly identify the patient strength and actual and potential problem (diagnosing) - Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning) - Execute the care plan (implementing) -Evaluat the effectiveness of the care plan in terms of patient goal achievement (evaluating)

Epidermis

- top layer of skin - Composed of layers of stratified epithelial cells which form a protective, waterproof layer of keratin material - Have no blood vessels of their own and depend on underlying tissues for nourishment and waste removal - when well nourished, regenerates relatively easily and quickly

Cheilosis

- ulceration and dry scaling of the lips with fissures at the angles of the mouth - most often caused by vitamin b complex deficiencies (especially riboflavin)

subcutaneous tissue

- underlying layer than anchors the skin layers to the underlying tissue of the body. - consists of adipose tissue, made up of lobules of fat cells, and connective tissue. - Stores fat for energy, serves as heat insulator for the body, and provides cushioning for protection. - Contains blood and lymph vessels, nerves, and fat cells

Perineal

-The __ area is dark, warm, and often moist, providing conditions that favor bacterial growth. -Neglecting cleaning for the patient who cannot provide self-care often results in physical and psychological discomfort for the patient, skin breakdown, and offensive odors.

General skin care principles

-assess the patients skin daily - cleanse the skin when indicated, such as when soiled using a no rinse ph balanced cleanser - avoid using soap and hot water -avoid excessive friction and scrubbing - minimize skin exposure to moisture (incontinence, wound leakage) use a skin barrier product that is necessary - use emollients (moisturizer)

Ear care

-cleansing -cerumen removal -hearing aid care Suggestions to help improve hearing: - Avoid noisy places for conversation - Choose well-lit places where it is easier to look at the speakers face, lips, and hands for cur to the conversation - Cup you hands behind your ear - Ask people to face you when they are speaking to you - Ask people to repeat what they said, if it was not clear to you, and to speak slowly - Consider buying amplifying devices so that you can hear you TV and radio without turning up the sound

As needed care (p.r.n. care)

-offer individual hygiene measure as needed -change clothing and bed linens of diaphoretic patients -provide oral care every 2 hours if indicated

Maslow's heierachy

1. Self actualization: morality, creativity, spontaneity, acceptance 2. Self-esteem: confidence, achievement, respect of others 3. love and belonging: friendship, family, intimacy, sense of connection 4. Safety and security: health, employment, property, family and social stability 5. Physiological needs: breathing, food, water, shelter, clothing, sleep

steps of planning

1. establish/determine priorities 2. Identify and write expected patient behavioral outcomes- a measurable standard used to assess whether or not the goal has been met 3. select appropriate evidence-based nursing interventions to meet these outcomes 4. communicate plan of care

Mouth and teeth

A person's general health influences the health of that person's ___, and proper care lends to overall health. - There is an established relationship between health ___ and a diet sufficient in calcium and phosphorus, along with vitamin D, which is necessary for the body to make use of these minerals. - Healthy conditions contributes to an intact body image. The beginning of the digestive process and tasting pleasure are enhanced. - poor health is associated with diabetes, cardiovascular disease, and metabolic syndrome

Tethered/Connected PHRs

A tethered, or connected, PR is linked to a specific health care organization's EHR system or to a health plan's information system. With a tethered PHR, patients can access their own records through a secure portal and see, for example, this trend of their lab results over the last year, their immunization history, or due dates for screenings.

Acute and Chronic Wounds

Acute - heal within days to weeks - wound edges are well approximated (edges meet to close skin surface) - risk of infection is low - usually progress through the healing process without interruption Chronic - do not progress through the normal sequence of repair - healing process is impeded - wound edges are often not approximated - risk for infection is increased - normal healing time is delayed >30 days - Remain in inflammatory phase of healing - include any wound that does not heal along the expected continuum, such as wounds related to diabetes, arterial or venous insufficiency, and pressure injuries.

Scar

An avascular collagen tissue that does not sweat, grow hair, or tan in sunlight. - The strength of the scar tissue remains less than that of normal tissue, even many years following injury and it is never fully restored. - If it is over a joint or other body structure, it may limit movement and cause disability

Plaque

An invisible, destructive, bacterial film that builds up on everyone's teeth and eventually leads to the destruction of tooth enamel.

Wound Complications: Dehiscence and Evisceration

Are the most serious post-op wound complications Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Evisceration is the most serious compilations of dehiscence. It occurs primarily with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area. Patients at greater risk for these complications include: obese and malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of (serosanguineous) fluid from the wound between post-op days 4-5 may be a sign of an impending dehiscence. If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the HCP. Once dehiscence occurs, the wound is managed like an open wound. Dehiscence and evisceration of an abdominal incisions is a medical emergency. Place the patient in the low Fowler's position and cover the exposed abdominal contents keeping the exposed viscera moist. Do not leave the patient alone, and be sure to provide reassurance and intravenous pain medications as appropriate. Notify the PCP immediately. This situation is an emergency that required prompt surgical repair so that patient should also be kept NPO

Hour of sleep care (H.S. care)

Before the patient goes to bed, offer to toilet them again, wash face and hands, and oral care. This is also a good time for a back massage as patients find it soothing and may help them to fall asleep. Some patients may also find a bath to be soothing and sleep promoting at this time. At this time it is also important to change soiled linens, position the patient comfortably, and ensure the call be is within reach.

Focus Charting

Bring focus of care back to the patient and the patient's concerns. A focus column is used that incorporates many aspects of a patient and patient care. Focus may be patient strength, problem, or need. Topics may be include patient concerns and behaviors therapies, responses, changes in condition, and significant events such as teaching, consultation, monitoring, management of activities of daily living, or assessment of functional health patterns. narrative portion of focus used the Data-Action-Response (DAR) format. Principle advantage of focus charting is the holistic emphasis on the patient and the patients priorities

Computed Tomography (CT scanning)

CT scanning is a noninvasive radiographic procedure whereby a body part can be scanned from different angles with an x-ray beam and a computer that calculates varying tissue densities and records a cross-sectional image

Personal Health Records

Contain the person's medical history, including diagnoses, symptoms, and medications. Some patient's scan in doctors notes, test results, CT images, and insurance information. Chief reason for a PHR to provide easy access to up-to-date, complete health information to assist in self care and communication with providers

Electronic health records

EHR and the ability to exchange health information electronically can help you provide higher quality and safer care for patients while creating tangible enchancements for your organization. Help providers better manage care for patients and provide better health by: - Proving accurate, up-to-date, and complete information about patients at the point of care - Enabling quick access to patient records for more coordinated, efficient care - securely sharing electronic information with patients and other clinicians - helping provide more effectively diagnose patients, reduce medical errors, and provide safer care - Improving patient and provider interaction and communication, as well as health care convenience - Enabling safer, more reliable prescribing -Helping promote legible, complete documentation and accurate, streamlines coding and billing - Enhancing privacy and security for patient data - Helping providers improve productivity and work-life balance - Enabling providers to improve efficiency and meet their business goals - Reducing cost through decreased paperwork, improved safety, reduced duplication of testing, and improved health

Afternoon care (p.m. care)

Ensure that the patient is comfortable after lunch and offer assistance with toileting, handwashing, and oral care. Straighten the bed or help someone to reposition for comfort.

Factors affecting wound healing: Systemic Factors

Factors not related to the wound itself also can prolong wound healing Age: • major skin layers arise from different embryologic origins, resulting in poor adherence between the epidermis and the dermis. This loose binding between the layers causes the layers to separate easily during an inflammatory process, placing infants and small children at risk for impaired skin integrity. Epidermal stripping, the unintentional removal of the epidermis with tape removal, is one type of such injury. Care should be taken to minimize tension, traction, and wrinkles on the skin when using tape on young patients. • Children and healthy adults, however, heal more rapidly than do older adults, in whom physiologic changes caused by aging result in diminished fibroblastic activity and circulation. Older adults are more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. Circulation and Oxygenation: Adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing. Certain physical conditions, because of their effect on circulation and oxygenation, can affect wound healing. Circulation may be impaired in older adults and in people with peripheral vascular disorders, cardiovascular disorders, hypertension, or diabetes mellitus. Oxygenation of tissues is decreased in people with anemia or chronic respiratory disorders and in those who smoke. In addition, large amount of subcutaneous and tissue fat (which has fewer blood vessels) in people who are obese may slow wound healing because fatty tissue is more difficult to suture, is more prone to infection, and takes longer to heal. Nutritional Status: Wound healing required adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and protein are necessary to rebuild cells and tissues. Vitamins A and C are essential for epithelialization and collagen syntheses. Zinc plays a role in proliferation of cells. Fluids are necessary for optimal function of cells. All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional states and fluid balance. Some patients who are obese suffer from protein malnutrition, which interferes with healing. Patients who are undernourished may lack the nutritional stores to promote wound healing. Wound Etiology (cause): Knowing the etiology (cause) of a wound directly impacts on assessment and treatment of the wound. It may also indicate the general health status of the patient and the associated likelihood of future wounds.For example, a wound that stems from a decrease in arterial blood flow to the extremities, a systemic issues, may recur; however, a wound from a spider bite may be a one-time even Medications and Health Status: Patients who are taking corticosteroid drugs or require postoperative radiation therapy are at hight risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection. The presence of a chronic illness (such as cardiovascular disease or diabetes mellitus) or impaired immune function can impair wound healing. Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including cells involved in would healing. Prolonged antibiotic therapy increases a patient's risk for secondary infection and superinfection Immunosuppression: Suppression of the immune system as a result of disease (e.g., AIDS, lupus), medication (e.g., chemotherapy), or age (e.g., Changes associated with advancing age) can delay wound healing Adherence to Treatment Plan: Non-adherence to the treatment place can negatively impact wound healing

Factors affecting wound healing: Local factors

Factors occurring local to the wound can prolong wound healing. Pressure: Disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing Desiccation (dehydration): Process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. Wounds that are kept moist and hydrated experience enhanced epidermal cell migration, which supports epithelialization (epithelial cell migration to the wound) Maceration (overhydration): Softening and breakdown of skin, results from prolonged exposure to moisture. Overhydration of cells related to urinary/fecal incontinence can also lead to maceration and impaired skin integrity. This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin. Trauma: Repeated trauma to a wound area results in delayed healing or the inability to heal. Edema: Interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue Infection: Bacteria in a wound increases stress on the body, requiring increased energy to deal with the invaders. Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job or repair and healing. In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death. Excessive Bleeding: Results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood or drainage of any type is an excellent place for growth of bacteria and promotes infection Necrosis (death of tissue): Dead tissue present in the wound delays healing. Dead tissue appears as slough- moist, yellow, stringy tissue- and eschar (appears ad dry, black, leathery tissue). Healing of the wound will not take place with necrotic tissue in the wound. Removal of dead tissue must occur for healing to being Biofilm (a thick grouping of microorganisms): Are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and protein. This barrier contributes to decreased effectiveness of antibiotics against bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient. The bacteria also produce a protective matrix that attaches the biofilm to the wound surface. Biofilms impair wound healing and contribute to chronic wound inflammation and wound infection

Wound Complications: Fistula Formation

Fistula- abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. They may be created purposefully (an arteriovenous (AV) fistula is created surgically to provide circulatory access for kidney dialysis) Is often the result of infection that has developed into an abscess- a collection of infected fluid that has not been drained. Accumulated fluid applies pressure to surrounding tissues, leading to the formation of unnatural passage between two viscous organs or an organ and the skin. The presence of a fistula increases the risk for delayed healing, additional infection, fluid and electrolyte imbalances, and skin breakdown

gliding joint

Flat surfaces of the bone slide over one another; flexion-extension and abduction-adduction can occur (e.g., carpal bones of wrist and tarsal bones of feet).

Wound Complications: Hemorrhage

Hemorrhage may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain. Check dressing and wound frequently during the first 48 hours after injury. If excessive bleeding does occur, additional pressure dressing or packing may be necessary, fluid replacement is probably necessary, and surgical intervention may be required. Internal hemorrhage causes the formation of a hematoma- a localized mass of usually clotted blood. If the bleeding leads to a large accumulation of blood, it can put pressure on surrounding blood vessels and cause tissue ischemia (deficiency of blood to an area)

ISBAR communication technique

Identity/ Introduction: communicate who you are, where you are, and why you are communicating Situation: Communicate what is occurring and why the patient is being handed of to another department or unit Background: Explain what led to the current situation and put it in context if necessary Assessment: give your impression of the problem Recommendation: Explain what you would do to correct the problem

tartar

If unchecked, plaque builds up and, along with dead bacteria, forms hard deposits at the gum lines. attacks the fivers that fasten teeth to the gums and eventually attacks bone tissue. teeth loosen and fall out

Risk for Pressure Injury Development

Immobility: Patients who spend long periods of time in bed or seated without shifting properly are at great risk for pressure injury. Patients who are unconscious and paralyzed, those with cognitive impairments, or those with other physical limitation such as a fracture, are subject to pressure injuries if allowed to remain in one position for extended time. Emotionally depressed at risk due ot not moving around much. Nutrition and Hydration Protein-calorie malnutrition predisposes a person to pressure injury formation because poorly nourished cells are damaged easily. Protein deficiency leading to a negative nitrogen balance, electrolyte imbalances, and insufficient caloric intake also predispose the skin to injury. Vitamin c deficiency causes capillaries to become fragile, resulting in poor circulation. Dehydration/edema can interfere with circulation and subsequent cell nourishment Moisture Prolonged moisture on the skin reduces the skin's resistance to trauma, particularly damage from friction and shear. When skin is damp (incontinence, perspiration, drainage) it required less friction to blister and abrade, which can lead to pressure injury. Incontinence makes the kin more susceptible to incontinence-associated dermatitis (IAD), which is characterized by inflammation and/or breakdown and erosion of the skin due to exposure to stool or urine. IAD occurs primarily because stool exposes the skin to digestive enzymes and urine over hydrates the skin and makes the skin more alkaline, which is abnormal and impacts on the ability of the skin to resist pathogens. Mental Status Apathy, confusion, or a comatose state can diminish self-care abilities and increase the likelihood of skin breakdown Age Older adults are at a greater risk because the aging skin is more susceptible to injury. Chronic and debilitating diseases which are also common may adversely affect circulation and oxygenation of dermal structures, and problems with malnutrition and immobility all pose risk for pressure injury development

Progress notes

Inform caregivers of the progress a patient is making toward achieving expected outcomes.

Intentional and unintentional wound

Intentional wound - the result of planned invasive therapy or treatment. - - - Purposefully created for therapeutic purposes. - Examples: surgery, intravenous therapy, lumbar puncture. - Wound edges are clean and bleeding is normally controlled. - Risk for infection is decreased and healing is facilitated because it was made under sterile condition Usually healed by primary intention Unintentional Wounds - Accidental. - occur from unexpected trauma, such as accidents, forcible injury (stabbing or gunshot) and burns. - contamination is likely because the wound occurred in an unsterile environment - wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled which created high risk for infection and longer healing time

enema

Introduction of a solution into the large intestine, usually to remove feces

Wound assessment

Involves inspection (sight and smell) and palpation for appearance, drainage, odor and pain. Determines the status of the wound, identifies barriers to the healing process, and identifies signs of complications

Documentation

Is the written or electronic legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating

Providing eye care

Normally eyes are kept clean with lacrimal secretion however during illness the eyes may produce more secretions than normal Use the following techniques when secretion adhere to the eyelashes and become dry and crusty - Wear gloves during the cleaning procedure - Use water or normal saline and a clean washcloth or compress to clean the eyes. Never use soap to clean the eyes because soap is irritating to eye tissue. - Dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. Turn the cleaning cloth and use a different section for each stroke. - Continue this technique, using a different section of the cleaning cloth for each stroke, until the eye is clean - If the eyelashes are matted with secretions or debris that cannot be removed by wiping, apply a warm, wet compress to the closed eye for 3-5 mins to loosen the secretions so that they may be removed in a painless manner

Progress notes

Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes

Open and Closed wound

Open Wound - intentional or unintentional. - Skin surface is broken, providing a portal of entry for microorganisms - bleeding, tissue damage, and increased risk for infection and delayed healing may accompany Closed Wound - results from a blow, force, or strain caused by trauma such as fall, assault, or a motor vehicle accident. - skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur

Stage 2

Partial-thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present an intact or ruptured serum-filled blister.

Providing Perineal Care

Perineal care may be carried out while the patient remains in bed. When performing perineal care, follow these guidelines: - Assemble supplies, and provide for privacy - Explain the procedure to the patient, perform hand hygiene, and put on disposable gloves - Wash and rinse the groin area (both male and female patients). Use a small amount of mild nonsoap cleaning agent and water, or disposable cleaning cloth - For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over the genital area. Always proceed from the least contaminated area to the most contaminated area. Use a clean portion of the washcloth for each stroke. Rinse the washed areas well with plain water. - For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Always proceed from the least contaminate area to the most contaminated are. Rinse the washed areas well with plain water. In an uncircumcised male patient, retract the foreskin (prepuce) while washing the penis. Pull the uncircumcised male patient's foreskin back into place over the glans penis to prevent constriction of the penis, which may result in edema and tissue injury. It is not recommended to retract the foreskin for cleaning during infancy and childhood, as injury and scarring could occur. Wash and rinse the male patient's scrotum. Handle the scrotum, which houses the testicles, with care because the area is sensitive - Dry the cleaned areas and apply an emollient as indicated. Avoid use of powder. Powder may become a medium for the growth of bacteria. - Turn the patient on their side and continue with cleansing the anal area. Continue in the direction of least contaminated to most contaminated. In the female, cleanse from vagina towards the anus. In both female and male patients, change the part of the washcloth being used with each stroke until the area is clean. Rinse and dry the area. - Remove gloves and perform hand hygiene. Continue with additional care as necessary

Wound Complications: Pressure Injury

Pressure Injury (decubitus ulcer, pressure sore, bedsore)- localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device. (OG:pressure ulcer) - may be acute or chronic. - most develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction. - Costly in terms of patient discomfort, disfigurement, decreased quality of life, and health care expenditures. - Most occur in older adults as a result of aging skin, chronic illnesses, immobility, malnutrition, fecal/urinary incontinence and altered level of consciousness. - Other at risk: People with spinal cord injuries, traumatic brain injuries, or neuromuscular disorders where sensory perception may be altered. - Aggressive intervention/ treatment can spare the patient unnecessary pain/discomfort, prevent further tissue deterioration, hasten wound healing, and save millions of health care dollars.

Negative Pressure Wound Therapy

Promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria of the wound, and the removal of excess wound fluid, while providing a moist wound healing environment

Functions of skin

Protection temperature regulation psychosocial sensation vitamin D production immunologic absorption elimination

Bathing

Purpose: - cleaning the skin -Acting as a skin conditioner - Helping to relax a restless person - Promoting circulation by stimulating the skin's peripheral nerve endings and underlying tissues - Serving as a musculoskeletal exercise through activity involved with bathing, thereby improving joint mobility and muscle tonus. - Stimulating the rate and depth of respirations - Promoting comfort through muscle relaxation and skin stimulation - Providing sensory input - Helping to improve self-image - Providing an excellent opportunity to strengthen the nurse-patient relationship, to thoroughly assess the patient's integumentary system, to observe the patient's physiologic and emotional status closely, to teach the patient as indicated, and to demonstrate care and interest in that patient's general welfare.

SMART

S:Specific: state what you'll do, use action words M: Measurable: provide a way to evaluate/ use metrics or data targets A: Achievable- within your scope/ possible to accomplish/attainable R: Relevant- Makes sense within your job function/ improves the business in the same way T: Time-Bound- state when you'll get it done/ be specific on dae or time frame

maintaining normal voiding habits

Schedule, Urge to Void, Privacy, Position, and Hygiene.

Continent Urinary Diversion

Shows how the ureters are diverted into a segment of ileum and cecum in an Indian pouch. A surgical alternative that used a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma.

Measuring wounds and pressure injuries

Size of the wound - Draw the shape and describe it - measure the length, width, and diameter (if circular) Depth of the wound - Perform hand hygiene, put on gloves - Moisten a sterile, flexible applicator with saline and inset it gently into the wound at a 90-degree angle with the tip down - Mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin - Remove the swab and measure the depth with a ulcer Wound Tunneling - Use standard precautions; use appropriate transmission-based precautions when indicated - Perform hand hygiene. Put on gloves. - Determine direction: Moisten a sterile, flexible applicator with saline and gently inset a sterile applicator into the site where tunneling occurs. View the direction of the applicator as if it were the hand of a clock. The direction of the patient's head represents 12 o'clock. Moving in a clockwise direction, document the deepest sites where the wound tunnels. - Determine the depth: while the applicator is inserted into the tunneling, mark the point on the swab that is even with the wound's edge, or grasp the applicator with thumb and forefinger at the point corresponding to the wound's margin. Remove the swab and measure the depth with a ruler - Document both the direction and the depth of tunneling

SOAP

Subjective data Objective data Assessment (caregivers judgement about the situation) Plan - used to organize entries in the progress notes of the POMR

postvoid residual (PVR)

The amount of urine remaining in the bladder immediately after voiding

Critical/collaborative pathways

The case management plan is a detailed, standardized plan of care that is developed for a patient population with a designated diagnosis or procedure. It includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

MICTURITION, voiding urination

The process of emptying the bladder

bedside report

The trend today is toward a standardized, streamlines shift report system at the bedside. the oncoming and outgoing nurses seeing the patient together, reviewing medication records and the health care providers and nursing orders, and establishing patient goals for the shit

Functional Incontinence

Urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory or disorientation

Discharge summary

When a patient is discharged from care or transferred from one unit, institution, or facility to another. Should be written that concisely summarizes the reason for treatment, significant findings, the procedures performed and treatment rendered, the patient's condition on discharge/transfer, and any specific pertinent instructions given to the patient and familt.

therapeutic relationship

When the relationship between the carer and the person who is being cared for is focused on promoting or restoring the health and well being of the person being cared for in the relationship

Wound Complications: Infection

Wound complications include infection, hemorrhage, dehiscence, evisceration, and fistula. These complication increase the risk for generalized illness and death, lengthen the patient's need for health care interventions, and add to health care costs. Infection: Wound infection results when that patient's immune system fails to control the growth of microorganisms. Microorganisms can invade a wound at the time of trauma, during surgery, or at any time after the initial wound occurs. A contaminated wound is more liked to become infected than one that is not contaminated. Additionally, the risk of infection is increased in a surgical wound created during a procedure involving the intestines because the risk for contamination with fecal material is high. Wound infections also occur as a result of hospital-acquired infection. Symptoms of wound infection usually become apparent within 2-7 days after the injury or surgery; often, the patient is at home. Symptoms include: purulent drainage, increased drainage, pain, redness, and swelling and around the wound, increased body temperature, and increased WBC, delayed healing and discoloration of granulation tissue in the wound. In patients with infection in a chronic wound, pain and delayed healing may be the only symptoms. Wound infections impair healing. Wound infections can lead to other complications, including development of chronic wounds, osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood or tissue)

Adequate

___ skin hygiene, including foot care, contributes to maintaining skin condition and integrity, and important first line of defense, preventing and entry of pathogens, minimizing absorption of harmful substances, and preventing excessive water loss

sinus tract

a cavity or channel underneath the wound that has the potential for infection

health promotion

a clinical judgement concerning motivation and the desire to increase wellbeing and human potential

patient record

a compilation of a patients health information

Outcome and Assessment Information Set (OASIS)

a group of data elements that: - represent core items of a comprehensive assessment for an adult home care patient - Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement. useful for outcome monitoring, clinical assessment, care planning, and other internal facility-level applications. Encompass sociodemographic, environmental, support system, health station, and functional status attributes of nonmaternity adult patient

Source-oriented record

a paper format in which each health care group keeps date on its own separate form. Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel.

Purposeful rounding

a proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs.

syndrome

a specific cluster of nursing diagnoses that occur together and are best addressed/ treated

hinge point

a spool like surface of one bone fits into a concave surface of another bone; only

halitosis

a strong mouth odor or persistent bad taste in the mouth

ileal conduit

a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel.

NUrsing process

a systematic method that directs the nurs, with the patient's participation to: 1. Assess the patient to determine the need for nursing care. 2. determine nursing diagnoses for actual and potential health problems. 3. Identify expected outcomes and plan care. 4. implement the care. 5. evaluate the results

Critical thinking

a systematic way to form and shape ones thinking

Nursing Process

a systematic, rational, and organized step by step problem solving method for planning and providing individualized care

Incident Reports (variance report/ occurrence report)

a tool used by health care facilities to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a patient, employee, or visitor.

Evaluation statement

a two-par statement: how well the outcome is met and patient information/evidence to support this conclusion. Followed by signature

alopecia

absence or loss of hair

dependent interventions

activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.

Independent interventions

activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills

Morning care (a.m. care)

after breakfast, complete morning care, which includes: bathing, oral care, toileting, mouth care, back massage, special skin care measure (decubitus ulcer or fungal infection), hair care (includes shaving if indicated), cosmetics, dressing, and positioning. This is the time to change the bed linens and tidy the bedside area also. When completed, patient should feel refreshed and should be in a comfortable/ safe environment - self-care (patients are capable of managing their personal hygiene independently once oriented in the bathroom), partial care (patient most often receive morning hygiene care at the bedside or seated near sink in the bathroom), complete care (patients require nursing assistance with all aspects of personal hygiene. Complete bed bad)

Risk assessment: Waterlow Scale

age and gender (sex), build and weight, continence, skin type, mobility, nutrition, and special population-specific risks

information specialists

aim to create an environment that supports timely, accurate, secure, and confidential recording and use of patient- specific information

confidential information

all information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. - patient names and all identifiers such as address, telephone and fax number, social security number, and any other personal information includes the reason the patient is sick or in the hospital, office, or clinic, the assessment and treatments the patient receives, and information about past health conditions

Health Information Exchange (HIE)

allows doctors, nurses, pharmacists, or other health care providers, and patients to appropriately access and securely share a patient vital medical information electronically, improving the speed, quality, safety and cost of patient care.

ileostomy

allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma

Dressing

an ideal __ should maintain a moist environment, be absorbent, provide thermal insulation, act as a barrier, reduce or eliminate pain at the wound site, and allow for pain-free removal

patient record purpose

ana states that the most important is "communicating within the health care team and providing information for the professional, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research and quality activities

Urinary incontinence

any involuntary loss of urine

oral malignancies

appearing as lumps or ulcers - must be distinguished from benign mouth problems because early detection may lead to cure, later detection can lead to radical surgery or death

Transient incontinence

appears suddenly and lasts for 6 months or less. Caused by treatable factors: confusion secondary to acute illness, infection and as a result of medical treatment, such as the use of diuretics or intravenous fluid administration

LPN role: nursing process

assist with and follow the established plan

bacteriuria

bacteria in the urine

Foot care;

bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections

hematuria

blood urine, may be caused by anticoagulants

Indwelling Urethral catheter

catheter that remains in place for continuous urine drainage; synonym for Foley catheter

affective outcomes

changes in patient values, beliefs, and attitudes.

a risk nursing diagnoses

clinical judgements that a patient is vulnerable to develop certain problmes

Care plan

communicate the patients problems or diagnoses' related goals, outcomes, and interventions and progress or resolution of the problems.

suppository

conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature

Resident Assessment Instrument

consists of 4 basic components: - Minimum data set- a core set of screening, clinical, and functional status elements that form the foundation of the comprehensive assessment of all residents in long-term care facilities certified to participate in medicare and medicaid. The items in the minimum data set standardize communication about resident problems and condition. - Triggers: Specific resident responses for one or a combination of minimum data set elements that identify residents who either have or are at risk for developing specific functional problems and who require further evaluation using resident assessment protocols. - Resident Assessment Protocols: Structured, problem-oriented frameworks for organizing minimum data set information and examining additional clinically relevant information about a resident. Resident assessment protocols help identify social, medical, nursing, and psychological problems and form the basis for individualized care planning - Utilization guidelines: specified in state operation manuals that direct when and how to use the RAI

Sanguineous drainage

consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

confer

consult with someone to exchange ideas or to seek information, advice or instructions.

Documentation records

contain data used to facilitate quality, evidence-based patient care, serve as financial and legal records, help in clinical research, and support decision analysis

urine

contains organic, inorganic, and liquid wastes

total incontinence

continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation.

Orthopedics

correction or prevention of disorder of body structures used in locomotion

Caries

decay of teeth with the formation of cavities

Stage 1

defined, localized area of intact skin with nonblanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Intact skin with a localized area of nonblanchable erythema. Presence of blanchable erythema

cognitive outcomes

describe increases in patient knowledge or intellectual behaviors

psychomotor outcomes

describe the patients achievement of new skills

Evaluate

determine if goals were met and outcomes achieved. - the final step in the nursing process - is a continuous process - Document patient responses to each intervention - Determines if the patient achieved the outcomes - Determines if the care plan will be continues, modified, or completed

factors affecting bowel eliminat

developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic processes, medications, and procedures, such as diagnostic tests and surgery

Professional codes of ethics, facility policies, and state and federal privacy legislation

dictate how patient information can be communicated (spoken verbally and in writing), where and how it can be stored, the appropriate people and entities to whom it may be divulges, and the purposes for which it may be divulged.

Paralytic Ileus

direct manipulation of the bowel during abdominal surgery inhibits peristalsis

Cystoscopy

direct visual examination of the bladder, ureteral orifices, and urethra with a cystoscope. It is used to view, diagnose, and treat disorders of the lower urinary tract, interior bladder, urethra, male prostatic urethra, and ureteral orifices.

cerumen

ear wax

Flow sheets

efficiently record routine aspects of nursing care. - Enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being.

critical thinking indicators

evidence-based descriptions of behaviors that demonstrate knowledge, characteristics, and skills that promote critical thinking in clinical practices

Reflex Incontinence

experience emptying of the bladder without the sensation of the need to void

factors influencing elimination

food and fluid intake: intake and output should be about the same Psychological Variables Activity and Muscle Tone: immobility, decreased bladder and sphincter tone, childbearing, muscle atrophy due to decreased estrogen levels Pathologic Conditions: Diseases associated with renal problems included congenital urinary tract abnormalities, polycystic kidney disease, UTI, urinary calculi (kidney stones), hypertension, diabetes mellitus, gout, and certain connective tissue disorders Medications nephrotoxic (capable of causing kidney damage). Abuse of analgesics, can cause nephrotoxicity.

Stage 4

full-thickness tissue loss with exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on some part of the wound bed; epibole, undermining and/or tunneling often occur Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendion, ligament, cartilage or bone in the ulcer. slough.eschar may be visible. Epibole (rolled edges), undermining and or tunneling often occur. Depth varies by anatomical location.

Stage 3

full-thickness tissue loss. Subcutaneous fay may be visible and epibole (rolled wound edges) may occur. (bone, tendon, or muscle is NOT exposed)/ May include undermining and tunneling Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Depth of tissue damage caries by anatomical locations. Areas of significant adiposity can develop deep wounds.

Assess

gather information about the patient and/or situation - collection and verify data from sources - cues, inferences, cali

cleaning enemas

given to remove feces from the colon - relieve constipation or fecal impaction - prevent involuntary escape of fecal material during surgical procedures - promote visualization of the intestinal tract by radiographic or instrument examination - Help establish regular bowel function during a bowel-training program

factors affecting movement and alignment

growth and development, physical health, mental health, lifestyle variables, attitude and values, fatigue and stress, and external factors such as weather influences

function of the kidney

help maintain the composition and volume of body fluids.

self-actualization needs

highest level of hierarchy which include the need for people to reach their full potential through development of their unique capabilities

Diagnose

identify patient's problems or problem at hand - interpret and analyze data - identify patient strengths and weakness/health problems - Formulate nursing diagnosis -prioritize - Statement that describes the patient's actual or potential response to a health problem that the nurse is licensed and competent to treat

Purpose of the nursing process

identify, diagnose and treat human responses to actual or potential problems to health and illness. organization quality individualization flexibility collaboration

HIPPA

if a health institution wants to release a patients health information for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization Permitted Disclosure of PHI while the authorization rule covers most situations in which patient information is released for purposes other than treatment, payment, and routine health care operations, there are some exceptions to the authorization rule for the good of the general population. These 3 exceptions show situations in which authorization is NOT required prior to releasing the patients information: Public health activities - tracking and notification of disease outbreaks - infection control - statistics related to dangerous problems with drugs or medical equipments Law Enforcement and Judicial Proceedings - Medical records crucial to the investigation and prosecution of a crime - medical records to identify victims of a crime or disaster - Medical personnel reporting incidents of child abuse, neglect, or domestic violence - Medical records released according to a valid subpoena Deceased people - PHI needed by coroners, medical examiners, and funeral directors - PHI needed to facilitate organ donations - PHI provided to law enforcement in the case of a death form a potential crime Incidental Disclosure of PHI incidental disclosure of PHI defined as a secondary disclosure that cannot reasonably be prevent, is limited in nature, and occurs as a by-product of an otherwise permitted use of disclosure of PHI Examples: - Use of Sign-In sheets: provided that the sign-in sheet does not contain information on the reason for the patients visit - The possibility of a confidential conversation being overheard: provided that the surrounds are appropriate for a confidential conversation and voices are kept down - Placing a patient charts outside exam rooms: provided that unauthorized public traffic is not permitted in the area of the exam rooms and face sheets are turned toward the wall - Use of white boards: provided that only the minimum information needed for the purpose of the white board is used - X-Ray light boards that can be seen by passer-by: Provided that patient x-rays are not left unattended on the light board - Calling out names in the waiting room: provided that the reason for the patients visit is not mentioned - Leaving appointment reminder voicemail message: provided that the minimum amount of info is disclosed

Removing Contact Lenses

if a patient wears contact lenses but is unable to remove them, use the following guideline to safely remove them Rigid Gas Permeable (RGP) Lenses - If the lens is not centered over the cornea, apply gentle pressure on the lower eyelid to center the lens - Gently pull the outer corner of the eye toward the eye - Position the other hand below the lens to receive it and ask the patient to blink Alternately - Gently spread the eyelids beyond the top and bottom edges of the lens - Gently press lower eyelid up against the bottom of the lens - After the lens is tipped slightly, move the eyelids toward one another to cause the lens to slid out between the eyelids Soft Contact Lenses - Have the patient look forward. Retract the lower lid with one hand. Using the pad of the index finger on the other hand, move the lends down on the sclera - Using the pads of the thumb and index finger, grasp the lens with a gentle pinching motion and remove Storing Lenses storage cases are marked L and R, designating left and right lenses, as lenses may be different for each eye. It is important to place the first lens in its designated cup in the case before removing the second lens to avoid mixing them

cutaneous ureterostome

incontinent cutaneous urinary diversion which the ureters are directed through the abdominal wall and attached to an opening in the skin

computerized documentation and electronic health records

increasingly, computer systems are used for nursing docummentation in the patient record: in such systems the nurse may: 1. Call up the admission assessment on the computer screen and key in patient data 2. Develop the care plan using computerized care plans available for each North American Nursing Diagnosis Association (NANDA)= approved diagnosis or other approved problem list 3. Add to the patient database as new data are identified and modify the care plan accordingly 4. Receive a work list showing the treatments, procedures, and medications necessary for each patient throughout the shift. 5. Document care immediately, using the computer terminal at the patients bedside

Mixed Incontinence

indicates that there is urine loss with features of two or more types of incontinence

Prediculosis

infestation with lice - pediculus humanus capitis- infests the hair and scalp - Pediculus humanus corporis- Infests the body - Phthirus pubis- infests the shorter hairs on the body, usually the pubic and axillary hair

Gingivitis

inflammation of the gingiva, the tissue that surrounds the teeth

stomatitis

inflammation of the oral mucosa - numerous causes, such as bacteria, virus, mechanical trauma, irritants, nutritional deficiencies, and systemic infection. - Symptoms may include heat, pain, increased flow of saliva, and halitosis

RN role: nursing process

initiate, evaluate and follow the established plan

promoting normal nuringation

interventions to support normal voiding habits fluid intake strengthening of muscle tone stimulating urination resolving urinary retention assist with toileting.

Overflow Incontinenve

involuntary loss of urine associated with overdistention and overflow of the bladder

stress incontinence

involuntary loss of urine related to an increase in intra-abdominal pressure

fecal incontinence

involuntary or inappropriate passing of stool or flatus

barium Enema

involves a series of radiographs that examine the large intestine after rectal installation of barium sulfate

Serosanguineous drainage

is a mixture of serum and red blood cells. It is light pink to blood tinged.

serous drainage

is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.

Change-of-shift report (handoff)

is given by a primary nurse to the nurse replacing them, or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient

Purulent drainage

is made up of WBC, liquified dead tissue debris, and both dead and live bacteria. is thick, often has a musty or foul odor, and varies in color (such as dark yellow/green, depending on the causative organism.

Endoscopy

is the direct visual examination of body organs or cavities.

caring

is the human mode of being

Ergonomics

is the practice of designing equipment and work tasks to conform to the capability of the worker and proves a means for adjusting the work environment and work practices to prevent injuries

Fissures

linear break on the margin of the any

Pressure injuries

may be classified as 1- partial thickness where all or a portion of the dermis is intact 2- Full thickness where the entire dermis and sweat glands and hair follicles are severed, which can expose bone, tendon, or muscle 3. unstageable, a full-thickness loss where the true depth cannot be determined; may also involve deep tissue injury

Dry oral mucosa

may simply be related to dehydration or may be caused by mouth breathing alteration in salivary functioning or certain medications

Urodynamic studies

measure how urine flows, is stored, and is eliminated in the lower urinary tract. Used to identify abnormal voiding patterns in people with incontinence or the inability to void normally

Risk assessment: Braden scale

mental status, continence, mobility, activity, and nutrition. 19-23 indicates no risk. 15-18 mild risk, 13-14 moderate risk 10-12high risk and 9 or lower very high risk

protected health information

might be found in the patient medical record, computer systems, telephone calls, voice mails, fax machines, emails that contain patient information and conversations about patients among clinical staff

Renal Ultrasound

noninvasive procedure that involves the use of ultrasound to visualize the renal parenchyma and renal blood vessel. It is used to characterize renal masses and infections, visualize large calculi; detect malformed kidneys; provide guidance during other procedures, such as biopsy; and monitor the status of renal transplant and kidney development in children with congenital processes

etiology

nursing interventions derived from the cause (____) of the problem

thoughtful practice

nursing practice that is considerate and compassionate. A thoughtful nurse always keeps the person at the center of caregiving in order to promote the humanity, dignity, and well being of the patient.

collecting data

observing, interviewing, examining

urinary retention

occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated: medications, an enlarged prostate, or vaginal prolapse

Stress Incontinence

occurs where there is an involuntary loss of urine related to an increase in intra-abdominal pressure. Occurs during coughing, sneezing, laughing, or other physical activities.

Intermittent Urethra catheters

or straight catheters, are used to drain the bladder for shorter periods.

Problem-oriented medical record (POMR)

organized around a patient's problems rather than around sources of information. All health care professionals record information on the same forms. The entire health care team works together in identifying a master list of patient problems. Includes the defined database,problem list, care plans, and progress notes

patient care summary

overview of valuable patient information

physiologic needs

oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest must be met at least minimally to maintain life

Standalone PHRS

patients fill in information from their own records, and the information is stored on patients' computers or the Internet. In some cases, a standalone PHR can also accept data from external sources, including providers and laboratories. With a standalone PHR, patients could add diet or exercise information to track progress over time. Patient can decide whether to share the information with providers, family members, or anyone else involved in their care

incontinent

patients who experience involuntary or uncontrolled loss of urine

continent

patients who have self-control over urination

autonomic bladder

people whose bladders are no longer controlled by the brain because of injury or disease also void by reflex only

Implement

perform or "put in to action" the nursing interventions identified during the planning phase - The "action" phase of the nursing process - Describes the performance of nursing interventions necessary for achieving the expected outcomes - Reassess- during each encounter with the patient, the nurse assesses the patients function (may need revisions) - document action taken

Periodontitis

periodontal disease, is marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms: bleeding gums, swollen, red, painful gum tissue, receding gum lined with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; loose teeth

contractures

permanent contraction of a muscle

colostomy

permits formed feces in the colon to exit through the stoma

Risk assessment: Norton scale

physical and mental conditions, activity, mobility, and incontinence

physiologic outcomes

physical changes in the patient

problem focused

present a problem that has been validated by defining characteristics

suspected deep-tissue injury

presents as persistent, nonblanchable purple or maroon discoloration of intact or nonintact skin, or separation of the epidermis that reveals a dark wound bed or blood-filled blister. May initially present as a painful, firm, mushy, boggy, warmer, or co bb area as compared to adjacent tissue. Usually results from intense and/or prolonged pressure and shearing where the bone and muscle interface. Wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.

documentation: commuication

primary purpose of the patient record is to help health care professionals form different disciplines (who interact with the patient at different times) communicate with one another. - fosters continuity of care

bowel training program

program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas

narrative notes

progress notes written by nurses in a source-oriented record. Address routine care, normal findings (findings that do not call for changes in the care plan), and patient problems identified in the care plan.

incontinence associated dermatitis

prolonged contact of the skin with urine or feces leads to form of moisture-associated skin damage

fecal impaction

prolonged retention of an accumulation of fecal material that formas a hardened mass

confidentiality provision of the patient safety rule

protect identifiable information being used to analyze patient safety events and improve patient safety

Health Insurance Portability and Accountability Act (HIPAA)

protects the privacy of individually identifiable health information

magnetic resonance imagin

provides physiologic information and detailed anatomic views of tissues using a superconducting magnet and radio frequency signals

Retrograde Pyelogram

radiographic and endoscopic examination of the kidneys and ureters, with placement of ureteral catheter up to the level of the renal pelvis as part of the endoscopic examination. Contrast material is then injected into the renal pelvis through the ureteral` catheter, followed by radiographic images

Intravenous pyelogram (excretory or intravenous urography)

radiographic examination of the kidney and ureter after a contrast material is injected intravenously. used to diagnose renal disease and urinary tract dysfunction

Graphic record

record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, fluid intake and output, bowel movements, and other patient characteristics.

Nephrons

remove the end products of metabolism, such as urea, creatinine, and uric acid from the blood plasma and form urine. Maintain and regulate fluid balance through the mechanisms of selective reabsorption and secretion of water, electrolytes, and other substances

HIPPA breach not

required covered entities and business associates to provide notification following a breach of unsecured protected health information

Retention Enema

retention enemas are retained in the bowel for a prolonged period for different reasons

self-esteem needs

second highest level of hierarch, which includes the need for a person to feel good about them-self, to feel pride and a sense of accomplishments

safety and security

second priority and have both physical and emotional component. physical safety and security means being protected from potential and actual harm

Plan

set goals for care and desired outcomes- identify appropriate nursing interventions -establish "goal or outcome" for your patient based off of your data collection, assessment, findings and nursing problem/diagnosis -develop strategies (interventions) for caring for the health problems and to achieve outcomes

HIPPA Security Rule

sets national standards for the security of electronic protected health information

Charting by exception

shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented.

Early morning care

shortly after the patient wakes up, assisting them with toileting and then providing comfort measures to refresh the patient and prepare them for breakfast, including washing the face and hands and providing mouth care.

The Joint Commision

specifies that nursing care data related to patient assessment, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the patient record - only permanent legal document that detail's the nurses's interactions with the patient.

State of health: skin

state of a person health and therapeutic treatments have a direct effect on the condition of the skin. Proper nutrition, adequate circulation, and good overall health are important for healthy skin - Very thing and very obese people tend to be more susceptible to skin irritation and injury - Fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body. This is termed fluid volume deficit or dehydration (depending on whether there are intracellular and or/ intravascular and sodium loss) and makes the skin appear loose and flabby - Excessive moisture such as perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. Excessive moisture may also occur as a result of incontinence of urine/stool - Jaundice, a condition caused by excessive bile pigment in the skin, results in a yellowish color. The skin is often itchy and dry; patients with jaundice are more likely to scratch their skin and cause open lesion, with the potential for infection - Diseases of the skin such as eczema and psoriasis may have a genetic predisposition and often causes lesions that require special care

functions of teh skeletal sustem

supporting the soft tissues over the body protectin crucial components of the body furnishing surfaces for the attachments of muscles, tendons, and ligaments which in turn pill on the individual bones and produce movement providing storage areas for minerals such as calcium and fat producing blood cells (hematopoiesis)

ostomy

surgically formed opening from the inside of an organ to the outside

PIE charting

system is unique in that it does not develop a separate care plan. Care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). Patient assessment is performed and documented at the beginning of each shift. Patient problems identified in these assessment are numbered, documented in the progress notes, worked up using the Problem, Intervention, Evaluation format, and evaluated each shift

eschar

tan, brown , or black hardened dead tissue (necrosis). Stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels or ischemic limb should not be removed or softened.

Tonus

term used to describe the state of slight contraction- the usual state of skeletal muscles

Nails

the __ are an accessory structure of the skin composed of epithelial tissue - Healthy __ beds are pink, convex, and evenly curved. - With certain pathologic conditions, and to some extent with again, the __ become ridged and areas become concave. - Hygienic care includes keeping the __ trimmed and clean

Wound care

the goal of wound care is to promote tissue repair and regeneration so that the skin integrity is restored

bowel incontinence

the inability of the anal sphincter to control the discharge of fecal and gaseous material

verval order

the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency when the physician or nurse practitioner is present by finds it impossible, owing the emergency situation to write the order. the order must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist, who receives, reads back, documents, and executes the order.

stoma

the opening of the ostomy attached to the skin

condyloid joint

the oval head of one bone fits into a shallow cavity of another bone. flexion-extension and abduction-adduction can occur

Patient care ergonomics

the practice of designing the equipment and work tasks to conform to the capability of the worker in relation to patient care

defecation

the process of bowel Elimination

consultation

the process of inviting another professional to evaluate the patient and make recommendations to you about the patient's treatment

Referral

the process of sending or guiding the patient to another source for assistance

read back

the recipient reads back the message as they heard and interpreted it. The person giving the order then confirms that such recording and interpretation of the order is correct.

ball and socket joint

the rounded head of one bone fits into a cuplike cavity in the other; flexion-extension, abduction-adduction, and rotation can occur

Bariatrics

the science of providing health care for those who have extreme obesity, taking both a patient's weight and the distribution of this weight throughout the body into consideration. Patients with bariatric needs are at increased risk of skin breakdown and therefore required focused nursing care to prevent skin issues.

Interdependent interventions

therapies that require the combined knowledge, skill, and expertise of multiple health care providers

abdominal ct scan

thin beams of x rays are directed at and moved around the abdomen, resulting in computer-manipulated pictures that are not obscured by overlying anatomy

love and well being

this is the 3rd priority. includes the understand and acceptance of others in both giving and receiving love, and the feeling of belong to groups such as families, peers, friends, and neighborhood/communities

Initial nursing assessment

typical electronic form used to record the initial database obtained from the nursing history and physical assessment. Provide baseline for later comparisons as the patient conditions change.

occurence charting (variance charting)

unexpected event, the cause of the even, actions taken in response to the event. and discharge planning.

suprapubic catheter

used for long term continuous drainage

abdominal ultrasound

uses ultrasound waves to visualize orange via a small transducer places against the skin

esophagogastroduodenoscopy

vistual examination of the esophagus, the stomach, and the duodenum

colonoscopy

visual examination of the large intestine from the anus to the ileocecal valve

sigmoidoscopy

visual examination of the sigmoid colon, the rectum, and the anal canal

unstageable

when the clinician is unable to visualize the extent of tissue damage due to slough or eschar, pressure injuries are classified as ___. Eschar and/or slough must be removed before the stage can be determined.

niuretics

which commonly are used in the treatment of hypertension and other disorders, prevent the reabsorption of water and certain electrolytes in the tubules.

Specific gravity

which is the measure of the density of urine compared with the density of water

Slough

yellow, tan, gray, green, or brown dead tissue