3106: EXAM 2
Three pressure-related factors contribute to pressure ulcer development:
(1) pressure intensity, (2) pressure duration, and (3) tissue tolerance.
Magnesium
(1.3-2.1 mEq/L) Role -Activator in many key enzyme reactions -Exerts similar effect as Ca++ on neuromuscular function -Used to prevent convulsions for preeclampsia
Hypomagnesemia
(<1.3mEq/l) -Rare if adequate diet -Often occurs with other imbalances -If Mg++ low, can't correct K+and Ca++ imbalances -Often seen in critically ill -Alcoholism
physical examination
(conducted during a nursing history and at any time a patient presents a symptom)
Patient-centered interview
(conducted during a nursing history)
Periodic assessments
(conducted during ongoing contact with patients)
Metabolic acidosis
(nonrespiratory cause) -Excess of fixed acids -pH decreases (< 7.35), HCO3 (< 21mEq/L) A cardinal sign! -Compensation: buffer, lungs á resp.& depth to blow off CO2, kidneys excrete H+ and retain HC03 -Noncarbonic acids increase (renal insufficiency) or bicarb decreases -Lungs compensate by getting rid of CO2
Respiratory acidosis
-*Hypoventilation and retention of CO2 -Retain C02 leads to carbonic acid build up -Decrease pH <7.35 -Compensation: buffer system, kidneys excrete more H+, conserve HCO3 -Kidneys conserve bicarb and secrete acids
Assessment data sources
-*Patient (Best, primary source of data) -Family caregivers and significant others -Health care team -Medical records -Other records and the scientific literature -Nurse's experience
Body Composition of a 70 kg Male
-70 kg Man: -42 L of water: -30 L ICF -11 L ECF (of this 8L interstitial, 3L plasma) 5-6 L of fluid is secreted into and reabsorbed from the GI tract every day, loss of this fluid from vomiting or diarrhea can produce serious fluid and electrolyte imbalances.
Nursing diagnosis
-A clinical judgment made by a nurse to describe a patient's response or vulnerability to health conditions or life events that a nurse is licensed and competent to treat (NANDA-I, 2018b). -The 2nd step in the nursing process.
Nursing Process
-A critical thinking five step process that professional nurses use to apply the best available evidence to deliver nursing care. -Enables nurses to deliver holistic, patient-centered care (ANA, n.d.) -A problem Solving Process to plan care. -Is in orderly, systematic, cyclical. -Involves the patient with the goal being to nurture the patient to maintain health. -It is dynamic and changing, constantly moving back and forth between the steps. -Begins with first contact with the patient.
Collaborative Problem
-A problem that requires both medicine and nursing interventions to treat. -All physiological complications are not collaborative problems. -If a nurse can prevent the onset of a complication or provide the primary treatment for it, then the diagnosis is a nursing diagnosis. -Collaboration will better manage the multiple factors that influence the health of individuals, families, and communities.
How do I prioritize the Nursing Diagnosis:
-ABC's - Airway, Breathing, Circulation -Basic Needs - Maslows Hierarchy of Needs -Safety
Sodium (Na+)
-Accounts for 90% of extracellular fluid cations -Necessary for proper fluid balance -Imbalances in sodium impact ECF/ICF fluid balance. -Critical electrolyte for nerve conduction -Kidneys are primary regulator of sodium balance -Adults: 136-145 mEq/L
Causes of Hypomagnesemia
-Alcoholism-causes decrease in Mg absorption in intestines due to decrease in liver enzymes -Severe or chronic malnutrition -Malabsorption syndromes- (Crohn's) -GI losses -Renal losses -Prolonged IV or TPN without Mg++ replacement -Drugs: antacids inhibit uptake of mag from intestines -Excessive calcium intake inhibits Mg++ absorption -Drugs: antacids inhibit uptake of Mg++ from intestines -Excessive calcium intake inhibits Mg++ absorption
Standard Nursing Interventions
-Allow nurses to act more quickly and appropriately -Help capture patient care information that can be shared across disciplines and care settings
Maintenance and promotion of lung expansion
-Ambulation: therapeutic benefits of activity include increase in general strength and lung expansion -Positioning: frequent changes of position reduce stasis of pulmonary secretions and decreased chest wall expansion -Incentive spirometry: pic
What is spirituality?
-An awareness of one's inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself. -Includes personal beliefs that help a person maintain hope and get through difficult situations. -The human spirit is powerful, and spirituality has different meanings for different people. -Nurses need to be aware of their own spirituality to provide appropriate spiritual care to others.
Scientific Knowledge Base
-An individual's intrinsic spirit seems to be an important factor in healing. -Healing often takes place because of believing. -Spirituality has a positive impact on the ability to cope with anxiety, stress, and depression. -A person's inner beliefs and convictions are powerful resources for healing.
Critical Thinking Prompts the Nurse to.....
-Answers the question "what if..." -Guides actions and interventions -Allows the thinker to anticipate needs -Bring together many sources of data, discard what is not important, and determine a course of action
Arterial Blood Gases (ABG)
-Arterial Blood Gases (ABG) -Three parts of the ABG give you information about acid/base status. -pH - measure of hydrogen ion concentration -PaCO2 - partial pressure of carbon dioxide (respiratory component) -HCO3 - bicarbonate (metabolic component) -PaO2 - oxygen status
Normal Fluid Delivery
-Arterial pressure drives fluid from the vascular space -Venous pressure is lower and allows fluid and wastes to return to the vascular space -Albumen prevents overdelivery of fluids and supplements venous return by drawing fluid out
Spiritual Health: Assessment
-Ask about their faith/belief system, religious source, life's satisfaction, connectedness with community/culture, understanding of their illness' limitations or threat to their wellbeing -use open-ended questions -Assessment expresses a level of caring and support -Taking a faith history reveals patient's beliefs about life, health, and a Supreme Being -Through the patient's eyes -Assessment tools: -Listening -Ask direct questions -FICA (Faith, Importance, Community, Address) -Spiritual well-being (SWB) scale -BE COMPASSIONATE AND REMOVE PERSONAL BIASES
Assessing Spirituality
-Assess the patients faith and beliefs -Review the patient's view of life, self-responsibility, and life satisfaction -Assess the extent of the patient's fellowship and community -Review if the patient practices religion and rituals
Five steps of the nursing process
-Assessment -Nursing Diagnosis -Planning and Outcome Identification -Implementation -Evaluation
Patient Teaching - Hypermagnesemia
-Avoid constant use of antacids and laxatives that contain Mg, especially if urine output is decreased -Increase fiber -Drink adequate fluids to promote fecal elimination (if not contraindicated)
Water balance
-Balance of H20 intake and excretion -Controlled by thirst and the kidneys (action of ADH) released in hypothalamus
Follow these guidelines to ensure safe medication administration:
-Be vigilant during med admin & avoid distractions -Ensure patients receive the appropriate meds -Know why your patient is receiving each medication; what you need to do before, during, and after med admin; and evaluate the effectiveness of meds and any adverse effects. -Verify that medications have not expired -Use 2+ identifiers before administering medications, and check against the MAR -Before administering med, ensure all info is correct -Clarify unclear medication orders and ask for help whenever you are uncertain about an order or calculation. -Use strict aseptic technique during parenteral medication prep and admin -Educate patients about each medication they take while administering meds. -Most of the time cant delegate med admin -Follow safety guidelines to prevent needlestick injuries.
Safety Guidelines For Nursing Skills (med admin)
-Be vigilant during medication administration. -Verify that medications have not expired by checking labels. -Use at least two identifiers before administering meds, and check against the MAR -Before administering medication, check for accuracy three times. -Clarify unclear medication orders and ask for help if needed. -Use the technology available in your agency when preparing and giving medications. -Use strict aseptic technique during parenteral medication preparation and admin -Educate patients about each medication. -Most of the time you cant delegate med admin -Follow safety guidelines to prevent needlestick injuries.
Goals
-Broad statement that describes client change -Client specific -The opposite of the diagnostic stem -Short-term: (Usually < a week, acute care may be hours) -Long-term: (days, weeks or months) -Often based on standards of care or clinical guidelines established for minimal safe practice.
Metabolic acidosis signs and symptoms
-CNS depression - headache, confusion, drowsiness -Kussmaul respirations -Dysrhythmias
Assessment findings/Signs and symptoms of Hyperkalemia
-CV = most severe; tachycardia to brady, ECG changes, dysrhythmias, cardiac arrest -Neuromuscular: vague muscle weakness, anxiety, irritability -GI: N/V. diarrhea, cramps -GU: oliguria -Lab = á serum osmolality; ácreatinine & BUN
Assessment findings/Signs and symptoms Hypokalemia
-CV: arrhythmias; hypotension, slow, weak pulse, ECG changes -GI: impaired motility, â bs -Neuro: fatigue, confusion -Muscle weakness (can be life-threatening if respiratory muscles are effected) -GU: polyuria
Collaborative Management of Hypocalcemia
-Ca++ supplements -Po or IV -IV= do not give IV push except in extreme emergencies; (can cause burning necrosis and tissue sloughing) -Vitamin D -Dietary Consult -Monitor lab values -Neuro: safety -Foods/ fluids rich in calcium -Educate!!
Criteria for Nursing Diagnoses
-Can be resolved by Nursing Interventions -Client Problem NOT Nursing Problem
Interstitial Oncotic Pressure increased
-Capillary walls damaged, plasma proteins accumulate in interstitium; draws fluid into interstitium -Causes: trauma, burns, inflammation, major surgery
Hypomagnesemia: what do you see
-Cardiac irritability-arrhythmias (can be lethal if previously had an MI) -GI symptoms-dec contractility causes anorexia, abdominal distention -Psychological-depression, confusion, psychoses
Patient Teaching - Hypomagnesia
-Caution clients about taking supplements without consulting HCP -Know your foods high in magnesium
Thirst
-Changes in plasma concentration are monitored in the hypothalamus -Thirst mechanism and ADH excretion are triggered -Conscious ingestion of fluids in response to health habits or social situations -Sensitivity of thirst mechanism decreases in older adults
Supplemental Potassium
-Check renal function. 1st -check output!!! Know GFR (glomerular filtration rate). Orders may be written based on GFR. -PO K+ -Don't dissolve effervescent tabs in mouth -Give with meals -Teach client to report weakness, pulse changes, black tarry stools
The body compensates using three mechanisms.
-Chemical Buffers (Work right now) -Respiratory system (Maximum effectiveness in hours but cannot sustain) -Renal system (Takes days but can maintain balance over time)
Distribution of meds is influenced by:
-Circulation -Membrane permeability - ability of the medication to pass through tissues and membranes to enter a target cell. -Protein binding - the degree to which the medication binds to the serum protein.
Wound Care
-Cleaning skin and drain sites -Clean per Dr. orders -Clean from least contaminated to the surrounding skin -When irrigating, allow the solution to flow from the least to most contaminated area
Nurse- and health care provider-initiated standard interventions include
-Clinical practice guidelines and protocols -Care bundles -Standing orders -Nursing Interventions Classification (NIC) interventions -Standards of practice
3rd spacing of fluids
-Common after trauma, surgery -Fluid where normally is none -Degree R/T severity -Fluid is useless to cells
Compare Achieved Effect with Goals and Outcomes
-Compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. -Evaluate whether the results of care match the expected outcomes and goals set for a patient.
Mixed acid base
-Concurrent respiratory and metabolic Imbalance -pH normal; pC02 & HC03 both abnormal -Eg. cardiac arrest
What is our body fluid made of?
-Contains oxygen, nutrients, excretory products -Electrolytes are substances that separate into electrically charged particles when dissolved in water -Cations are positively charged: Sodium (Na+), potassium (K+), calcium (Ca2+), magnesium (Mg2+) -Anions are negatively charged: Chloride (Cl-), bicarbonate (HCO3-), phosphate (PO43-), sulfate (SO42-) -Nonelectrolytes are substances that do not carry an electric charge (glucose/albumin)
Nurses must be alert for increased fluid requirements when a child has which of the following? A.Fever B.Mechanical ventilation C.Heart Failure D.Increased intracranial pressure
-Correct answer is A=fever. Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. -B=Incorrect. Mechanical ventilation. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child, but not as significant as the fluid losses that occur with fever. -C=Incorrect. Heart failure is a case of fluid overload in children. -D=Incorrect. Increased intracranial (ICP) does not lead to increased fluid requirements.
Management of respiratory acidosis
-Cough, deep breathe**** -Bronchodilation -Humidity -Suction
Vaginal or Rectal administration
-Creams, foams, tablets, liquids, suppositories, and gels can be administered vaginally. -Proper placement often requires special applicator •Clean gloves used to admin rectal suppositories -Vaginal and rectal suppositories often refrigerated because they melt at body temp -Offer an absorbent pad and a comfortable undergarment to collect any medication drainage -Rectal meds are placed above the internal anal sphincter and against mucous membrane -Liquid meds are instilled in rectum using an enema solution -For laxatives, document how long patient was able to retain medication
The assessment process
-Data collection: Use information about a patient's needs to adapt your data collection. -Interpretation: Critically interpret assessment data to determine whether abnormal findings are present. (Cues and inferences) -Validation: Comparison of data with another source to determine data accuracy
Causes of Respiratory acidosis
-Decrease lung surface area -Emphysema -Severe Pneumonia -Atelectasis -Status asthmaticus -CNS depression -barbiturate or sedative overdose -Pulmonary edema -Obstruction -Sleep Apnea, Obesity -Diseases that impair respiratory muscles such as muscular dystrophy, Guillain-Barre syndrome.
Collaborative Management of Hypermagnesemia
-Decrease use of MgS04 -If severe resp. depression-ventilator -If due to renal failure-dialysis -Saline infusions with diuretics -Caution: side effect may be loss of Ca++ which makes Mag effect worse -May have to give IV calcium -Focus on prevention! -Assessment -Vital signs, resp. function, ECG changes, urine output, LOC -May need to assess every hour if necessary -Safety issues and seizure precautions -Report any changes in DTRs
Assessment findings: Hyponatremia
-Decreased level of consciousness (Confusion, lethargy, coma) -Seizures if develops rapidly or is very severe -Laboratory findings: Na+< 136 mEq/L, Serum osmolality < 285 mOsm/kg (285 mmol/kg) **All about fluid and neuro!!
Physiological Factors Affecting Oxygenation
-Decreased oxygen-carrying capacity: when the body doesn't have enough RBCs to carry oxygen -Hypovolemia: occurs when shock or dehydration causes extracellular fluid loss and reduced circulating blood volume; resulting in hypoxia to body tissues -Decreased inspired oxygen concentration: oxygen-carrying capacity of the blood decreases -Increased metabolic rate: level of oxygenation declines when body systems are unable to meet this demand; normal in pregnancy, wound healing and exercise
Factors to consider in selection of interventions
-Desired patient outcomes -Characteristics of the nursing diagnosis -Research base knowledge for the intervention -Feasibility for doing the intervention -Acceptability to the patient -Your own competency
Outcomes
-Desired result of nursing care -Usually has a time frame -NOC (Nursing Outcome Classification)- a valuable resource in selecting goals and outcomes linked to NANDA nursing diagnosis
Nurse's Role in Medicaiton Administration
-Determines medications ordered are correct -Assesses patient's ability to self-administer -Determines medication timing -Administers medications correctly -Closely monitors effects -Provides patient teaching -Doesnt delegate medication administration to AP
Risk diagnosis Nursing Diagnostic Statements
-Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. -Risk for Impaired Skin Integrity -Cannot use 'Risk for' on every diagnosis.
Assessment findings: Hypernatremia
-Direct effect on excitability and conduction of neurons, therefore more easily activated -Neuro: decreased level of consciousness, (confusion, lethargy, coma) -Seizures if it develops rapidly or is severe. -Laboratory Findings: -Na+ > 145 mE/L -Serum osmolality > 295 mOsm/kg(295 mmol/kg) **All about fluid and neuro!!
Respiratory acidosis signs and symptoms
-Dyspnea at rest -Disorientation -Tachycardia -Lab values - hyperkalemia may result as H+ moves into cells, causing a shift of potassium out of the cell.
Pulmonary Health Implementation: Acute Care
-Dyspnea management -Airway maintenance -Mobilization of pulmonary secretions -Hydration -Humidification -Nebulization -Coughing and deep-breathing
Medication classification indicates the:
-Effect of medication on body system -Symptoms the medication relieves -Medication's desired effect Usually each class contains more than one medication that is used for the same type of health problem. For example, patient's who have asthma may take a variety of medications including the beta2-adrenergic agonists to control their illnesses. The beta2-adrenergic agonists contain more than 15 different medications.
Metabolic Alkalosis
-Excess of bases or deficits in acids -Increase in pH : pH >7.45, HCO3>28 -Compensate: lungs â respirations to retain CO2, kidneys retain H+, excrete HC03 -Noncarbonic acids decrease (vomiting or diarrhea) or bicarb increases -Lungs compensate by slowing depth/rate
Evaluation
-Fifth step in nursing process -Determines whether a patient's condition or well-being improved after nursing interventions were delivered -The outcomes of nursing practice are the measurable conditions of patient, family, or community status; behavior; or perception. -These outcomes are the criteria for judging the success in delivering nursing care.
When an error occurs
-First assess the patient's condition, then notify the health care provider -When patient is stable, report the incident -Complete an incident report -Report near misses and incidents that cause no harm
History of Nursing Process
-First introduced in 1955 as a 3 step process. -In 1982 NCLEX state board exams started to include NP in test questions. -From this day on NP will become a part of you........... -Each clinical in every course you will complete a clinical paper that uses Nursing Process.
Chemical Buffers
-First line of defense -Chemical buffers act immediately to protect cells -Bicarbonate buffers -Phosphate buffers -Protein buffers -Neutralize acid or make it weaker -Body is more effective with excess acid than excess base -Quick action to minimize damage until other systems take over
Environmental Theory
-Florence Nightingale -the nurse's role is to manipulate tha patients environment to maximize healing, care for nutritional needs and provide comfort -the nurse promotes healing by "the proper use of fresh air, light, warmth and cleanliness"
Fluid Balance by Age
-Fluid balance in an infant is extremely important because percentage of total body weight is highest in an infant - 70-80%. -By age 2 the percentage of body weight that is fluid is approximately the same as that of a young to middle-aged adult - 50-60%. -Because the elderly have a much lower percentage of body weight that is fluid - 45-55%, they are also highly likely to develop fluid imbalance. -Men: % of H20 > than women -Older adults/very young = less fluid reserve
Plasma Oncotic Pressure decrease
-Fluid stays in interstitium -Causes: excessive protein loss (nephrotic syndrome), liver disease (decreased protein synthesis), malnutrition (decreased protein intake) -Sooooo......Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues causing edema. when plasma protein is low due to protein loss (renal disorders), deficient protein synthesis (liver disease), or deficient intake (malnutrition)
Why are fluid and electrolytes important?
-Fluid, electrolyte, and acid-base balances within the body maintain the health and function of all body systems. -Fluid is inside the cells and surrounds all the cells. Cellular fluids contain electrolytes such as sodium and potassium and also have a degree of acidity. -Characteristics of body fluids include the fluid amount (volume), concentration (osmolality), composition (electrolyte concentration), and degree of acidity (pH).
Collaborative Management of Hypercalemia
-Fluids: 3000-4000 ml/day - to dilute calcium and promote excretion -Diuretics -Calcitonin - reduces bone resorption -Mobilization-get the pt. moving!
Assessment findings/Signs and symptoms of Hypercalcemia
-GI: decreased peristalsis, constipation -Lethargy -Cardiac abnormalities - cardiac arrest if severe -CNS: decreased memory, confusion, psychosis; weak muscles; hypoactive dtrs (deep tendon reflexes) -Renal: kidney stones -Bone pain -Muscle fatigue
Spiritual Health: Planning
-Goals and outcomes: based on diagnoses you have created for the patient; focus on helping patients integrate their own spiritual beliefs -Setting priorities -Collaboration *TERMINALLY ILL - SPIRITUAL CARE IS OFTEN MOST IMPORTANT NURSING INTERVENTION*
Nursing Process: Implementation Skin
-Health promotion -Prevention of pressure ulcers -Topical skin care and incontinence management -Positioning -Support surfaces -Acute Care -Management of pressure ulcers -Wound management -Debridement -Education -Nutritional status -Protein status -Hemoglobin -First aid for wounds -Hemostasis -Cleaning -Protection -Dressings -Suture/staple care -Drainage evacuation -Bandages and dressings
Implementation: med admin
-Health promotion: patient and family caregiver teaching -Acute care: receiving, transcribing, and communicating medication orders; accurate dose calculation and measurement -Avoidance of distractions: correct admin; document med admin -Special considerations: infants and children; older adults; Polypharmacy
Complications of wound healing are caused by:
-Hemorrhage -Infection -Dehiscence -Evisceration
Assessment: med admin
-History: review the patient's medical history (allergies, meds, diet history, perceptual or coordination problems) -Patient's current condition -Patient's attitude about medication use -Factors affecting adherence to med therapy -Patient's learning needs
Respiratory Alkalosis
-Hyperventilation gets rid of more CO2 -Excessive C02 elimination -Reduces carbonic acid -Raises pH -Compensation: buffer, kidneys excrete more HCO3, retain H+ -kidneys excrete more HCO3, retain H+
Caution with administering hypotonic solutions.....
-Hypotonic solutions are contraindicated in patients who have intracranial pressure as this type of solution will increase the fluid shift into the brain cells and increase cerebral edema. -Also contraindicated in patients that have abnormal fluid shifts such as occurs in patients with burns.
Problem-focused Nursing Diagnostic Statements
-Identify an undesirable human response to existing problems or concerns of a patient. -Impaired Skin Integrity
Health promotion (Wellness) Nursing Diagnostic Statements
-Identify the desire or motivation to improve health status through a positive behavioral change. -Readiness for Enhanced knowledge or -Readiness for Enhanced Health Management
Buffer systems work together
-If a metabolic disturbance causes a pH shift, the lungs compensate by adjusting depth and rate of breathing. -If a respiratory disturbance causes a pH shift, the kidneys compensate by adjusting acid and bicarbonate levels. -If one system fails, others try to compensate
Nursing Diagnosis: Pulmonary Health
-Impaired Cardiac Output -Acute Pain -Activity Intolerance -Risk for Activity Intolerance -Impaired Airway Clearance
Nursing diagnoses that may apply during medication administration
-Impaired Health Maintenance -Lack of Knowledge (Medication) -Nonadherence (Medication Regimen) -Adverse Medication Interaction -Complex Medication Regimen (Polypharmacy)
Risk factors for pressure ulcer development
-Impaired sensory perception -Impaired mobility -Alteration in LOC -Shear -Friction -Moisture
Causes of Extracellular Fluid Volume Excess (FVE)
-Increased fluid intake/fluid overload IV fluids- too much or too fast -Excessive administration of Na+ containing isotonic IV fluids or oral intake of salty foods and water -Abnormal Fluid retention - Heart Failure -Interstitial to plasma fluid shifts (2nd spacing) -Liver cirrhosis - serum protein, albumin decreases
Attitudes that promote clinical thinking
-Independence -Open-mindedness -Intellectual humility -Challenging the status quo -Questioning -Seeking and Looking for answers -Confidence -Curiosity -Integrity -Perseverance
Where is the fluid located?
-Intracellular Fluid (ICF) ~ (2/3 of total). 40% of body weight -Fluid found "within" or inside the cells. -Extracellular (1/3 of total). 20% of weight -Fluid found outside the cells -Interstitial fluid- (75%)Surrounds the cells -Intravascular (20%)- Within the arteries, veins and capillaries (Plasma) -Transcellular- Eyes, brain, spinal canal, lymph, synovial tissue and eyes
Document Outcomes
-It is crucial to share information about a patient's progress and current status. -Accurate information needs to be present in a patient's medical record -Nurses and other health care team members know whether a patient is progressing -When documenting a patient's response to your interventions, describe the interventions, the evaluative measures used, the outcomes achieved, and the continued plan of care.
Acid/Base Balance
-Just as with fluid status, the body is constantly balancing for acid/base balance. -Infection, disease, and medications can impact the balance. -pH is how acid/base balance is measured. -Normal pH has a very narrow window.
Collaborative Management of Hypokalemia
-K+ supplements: po, IV -Stop diuretics -Monitor vital signs-apical pulse, note any irregularities -Full GI assessment -Monitor I&O -Educate re: foods high in K+
Nursing Health History
-Key component of a comprehensive assessment -Gather Subjective Data -Holistic assessment that covers all health dimensions (Emotional, Social, Cultural, Spiritual, Intellectual).
Dressing Changes
-Know type of dressing, and supplies needed. -Prepare the patient for a dressing change. -Review previous wound assessment notes. -Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change. -Describe procedure steps to lessen patient anxiety. -Gather all supplies. -Recognize normal signs of healing. -Answer questions about the procedure or wound. -Comfort measures -Administer analgesic medications 30 to 60 minutes before dressing changes -Carefully remove tape -Gently clean wound edges -Carefully manipulate dressings and drains to minimize stress on sensitive tissues -Turn and position patient carefully
Causes of Metabolic acidosis
-Lactic acid = anaerobic metabolism -Starvation -Shock, cardiac arrest -Severe diarrhea -Renal disease -Ingestions of acids
Osmolality
-Measures concentration of particles in solution. -Another way to think about osmolality is as the specific gravity of body fluids. -Osmotic pressure=drawing power of water -High conc. of solutes>rate to pull water -Measured by milliosmoles -Osmolality=normal osmotic pressure-state of water balance-pulling power of solution for H2O -Serum or plasma osmolality=275-295 mOs/kg -As plasma osmolality increases, thirst occurs. Sensed in hypothalamus, more ADH is released, more H20 is reabsorbed from the kidneys-more water retained -Opposite occurs with H20 excess
Metabolic Alkalosis signs and symptoms
-Most symptoms relate to calcium ionization(hypocalcemia): tingling fingers/toes, dizziness, hypertonic muscles. -CNS stimulation- irritability, nervousness. -Respiratory rate decreases as a compensatory mechanisms. -Arrhythmia's due to hypokalemia.
Assessment findings/Signs and symptoms of Hypocalemia
-Muscle cramps in extremities -Trousseau's sign; Chvostek's sign -Dysrhythmias -Fractures -Bleeding tendencies -Tetany-sustained muscle contractions /seizures -**Low calcium allows sodium to pass into cells, which increases depolarization. - ***Results in 'excitable' cells
When Body Functioning is Intact........
-Must have functioning respiratory & renal system -Carbonate system -resp -co2 + h2o -goal is to maintain 20:1 ratio (base: carbonic acid)
Inhaled or nebulized
-Nasal medications are administered by drop or nebulizer formulations into the nose -Inhalation medications are taken into the body through the respiratory tract (through nasal passages, oral passages, endotracheal tubes, or tracheostomy tubes) -Nebulizers are used to aerosolize medication into a fine-droplet or gas form that is then inhaled for delivery to the lungs -Use medical asepsis when administering nasal preparations (nose connected to sinus) -Decongestant sprays relieve symptoms of sinus congestion -When these meds used in excess, may have systemic effects such as increased heart rate and a rebound effect that increases congestion -Document if instilled into one or both nares and patient's response -Spacers are used to trap the med and allow inhalation over several breaths -Common uses for inhaled meds are to induce anesthesia during surgery & treat resp disorders -Assessment should be done before and after inhaled meds -Important patient education includes determining when inhaler is empty and needs replacement
Fluid movement
-Normally ECF & ICF are isotonic -Cell surrounded by hypotonic fluid = fluid moves into cell -Cell surrounded by hypertonic fluid = H20 leaves cell to dilute ECF
Benner Model of Novice to Expert
-Novice -Advanced Beginner -Competent -Proficient -Expert
Indirect Care
-Nursing treatments or procedures performed away from a patient(s) but on behalf of a patient -Communicating nursing interventions -Written or oral -Delegating, supervising, and evaluating the work of other staff members
Lifestyle factors influencing oxygenation
-Nutrition -Hydration -Exercise -Smoking -Substance abuse -Stress
Factors influencing pressure injury formation and wound healing are:
-Nutrition -Tissue perfusion -Infection -Age -Psychosocial impact of wounds
Methods to obtain data
-Observing -Listening -Translating -Reasoning -Using intuition -Validating
Artificial airways
-Oral airway -Endotracheal and tracheal airways -Invasive mechanical ventilation -Noninvasive ventilation -Chest tubes
Collaborative Management of Hypomagnesemia
-Oral magnesium tablets -Inc dietary intake: Leafy green vegs, choc, peanut butter, bananas -Parenteral magnesium IV (give slowly using an IV pump): Stop if loss of patellar reflex, flushing of face, dec BP -Vital signs q4h -Telemetry -Safety issues, seizure precautions -Monitor labs- (Mg++, K+, Ca++) -Notify HCP if pt. NPO >3days, especially if having other losses, malnourished, or if continues to have low K+ or low Ca++ even after treatment
Priority Setting
-Ordering of nursing diagnoses or patient problems to establish a preferential order for nursing interventions. -Problem-focused diagnoses and problems take priority over wellness, possible risk, and health promotion problems. -Helps you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems. -Establish priorities in relation to their ongoing clinical importance
Planning: med admin
-Organize care activities to ensure the safe administration of medications -Goals and outcomes: Setting goals and related outcomes contributes to patient safety and allows for effective use of time during medication administration. -Setting priorities: Provide the most important information about the medications first.
Concept Mapping
-Organizes assessment data -Places all of the cues together into clusters that form patterns which leads you to the next step of the nursing process, nursing diagnosis
Obstacles to critical thinking
-Overuse of the Habit Mode -Anxiety and Stress -Willingness to go with the status quo.... "We do it that way because that is the way it has always been done." -Lack of Confidence in One's Thinking
Causes of Respiratory alkalosis
-Pain -Anxiety attacks which cause hyperventilation -Early salicylate poisoning -Fever, especially infants
Evaluation: med admin
-Patient outcomes -Use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual findings.
Planning
-Planning involves setting priorities based on patient diagnoses and collaborative problems, identifying patient centered goals and expected outcomes and prescribing nursing interventions appropriate for each diagnosis. -Must be individualized to the unique needs of the patient. -3rd step in the Nursing Process
Implementing spiritual care into restorative and continuing care settings
-Prayer -Meditation -Supporting grief work
The process of any of these factors will cause wound deterioration:
-Predictive measures - a low score on the Braden scale predicts higher chances or pressure ulcer development. -Decreased mobility -Poor nutritional status -Moisture/incontinence -Pain
Conditions Affecting Chest Wall Movement
-Pregnancy -Obesity -Trauma -Neuromuscular diseases -Central nervous system alterations -Influences of chronic lung disease
Standing orders
-Preprinted document containing medical orders. -Directs patient care in a specific clinical setting.
Site of exchange
-Pressure is higher on the arteriole end of the capillary than the venous end -Hydrostatic pressure pushes fluid and solutes out on the arteriole end of the capillary -Oncotic pressure prevents overdelivery (maintains vascular volume) -Lower pressure on the venous side of the capillary allows for fluid, solutes, and waste to return to the venous system
Albumen (safety net)
-Protein molecule present in the blood -Cannot pass through a capillary membrane due to size -Draws water to the albumin molecule "water magnet" and supplements the return rate on the venous side -Prevents overdelivery of water due to pressure
Critical Thinking Promotes REFLECTION......
-Purposefully reviewing a situation to discover its purpose or meaning. Reflection is not intuitive. -It is purposefully visualizing a past situation and taking the time to honestly review everything you remember about it. -Allows you to gain new knowledge and raise questions about your practice -Improves ability to problem solve
Data documentation
-Record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology. -Baseline to identify a patient's health problems, to plan and implement care, and to evaluate a patient's response to interventions -Record all observations succinctly -Record any subjective information by using quotation marks.
Causes of Hypermagnesemia
-Renal insufficiency -Excessive use of Mg++ containing antacids/laxatives or administration of K+ sparing diuretics (conserves Mg++) -Severe dehydration and H20 losses-eg diabetic ketoacidosis
Evaluating an ABG - Look for compensation
-Respiratory and metabolic systems are linked and try to balance the equation. -Compensating values may be out of range, but do not make sense with the pH. -Compensation may be absent, partial or complete.
Restorative & Continuing Care
-Respiratory muscle training -Breathing exercises -Pursed-lip breathing -Diaphragmatic breathing -Home oxygen therapy (for those below 88% on room air)
Collaborative Management of Hyperkalemia
-Restrict K+ intake -Severe cases: dialysis; insulin & glucose; ion exchange resin: Kayexalate, sorbitol -NPO
7 rights of medication administration
-Right medication -Right dose -Right patient -Right route -Right time -Right documentation -Right indication
Nursing diagnoses associated with impaired skin integrity and wounds:
-Risk for infection -Imbalanced nutrition: less than body requirements -Acute or chronic pain -Impaired physical mobility -Impaired skin integrity -Risk for impaired skin integrity -Ineffective peripheral tissue perfusion -Impaired tissue integrity
Oxygen therapy:
-Safety precautions: oxygen is highly combustible; can easily cause fire if there is a spark or open flame -Supply of oxygen -Methods of oxygen delivery -Nasal cannula -High flow nasal cannula -Oxygen masks
Oncotic Pressure
-Same as colloid osmotic pressure -Defined as osmotic pressure exerted by colloids in solution -Pulls H2O into vascular space
Respiratory System
-Second line of defense -Respiratory centers in the brain, (medulla) sense pH changes. -Changes rate and depth of breathing to compensate. -Deeper and more frequent breaths eliminates more carbon dioxide from the lungs. ↑ RR and ↑ depth = ↓ CO2 (blow off acid) -Shallower or less frequent breaths eliminate less carbon dioxide from the lungs. ↓ RR and ↓ depth = ↑ CO2 (increased CO2 retention, increased acid. -The more carbon dioxide present, the more carbonic acid, and a more acidic pH.
Causes of Extracellular Fluid Volume Deficit (FVD)
-Severely decreased intake of water and salt -Increased output (diarrhea, vomiting) -Increased renal output (diuretics) -Loss of blood or plasma (hemorrhage, burns) -Massive sweating without water and salt intake
Renin-Angiotensin-Aldosterone cascade
-Special cells in the kidney sense a decrease in blood flow or sodium levels. The net effect is to restore blood volume and renal perfusion through sodium and water retention. -Renin is released into the bloodstream -Renin is converted (several steps) to angiotensin II (vasoconstrictor, sodium and water retention, stimulator of aldosterone production)
Be SMART in setting outcomes.
-Specific -Measurable -Attainable -Realistic -Timed/Timely
Pressure injuries are classified as:
-Stage 1: Non-blanchable erythema of intact skin -Stage 2: Partial-thickness skin loss with exposed dermis -Stage 3: Full-thickness skin loss with visible adipose fat. -Stage 4: Pressure Injury: Full-thickness skin and tissue loss -Deep tissue injury -Unstageable pressure ulcer
Evaluation: Involves Two Parts
-State if the outcome was: Met, Partially Met or Not met -What behaviors/criteria were used to evaluate the outcome.
Respiratory physiology
-Structure and function -Work of breathing -Pulmonary circulation -Respiratory gas exchange -Oxygen transport -Carbon dioxide transport
Parenteral K+
-Takes 40-60 mEq to inc. K+ by 1 mEQ -Parenteral = IV only-NEVER give IM or IV push -Adults: Do not exceed 10 mEq/hr IV, must be diluted in 100 mL of fluid, run over an hour. Preferred in a central line. -As continuous infusion- normal = 20-40mEq/L -Always on pump Irritating to veins
Management of Respiratory Alkalosis
-Talk them down -Inhale own C02(no longer recommended to breath into a bag) -Treat underlying cause -Emotional support -Rx FVD
Assessing Hydration in Infants and Children:
-Tears: absent -Mental Status: lethargic èflaccid è unresponsive. -Skin Turgor: notable delay in return -Capillary refill: > 3 sec, mottled, gray, cyanotic -Estimated % dehydration: Severe Deficit is >10% loss in a Child:>10% deficit (100 mL/kg) or Infant: 15% deficit (150 mL/kg)
Critical Thinking
-The ability to think in a systematic and logical manner. -A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant. -Recognizing that an issue exists, analyzing information, evaluating information, and drawing conclusions. -Evidence-based knowledge in critical thinking. -Essential in the nursing process. -Involves knowing as much as possible about each patient. -Need to sort out the information into patterns to clarify problems, recognize changes, and make appropriate care decisions under pressure. -Essential process for safe, efficient, and skillful nursing intervention. -Improves patients' outcomes.
Homeostasis
-The body uses several mechanisms to keep fluids and electrolytes in balance. -Osmosis (passive) - Fluids move from an area of lower solute/more fluid to an area of higher solute/less fluid until the solute concentrations are equal. -Example: Boiling a hot dog. -the body likes balance
Concepts related to F & E Balance
-The body will attempt to compensate for shifts and will adapt to changes in supply and demand. -If the body is unable to compensate for shifts, nursing interventions will replace, supplement, or stimulate. -As nurses it is important to anticipate interventions based on disease states,and changes in patient conditions.
How does the Holistic Caring Process differ from The Nursing Process?
-The holistic caring nursing process, the third of AHNA's five core values, describes the practice of holistic nursing in language derived from the nursing process while also highlighting the value of caring. -The holistic caring process involves six steps, instead of five, building on the first six ANA standards of care expected of all nurses. -Where the standard nursing process emphasizes the identification and treatment of patient conditions or problems, the holistic nursing process is centered around human health and wholeness and grounded in the worldview and philosophical principles of holistic nursing. -Holistic nursing focuses on protecting promoting and optimizing health and wellness, assisting healing; preventing illness and injury; alleviating suffering; supporting people to find peace, comfort, harmony and balance through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, populations and the planet.
Water in the body
-The primary fluid of the body is W A T E R ..... -Approximately 60% of the average healthy adult's weight is water. -In good health this volume remains relatively constant and the person's weight varies by < 0.2 kg (0.5 lb) in 24 hours regardless of the amount of fluid ingested. -Water is vital to health and normal cellular function, serving as a medium for metabolic reactions within cells, a transporter for nutrients, waste products and other substances a lubricant, an insulator and shock absorber, one means of regulating and maintaining body temperature.
Mixed Acid-Base Disorders
-The simultaneous occurrence of metabolic acidosis and respiratory acidosis, during respiratory and cardiac arrest. -The only mixed disorder that cannot occur is a mixed respiratory acidosis and alkalosis because it is impossible to have alveolar hypoventilation and hyperventilation at the same time. -Because the lungs respond to acid-base disorders with minutes, compensation for metabolic imbalances occurs faster than compensation for respiratory imbalances
Why is the nursing process important?
-The steps of the nursing process are the essential core of nursing practice developed by the American Nurses Association (ANA) so that all nurses regardless of role, population or specialty are expected to competently perform. (ANA, n.d.) -We speak of consistent language.
Renal System
-Third level of defense -Slowest but most powerful -Kidneys excrete acids (urine pH is 6 and can vary from 4-8) -Can reabsorb or excrete acids or bases to compensate. -If system fails, large component of pH balance is lost
Spiritual Health: Evaluation
-Through the patient's eyes -Include the patient in your evaluation of care to determine if their expectations were met -Patient outcomes: do you feel more connected to your spiritual source or family? Are you starting to feel more at peace with your diagnosis?
Calcium
-Total Ca++ = 9.0-10.5 mg/dl, app -(Approximate), text states abnormalities <9 and >10.5 -Ionized/ free Ca++ = 4.5-5.6 mg/dl -Cation found in both intra and extracellular fluid -Necessary for healthy bones and teeth, muscle contraction, cardiac function -Blood coagulation -Nerve impulses -Adult: 9.0-10.5 mg/dL -The most abundant cation in the body however the vast majority, 99% in the body is in the skeleton. -Calcium is regulated by a complex interaction of parathyroid hormone, calcitonin and calcitrol, a metabolite of Vitamin D. -Calcium and Phosphate levels have an inverse relationship in the body. -Transmit nerve impulses -Maintain cellular permeability -Form bones and teeth -Blood coagulation -Relaxes smooth muscle
Constructs of spirituality
-Transcendence -Connectedness -Faith and hope -Inner strength and peace -Purpose in life
Collaborative Management of FVE
-Treat the cause -Diuretic therapy -Fluid restriction -Para or thoracentesis -Low Na+ diet -Protein may be increased, if malnourished - to increase capillary oncotic pressure. -Early detection -Daily weights -Accurate, strict I&O -Monitor labs -Assess lung sounds, O2 sats -Assess edema
Collaborative Management of FVD
-Treat the cause -Parenteral replacement: isotonic fluids- LR, 0.9%NaCl -Blood-(if due to blood loss) -Electrolyte replacement as needed -Monitor VS, I & O, Daily weight -Asses and monitor lab values
Management of Metabolic acidosis
-Treat the cause- will correct the acidosis -Hyperkalemia may accompany metabolic acidosis as a result of a shift of K+ out of the cells. As the acidosis is corrected, potassium moves back into the cells, and hypokalemia may occur. -Hyperventilation to decrease CO2 levels is a compensatory action.
Medication Distribution Systems
-Unit dose systems - medication is dispensed in single-unit package. -Automatic medication dispensing system [AMDS])
Planning: Pulmonary Health
-Use critical thinking skills to synthesize information from multiple sources -Goals and outcomes -Realistic expectations, goals, and measurable outcomes -Setting priorities -Teamwork and collaboration
Eye drops
-Used to treat eye irritation, infections, or disorders such as glaucoma -Eyedrops can be used for diagnostic procedures or to anesthetize the eye for procedures -Document the eye in which med was instilled and patient's response to med
Management of Metabolic Alkalosis
-VS -I&O - (Volume depletion from GI losses may require administration of fluids. -Monitor electrolytes, treat hypokalemia. -Administer H2 receptor blockers, (Cimetidine to decrease gastric acid secretion) -Protect from falls
Causes of fluid shifts
-Venous H.P increase - fluid overload, heart failure, tourniquets, restrictive clothing, thrombosis, varicose veins. -Plasma O.P. decrease - when plasma protein is low due to protein loss (renal disorders), deficient protein synthesis (liver disease), or deficient intake (malnutrition) -Interstitial O.P. increase - trauma, burns, and inflammation can damage capillary walls and allow plasma protein to accumulate in the interstitium and holds it there -Obstruction of lymph. outflow
Venous Hydrostatic Pressure increase
-Venous end of capillary inhibits fluid movement back into capillary -Causes: fluid overload, CHF, tourniquet, restrictive clothing, varicose veins -fluid overload, heart failure, tourniquets, restrictive clothing, thrombosis, varicose veins.
Causes of Metabolic alkalosis
-Vomiting, gastric suction *most common - loss of highly acidic gastric fluids, diarrhea -Antacid overdose -Excessive diuresis - loss of potassium, hypokalemia predisposes alkalosis.
Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances
-age -environment -gi output -chronic diseases -trauma -therapies
movement of air through respiratory system
-air comes in through nasal or oral cavity -goes through pharynx -pharynx splits to the esophagus in the back and in front is the larynx -air goes through the larynx (voice box) -from larynx to trachea (cartilage) -trachea splits into two bronchi -bronchi split into smaller and smaller tubes -eventually split to be bronchioles (no cartilage) -air sacs on ends of bronchioles: alveoli
What does oxygen have to go through to get to the hemoglobin?
-alveolis (gas) -layer of fluid lining alveolis (liquid) -epithelial cells (liquid) -basement membrane (liquid) -connective tissue (liquid) -basement membrane (liquid) -endothelial cells (liquid) -plasmsa (liquid) -RBC (liquid) -almost all liquid (predominantly water) -going from gas all the way through many layers of liquid
Levels of critical thinking
-basic critical thinking -complex critical thinking -commitment
Implementation
-begins after you develop a patient's plan of care. It involves the performance of nursing and collaborative interventions necessary to achieve the goals and expected outcome needed to support or improve a patient's health. -Direct care interventions -Treatments nurses provide through interactions with patients or a group of patients -Indirect care interventions -Treatments performed away from a patient but on behalf of the patient or group of patients. -Documentation -Interprofessional collaboration the 4th step of the nursing process
Environmental factors influencing oxygenation
-being exposed to occupational pollutants
3 broad categories of medication names
-chemical -generic -trade
Comfort Theory
-comfort is a holistic phenomenon -comfort reflects holistic well-being -people experience comfort as feelings of relief, ease, and/or transcendence
Modeling and role modeling
-describes adaptation [striving for equilibrium] and assessment of adaptive potential -five aims of intervention: build trust; promote positive orientation; promote perceived control; promote strengths; and set mutual health-directed goals -nurse models the patient's world [building a model of the world from the patient's perspective] -role modeling healthy behaviors from within the patient's worldview
Theory of Transpersonal Caring and Caring Science
-emphasizes caring relationships between nurse and patient. -describes multiple truths, physical and nonphysical realities, relativity of time and space -caring ethic is foundational to all health care
Theory of Self-Transcendence
-focuses on self-transcendence as a human capacity to expand personal boundaries intrapersonally, interpersonally and transpersonally -other key concepts include vulnerability and well-being
Interpersonal Relations Theory
-focuses on the importance of the nurse-patient relationship -nurses can provide better care to their patients if they build a strong relationship based on mutual respect -evolves around three phases: orientation, working and termination
Science of Unitary Beings
-major concepts include unitary human beings, human energy field, and environmental energy field. -argues for evolution of people in irreversible and unidirectional ways
Theory of health as expanding consciousness
-nursing is caring: a moral imperative -health is expanding consciousness that includes an individual's total pattern -health-illness is a unitary process -people are open systems -research is praxis
Developmental factors influencing oxygenation
-older patients might not have as strong of a cough -could have osteoporosis that impacts the size and shape of the thorax -chronic heart disease -weakened immune system
Electrolyte Concentrations
-oncentration of electrolytes vary by location Extracellular -Sodium, chloride, bicarbonate -Others in lower concentrations Intracellular -Potassium, magnesium, phosphate, sulfate -Others in lower concentrations
What happens when we breathe in
-our brain is telling our diaphragm to contract -diaphragm contracts, gets shorter and opens up space for lungs -lungs expand to fill the space (pressure inside goes down as volume rises) -less pressure inside than outside (negative pressure) -air wants to go from high pressure to low pressure -air flows into lungs -oxygen will go into alveoli and into arteries and then back into veins as oxygen attached to hemoglobin
What impacts pH?
-pH can shift due to either carbonic acid or bicarbonate. -Hydrogen ions are the root product which impact pH -If hydrogen goes up or bicarbonate goes down, pH decreases. (The acidity increases because of the level of hydrogen goes up (acid) OR the acidity goes up because there is less bicarbonate (base)) -Acidosis occurs at < 7.35. -If hydrogen decreases or bicarbonate increases, pH will increase. (pH becomes more basic due to less acid (hydrogen) or more base (bicarbonate)) -Alkalosis occurs at > 7.45
Classifying pH
-pH is the measurement of the concentration of hydrogen ions. -Lower the pH, the higher the H+ conc. -Lower numbers (<7.35) correspond to acidic states. Higher numbers (>7.45) correspond to alkaline states. -Normal pH is 7.35-7.45. Blood is slightly alkaline. -pH of less than 6.8 or greater than 7.8 is usually fatal.
4 factors that influence oxygenation
-physiological -developmental -lifestyle -environmental
Medical History regarding Fluid, Electrolyte, and Acid-Base Imbalances
-recent surgery -gi output -acute illness/trauma -chronic illness
Theory of integral nursing
-the core concept is healing -nursing is a healing process of knowing, doing and being -the theory has three intentions: embrace the unitary whole person; explore fully the integral process; expand the nurse's capacities to heal
There are 2 main types of medication actions:
-therapeutic effect -adverse effect
When would a nurse use critical thinking?
-while performing a nursing assessment -when making a nursing diagnosis -when planning a nursing intervention -when carrying out nursing specialties, like case management and infection control -when they encounter a problem that appears to have no straight forward answer
Respiratory Alkalosis signs and symptoms
-↑ neuromuscular irritability -Tingling around mouth, spasms of fingers -Sx of hyperventilation - lightheadedness, sometimes loss of consciousness. -Lab values
Two stages of assessment
1) Collection of information from a primary source (the patient) and secondary sources. 2)The interpretation and validation of data to determine whether more data are needed or the database is complete.
Key Points EBT Article
1) Hydration matters in all persons especially older adults and adequate fluid consumption has been associated with fewer falls, lower rates of constipation, lower rates of laxative use as well as better rehabilitation outcomes in orthopedic patients and reduced risk of bladder cancer in men. 2) Potential consequences of dehydration include medication toxicity, urinary and respiratory infections, delirium, electrolyte imbalance, hyperthermia and longer time to wound healing especially pressure ulcers. Even higher mortality rates among hospitalized older adults.3) Indicators of hydration status include urine color charts, serum sodium and osmolality, BUN. Clinical assessments include dry oral mucosa, furrowed tongue, sunken eyes, a rapid pulse. Skin turgor on the sternum is not a reliable indicator in older adults. 4) Nursing implications include prevention of dehydration by calculating a fluid goal, consider fluid preferences, and evaluation "hydration habits". How often are patient's at risk because nurses fail to assess their ability to pour from a bedside pitcher???
Critical Thinking Model of Nursing Judgement
1. Basic Critical Thinking: Beginning nurses are task-oriented. Rely on the experts. Thinking is concrete. 2. Complex Critical Thinking: Rely less on experts and trust their own decisions more. Able to creatively adapt a procedure to the specific needs of the patient. 3. Commitment: Make choices without assistance from others. Accepts accountability for decisions. You choose an action or belief based on available alternatives. Sometimes an action is not to act or delay your action for a later time.
The following three principles are important when cleaning an incision or the area surrounding a drain:
1. Clean in a direction from the least contaminated area, such as from a wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to most contaminated area
Skills Needed to Implement Nursing Interventions:
1. Cognitive - nursing knowledge. 2. Interpersonal Skills - therapeutic communication. 3. Psychomotor Skills - skill, procedures, "doing".
Steps of evaluating an ABG
1. Evaluate the pH. -Is it normal? (7.35-7.45) -Is it acidic? (< 7.35) -Is it alkaline? (> 7.45) 2. Evaluate the PaCO2 (respiratory component) -Is it normal? (35-45 mm Hg) -Is it high? (> 45) -Is it low? (< 35) -Does the value make sense with the pH? (too much or too little acid) 3. Evaluate the HCO3 (bicarbonate-metabolic component) -Is it normal? (21-28 mEq/L) -Is it high? (> 28) -Is it low? (< 21) -Does the bicarbonate value make sense with the pH? (too much or too little bicarb) 4. Identify the abnormalities -Is the pH abnormal? (if no, great...) -If not, identify acidosis or alkalosis -Identify if PaCO2 and/or HCO3 are out of range (Identify if high or low) -Determine which value makes sense with the pH to determine point of origin 5. Evaluate oxygen status -Evaluate PaO2- (80-100 mm/Hg) -Evaluate SaO2- (95-100%)
Three factors are evident when a healing relationship develops between nurse and patient:
1. Realistically mobilizing hope for the nurse and patient 2. Finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the patient 3. Helping the patient use social, emotional, and spiritual resources
Implementation - Preparing for Action
1. Reassess the client. - Continuous process, each time you talk to the patient. In clinical you will talk to the nurses, maybe listen to report. 2. Review and Revise careplan. 3. Organize resources and delivery. - time management, equipment, personnel, environment, client. 4. Anticipate and prevent complications.
3 mechanisms to eliminate acid excess from the Kidneys
1. Secretion small amts. free H+ in renal tubule 2. Combines H+ with NH3 to form ammonium (NH4) 3. Excretion of weak acids -Urine pH can be 4-8
FVE Interventions
1. VS q4h- report inc HR, BP, RR 2. Check breath sounds q4h, report crackles 3.Weigh daily 4.Monitor peripheral edema q shift 5. Strict I/O
Collaborative management of Hypernatremia
1.Replace fluids being lost if cause Hypotonic solution (D5W)-why? 2. Na+ restriction -Treat underlying cause -Diuretics (to remove Na) -Dialysis
Outcomes to look for FVE
1.VS within pt's. baseline range(specify) 2.Breath sounds clear on auscultation 3.Wt decrease from (specify) to baseline of (specify range) 4.Peripheral edema will dec. from 3+ to O in 3 days Evaluation: peripheral edema -3+ to 0; outcome met
Outcomes to look for FVD
1.skin warm, dry 2.Cap refill <3 sec. 3.BP > 100 (at patients baseline range) 4.UO = 30-50cc/hr Evaluation: BP 108/60 outcome met
Phases of 3rd spacing
1st phase: vascular to interstitial: 24-48 hours; looks like Fluid volume deficit & shock 2nd phase: tissue to vascular space: 3-5 days after injury; looks like fluid overload
Fluid Spacing
1st space = normal distribution of fluid in ICF & ECF compartments 2nd spacing = abnormal accumulation of interstitial fluid (edema) 3rd spacing = fluid accumulates where normally there is none or minimal amount (ascites, burns) Fluid is trapped and essentially unavailable for functional use.
Calculating fluid loss/gain
2.2 lbs. = 1 kg = 1 liter*** Shows importance of accurate body weight
Autonomy vs. Shame and Doubt
20-36 months -Fascination with magic and mystery -Often believes that illness is related to bad behavior -Begins to learn the difference between right and wrong -Imitates parents' spiritual or religious actions; recites prayers and sings simple religious songs, but does not understand their meanings -Interprets meanings literally
Initiative vs. Guilt
3-6 years -Feels guilty when not acting responsibly -Influenced by spiritual and religious stories, examples, moods, and actions -Models moral behaviors of parents -Begins to ask about God or supreme beings
Phosphorus:
3.0-4.5 mg/dL -Critical component of all body tissues. -It is essential to the function of muscle and red blood cells -Essential in the formation of adenosine triphosphate (ATP) -Maintenance of acid/base balance -85% is located in bones and teeth -Primary anion of ICF -Metabolism of carbohydrates, proteins and fats.
Potassium (K+)
3.5-5.0 mEq/L •Primary cation in intracellular fluid. •Serum levels can spike if there is major cell damage (Where does K+ 'live'?). •Critical electrolyte in the transmission of nerve impulses (***Cardiac***). •80% excreted by the kidneys. •Adult: 3.5-5.0 mEq/L (Serum!!) **Too high or too low results in cardiac arrhythmias. -Normally 98% in ICF -Critically important
Roughly how many alveoli are in each lung?
300 million
What position most effectively promotes lung expansion
45 degree semi-fowlers
Industry vs. Inferiority
6-12 years -Wants to learn about spirituality -Has a clear picture of God or supreme being, morality, and the difference between right and wrong -Sorts fantasy from fact -Demands proof of reality and believes literal meanings of spiritual stories
What is the internal surface area of your alveoli (total surface area where o2 absorbed or co2 absorbed out of blood)?
75 square meters
Pt. in state of H20 excess, amount of solute is decreased or H20 is increased. What would be the plasma osmolality?
< 275 mOs/kg
Hypophosphatemia:
< 3.0 mg/dL -May occur during the administration of calories to patients with severe protein-caloric malnutrition. Most likely from overzealous intake or administration of simple carbohydrates. -Respiratory alkalosis, phosphorus binding by antacids -Low magnesium levels, low potassium levels and hyperparathyroidism can contribute to low phosphorus levels. -Clinical Manifestations: Most signs and symptoms related to ATP deficiency such as fatigue, impaired oxygen delivery to tissues - increased respiratory rate, muscle weakness, impaired wound healing. -Management: Be alert for early signs of hypophosphatemia, protect from infection, administer parenteral nutrition to malnourished patients slowly to avoid rapid shifts of phosphorus into the cells. Supplements such as Neutra-Phos capsules and dietary sources of phosphorus.
Hypocalcemia
< 9.0 mg/dL -Hypoparathyroidism, thyroid or neck surgery -Impaired GI absorption -Chronic diarrhea, laxative misuse -End-stage renal disease -Acute pancreatitis (decreased absorption and increased output) -decreased dietary intake -Vitamin D deficiency -Multiple blood transfusions (citrate-used to anticoagulate the blood combines with calcium)
Hypercalcemia
> 10.5 mg/dL -Metastatic malignancy, bone tumors -Hyperparathyroidism -Prolonged immobilization -Excessive Ca++ intake -Oliguric phase of renal failure
Hypermagnesemia
>2.1 mEq/L -Level of 5-7: drowsiness -7-10 no deep tendon reflexes (dtrs) -10-12 respiratory depression -12-15 coma -15-20 cardiac arrest
Pt. is in state of H20 deficit or solutes too high. What would be the plasma osmolality?
>295mOs/kg
Hyperphosphatemia:
>4.5 mg/dL -Most commonly seen renal failure -The primary complication of increased phosphorus is metastatic calcification, soft tissue, joints and arteries, which occurs when the calcium-magnesium product (calcium x magnesium exceeds 70 mg/dL) -Clinical manifestations: few, tetany -Management: Measure to decrease the serum phosphate level and bind phosphorus in the GI tract. Restrict food high in phosphorus such as hard cheeses, cream, nuts, meats, whole-grain cereals, dried fruits, fried vegetables, food made with milk.
Pressure Intensity
A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary. Therefore, when the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur. If the patient has reduced sensation and cannot respond to the discomfort of the ischemia, tissue ischemia, and tissue death result. The clinical presentation of obstructed blood flow occurs when evaluating areas of pressure. After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin turns red. The effect of this redness is vasodilation (blood vessel expansion), called hyperemia (redness).
Nasal cannula
A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.
Changing Dressings
A health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. An order to "reinforce dressing prn" (add dressings without removing the original one) is common right after surgery, when the health care provider does not want accidental disruption of the suture line or bleeding. The medical or operating room record usually indicates whether drains are present and from which body cavity they drain. Always know the type of wound and dressing, the presence of underlying drains or tubing, and the type of supplies needed for wound care. Poor preparation causes a break in aseptic technique or accidental pulling of wound tissue or dislodgement of a drain. Your judgment in modifying a dressing-change procedure is important during wound care, particularly if the character of a wound changes. Notifying the health care provider of any change is essential.
Medical errors
A medical error is any preventable event that may cause inappropriate medication use or jeopardize patient safety. -More people die from medical errors than from chronic lower respiratory diseases, accidents, stroke, Alzheimer's disease, and diabetes mellitus.
When does a nurse initiate a Nursing Diagnosis?
A nursing diagnosis is made when a nurse identifies a health-related problem or the potential to develop a problem based on patient data.
Sitz Baths
A patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, or vaginal inflammation benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The patient sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water. Immersing the entire body causes widespread vasodilation and nullifies the effect of local heat application to the pelvic area. The desired temperature for a sitz bath depends on whether the purpose is to promote relaxation or to clean a wound. It is often necessary to add warm or cool water during the procedure, which normally lasts 20 minutes, to maintain a constant temperature. Agency procedure manuals recommend safe water temperatures. A disposable sitz basin contains an attachment resembling an enema bag that allows gradual introduction of additional water. Prevent overexposure of patients by draping bath blankets around their shoulders and thighs and controlling drafts. A patient should be able to sit in the basin or tub with feet flat on the floor and without pressure on the sacrum or thighs. Because exposure of a large part of the body to heat causes extensive vasodilation, assess the pulse and facial color and ask whether the patient feels light-headed or nauseated.
Pressure injury
A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device or other device. The injury can present as intact skin, a blister, or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.
Pressure Ulcer
A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. •Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. •If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results.
Filtration
A process whereby fluid and solutes move together across a membrane from one compartment to another in response to fluid pressure to create an equilibrium. The movement is from an area of higher pressure to one of lower pressure -An example of filtration is tissue perfusion whereby water, nutrients and waste products are exchanged at the capillary bed. This exchange occurs as a result of a difference in hydrostatic pressure between the capillaries and the tissue space.
Hope
A spiritual person's faith brings hope. When a person has the attitude of something to live for and look forward to, hope is present. It is a multidimensional concept that provides comfort while people endure life-threatening situations, hardships, and other personal challenges. Hope is closely associated with faith; it is energizing and motivates people to achieve goals, such as adopting healthy behaviors. People express hope in all aspects of their lives to help them deal with life stressors. It is a valuable personal resource whenever someone is facing a loss or a difficult challenge.
Hyperventilation
A state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism
Transformational leadership:
A style of leadership in which the individual identifies the needed change and creates a clearly articulated vision to guide the change through inspiration, integrity, and mutual respect. The change is accomplished with the commitment of the group members and by maximizing human potential and mentorship.
Crisis:
A sudden, unpredictable, and potentially dangerous event requiring the president to play the role of crisis manager. Developmental (marriage, childbirth), situational (car crash, severe illness), adventitious (natural disaster)
Clinical practice guidelines and protocols
A systematically developed set of statements about appropriate health care for specific health care problems or clinical situations.
Comfort Measures
A wound is often painful, depending on the extent of tissue injury, and wound care often requires the use of well-timed analgesia before any wound procedure. Administer analgesic medications 30 to 60 minutes before dressing changes, depending on the time of peak action of a drug. In addition, several techniques are useful in minimizing discomfort during wound care. Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound.
The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated. B. migrate across the incision. C. appear slightly pink. D. slightly overlap each other.
A. are approximated.
Habits (5 modes of thinking)
Accepted ways of doing things that work, save time, are necessary.
Toxic effect of medication
Accumulation of medication in the bloodstream. For example toxic levels of morphine will cause severe respiratory depression.
Valvular heart disease
Acquired or congenital disorder of heart valves; valve either does not open or close completely -causes hardening (stenosis) or impaired closure of the valves -when stenosis occurs the flow of blood through the valves is obstructed causing the ventricle to hypertrophy or enlarge. if condition is left untreated left or right sided heart failure occurs
Active Transport
Active transport is a process that requires energy to move molecules against a concentration gradient. This energy source is ATP adenosine triphosphate. An example is the Sodium-Potassium pump allows sodium and potassium to move in and out of cells to maintain certain concentrations. Na+ moves out of the cell and K+ moves into the cell. ATP
Nursing interventions
Activities that the nurse plans and implements to help the patient achieve identified outcomes -RN must determine appropriate level of care for delegation of interventions. -Know scope of practice of all personnel involved with the client. -Delegate tasks based on job description, competency, scope of practice. -The RN is ultimately responsible!!
Acute Illness/Trauma and fluids
Acute conditions that place patients at high risk for fluid, electrolyte, and acid-base alterations include respiratory diseases, burns, trauma, GI alterations, and acute oliguric renal disease. -respiratory disorders -burns -trauma
Urination
Adequate blood flow and pressure is critical for kidney function -Average standard (especially postop) is 30 mL/hr or 0.5 mL/kg/hr Urine output reflects status of other systems Kidneys filter the blood and excrete compounds: -Waste products -Electrolytes -Excess fluid -Selectively retain or excrete fluid and electrolytes Kidney failure and malfunction will manifest itself in other systems***
Identity vs. Identity Confusion
Adolescence -Reflects on inconsistencies in stories -Begins to question spiritual practices, forms own opinions, and occasionally discards parents' beliefs -Abstract reasoning leads to exploration of moral issues -Spirituality comes from connectedness with family, nature, and God or a supreme being
Inserting the Intravenous Line
After you collect the equipment at the patient's bedside, prepare to insert the IV line by assessing the patient for a venipuncture site. The most common IV sites are on the inner arm. Do not use hand veins on older adults or patients who are ambulatory. IV insertion in a foot vein is common with children but avoid these sites in adults because of the increased risk of thrombophlebitis. As you assess a patient for potential venipuncture sites, consider conditions that exclude certain sites. Venipuncture is contraindicated in a site that has signs of infection, infiltration, or thrombosis. An infected site is red, tender, swollen, and possibly warm to the touch. Exudate may be present. Do not use an infected site because of the danger of introducing bacteria from the skin surface into the bloodstream. Avoid using an extremity with a vascular (dialysis) graft/fistula or on the same side as a mastectomy. Avoid areas of flexion if possible and choose the most distal appropriate site. Using a distal site first allows for the use of proximal sites later if the patient needs a venipuncture site change.
Cleaning Skin and Drain Sites
Although a moderate amount of wound exudate promotes epithelial cell growth, some health care providers order cleaning a wound or drain site if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin. Wound cleaning requires good hand hygiene and aseptic techniques. You can use irrigation to remove debris from a wound.
Spirituality Assessment
Although spirituality assessment and interventions are discussed separately here, a holistic approach to spiritual caregiving recognizes that they are often same process. Appropriate assessment is basic to integrating spirituality into holistic care. Many scales for assessing spirituality and spiritual caregiving have been developed for use in clinical and educational settings and in research.
Nutritional Status and wounds
An assessment of a patient's nutritional status is an integral part of the initial assessment data for any patient, especially one at risk for impaired skin integrity. The Joint Commission recommends nutritional assessment within 24 hours of admission. Weigh the patient and perform this measure more often for at-risk patients. A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 lb in a brief period are all signs of actual or potential nutritional problems. Assess the patient's mouth and teeth for oral sores and ill-fitting dentures that impact nutritional intake.
Appreciative inquiry:
An asset-based approach built on the assumption that every organization has positive elements and processes and that these strengths can be the starting point for positive change.
Cultural transformational agent:
An individual who holds the vision for and works to actualize a plan to transform the culture of an organization to become a caring, healing environment.
Hemoglobin
An iron-containing protein in red blood cells that reversibly binds oxygen. -four oxygen can bind to one hemoglobin Hemoglobin, which is a carrier for oxygen and carbon dioxide, transports most oxygen (approximately 97%). The hemoglobin molecule combines with oxygen to form oxyhemoglobin.
Oxygen masks
An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either the mouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source.
Self-adhesive, transparent film
Another type of dressing is a self-adhesive, transparent film that traps moisture over a wound, providing a moist environment to encourage epithelial cell growth. A transparent dressing adheres to undamaged skin, does not need a secondary dressing, and permits viewing of the wound. It is ideal for small superficial wounds such as a stage 1 pressure injury or a partial-thickness wound. Use a film dressing as a secondary dressing and for autolytic debridement of small wounds. It serves as a barrier to external fluids and bacteria but still allows the wound surface to "breathe" because oxygen passes through the transparent dressing. This dressing promotes a moist environment to encourage epithelial cell growth. It adheres to undamaged skin, does not need a secondary dressing, and permits viewing of the wound.
Dietary Intake and fluids
Assess dietary intake of fluids; salt; and foods rich in potassium, calcium, and magnesium. Ask patients if they follow weight-loss diets. Starvation diets or those with high fat and no carbohydrate content often lead to metabolic acidosis. In addition, assess a patient's ability to chew and swallow, which, if altered, interferes with adequate intake of electrolyte-rich foods and fluids.
Lifestyle and fluids
Assess your patient's alcohol intake. How many days does a person have an alcoholic drink each week, and how many drinks does he or she have at any one time? Chronic alcohol abuse commonly causes hypomagnesemia, in part because it increases renal magnesium excretion.
Ritual and Practice
Assessing the use of rituals and practices helps you understand a patient's spirituality. Rituals include participation in worship, prayer, sacraments (e.g., baptism, Holy Eucharist), fasting, singing, meditating, scripture reading, and making offerings or sacrifices. Different religions have different rituals for life events. For example, Buddhists practice baptism later in life and find burial or cremation acceptable at death. Followers of Islam practice Salah, the second of the Five Pillars of Islam, requiring all Muslims who have reached puberty to worship five times daily, facing the holy city of Mecca. Orthodox and conservative Jews circumcise their newborn sons 8 days after birth. Determine whether illness or hospitalization has interrupted a patient's ability to follow usual rituals or practices. A ritual often provides the patient with structure and support during difficult times. If rituals are important to a patient, use them as part of nursing intervention.
Direct, independent intervention:
Assessment due to change in status
Mobility and wounds
Assessment includes documenting the baseline level of mobility and the potential effects of impaired mobility on skin integrity. Documenting assessment of mobility includes obtaining data regarding the quality of muscle tone and strength. For example, determine whether the patient is able to lift his or her weight off the sacral area and roll the body to a side-lying position. Some patients have inadequate range of motion to move independently into a more protective position. Finally, assess a patient's activity tolerance to determine whether the patient can be transferred to a chair or ambulated more often to relieve pressure from lying down.
Spiritual Care-Giving Scale
Attributes for spiritual care Spiritual perspectives Defining spiritual care Spiritual care attitudes Spiritual care values
Denial:
Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain (e.g., a person refuses to discuss or acknowledge a personal loss)
Quick stroke assessment
Balance (loss of balance, headaches or dizziness) Eyes (blurred vision) Face (one side of face is drooping) Arms (arm or leg weakness) Speech (speech difficulty) Time (time to call for ambulance immediately)
What occurs faster: compensation for metabolic imbalances or for respiratory imbalances
Because the lungs respond to acid-base disorders within minutes, compensation for metabolic imbalances occurs faster than compensation for respiratory imbalances.
Assessment for Temperature Tolerance
Before applying heat or cold therapies, assess a patient's physical condition for signs of potential intolerance to heat and cold. First observe the area to be treated. Assess the skin, looking for any open areas such as alterations in skin integrity (e.g., abrasions, open wounds, edema, bruising, bleeding, or localized areas of inflammation) that increase a patient's risk for injury. Because a health care provider commonly orders heat and cold applications for traumatized areas, the baseline skin assessment provides a guide for evaluating skin changes that can occur during therapy. Assess neurological function, testing for sensation to light touch, pinprick, and mild temperature variations. Sensory status reveals the ability of a patient to recognize when heat or cold becomes excessive. Assess a patient's mental status to be sure that he or she can correctly communicate any issues with the hot or cold therapy. Level of consciousness influences the ability to perceive heat, cold, and pain. If a patient is confused or unresponsive, the nurse needs to make frequent observations of skin integrity after therapy begins.
Trust vs. Mistrust
Birth to 18 months -Spiritual well-being provided by parents -Trust provides basis for hope -Love, affection, security, and a stimulating environment promote spirituality
Colloid Osmotic Pressure
Blood contains albumin and other proteins known as colloids. These proteins are much larger than electrolytes, glucose and other molecules that dissolve easily. Blood colloid osmotic pressure also known as oncotic pressure, is an inward -pulling force that helps move fluid from the interstitial area back into capillaries.
Plateau
Blood serum concentration is reached and maintained after repeated fixed doses.
Burns and fluids
Burns place patients at high risk for ECV deficit from numerous mechanisms, including plasma-to-interstitial fluid shift and increased evaporative and exudate output. Fluid loss increases with the percentage of body surface burned. Patients with burns have cellular damage that releases potassium into the blood, and they may become hyperkalemic. In addition, these patients often develop metabolic acidosis because of greatly increased cellular metabolism, which produces more metabolic acids than their kidneys are able to excrete.
Cardiopulmonary resuscitation
CPR -Restoration of cardiopulmonary functioning:
Indirect, dependent intervention:
Call an ordered referral to a specialist
Role of Selected Nutrients in Wound Healing
Calories Fuel for cell energy "Protein protection" 35-40 kcal/kg/day or enough to maintain positive nitrogen balance Protein Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function 1-1.5 g/kg/day or enough to maintain positive nitrogen balance Poultry, fish, eggs, beef Vitamin C (ascorbic acid) Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant 100-1000 mg/day Need long time to develop clinical scurvy from vitamin C deficiency Low toxicity Citrus fruits, tomatoes, potatoes, fortified fruit juices Vitamin A Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation 1600-2000 retinol equivalents per day Supplement if deficient 20,000 units × 10 days Green leafy vegetables (spinach), broccoli, carrots, sweet potatoes, liver Can reverse steroid effects on skin and delayed healing Vitamin E No known role in wound healing, antioxidant None Fish, oysters, liver, dark meat, eggs, legumes Zinc Collagen formation, protein synthesis, cell membrane and host defenses 15-30 mg Correct deficiencies No improvement in wound healing with supplementation unless zinc deficient Use with caution—large doses can be toxic May inhibit copper metabolism and impair immune function Vegetables, meats, legumes Fluid Essential fluid environment for all cell function 30-35 mL/kg/day Increase by another 10-15 mL/kg if patient is on an air-fluidized bed Use noncaffeine, nonalcoholic fluids without sugar Water is best—6-8 glasses/day
Objective data
Can observe directly. -The client's blood pressure is 150/88. -There is a stage II pressure injury, 2cm x 2cm on the Rt heel. SIGNS
Subjective data
Cannot observe directly. Patients' verbal descriptions of their health problems includes patient feelings, perceptions, and self-reported symptoms -"I've got a tingling pain in my foot." -"I feel so sick to my stomach." SYMPTOMS
Chronic illnesses and fluids
Chronic Illness Many chronic diseases create ongoing risk of fluid, electrolyte, and acid-base imbalances. For example, type B chronic obstructive pulmonary disease (COPD) often causes chronic respiratory acidosis. In addition, the treatment regimens for chronic disease often cause imbalances. Assess patients for the presence of these conditions -cancer -heart failure
Serous
Clear, watery plasma
cold therapy
Cold therapy refers to the superficial application of cold to the surface of the skin, with or without compression and with or without a mechanical recirculating device to maintain cold temperatures. Cold therapy is designed to treat the localized inflammatory response of an injured body part that presents as edema, hemorrhage, muscle spasm, or pain. Improvement to joint mobility following cold therapy is related to reducing pain and swelling, inhibiting muscle spasm, and reducing muscle tension. Cold therapy most commonly is used immediately after soft tissue and musculoskeletal injuries such as sprains or strains; however, it has been used in the postoperative setting with patients who have undergone orthopedic surgeries, spinal fusion, and lumbar discectomy. Research trials of cold therapy have been inconsistent and frequently found no differences compared with no cold therapy in postoperative pain or analgesic use
nursing interventions classification interventions
Common interventions recommended for various nursing diagnoses.
Compassion fatigue:
Compassion fatigue is a condition that can overwhelm health care providers and cause physical, mental, and emotional health issues. The feelings of hopelessness and anxiety from compassion fatigue usually result in feelings of inadequacy and lower self-esteem. These factors can lead to the health care provider lashing out in an attempt to cope with these feelings and stress. This often manifests itself as lateral violence, which refers to a deliberate and harmful behavior demonstrated in the workplace by one employee to another. This includes health care providers engaging in bullying and potentially assaultive behaviors toward co-workers -A state of burnout and secondary traumatic stress -Caring for others who are suffering -Emotional exhaustion -Can overwhelm health care providers and cause physical, mental, and emotional health issues -Can result in a negative work environment
Connection
Connection is the third principle of influential leadership and is regarded as a core strategy to build and strengthen a compassionate culture that promotes effective relationships and "raises everyone's level of energy, engagement, motivation, and performance." Sharing meaningful experiences through authentic connection fosters organizational commitment and drives performance excellence.
Regression:
Coping with a stressor through actions and behaviors associated with an earlier developmental period
IV Equipment
Correct selection and preparation of IV equipment helps in safe and rapid placement of an IV line. Because fluids infuse directly into the bloodstream, sterile technique is necessary. Organize all equipment at the bedside for an efficient insertion. IV equipment includes VADs; tourniquet; clean gloves; dressings; IV fluid containers; various types of tubing; and electronic infusion devices (EIDs), also called infusion pumps . VADs that are short peripheral IV catheters are available in a variety of gauges, such as the commonly used 20 and 22 gauges. A larger gauge indicates a smaller-diameter catheter. A peripheral VAD is called an over-the-needle catheter; it consists of a small plastic tube or catheter threaded over a sharp stylet (needle). Once you insert a stylet and advance the catheter into the vein, you withdraw the stylet, leaving the catheter in place. These devices have a safety mechanism that covers the sharp stylet when withdrawing it to reduce the risk of needlestick injury. Needleless systems allow you to make connections without using needles, which reduces needlestick injuries.
Subjective Findings
Create a nonthreatening environment when assessing a patient's level of stress and coping resources. Sit at the same height as the patient, arranging the interview environment with the chairs at a 90-degree angle or side by side so that you can maintain or avoid eye contact comfortably. Begin to develop a trusting relationship with your patient while you gather information about the patient's health status from his or her perspective. Use the interview to determine the patient's view of the stress, coping resources, any possible maladaptive coping, and adherence to prescribed medical recommendations such as medication or diet. If the patient is using denial as a coping mechanism, assess if he or she is overlooking necessary information. As in all interactions with the patient, respect the confidentiality and sensitivity of the information shared.
Skills of Critical Thinking
Critical analysis -What if... Socratic questioning -What do I know? Does it apply here? Deductive reasoning -Big concepts to specific examples Inductive reasoning -Specific examples to big concepts
A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has no odor. B. a culture is negative. C. the edges reveal the presence of fluid. D. it shows purulent drainage coming from the incision site.
D. it shows purulent drainage coming from the incision site.
A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. protection from the external environment. D. moisture needed for wound healing.
D. moisture needed for wound healing.
Daily weights
Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid, usually ECF, but do not indicate shift between body compartments. Weigh patients with heart failure and those who are at high risk for or actually have ECV excess daily. Daily weights are also useful for patients with clinical dehydration or other causes or risks for ECV deficit. Weigh the patient at the same time each day with the same scale after a patient voids. Calibrate the scale each day or routinely. The patient needs to wear the same clothes or clothes that weigh the same; if using a bed scale, use the same number of sheets on the scale with each weighing. Compare the weight of each day with that of the previous day to determine fluid gains or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care.
What does decreased hemoglobin cause?
Decreased hemoglobin levels, seen in patients with anemia or blood loss, alter a patient's ability to transport oxygen, causing disturbances in oxygenation.
Pulmonary veins
Deliver oxygen rich blood from the lungs to the left atrium
Deep tissue injury
Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones.
Cultural Aspects of Care Impact of Skin Color
Detecting cyanosis and other changes in skin color in patients is an important clinical skill. However, this detection becomes a challenge in patients with darkly pigmented skin. Color differentiation of cyanosis varies according to skin pigmentation. In patients with darkly pigmented skin, you need to know the individual's baseline skin tone. • Patients with darkly pigmented skin cannot be assessed for pressure injury risk by examining only skin color • Use natural lighting • Assess for changes in sensation, temperature, or tissue consistency, which may precede visual skin changes • Examine body sites with the least melanin such as under the arm for underlying color identification • Palpate surrounding tissues to identify any changes in temperature, edema, or tissue consistency between area of injury or suspected injury and normal tissue • Circumscribed area of intact skin may be warm to touch. • Localized heat (inflammation) is detected by making comparisons to surrounding skin. • Edema may occur with induration of more than 15 mm in diameter, and skin may appear taut and shiny
Edema
Disease processes alter these forces and fluid accumulates in the interstitial spaces Known as edema. People with heart failure often develop edema. Venous congestion from a weakened heart that no longer pumps effectively increases capillary hydrostatic pressure, causing edema by moving excessive fluid into the interstitial space. Inflammation is another cause of edema. It increases capillary blood flow and allows capillaries to leak colloids into the interstitial space. The resulting increased capillary hydrostatic pressure and increased interstitial colloid osmotic pressure produce localized edema in the inflamed tissues.
Hemostasis stage
During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair.
Alarm Stage
During the alarm stage the central nervous system is aroused, and body defenses are mobilized; this is the fight-or-flight response . During this stage rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine, heart rate, blood flow to muscles, oxygen intake, and mental alertness. In addition, the pupils of the eyes dilate to produce a greater visual field. If the stressor poses an extreme threat to life or remains for a long time, the person progresses to the second stage, resistance.
Ear drops
Eardrops used to treat ear infections and associated pain, soften earwax to ease removal, apply a local anesthetic, and destroy insects trapped in the ear canal -The internal ear is very sensitive to temp changes: warm med to room temp before -If tympanic membrane has been damaged, all procedures are performed with sterile technique to prevent infection -Document the ear in which med was instilled and patient's response to med
Primary intention wound healing
Edges are approximate
Secondary intention wound healing
Edges are not approximated
Sociocultural Factors
Environmental and social stressors often lead to developmental problems. Potential stressors that affect any age-group but that are especially stressful for young people include prolonged poverty and physical disability. Children become vulnerable when they lose parents and caregivers through divorce, imprisonment, or death or when parents have mental illness or substance-abuse disorders. Living under conditions of continuing violence, disintegrated neighborhoods, or homelessness affects people of any age, especially young people. A person's culture also influences stress and coping. Cultural variations produce stress, particularly if a person's values differ from the dominant culture in aspects of gender roles, family relationships, and religious beliefs. Other aspects of cultural variations begin with language difference, geographical location, family relationships, time orientation, access to health care programs, and disparities in health care.
Skin
Epidermis •Top layer of skin Dermis •Inner layer of skin •Collagen Dermal-epidermal junction •Separates dermis and epidermis
primary appraisal
Evaluating an event in terms of personal meaning is primary appraisal . Appraisal of an event or circumstance is an ongoing perceptual process. Stress results when a person identifies an event or circumstance as a harm, loss, threat, or challenge.
Inquiry (5 modes of thinking)
Examining issues in depth and questioning that which may seem immediately obvious, "critical thinking".
Therapeutic effect of medication
Expected or predicted physiological response
Dissociation:
Experiencing a subjective sense of numbing and a reduced awareness of one's surroundings
Bodily Responses to Heat and Cold
Exposure to heat and cold causes systemic and local responses. Systemic responses occur through heat-loss mechanisms (sweating and vasodilation) or mechanisms promoting heat conservation (vasoconstriction and piloerection) and heat production (shivering). Local responses to heat and cold occur through stimulation of temperature-sensitive nerve endings within the skin. This stimulation sends impulses from the periphery to the hypothalamus, which becomes aware of local temperature sensations and triggers adaptive responses for maintenance of normal body temperature. If alterations occur along temperature sensation pathways, the reception and eventual perception of stimuli are altered.
Chest physiotherapy
External chest wall manipulation using percussion, vibration, or high-frequency chest wall compression (HFCWC) -postural drainage: used to assist in secretion clearance -table 41.6 shows different position for postural drainage
Transcellular fluid
Eyes, brain, spinal canal, lymph, synovial tissue and eyes (small amount of extracellular fluid)
Nursing Diagnosis
FOCUS is human/patient response to a health condition. GOAL - help the patient reach maximum level of function and wellness. Ex: Ineffective Airway Clearance R/T Increased Secretions
Medical Diagnosis
FOCUS is identification and treatment of a disease. GOAL - to confirm a medical diagnosis, then treat and manage the medical condition. Ex: Chronic Obstructive Pulmonary Disease with Pneumonia
Fellowship and Community
Fellowship is one kind of relationship that an individual has with other people, including immediate family, close friends, associates at work or school, fellow members of a place of worship, and neighbors. More specifically, this includes the extent of the community of shared faith between people and their support networks. Many times social support from faith-based groups helps patients cope with illness and participate in health promotion behaviors. To assess a patient's supportive community, ask questions such as "Who do you find to be the greatest source of support in times of difficulty?" or "When you've faced difficult times in the past, who has been your greatest resource?" Explore the extent and nature of a person's support networks and their relationship with the patient.
Parenteral Replacement of Fluids and Electrolytes
Fluid and electrolytes may be replaced through infusion of fluids directly into veins (intravenously) rather than via the digestive system. Parenteral replacement includes parenteral nutrition (PN), IV fluid and electrolyte therapy ( crystalloids ), and blood and blood component (colloids) administration. IV devices are called peripheral IVs when the catheter tip lies in a vein in one of the extremities; they are called central venous catheters (CVCs) or IVs when the catheter tip lies in the central circulatory system (e.g., in the vena cava close to the right atrium of the heart)
Intracellular fluid
Fluid found "within" or inside the cells. (2/3 of total). 40% of body weight
Extracellular fluid
Fluid found outside the cells (1/3 of total). 20% of body weight
Fluid intake
Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, soup), drinks (e.g., water, coffee, juice), or receives through nasogastric or jejunostomy feeding tube. IV fluids (continuous infusions and intermittent IV piggybacks) and blood components also are sources of intake. Water swallowed while taking pills and liquid medications counts as intake. A patient receiving tube feedings often receives numerous liquid medications, and water is used to flush the tube before and/or after medications. Over a 24-hour period these liquids amount to significant intake and always are recorded on the I&O record. Ask patients who are alert and oriented to help with measuring their oral intake and explain to families why they should not drink or eat from the patient's meal trays or water pitcher.
Fluid output
Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes. Record a patient's urinary output after each voiding. Instruct patients who are alert, oriented, and ambulatory to save their urine in a urinal or a calibrated insert, which attaches to the rim of the toilet bowl. Teach patients and families the purpose of I&O measurements. Also teach them to notify the nurse or assistive personnel (AP) to empty any container with voided fluid or how to measure and empty the container themselves and report the result appropriately. Patients need to have good vision and motor skills to perform these measurements. Active involvement of patient and family is an aspect of patient-centered care that is essential to maintaining accurate I&O measurements. When a patient has an indwelling urinary catheter, drainage tube, or suction, record output (e.g., at the end of each nursing shift or every hour) as the patient's condition requires.
Osmosis
Fluids move from an area of lower solute/more fluid to an area of higher solute/less fluid until the solute concentrations are equal. -movement of H20 from area of dilute solute to more conc solute (passive)
Unstageable pressure ulcer
Full-thickness Skin or Tissue Loss—Depth Unknown. Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.
Stage 3 Pressure Ulcer
Full-thickness skin loss with visible adipose fat. •Full-thickness Skin Loss. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.
Gauze sponges
Gauze sponges are the oldest and most common dressing. They are absorbent and are especially useful in wounds to wick away wound exudate. Gauze is available in different textures and various lengths and sizes; the 4 × 4 is the most common size. Gauze can be saturated with solutions and used to clean and pack a wound. When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out (leaving the gauze only moist), unfolded, and lightly packed into the wound. Unfolding the dressing allows easy wicking action. The purpose of this type of dressing is to provide moisture to the wound yet to allow wound drainage to be wicked into the dry cover gauze pad.
Effects of Heat Application
Generally heat is quite therapeutic, improving blood flow to an injured part. However, if it is applied for 1 hour or more, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. Periodic removal and reapplication of local heat restores vasodilation. Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering.
Nursing Process: Planning Skin
Goals and outcomes -Plan interventions according to •Risk for pressure ulcers •Type and severity of the wound •Presence of complications Setting priorities -Preventing pressure ulcers -Promoting wound healing Teamwork and collaboration is the key to wound healing.
Care bundle
Group of interventions related to a disease process or condition.
Assessment: Patient History and Pulmonary Health
Health Risk: family hx of lung cancer and CVD Environmental Exposures Pain Smoking Fatigue Respiratory Infections Dyspnea Allergies Cough Medications
Spiritual Health: Implementation
Health promotion: Establishing presence—involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; "being with" rather than "doing for" -Supportive healing relationship: Mobilize hope, Provide interpretation of suffering that is acceptable to patient, Help patient use resources.
Trauma and fluids
Hemorrhage from any type of trauma causes ECV deficit from blood loss. Some types of trauma create additional risks. For example, crush injuries destroy cellular structure, causing hyperkalemia by massive release of intracellular K + into the blood. Head injury typically alters ADH secretion. It may cause diabetes insipidus (deficit of ADH), in which patients excrete large volumes of very dilute urine and develop hypernatremia. In contrast, head injury may cause the syndrome of inappropriate antidiuretic hormone (SIADH), in which excess secretion of ADH causes hyponatremia by retaining too much water and concentrating the urine.
Hypermagnesemia: what do you see
High Mg blocks release of acetylcholine from myoneural junction decrease in muscle cell activity -hypotension-peripheral vessel dilation -Bradycardia -ECG changes- (Heart block, PVCs) -Sedative effects-muscle weakness, lethargy, drowsiness. Loss of DTRs, resp. paralysis, loss of consciousness -Acute elevation in Mg2+ can cause flushing and feeling of warmth
High flow nasal cannula
High-flow nasal cannula may be beneficial in patients with ARDS. An alternative to intubation & mechanical ventilation Associated with nosocomial pneumonia and barrow trauma Heated humidification and large-bore nasal prongs to deliver oxygen at flows of up to 50 L/min. Usually well tolerated; allows the patient to talk, eat, and move around.
Prioritizing by importance
High: Nursing diagnoses that, if untreated, result in harm to a patient or other. -Maslow's hierarchy of needs. Intermediate: Nonemergent and not life-threatening. Low: Not always directly related to a specific illness or prognosis but affect a patient's future well-being.
CV 4: Holistic education and research
Holistic nursing is further realized through education and research.16,p.18 Holistic nurses value all the ways of knowing and learning. Educators need to be familiar with the American Association of Colleges of Nursing (AACN), which includes language for baccalaureate generalist graduates to practice from a holistic, caring framework.19 Holistic nurses look at alternative philosophies of science and research methods that are compatible with investigations of humanistic and holistic occurrences.
Fluid balance regulation
Hormones communicate the regulation of fluid levels: -Antidiuretic hormone (ADH) - Restores blood volume by reducing urine output -Decreased blood volume and increased solute concentration are sensed by the brain -ADH is produced by the hypothalamus -Kidneys retain water, which increases intravascular volume and decreases solute concentration -Renin-Angiotensin-Aldosterone cascade -Special cells in the kidney sense a decrease in blood flow or sodium levels. The net effect is to restore blood volume and renal perfusion through sodium and water retention. -Renin is released into the bloodstream -Renin is converted (several steps) to angiotensin II (vasoconstrictor, sodium and water retention, stimulator of aldosterone production) -Aldosterone causes the kidneys to retain sodium and water
Environment and fluids
Hot environments increase fluid output through sweating. Sweat is a hypotonic sodium-containing fluid. Excessive sweating without adequate replacement of salt and water can lead to ECV deficit, hypernatremia, or clinical dehydration. Ask patients about their normal level of physical work and whether they engage in vigorous exercise in hot environments. Do the patients have fluid replacements containing salt available during exercise and activity?
Hydrocolloid dressing
Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds; they are available in a variety of sizes and shapes. This type of dressing absorbs drainage through the use of exudate absorbers in the dressing; maintains wound moisture; slowly liquefies necrotic debris; and can be left in place for 3 to 5 days. In addition, hydrocolloid dressings are impermeable to bacteria and other contaminants, act as a preventive dressing for high-risk friction areas, and are self-adhesive and mold to the wound. The hydrocolloid dressing is useful on shallow-to-moderately deep dermal injuries. Hydrocolloid dressings cannot absorb drainage from heavily draining wounds, and some are contraindicated for use in full-thickness and infected wounds. Most hydrocolloids leave a residue in the wound bed that is easy to confuse with purulent drainage.
Hydrogel dressing
Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings are indicated for use in partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. They debride necrotic tissue by softening the necrotic area. They can be very useful in painful wounds because they are very soothing to a patient and do not adhere to the wound bed and thus cause little pain during removal. A disadvantage is that some hydrogels require a secondary dressing and you must take care to prevent periwound maceration. Hydrogels also come in a tube; thus you are able to squirt the gel directly into the wound base.
Nonblanchable erythema
If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.
Warm Soaks
Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution. Sometimes a soak is also accompanied by wrapping the body part in dressings and saturating them with the warmed solution. Position the patient comfortably, place waterproof pads under the area to be treated, and heat the solution to about 40.5° to 43°C (105° to 110°F). Pour solution into a clean or sterile basin or container, then immerse the body part. Cover the container and extremity with a towel to reduce heat loss. It is usually necessary to remove the cooled solution and add heated solution after about 10 minutes. The challenge is to keep the solution at a constant temperature. Never add a hotter solution while the body part remains immersed. After any soak dry the body part thoroughly to prevent maceration.
Faith
In addition to being a component of spirituality, the concept of faith has other definitions. It is a cultural or institutional religion such as Judaism, Buddhism, Islam, or Christianity. It is also a relationship with a divinity, higher power, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Reasoning faith provides confidence in something for which there is no proof. It is an acceptance of what reasoning cannot explain. Sometimes faith involves a belief in a higher power, spirit guide, God, or Allah. It is also the way a person chooses to live. It gives purpose and meaning to an individual's life, allowing for action.
Exhaustion Stage
In the exhaustion stage continuous stress causes progressive breakdown of compensatory mechanisms. This occurs when the body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation. The physiological response has intensified, but the person's ability to adapt to the stressor diminishes. Even in the face of chronic demands, an ongoing state of chronic activation can occur. This chronic arousal with the presence of powerful hormones causes excessive wear and tear on bodily organs and is called allostatic load . A persistent allostatic load can cause long-term physiological problems such as chronic hypertension, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders.
Inflammation stage
In the inflammation stage, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and causes movement/migration of serum and white blood cells into the damaged tissues
Hypoxia
Inadequate tissue oxygenation at the cellular level -life-threatening CAUSES: -decreased hemoglobin level -diminished concentration of inspired oxygen -inability of tissues to extract oxygen from blood -decreased defusion of oxygen from the alveoli to the blood -poor tissue perfusion with oxygenated blood -impaired ventilation s&s: apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness and behavioral changes. cyanosis, blue discoloration, is a late sign.
Gastrointestinal Output and fluids
Increased output of fluid through the GI tract is a common and important cause of fluid, electrolyte, and acid-base imbalances that requires careful assessment. Vomiting and diarrhea, either acute or chronic, can cause ECV deficit, hypernatremia, clinical dehydration, and hypokalemia by increasing the output of fluid, Na + , and K + . In addition, chronic diarrhea can cause hypocalcemia and hypomagnesemia by decreasing electrolyte absorption. Removal of gastric acid from the body
Importance of water
Individuals cannot live without body fluid When an individual loses fluids, by vomiting for example, some of the normal fluid content of the body is lost. If the vomiting continues and the person does not drink fluids, the loss may become serious. The individual will experience dry mucous membranes, an increase in body temperature, and may become lethargic. If the fluid loss goes untreated over time the body's compensatory mechanisms will no longer maintain an adequate fluid balance, and the individual's health may become compromised. Depending on the severity, fluid loss can lead to irreversible heath problems or death. A loss of 20% of the body's fluid content is fatal.
Vocation
Individuals express their spirituality on a daily basis in life routines, work, play, and relationships. It is often a part of a person's identity and vocation. Determine whether illness, injury, or hospitalization alters the ability to express some aspect of spirituality as it relates to the person's work or daily activities. Expression of spirituality includes showing an appreciation for life in the variety of things people do, living in the moment and not worrying about tomorrow, appreciating nature, expressing love toward others, and being productive. When illness or loss prevents patients from expressing their spirituality, understand the psychological, social, and spiritual implications and provide appropriate guidance and support. Questions to ask include, "How has your illness affected the way you live your life spiritually at home or where you work?" or "How has your illness affected your ability to express what's important in life for you?"
Rhinitis
Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge (mild allergic reaction)
FVD Interventions
Interventions 1.Monitor VS q4h 2.Daily wt: 3.Assist with ambulation 4.Accurate I&O 5.Administer blood, fluids as ordered.
Trauma
Intrusive flashbacks or even intentional thinking back trigger a wave of the same emotions and chemicals experienced during trauma. Early trauma is recognized as having a significant effect on health. Autoimmune diseases develop; the particular disease is dependent upon genetics, environment, and lifestyle. Children who experienced trauma have higher levels of cortisol in their hair, and in a 2015 study, this translated directly to significantly more childhood disease compared to those who were not traumatized. Long-term and unremitting stress can reduce immune function and increase the inflammatory response, and the body enters an illness state. The continuous presence of high levels of cortisol and other stress chemicals triggers inflammatory processes; increases the risk of such disorders as osteoporosis, ulcers, and Alzheimer's disease; and leads to immune system imbalance. Autoimmune diseases are triggered.
Irrigation
Irrigation Irrigation is a way of cleaning wounds. Use an irrigation syringe to flush the wound with a constant low-pressure flow of solution. The gentle washing action of the irrigation cleanses a wound of exudate and debris. Irrigation is particularly useful for open, deep wounds; wounds involving an inaccessible body part such as the ear canal; or when cleaning sensitive body parts such as the conjunctival lining of the eye. Irrigation of an open wound requires sterile technique. Use a 35-mL syringe with a 19-gauge soft angiocatheter to deliver the solution. This irrigation system has a safe pressure and does not damage healing wound tissue. It is important to never occlude a wound opening with a syringe because this results in the introduction of irrigating fluid into a closed space. The pressure of the fluid causes tissue damage and discomfort and possibly forces infection or debris into the wound bed. Always irrigate a wound with the syringe tip over but not in the drainage site. Make sure that fluid flows directly into the wound and not over a contaminated area before entering the wound.
Absorption of Medication
Is the passage of medication molecules into the blood from the site of administration.
Body Fluids and wounds
It is important to prevent and reduce the patient's exposure to body fluids; when exposure occurs, provide meticulous hygiene and skin care. Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure injury formation. Some body fluids such as saliva and serosanguineous drainage are not as caustic, and the risk of skin breakdown from exposure to these fluids is low. However, exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Frequent exposure to urine and fecal contents increases patients' risk for incontinence-associated dermatitis (IAD). Additionally, exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. These fluids have digestive qualities that can irritate and break down the skin quickly.
Pruritus
Itching of skin; accompanies most rashes (mild allergic reaction)
Hypokalemia :
K+<3.5mEq/L -Most common cause = losses through kidneys (example potassium wasting duretics) or GI tract, prolonged NPO without replacement -Transcellular shifts
Hyperkalemia
K+>5.OmEq/L -Massive intake of K+ -*Most common cause = impaired renal excretion -Massive trauma (burns, crushing injuries, severe infections) -Potassium sparing diuretics, ACE Inhibitors
Stress impact to the body
KNOW THIS
Pressure Duration
Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure. Both types of pressure cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. Clinical implications of pressure duration include evaluating the amount of pressure (checking skin for nonblanching hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches).
Hydrostatic pressure
Major force that moves H20 out of vascular system at the capillary level -In the blood vessels HP is the B/P generated by the contraction of the heart. -Decreases from the arterial to the venous end of the capillary.
Compensation:
Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset (e.g., a person who is a poor communicator relies on organizational skills)
Respiratory Disorders and fluids
Many acute respiratory disorders predispose patients to respiratory acidosis. For example, bacterial pneumonia causes alveoli to fill with exudate that impairs gas exchange, causing the patient to retain carbon dioxide, which leads to increased PaCO 2 and respiratory acidosis.
Types of Solutions
Many prepared IV solutions are available for use. An IV solution is isotonic, hypotonic, or hypertonic. Isotonic solutions have the same effective osmolality as body fluids. Sodium-containing isotonic solutions such as normal saline are indicated for ECV replacement to prevent or treat ECV deficit. Hypotonic solutions have an effective osmolality less than body fluids, thus decreasing osmolality by diluting body fluids and moving water into cells. Hypertonic solutions have an effective osmolality greater than body fluids. If they are hypertonic sodium-containing solutions, they increase osmolality rapidly and pull water out of cells, causing them to shrivel. The decision to use a hypotonic or hypertonic solution is made on the basis of a patient's specific fluid and electrolyte imbalance. -Additives such as potassium chloride (KCl) are common in IV solutions (e.g., 1000 mL D 5 ½ NS with 20 mEq KCl at 125 mL/hr). Administer KCl carefully because hyperkalemia can cause fatal cardiac dysrhythmias. Under no circumstances should KCl be administered by IV push (directly through a port in IV tubing ). Verify that a patient has adequate kidney function and urine output before administering an IV solution containing potassium. Patients with normal renal function who are receiving nothing by mouth should have potassium added to IV solutions. The body cannot conserve potassium, and the kidneys continue to excrete it even when the plasma level falls. Without potassium intake, hypokalemia develops quickly.
Maturation stage
Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. -The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. -Collagen fibers undergo remodeling or reorganization before assuming their normal appearance. Usually, scar tissue forms and it contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals, the scar tissue may be more highly pigmented than surrounding skin.
Output measurement
Measuring and recording all liquid intake and output (I&O) during a 24-hour period is an important aspect of fluid balance assessment. Compare a patient's 24-hour intake with his or her 24-hour output. The two measures should be approximately equal if the person has normal fluid balance ( Felver, 2019c ). To interpret situations in which I&O are substantially different, consider the individual patient. For example, if intake is substantially greater than output, there are two possibilities: the patient may be gaining excessive fluid or returning to normal fluid status by replacing fluid lost previously from the body. Similarly, if intake is substantially smaller than output, there are also two possibilities: the patient may be losing needed fluid from the body and developing ECV deficit and/or hypernatremia or returning to normal fluid status by excreting excessive fluid gained previously.
Direct, collaborative intervention:
Medication administration per order set
Metabolism of Medications
Metabolism -Medications are metabolized into a less-potent or an inactive form that is easier to excrete. -Biotransformation (process by which a substance changes from one chemical to another) occurs under the influence of enzymes that detoxify, break down, and remove active chemicals. -Most biotransformation occurs in the liver, although the lungs, kidneys, blood and intestines also metabolize the medications.
Microbiome
Microbiome There is also increasing evidence that we can use probiotics to help persons suffering from a variety of illnesses. These include not only bowel disease like irritable bowel syndrome but also psychiatric illness or diabetes. Researchers can now discern which strains of gut bacteria affect the nervous system and even map the exact pathways through which specific gut bacteria influence the brain. For example, people suffering from major depression frequently have elevated levels of the hormone cortisol and the messenger proteins called cytokines, which are released in response to stress.
Generativity vs. Stagnation
Middle-age adulthood -Develops appreciation of past spiritual experiences -Embraces people from different faiths and religions -Reviews value system during crisis -Values others
Mindfulness-Based Stress Reduction
Mindfulness is a moment-to-moment present awareness with an attitude on nonjudgment, acceptance, and openness. This technique entails focusing on attentiveness on regular activities and truly enjoying pleasant experiences. Mindfulness-based stress reduction (MBSR) meditative practices are effective in reducing psychological and physical symptoms or perceptions. They are effective in stress management and symptom control with certain chronic conditions. Through mindfulness exercises people learn to self-regulate awareness and attention to feeling and implement effective changes. Patients use cognitive exercises and subjective experiences to process images or feelings. Patients evaluate these feelings as pleasant or unpleasant and learn strategies to enhance the pleasant experiences and replace the unpleasant experiences. Through MBSR patients can control their stress response to illnesses and treatments, employees can manage job-related stress, and students can learn to manage stress anxiety.
heat therapy
Moist heat applications are therapeutically beneficial in increasing muscle and ligament flexibility; promoting relaxation and healing; and relieving spasm, joint stiffness, and pain. Moist heat has many indications; however, it is most commonly used following the acute phase of a musculoskeletal injury and during and after childbirth, surgery, and superficial thrombophlebitis. Moist heat applications include warm compresses and commercial moist heat packs, warm baths, soaks, and sitz baths. Dry heat is also used to reduce pain and increase healing by increasing blood flow in tissues and can be used at a low level for a longer period with little chance of tissue injury
Medication tolerance
More medication is required to achieve the same therapeutic effect. Occurs over time. Patients hospitalized for acute illnesses do not develop medication tolerance.
facilitated diffusion
Movement of specific molecules across cell membranes through protein channels -Facilitated diffusion is passive and requires no energy other than that of a concentration gradient. -Glucose transport into the cell is an example of facilitated diffusion. There is a carrier molecule on most cells that increases or facilitate the rate of diffusion of glucose into these cells.
NANDA
N - North A - American N - Nursing D - Diagnosis A - Association -Common clinical language -Universal communication -Continuity of care -Identifies a patient's response or vulnerability to health conditions of life events.
Hyponatremia:
Na+ < 136 mEq/L Gain of relatively more water than salt. -Due to water excess: (Na+ dilution) -(cardiac, renal, hepatic failure) -Psych Disorders (results in excessive water intake Loss of relatively more salt than water -GI causes, kidney, skin
Hypernatremia:
Na+ > 145 mEq/L 1.Loss of relatively more water than salt -Insensible losses (excessive perspiration and respiratory output without increased water intake) -Diabetes insipidus (ADH deficiency) 2.Loss of relatively more salt than water -Administration of tube feeding, hypertonic parenteral fluids or salt tablets. -Water deprivation, loss of thirst drive
Severe hypomagnesia
Neuromuscular signs -Tetany, convulsions, Chvostek's and Trousseau's signs -Vasospasms can lead to stroke
Partial Compensation
Non matching component is abnormal, and pH is still abnormal. -pH-7.35-7.45, PaCO2-(35-45 mm Hg), HCO3-(21-28 mEq/L) -pH 7.32 -PaCO2-60 mm Hg -HCO3-30 mEq/L -Respiratory acidosis with partial compensation because... -pH is still acidotic -The high PaCO2 makes sense with the pH -The high HCO3 does NOT make sense with the acidotic pH BUT shows the body is trying to balance the increase in acid
Stage 1 Pressure Ulcer
Non-blanchable erythema of intact skin •Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
Compensation
Non-matching component is abnormal, but pH is normal -pH 7.32 -PaCO2-60 mm Hg -HCO3-30 mEq/L -Check pH -Look at the value matching pH; does respiratory or metabolic component match pH -Determine extent of compensation
Absent Compensation:
Non-matching is normal & pH is still abnormal nThere is NO compensation, so problem is acute!
Nutrition and wounds
Normal wound healing requires proper nutrition. Deficiencies in any of the nutrients result in impaired or delayed healing . Physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals zinc and copper. Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested in food. Vitamin C is necessary for synthesis of collagen. Vitamin A reduces the negative effects of steroids on wound healing. Trace elements are also necessary (i.e., zinc for epithelialization and collagen synthesis and copper for collagen fiber linking).
Standards of practice
Nurses use the ANA Standards of Professional Nursing Practice as evidence of the standard of care provided to patients.
Medications and fluids
Obtain a complete list of your patient's current medications, including over-the-counter (OTC) and herbal preparations, to assess the risk for fluid, electrolyte, and acid-base imbalances. Use a drug reference book or reputable online database to check the potential effects of other medications. Ask specifically about the use of baking soda as an antacid, which can cause ECV excess because of its high sodium content that holds water in the extracellular compartments. For an individual who uses laxatives, ask about the type of laxative, the frequency of use, and the consistency and frequency of stools. Multiple loose stools remove fluid and electrolytes from the body, thus causing numerous imbalances.
Objective Findings
Obtain objective findings related to stress and coping through observation of the appearance and nonverbal behavior of a patient. Observe grooming and hygiene, gait, characteristics of the handshake, actions while sitting, quality of speech, eye contact, and the attitude of the patient during the interview. Before the interview begins or at the end of the interview, depending on the anxiety level of the patient, obtain basic vital signs to assess for physiological signs of stress such as elevated blood pressure, heart rate, or respiratory rate. Make certain to incorporate cultural components of interpreting the patient's nonverbal communication behaviors.
Hypoventilation
Occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide s&s: mental status changes, dysrhythmias, potential cardiac arrest
Ego identity vs. Despair and Disgust
Older adulthood -Values love and interactions with others -Focuses on overcoming oppression and violence -Beliefs vary based on many factors such as gender, past experiences, religion, economic status, and ethnic background
Oliguric Renal Disease
Oliguria occurs when the kidneys have a reduced capacity to make urine. Some conditions such as acute nephritis cause sudden onset of oliguria, whereas other problems such as chronic kidney disease lead to chronic oliguria. Oliguric renal disease prevents normal excretion of fluid, electrolytes, and metabolic acids, resulting in ECV excess, hyperkalemia, hypermagnesemia, hyperphosphatemia, and metabolic acidosis. The severity of these imbalances is proportional to the degree of renal failure. Although chronic kidney disease is progressive, successful management of imbalances is possible with dietary restriction of sodium and other electrolytes, fluid restriction in severe cases, and eventually dialysis or renal transplant
Medication interactions
One medication modifies the action of another
negative-pressure wound therapy (NPWT)
One treatment modality for wounds is negative-pressure wound therapy (NPWT) or vacuum-assisted closure (one brand name is V.A.C.). NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid . The vacuum-assisted closure (V.A.C.) is a device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together. NPWT supports wound healing by reduction of edema and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion. Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden. The V.A.C. Instill system allows intermittent instillation of fluids into a wound and liquefies infectious material and wound debris, especially in wounds not responding to traditional NPWT
Enteral Replacement of Fluids
Oral replacement of fluids and electrolytes is appropriate as long as the patient is not so physiologically unstable that they cannot be replaced rapidly enough. Oral replacement of fluids is contraindicated when a patient has a mechanical obstruction of the GI tract, severe nausea, is at high risk for aspiration, or has impaired swallowing. Some patients unable to tolerate solid foods are still able to ingest fluids. Strategies to encourage fluid intake include offering frequent small sips of fluid, popsicles, and ice chips. Record one-half the volume of the ice chips in I&O measurement. For example, if a patient ingests 240 mL of ice chips, you record 120 mL of intake. Encourage patients to keep their own record of intake to involve them actively. Family members who are properly instructed can also help. Pay attention to each patient's preferred temperature of oral fluids. Cultural beliefs regarding appropriate fluids and fluid temperature may become a barrier to achieving adequate fluid intake unless the fluid with the preferred temperature is available -When replacing fluids by mouth in a patient with ECV deficit, choose fluids that contain sodium (e.g., Pedialyte and Gastrolyte). Liquids that contain lactose or have low-sodium content are inappropriate when a patient has diarrhea. -A feeding tube is appropriate when a patient's GI tract is healthy, but he or she cannot ingest fluids (e.g., after oral surgery or with impaired swallowing). Options for administering fluids include gastrostomy or jejunostomy instillations or infusions through small-bore nasogastric feeding tubes
Risk for injury related to altered thought processes & muscle weakness: Outcomes and Interventions
Outcomes 1)Pt complies with safety precautions (list) 2)Pt remains injury free Interventions 1)Side rails up 2)Assist with walking 3)Call light w/i reach 4)Decreased stimuli 5)Reorient to time and place PRN 6)Monitor Na level
Risk for decreased cardiac output related to dysrhythmia secondary to hyperkalemia outcomes and interventions
Outcomes 1)VS remain in pt's normal range 2)EKG = NSR K+ lowers from (specify) to more normal range Interventions 1)Vitals signs q4h and prn 2)Continuous EKG- watch for tachy, brady, dysrhythmias 3)Labs: monitor K: report changes to MD 4)Cap refill, CMS q shift
Risk for decreased cardiac output related to weak myocardial contraction outcomes and interventions
Outcomes 1.K+ will increase from (specify) to more normal range of... 2.VS w/i pt's baseline range 3.EKG = NSR- no vent dysrhythmias Interventions 1.Administer K+ supplements 2.Monitor serum K+ levels 3.Orthostatic VS q shift 4.Cardiac monitor- report changes
Idiosyncratic reaction of medication
Overreaction or underreaction or different reaction from normal. For example, a child who receives diphenhydramine, an antihistamine, may become extremely agitated, or excited instead of drowsy.
tissue perfusion
Oxygen fuels the cellular functions essential to the healing process; therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing. Patients with diabetes and peripheral vascular disease are at risk for poor tissue perfusion because of poor circulation. Oxygen requirements depend on the phase of wound healing (e.g., chronic tissue hypoxia is associated with impaired collagen synthesis and reduced tissue resistance to infection).
Pros and cons of oral administration
PROS •Convenient •Most Economical •Safest Method •Easiest Method CONS •Slower onset •Can irritate lining of GI tract, discolor teeth, or have unpleasant taste. •Gastric secretions destroy some medications •Can't give to patients who are unconscious, confused, or unable to swallow
Pros and cons of inhaled or nebulized
PROS •Nasal: Provides local effect •Inhaled: Rapid absorption •Provides rapid relief for local respiratory problems •Used for introduction of general anesthetic gases CONS •Can be irritating to nose/nasal passages •Inhaled: Some local agents cause serious systemic effects
Pros and cons of vaginal and rectal administration
PROS •Rapid absorption •Local effects are directly applied •Therapeutic effects provided by local application to the involved sites •Aqueous solutions are readily absorbed and capable of causing systemic effects •Potential route of administration when oral medications are contraindicated CONS •More invasive •Mucous membranes are highly sensitive to some medication concentrations
Pros and cons of topical or transdermal administration
PROS •Topical: Provides local effect •Painless •Limited Side Effects •Transdermal: prolonged systemic effects with limited side effects CONS •Topical: Patients with skin abrasions are at risk for rapid medication absorption and systemic effects •Medications are absorbed through the skin slowly. •Absorption is affected by the vascularity of the application site •Transdermal: Medication leaves oily or pasty substance on skin and sometimes soils clothing
Pros and cons of eye and ear drops
PROS •Usually treating the area directly CONS Cross-contamination is a potential problem with eye
Serosanguineous
Pale, pink, watery of clear and red fluid
Parenteral Nutrition
Parenteral nutrition (PN), also called total PN (TPN), is IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a patient's needs. Depending on their osmolality, PN solutions are administered through a CVC in cases of high osmolality or through a peripheral intravenous (IV) line for lower osmolality solutions. Safe administration depends on appropriate assessment of nutrition needs, meticulous management of the CVC or IV to prevent infection, and careful monitoring to prevent metabolic complications.
Stage 2 Pressure Ulcer
Partial-thickness skin loss with exposed dermis •Partial-thickness. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury.
Objective data can validate subjective data.
Patient complains of "burning, throbbing pain after twisting rt ankle. Instruct them to rate their pain on a scale of 0-10.
Heart Failure and fluids
Patients who have chronic heart failure have diminished cardiac output, which reduces kidney perfusion and activates the RAAS. The action of aldosterone on the kidneys causes ECV excess and risk of hypokalemia. Most diuretics used to treat heart failure increase the risk of hypokalemia while reducing the ECV excess. Dietary sodium restriction is important with heart failure because Na + holds water in the ECF, making the ECV excess worse. In severe heart failure a restriction of both fluid and sodium may be prescribed to decrease the workload of the heart by reducing excess circulating fluid volume.
Restriction of Fluids
Patients who have hyponatremia usually require restricted water intake. Patients who have very severe ECV excess sometimes have both sodium and fluid restrictions. Fluid restriction often is difficult for patients, particularly if they take medications that dry the oral mucous membranes or if they are mouth breathers. Explain the reason that fluids are restricted. Make sure that the patient, family, and visitors know the amount of fluid permitted orally and understand that ice chips, gelatin, and ice cream are fluids. Help the patient decide the amount of fluid to drink with each meal, between meals, before bed, and with medications. It is important to allow patients to choose preferred fluids unless contraindicated. Frequently patients on fluid restriction can swallow a number of pills with as little as 1 oz (30 mL) of liquid.
Identification:
Patterning behavior after that of another person and assuming that person's qualities, characteristics, and actions
Connectedness
People who are connected to themselves, others, nature, and God or another Supreme Being usually report higher levels of physical and emotional health. One way patients remain connected is by praying. Prayer is personal communication with one's higher power that provides a sense of hope, strength, security, and well-being; it is a part of faith. Patients often use prayer when other treatments are ineffective, when they are experiencing fear or anxiety, or when they feel that they have no control over what is happening to them. Help patients become or remain connected by respecting each patient's unique sense of spirituality. Assess a patient's connectedness by asking open-ended questions: "Whom do you believe is the most important person in your life?" "In what way do you stay connected spiritually?" "Is prayer something helpful to you?" or "What feeling do you have after you pray?"
CV 1: Holistic philosophy, theories, and ethics
Philosophical, theoretical, and ethical foundations define the who and why of holistic nursing. Holistic nurses embrace a professional ethic of caring and healing that seeks to preserve the wholeness and dignity of self and others. Holistic practice uses presence, intentionality, compassion, and authenticity throughout the holistic nursing process
Two Types of Medication dependence/addiction
Physical - is a physiological adaptation to a medication that manifests by intense physical disturbance when the medication is withdrawn. Psychological - a patient desires the medication for benefit other than the intended effect
FVE: Assessment findings
Physical Assessment -Weight gain -Edema -Tachycardia -HTN (however, large volumes can be retained without a change in BP) -Distended neck veins -Crackles in lungs -If severe - confusion, pulmonary edema Laboratory Findings -Decreased hematocrit -Decreased BUN (hemodilution)
FVD: Assessment findings
Physical Assessment: -Weight loss -Orthostatic hypotension -Tachycardia (an increase in pulse by > 20/min is a more sensitive indicator than a decrease in BP) -Dry mucous membranes -Poor skin turgor -Dark yellow urine -If severe - thirst, restlessness, confusion, hypotension, urine output < 30 mL/hr, hypovolemic shock. Laboratory Findings: -Increased hematocrit -Increased BUN > 20 mg/dL (hemoconcentration) -Increased urine specific gravity > 1.030.
Touching
Physical contact through touch in its myriad forms may foster connection. Sensitivity to the meaning of touch for each person is essential in using touch therapeutically. When appropriate, a hand on the shoulder can provide support, a handclasp can convey understanding and presence, an arm around the waist can literally and figuratively give a lift. One patient described a nurse's support in saying, "When the doctor came in to give me the news, she was standing beside me and I could feel her hand on my arm the whole time the doctor was talking. I was so glad that she was just there with me." At times when words cannot be found, or in circumstances where persons are more comfortable with physical expression than with words, touch is a powerful expression of spirit and an instrument of healing.
Assessment and Pulmonary Health: Exam
Physical examination -Inspection: should include observation of the nails for clubbing, neck veins, chest, skin and peripheral edema -Palpation: legs and feet for pitting edema and pulses -Percussion: of chest -Auscultation: of lungs and heart; look for diminished lung sounds, crackles, etc Diagnostic tests
Positioning
Positioning Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention. The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces. Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort. A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences. The WOCN guidelines recommend a 30-degree lateral position, which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions.
Spiritual Health: Diagnosis
Potential diagnoses include: -Risk for Spiritual Distress -Defective Spiritual Distress -Hopelessness -Spiritual Distress -Decreased Spiritual Distress
Praying and Meditating
Prayer and meditation are spiritual disciplines practiced in many traditions, both cultural and religious. Appreciating the personal nature of these disciplines, the nurse, with respect and sensitivity, can help patients remember or explore ways in which they reach out to and listen for God or the Sacred Source. Recalling the place and meaning of prayer and the ways in which they experience the presence of and communion with God or the Sacred Source provides patients with a rich resource. In the clinical setting, both the nurse's and the patient's understanding of prayer will determine the role of prayer.
Side effect of medication
Predictable, and unavoidable secondary effect. Common side effects are nausea, vomiting, diarrhea, constipation and drowsiness.
Stage 4 Pressure Ulcer
Pressure Injury: Full-thickness skin and tissue loss •Full-thickness Tissue Loss. Full-thickness tissue loss with exposed bone, tendon, or muscle. Subcutaneous fat may be visible and slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location.
Economic Consequences of Pressure Injuries
Pressure injuries are a continual problem in acute and restorative care settings, especially in patients 65 years and older . Paralysis and spinal cord injury are common preexisting conditions among younger adults with primary diagnosis of pressure injuries. Older adults admitted to acute and long-term facilities are a vulnerable population. Although the cost to provide pressure injury prevention to patients at risk can impact health care services' budgets, the costs to treat a severe pressure injury are substantially higher. When a pressure injury occurs, the length of stay in a hospital and the overall cost of health care increase. These injuries are also costly to patients in terms of disability, pain, and suffering. About 1.6 million patients each year in acute care settings develop pressure injuries, representing a cost of $11 billion to $17.2 billion to the US health care system. The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008, whereby hospitals no longer receive reimbursement for care related to stage 3 and 4 pressure injuries that occur during a hospitalization. Guidelines such as the WOCN Guidelines help reduce or eliminate the occurrence of pressure injuries and prevent the expenses that will not be reimbursed.
Urticaria (hives)
Raised, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and pale centers (mild allergic reaction)
Fostering Connectedness
Relationships are a major aspect of spirituality. Awareness and an appreciation of important relationships in the patient's life enable the nurse to help strengthen meaningful and supportive bonds. Some family members may need encouragement and guidance to visit or call. Patients may need assistance in sharing some aspects of their situation with others—even when they very much want to explain what is happening to them and express their feelings about it. Nurses can remind patients of their network of care and support by recognizing and affirming the support of significant others. Statements such as "you seem especially close to Marta" may provide an opportunity for sharing about a special relationship. Photographs, artwork, and memorabilia of loved ones provide reminders of connections beyond the confines of illness or injury. Visits from pets may be as spiritually uplifting for some people as those from humans. Imagery, pictures, and stories can foster connection with important places, people, and experiences.
Sleep and overall health
Relevant to the connection between thoughts, behaviors, and health is sleep. Restricting sleep to 4 hours a night results in higher blood pressures and reduced function of the entire cardiovascular system. Inflammatory markers increase in the blood, amplifying any chronic pain or inflammatory diseases. Cells begin showing insulin-resistant behaviors that are known to lead to diabetes. Appetite increases and activity decreases, predisposing the individual to obesity. Those who are sleep deprived develop less immunity from vaccines, implying impaired immune function. Sleep apnea, teeth grinding, and other sleep disorders have been directly linked to increased perceived stress and subsequent health issues. Sleep apnea significantly increases inflammation in the body and has been shown to lead to cardiovascular disease. Sleep deprivation increases symptoms of mental health disorders and decreases perceived coping ability. Inadequate sleep is strongly linked to an increased risk of dying.
Religion
Religion is associated with the "state of doing," or a specific system of practices associated with a particular denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person practices to outwardly express spirituality. Many people practice a faith or belief in the doctrines and expressions of a specific religion or sect, such as the Lutheran church or Judaism. People from different religions view spirituality differently.
Total Recall (5 modes of thinking)
Remembering facts or where to look for them.
Ensuring Opportunities for Rest and Leisure
Rest, leisure, and Sabbath time are integral aspects of holistic living and care of the spirit that enhance growth, creativity, and renewal (Mueller, 2000). Leisure is an attitude of the heart that facilitates connection with the inner self and the Sacred Source and opens one to reflect on and envision a life of doing to allow for more Being. Authentic leisure implies an approach to living that allows one to relax into a level of being that deepens self-awareness, nourishes one's wholeness, and enriches connections with the Sacred Source and other people. Assisting persons to consider the place of rest and leisure in their lives is part of holistic nursing. Taking stock of how they integrate rest and leisure into their own lives is a necessary part of self-care for nurses as well. In an increasingly busy society—where filling each moment is viewed in terms of productivity, where even leisure time is scheduled—the notion of rest and leisure deserves thoughtful consideration.
Antidiuretic hormone (ADH)
Restores blood volume by reducing urine output -Decreased blood volume and increased solute concentration are sensed by the brain -ADH is produced by the hypothalamus -Kidneys retain water, which increases intravascular volume and decreases solute concentration
Collaborative management of Hyponatremia
Rx cause of imbalance** -Mental status-safety -Restrict water if due to dilution -Increase sodium intake (oral or IV) -0.9% Normal Saline -If symptoms are severe, Hypertonic saline may be used (3%soln) CAUTION -Must be on pump -Only for short periods -300-400 mL to inc. 10 mEq (do not want to increase serum sodium by more than 12 mEq/L in 24 hours)
Secondary Appraisel
Secondary appraisal, the process by which a person considers possible available coping strategies or resources, occurs at the same time. Stress occurs if the demands placed on the person by the event exceed the ability to cope. Balancing factors contribute to restoring equilibrium. According to crisis theory, because feedback cues lead to reappraisals of the original perception, coping behaviors constantly change as individuals perceive new information. When coping behaviors are ineffective and repeated over and over, a state of stress can result. Stress emerges either when a person views an event as posing a significant risk of harm or when the person is not able to cope with the event's demands.
CV 5: Holistic nurse self-reflection and self-care
Self-reflection and self-care, as well as personal awareness of and continuous focus on being an instrument of healing, are significant requirements for holistic nurses16,p.20 Self-reflection is both self-care strategy and a professional practice integrating critical thinking of the mind and compassion of the heart. Caring for self is integral to holistic nursing.
Skin Nursing Assessment Questions
Sensation • Do you have tingling, decreased feeling, or absent feeling in your extremities? • Can you feel pressure when sitting or lying down? • When preparing a bath is your skin sensitive to heat or cold? Mobility • Do you have any physical limitations, injury, or paralysis that limits your ability to move on your own? • Can you change your position easily? • Tell me about any pain you have when you walk, sit down, or move about your home. Continence • Do you have any problems or accidents leaking urine or stool? • What help do you need when using the toilet? In what way? • How often do you need to use the toilet? During the day? At night? Presence of Wound • What do you believe caused your wound? • When did the wound occur? Where is it located? • When did you receive a tetanus shot? • What has happened to this wound since it occurred? What were the changes and what caused them? • What have you done to treat the wound? Which treatments, activities, or care have slowed or helped the wound to heal? • Do you have any pain, itching, or other symptoms with the wound? How are you managing the itching, and what works best for you? • Who helps you care for your wound?
Indirect, independent intervention:
Shift report
Pain and wounds
Significant research has been conducted in the study of pain in surgical patients with wounds. The routine assessment of pain in surgical patients is critical to selecting appropriate pain management therapies and to determine a patient's ability to progress toward recovery. The WOCN has recommended that assessment and management of pain also be included in the care of patients with pressure injuries. Use standard pain assessment tools to measure pain acuity, and be thorough in assessing the character of a patient's pain. Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure injury risk.
Situational Factors
Situational stressors in the workplace that affect nurses and other health care professionals include high-acuity patient load, job environment, constant distractions, responsibility, conflicting priorities, and intensity of care (e.g., trauma, emergency, or critical care areas). In addition, changing shifts increases fatigue and work-related stress. Some nurses often ease coping with shift work by knowing their own circadian rhythms. People who function best in the morning have the greatest difficulty with night work and changing shifts. As people age, they tend to become more morning oriented. Morning people need to be counseled about the potentially negative effects of night work for them. In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible.
Rash
Small, raised vesicles that are usually reddened; often distributed over entire body (mild allergic reaction)
The Theory of Unitary Caring
Smith, a scholar of unitary science, caring science, theory-guided practice, and holistic practice, developed the theory of unitary caring. She describes the theory as grounded in the following concepts: manifesting intention, appreciating pattern, attuning to dynamic flow, experiencing the infinite, and inviting creative emergence. The concepts come alive in the intentional caring healing hands therapies such as massage, therapeutic touch, hand massage, and the simple yet complex touch of compassionate nurses. This theory has been advanced in palliative care, care of older adults, caring at a community-based primary care center, and as the curriculum model at least one school of nursing.
Social Support
Social Support Another area of interest in PNI is how the environment influences health and wellness. The social environment is integral to wellness. Loneliness is a risk factor for coronary heart disease. Women with close female friends have better breast cancer outcomes, developmental stages are positively met for those who live in supportive families, and the symptoms of irritable bowel syndrome are less for those with meaningful social support. Assessing and finding ways to enhance the social environment for our patients become parts of the nurse's role. Nurses can refer patients to support groups and other family services with an understanding that this will improve immune function and healing.
Single (one-time orders)
Sometimes a doctor orders a medication to be given at a specified time e.g. Ativan 1mg IV on call to MRI.
Life and Self-Responsibility
Spiritual well-being includes life and self-responsibility. Individuals who accept change in life, make decisions about their lives, and are able to forgive others in times of difficulty have a higher level of spiritual well-being. During illness patients often are unable to accept limitations or do not know how to regain a functional and meaningful life. Their feelings and struggles often reflect spiritual distress. However, they often use their spiritual well-being as a resource for adapting to changes and dealing with limitations. Assess the extent to which a patient understands the limitations or threats posed by an illness (e.g., activity restriction, sexual intimacy with a partner, risk of medical complications) and the manner in which he or she chooses to adjust to them. Ask, "Tell me how you feel about the changes caused by your illness" and "How do these changes affect what you now need to do?"
Life Satisfaction
Spiritual well-being is tied to a person's satisfaction with life and what he or she has accomplished, even in the case of children. When people are satisfied with life and how they are using their abilities, more energy is available to deal with new difficulties and resolve problems. You assess a patient's satisfaction with life by asking questions such as "How happy or satisfied are you with your life?" or "Tell me how satisfied you feel about what you have accomplished in life" or "Describe what makes you feel dissatisfied with your life."
Culture
Spirituality is a personal experience within a cultural context. It is important to know a patient's cultural background and assess his or her values about the health care problem and impending treatment. It is common in many cultures for individuals to believe that they have led a worthwhile and purposeful life. Remaining connected with their cultural heritage often helps patients define their place in the world and express their spirituality. Asking them about their faith and belief systems is a good beginning for understanding the relationship between culture and spirituality.
Quality and safety education for nurses (QSEN)
Standard competencies in knowledge, skills, and attitudes for the preparation of future nurses .
Stress
Stress is described as a feeling of being overwhelmed, worried, or run down. Stress can affect everyone regardless of age, socioeconomic status, gender, or profession. An overabundance of stress reduces the function of the immune, cardiovascular, neuroendocrine, and central nervous systems. Stressors are the triggers of stress and are a normal part of life. We are required to adapt, and when stress is perceived, the organism is physiologically prepared to attack or flee from the threat. When one experiences stress, one's biology, emotions, social support, motivation, environment, attitude, immune function, and wellness are all relevant to the experience of stress and have a clear influence on the human being. -An actual or alleged hazard to the balance of homeostasis -Can impact the physical and mental well-being of patients -Nurses need to consider their own stress
Burnout
Stressors such as rapid changes in health care technology, diversity in the workforce, organizational restructuring, and changing work systems place stress on employees. Burnout occurs as a result of chronic stress. In nursing, burnout results when nurses perceive the demands of their work exceed perceived resources. It is manifested as emotional exhaustion, poor decision making, loss of a sense of personal identity, and feelings of failure.
Maturational Factors
Stressors vary with life stage. According to Erikson's developmental theory, individuals experience predictable stages of development as particular tasks are accomplished and mastered for each stage. Children who are in the stage of initiative versus guilt identify stressors related to physical appearance, families, friends, and school. During this stage, teaching impulse control and cooperative behaviors is imperative. Preadolescents experience stress related to self-esteem issues, changing family structure as a result of divorce or death of a parent, or hospitalizations. Erikson asserts that during this stage, they can develop a sense of inferiority without proper support for learning new skills. As adolescents search for identity with peer groups and separate from their families, they also experience stress.
Recent Surgery and fluids
Surgery causes a physiological stress response, which increases with extensive surgery and blood loss. In the first 24 to 48 hours after surgery, increased secretion of aldosterone, glucocorticoids, and ADH cause increased ECV, decreased osmolality, and increased potassium excretion. In otherwise healthy patients these imbalances resolve without difficulty, but patients who have preexisting illnesses or additional risk factors often need treatment during this period. through vomiting or nasogastric suction can cause metabolic alkalosis. In contrast, removal of the bicarbonate-rich intestinal or pancreatic fluids through diarrhea, intestinal suction, or fistula can cause metabolic acidosis
Assessment
The 1st step of the nursing process - Assessment is essential to learn as much as you can about each patient's health condition and health problem by partnering with the patient and family caregivers in a therapeutic relationship. -collection of information -interpretation and validation of data
Braden Scale
The Braden scale was developed based on risk factors in nursing home patient populations. It is used to predict the patients are risk for developing pressure ulcers. It is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development.
Tissue Tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures. The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure: the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure. The second factor related to tissue tolerance is the ability of the underlying skin structures (blood vessels, collagen) to help redistribute pressure. Systemic factors such as poor nutrition, aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied pressure.
Blood Flow Regulation
The amount of blood ejected from the left ventricle each minute is the cardiac output . The normal cardiac output is 4 to 8 L/min in the healthy adult at rest. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. For example, cardiac output increases during exercise, pregnancy, and fever but decreases during sleep. The following formula represents cardiac output: CO (cardiac output) = SV (stroke volume) x HR (heart rate)
Effects of Cold Application
The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. Skin tissues freeze from exposure to extreme cold.
Systemic Circulation
The arteries of the systemic circulation deliver nutrients and oxygen to tissues, and the veins remove waste from tissues. Oxygenated blood flows from the left ventricle through the aorta and into large systemic arteries. These arteries branch into smaller arteries; then arterioles; and finally, the smallest vessels, the capillaries. The exchange of respiratory gases occurs at the capillary level, where the tissues are oxygenated. The waste products exit the capillary network through venules that join to form veins. These veins become larger and form the vena cava, which carry deoxygenated blood back to the right side of the heart, where it then returns to the pulmonary circulation
Arts and spirituality
The arts have a role in the life of the spirit. Many people find that various forms of artistic endeavor are doors to and expressions of the spirit. The term artist can include anyone who creates—the homemaker who cooks and sews and the carpenter who designs and builds, as well as the more easily recognized persons whose works are heard in symphonies or seen in galleries.
The Community Nursing Practice Model
The community nursing practice model42 (CNPM) emerged from a theoretical perspective of caring and analysis of years of community caring practice exemplars, called nursing situations. The CNPM is grounded in the values of respect for the wholeness and dignity of each person, family, and community. Additionally, nursing practice is intentionally actualized in the values of the World Health Organization's approach to primary health care: empowerment, multi-intersectoral collaboration, access, essentiality, and community participation. Furthermore, the CNPM advances the mission of a college of nursing in the southeastern United States, described nursing as "nurturing the wholeness of persons and environment in caring." The CNPM is depicted as a watercolor of three concentric circles of community, expertise, and support surrounding the core: a nursing situation. The fluidity of the watercolor illustrates the interconnectedness of persons and families with communities. The model has been advanced using participatory action approaches and qualitative methods of study.
Spiritual Well-Being
The concept of spiritual well-being has multiple dimensions. The common dimensions of spiritual well-being include meaning and purpose, a sense of peace or fulfillment, and connectedness with others and God or a higher power. Those who experience spiritual well-being feel connected to others and are able to find meaning or purpose in their lives. Those who are spiritually healthy experience joy, are able to forgive themselves and others, accept hardship and mortality, and report an enhanced quality of life.
Coronary Artery Circulation
The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste. The coronary arteries fill during ventricular diastole. The left coronary artery has the most abundant blood supply and feeds the more muscular left ventricular myocardium, which does most of the work of the heart
Personality and Wellness
The field of PNI began in cardiovascular rehabilitation, and back in the late 1980s, it was noticed that people with cardiovascular disease tend to have controlling personalities and are quick to anger. Stress and anger management training became part of the treatment regimen in response. Personality traits are thought to be well established and difficult to change by adolescence and are both genetic and environmental. Researchers have since been finding links to personality traits and specific disease. Can people who develop Parkinson disease be identified as high risk before the disease begins by screening their personality characteristics and level of needed locus of control? Would assessing personality type help earlier diagnosis in fibromyalgia patients? Perhaps we will one day predict bipolar disorder by examining extraversion/introversion characteristics of personality. Personality is part of the whole human being along with genetic and environmental roots, so we cannot be surprised that wellness and disease are linked to temperament and how we present ourselves to others.
Quantum Physics
The field of quantum physics in health examines the very tiny atomic level of interaction between the self and the environment. Molecules of emotions give off chemical, electrical, and subatomic waves that influence other bonds within the molecules. Thoughts induce emotions, and chains of protein twirl and change to something else and the cell changes. A better understanding of quantum physics in health will help us demonstrate the importance of intention, kindness, self-talk, and true presence in healing.
Packing a Wound
The first step in packing a wound is to assess its size, depth, and shape. These characteristics are important in determining the size and type of dressing used to pack a wound. The dressing needs to be flexible and in contact with the entire wound surface. Make sure that the type of material used to pack the wound is appropriate. If gauze is the appropriate dressing material, saturate with the ordered solution, wring out, unfold, and lightly pack into the wound. The entire wound surface needs to be in contact with part of the moist gauze dressing. It is important to remember not to pack a wound too tightly. Overpacking causes pressure on the wound bed tissue. Pack the wound only until the packing material reaches the surface of the wound; there should never be so much packing material that it extends higher than the wound surface. Packing that overlaps onto the wound edges causes maceration of the skin surrounding the wound.
Friction
The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called friction. Unlike shear injuries, friction injuries affect the epidermis or top layer of the skin (superficial skin loss). The denuded skin appears red and painful and is sometimes referred to as a sheet burn. A friction injury occurs in patients who are restless, in those who have uncontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes or transfer to a stretcher. This type of injury should not be classified as a pressure injury. Friction leads to pressure injury formation only when it causes harmful shear stress and strain.
Intravenous Therapy (Crystalloids)
The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the continuous infusion of fluids over a period of time. IV therapy requires a health care provider's order for type, amount, and speed of administration of a solution. You regulate IV fluid therapy continuously because of ongoing changes in a patient's fluid and electrolyte balance. To provide safe and appropriate therapy to patients who require IV fluids, you need knowledge of the correct ordered solution, the reason the solution was ordered, the equipment needed, the procedures required to initiate an infusion, how to regulate the infusion rate and maintain the system, how to identify and correct problems, and how to discontinue the infusion.
CV 2: Holistic caring process
The holistic caring process identifies what holistic nurses do—that is, the practice of holistic nursing. Holistic nurses provide care that recognizes the totality of the human being (the interconnectedness of body, mind, emotion, spirit, social/cultural relationships, context, environment, and energy). Holistic health is a multidimensional state of well-being as perceived by the individual. Holistic health integrates current trends, research, and evidence-based interventions specific to the patient's needs, problem, or situation. Holistic health elicits the patient's story to reveal the context and complexity of the human health experience.
Influential Leadership
The influential leadership framework, introduced by Michael Frisina in 2011, identifies three fundamental principles that facilitate effective performance for making a sustainable difference within organizations. -self-awareness -collaboration -connection
Diet Therapies
The intake of food satisfies and promotes a sense of comfort. Food and nutrition are important aspects of patient care and often an important component of some religious observances. Food and the rituals surrounding the preparation and serving of food are sometimes important to a person's spirituality. Consult with a dietitian to integrate patients' dietary preferences into daily care. In the event that a hospital or other health care agency cannot prepare food in the preferred way, ask the family to bring meals that fit into dietary restrictions posed by the patient's condition.
Excretion of Metabolic Acids
The kidneys excrete all acids except carbonic acid. They secrete H + into the renal tubular fluid, putting HCO 3 - back into the blood at the same time. If there are too many H + ions in the blood, renal cells move more H + ions into the renal tubules for excretion, retaining more HCO 3 - in the process. If there are too few H + ions in the blood, renal cells secrete fewer H + ions.
Primary line
The main IV fluid used in a continuous infusion flows through tubing called the primary line . The primary line connects to the IV catheter. Injectable medications such as antibiotics are usually added to a small IV solution bag and "piggybacked" as a secondary set into the primary line or as a primary intermittent infusion to be administered over a 30-to 60-minute period
Age and wounds
The physiological changes associated with aging affect all phases of wound healing. A decrease in the functioning of macrophages leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization.
Moisture
The presence and duration of moisture on the skin increases the risk of pressure injury. Moisture reduces the resistance of the skin to other physical factors such as pressure, friction, or shear. Prolonged moisture softens skin, making it more susceptible to damage. The term moisture-associated skin damage (MASD) is defined as inflammation and erosion to the skin caused by prolonged exposure to various sources of moisture, including wound drainage, urine or stool, perspiration, wound exudate, mucus or saliva
Proliferative Stage
The proliferative phase begins with the appearance of new blood vessels as reconstruction progresses and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. -Fibroblasts are present in this phase. Fibroblasts are the cells that synthesize collagen, providing the matrix for granulation. -Collagen provides strength and structural integrity to a wound. During this period the wound contracts to reduce the area that requires healing.
Psychosocial Impact of Wounds
The psychosocial impact of wounds on the physiological process of healing is unknown. Body image changes often impose a great stress on a patient's adaptive mechanisms. They also influence self-concept and sexuality. Factors that affect a patient's perception of a wound include: location, the presence of scars, stitches, drains (often needed for weeks or months), odor from drainage, and temporary or permanent prosthetic devices.
Myocardial Pump
The pumping action of the heart is essential to oxygen delivery. There are four cardiac chambers: two atria and two ventricles. The ventricles fill with blood during diastole and empty during systole. The volume of blood ejected from the ventricles during systole is the stroke volume . Hemorrhage and dehydration cause a decrease in circulating blood volume and a decrease in stroke volume. Myocardial fibers have contractile properties that allow them to stretch during cardiac filling. In a healthy heart this stretch is proportionally related to the strength of contraction. As the myocardium stretches, the strength of the subsequent contraction increases; this is known as the Frank-Starling (Starling's) law of the heart . In the diseased heart (cardiomyopathy), Starling's law does not apply because the increased stretch of the myocardium is beyond the physiological limits of the heart. The subsequent contractile response results in insufficient stroke volume, and blood begins to "back up" in the pulmonary (left heart failure) or systemic (right heart failure) circulation
Resistance Stage
The resistance stage also contributes to the fight-or-flight response, and the body stabilizes and responds in an attempt to compensate for the changes induced by the alarm stage. Hormone levels, heart rate, blood pressure, and cardiac output should return to normal, and the body tries to repair any damage that occurred. However, these compensation attempts consume energy and other bodily resources.
Administering Eye (Ophthalmic) Medications Delegation and Collaboration
The skill of administering eye medications cannot be delegated to assistive personnel (AP). The nurse instructs the AP about: • The specific potential side effects of medications and to report their occurrence. • The potential for temporary burning or blurring of vision after administration of eye medications.
Using Metered-Dose or Dry Powder Inhalers Delegation and Collaboration
The skill of administering inhaled medications cannot be delegated to assistive personnel (AP). The nurse instructs the AP about: • Potential side effects of medications and to report their occurrence to the nurse. • Reporting breathing difficulty (e.g., paroxysmal or sustained coughing, audible wheezing) to the nurse.
Administering Injections Delegation and Collaboration
The skill of administering injections cannot be delegated to assistive personnel (AP). The nurse instructs the AP about: • Potential medication side effects and allergic responses and the need to report their occurrence along with any changes in patient's vital signs or level of consciousness (e.g., sedation).
Administering Oral Medications Delegation and Collaboration
The skill of administering oral medications cannot be delegated to assistive personnel (AP). The nurse instructs the AP about: • Potential side effects of medications and to report their occurrence. • Informing nurse if patient condition changes or worsens (e.g., pain, itching, or rash) after medication administration.
Preparing Injections From Vials and Ampules Delegation and Collaboration
The skill of preparing injections from ampules and vials cannot be delegated to assistive personnel (AP).
Cancer and fluids
The specific fluid and electrolyte imbalances that occur with cancer depend on the type and progression of the cancer and the treatment regimen. Many patients with cancer develop hypercalcemia when their cancer cells secrete chemicals that circulate to bones and cause calcium to enter the blood. Other fluid and electrolyte imbalances occur in cancer because some types of tumors cause metabolic and endocrine abnormalities. In addition, patients with cancer are at risk for fluid and electrolyte imbalances as a result of the side effects (e.g., anorexia, diarrhea) of chemotherapy, biological response modifiers, or radiation.
The Theory of Compassion Energy
The theory of compassion energy47 provides a theoretical approach to the everydayness of nursing practice. Dunn, founder of the theory and a scholar of unitary and caring science, is a Reiki healer and is certified in holistic nursing. This theory emerged from years of reflective practice and the study of what kept nurses in nursing. Dunn described compassion energy as an intersubjective gift that awakens caring consciousness and inspires the nurse to know the patient as a whole. It is composed of compassionate presence, patterned nurturance, and intentionally knowing the one nursed and self as whole beings, and it aligns with holism as recognized by the holistic nurse. Intentional compassion energy is thus defined as the regeneration of the nurse's capacity to foster interconnectedness when the nurse activates the intent to nurse. Compassion energy provides an opening that uncovers what keeps nurses in nursing.
Shared Vulnerability
The theory of shared vulnerability emerged from a grounded theory study of caring for children with persistent head lice and many years of providing home visits to families with head lice infestations. Holistic values guiding the theory included a focus on the whole person and honoring relationship-centered care, as well as protecting and promoting the well-being of caregivers, children, and families. Parents caring for children were experiencing a stigmatized, chronic condition of shared vulnerability.
The Transactive Relationship Theory of Nursing
The transactive relationship theory of nursing (TRETON) is a middle-range theory that advances not only the usefulness of artificial intelligence in nursing practice but inspires engagement in the process of developing the capacity of humanoid healthcare robots as adjunctive to nursing practice. TRETON is grounded in the values of technological caring and mutual engagement in nursing encounters. Nursing encounters are described as the intentional transactional relationship between healthcare robots and human persons in the healthcare environment. There are three components of the nursing encounter: human engagement between the nurse and patient, technological engagement between the robot and the nurse, and engagement between the robot and the patient. Artificial intelligence in health care is here now and advancing in nursing practice. King and Barry bring artificial intelligence to life in the description of the usefulness of a healthcare robot called Robin in assisting with deep breathing and relaxation techniques. Holistic nursing practice has always been on the leading edge of innovative healing practices: energy work, meditative practices, visualization processes, music, and movement therapies. Now is the time!
Managing stress
The work of professional nursing is difficult as you see patients endure suffering from disease and painful therapies and as you try to manage care responsibilities in busy, fast-paced work settings. -Stress over a prolonged period or when extreme can lead to poor work productivity, impaired decision making and communication, and reduced ability to cope with clinical situations.
Factors influencing spirituality
There are many factors that can impact one's spirituality including: -Acute illness -Chronic illness -Terminal illness -Near-death experience -for good or bad
Stress Response
There is a cascade of hormones and chemicals that begins when the brain decides there is a threat. This is the fight-or-flight response, enacted when the body moves into a sympathetic state, preparing to expend energy, and shutting down nonessential systems. One of those nonessential systems that shuts down could be the production of natural killer cells that attack mutating cancer cells. The stress response is modified by the number of other concurrent stressors, social support, personality, and previously learned coping skills. Psychological stressors stimulate a physiologic response and are referred to as a reactive response. Perceived stressors begin in the areas of the brain that control cognition and emotions—the cerebral cortex and the limbic system.
Affective Immunology
There is increasing interest in the benefits of positive emotions on the immune system, and this has been called affective immunology, a specialty within the field of PNI. Laughter is a universal language that reduces the stress response, improves learning, increases heart rate and variability, enhances cardiac output, and may be protective against metabolic syndrome. The relationship between the immune system is bidirectional, and an unstable immune function will influence emotional response. As a result, the patient may experience an increase in pain, anxiety, unhealthy coping behaviors (such as drinking alcohol), or disturbances in interactions with others when they are ill. Studies are showing that generating happiness, hope, and other positive emotions improves immune function. This means that the healthy function of the immune system can be moderated by the conscious mind. Happiness and hope can be generated. Laughter therapy has positive immune benefits, and programs to enhance happiness are becoming part of the realm of patient care.
There are five risk factors associated with metabolic syndrome
They include a large waistline, an increased triglyceride level, a low high-density lipoprotein cholesterol level, hypertension, and hyperglycemia.
Purulent
Thick, yellow, green, tan, or brown
Knowing how you think (5 modes of thinking)
Thinking about one's thinking.
New Ideas and Creativity (5 modes of thinking)
Thinking modes special to you, opposite habits.
CV 3: Holistic communication, therapeutic healing environment, and cultural diversity
Through holistic communication, therapeutic healing environments, and diversity, holistic nurses transform their beliefs into practice, highlighting the how of holistic nursing.16,p.15 Holistic nurses provide culturally competent care. Recognizing culture may also provide an understanding of a person's concept of the illnesses or disease and appropriate treatment.
Evaluation: Pulmonary Health
Through the patient's eyes -Focus on evaluating how the disease is affecting day-to-day activities and how the patient believes he or she is responding to treatment Patient outcomes -Compare the patient's actual progress to the goals and expected outcomes of the nursing care plan to determine his or her health status
Duration
Time during which medication is present in concentration great enough to produce a response
onset
Time it takes after a medication is administered for it to produce a response
Myocardial Blood Flow
To maintain adequate blood flow to the pulmonary and systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself. Blood flow through the heart is unidirectional. The four heart valves ensure this forward blood flow. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open, and blood flows from the higher-pressure atria into the relaxed ventricles. As systole begins, ventricular pressure rises and the mitral and tricuspid valves close. Valve closure causes the first heart sound (S 1 ). During the systolic phase the semilunar (aortic and pulmonic) valves open, and blood flows from the ventricles into the aorta and pulmonary artery. The mitral and tricuspid valves stay closed during systole, so all of the blood is moved forward into the pulmonary artery and aorta. As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves. Valve closure causes the second heart sound (S 2 ). Some patients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation
Why should we assess the type of tissue in the wound base?
To provide information to help plan appropriate interventions. The assessment of tissue type includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal. Black, brown, tan, or necrotic tissue is eschar, which needs to be removed before healing can proceed.
5 modes of thinking
Total Recall Habits Inquiry New Ideas and Creativity Knowing how you think
Displacement:
Transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute (e.g., a person transfers anger over an interpersonal conflict to a malfunctioning computer)
Conversion:
Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty in sleeping, loss of appetite)
Adverse effect of medication
Unintended, undesirable, often unpredictable (side effect, toxic effect, Idiosyncratic reaction, allergic reaction, medication interactions, medication tolerance, medication dependence)
Allergic reaction
Unpredictable response to a medication
Caution with administering hypertonic solutions.....
Use cautiously with patients who cannot tolerate additional extracellular fluids, such as those with renal or cardiac dysfunctions.
Support Systems
Use of support systems is important for patients who are in any health care setting. They provide patients with the greatest sense of well-being during hospitalization and serve as a human link connecting the patient, the nurse, and the patient's lifestyle before an illness. Part of a patient's caregiving environment is the regular presence of supportive family and friends. Provide privacy during visits and plan care with the patient and the patient's support network to promote the interpersonal bonding that is needed for recovery. The support system is a source of faith and hope and an important resource in conducting meaningful religious rituals.
Securing Dressings
Use tape, ties, or a secondary dressing to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient's level of activity. You will most often use strips of tape to secure dressings. Nonallergenic paper and silicone tapes minimize skin reactions. Common adhesive tape adheres well to the surface of the skin, whereas elastic adhesive tape compresses closely around pressure bandages and permits more movement of a body part. Skin sensitive to adhesive tape becomes severely inflamed and denuded and, in some cases, even sloughs when the tape is removed. It is important to assess the condition of the skin under tape at each dressing change.
Implementation: Health Promotion Pulmonary Health
Vaccinations -Influenza, pneumococcal Healthy lifestyle -Eliminating risk factors, eating right, regular exercise (150 mins/wk moderate activity & 2 days of muscle-strengthening) Environmental pollutants -Secondhand smoke, work chemicals, and pollutants
Health promotion strategies to utilize when working with patients and their families.
Vaccinations, smoking-cessation programs, exercise programs, and nutritional support
Vascular Access Devices
Vascular access devices (VADs) are catheters or infusion ports designed for repeated access to the vascular system. Peripheral catheters are for short-term use (e.g., fluid restoration after surgery and short-term antibiotic administration). Devices for long-term use include central catheters and implanted ports, which empty into a central vein. Remember that the term central applies to the location of the catheter tip, not to the insertion site. Peripherally inserted central catheters (PICC lines) enter a peripheral arm vein and extend through the venous system to the superior vena cava, where they terminate. Other central lines enter a central vein such as the subclavian or jugular vein or are tunneled through subcutaneous tissue before entering a central vein. Central lines are more effective than peripheral catheters for administering large volumes of fluid, PN, and medications or fluids that irritate veins. Proper care of central line insertion sites is critical for the prevention of central line-associated bloodstream infection. Nurses and health care providers must have specialized education regarding care of CVCs and implanted infusion ports. Nursing responsibilities for central lines include careful monitoring, flushing to keep the line patent, and site care and dressing changes to prevent CLABSIs.
What four things are processes for providing adequate oxygenation from the alveoli to the blood.
Ventilation, diffusion, respiration, and perfusion
Decreased lung compliance, increased airway resistance, and the increased use of accessory muscles increase the
WOB, resulting in increased energy expenditure. Therefore, the body increases its metabolic rate and the need for more oxygen. The need for elimination of carbon dioxide also increases. This sequence is a vicious cycle for a patient with impaired ventilation, causing further deterioration of respiratory status and the ability to oxygenate adequately
Warm, Moist Compresses
Warm, moist compresses improve circulation, relieve edema, and promote consolidation of purulent drainage. A compress is a piece of gauze dressing moistened in a prescribed warmed solution. Heat from warm compresses dissipates quickly. To maintain a constant temperature, you need to change the compress often. You can use a layer of plastic wrap or a dry towel to insulate the compress and retain heat. Moist heat promotes vasodilation and evaporation of heat from the surface of the skin. For this reason a patient can feel chilly. Always try to control drafts within the room, and keep the patient covered with a blanket or robe.
Second victim syndrome:
When a medical error occurs that inflicts significant harm on a patient and the patient's family
Dehiscence
When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence. partial or total separation of wound layers
Assessing a patient's faith/beliefs
When assessing a patient's faith, first determine his or her beliefs, especially those that influence hope. For example, ask how a patient believes a chemotherapy drug will affect a newly diagnosed form of cancer. Ask the patient whether he or she believes in the skill or competence of his or her physician. Determine which of your patient's beliefs guide him or her to find meaning in life events and to thus make decisions. Ask your patient whether he or she is able to live according to his or her beliefs. Finally, assess to what extent your patient interrelates with self, others, and/or a source of authority. Faith in an authority (such as a health care provider or senior family member) provides a sense of confidence that guides a person in exercising beliefs and experiencing growth. Assess a person's faith in an authority by asking "To whom do you look to for guidance in life?" The patient's response to an open-ended question such as this is likely to open the door for a meaningful discussion. Listen carefully and explore what is meaningful to the patient.
Drainage Evacuation
When drainage interferes with healing, evacuation of the drainage is achieved by using either a drain alone or a drainage tube with continuous suction. You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies, around drain sites with significant drainage for skin protection. The skin barriers are soft material applied to the skin with adhesive. Drainage flows on the barrier but not directly on the skin. Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, immediately reset the evacuator to apply suction, and record the output.
Excretion of Carbonic Acid
When you exhale, you excrete carbonic acid in the form of CO 2 and water. If the PaCO 2 (i.e., level of CO 2 in the blood) rises, the chemoreceptors trigger faster and deeper respirations to excrete the excess. If the PaCO 2 falls, the chemoreceptors trigger slower and shallower respirations so that more of the CO 2 produced by cells remains in the blood and makes up the deficit. These alterations in respiratory rate and depth maintain the carbonic acid part of acid-base balance. People who have respiratory disease may be unable to excrete enough carbonic acid, which causes the blood to become more acidic and blood CO 2 to increase. If an increased respiratory rate is unable to correct the problem, the kidneys begin some compensatory excretion of metabolic acid.
Evisceration
With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency. Immediately place damp sterile gauze over site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery. The displacement of organs outside of the body.
Infection and wounds
Wound infection prolongs the inflammatory phase; delays collagen synthesis; prevents epithelialization; and increases the production of proinflammatory cytokines, which leads to additional tissue destruction. Indications that a wound infection is present include the presence of purulent drainage; change in odor, volume, or character of wound drainage; redness in the surrounding tissue; fever; or pain.
Tertiary intention wound healing
Wound is left open for several days, then wound edges are approximated.
blanchable hyperemia
You assess an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanchable hyperemia .
Intimacy vs. Isolation and Loneliness
Young adulthood -Establishes self-identity and world view -Forms independent beliefs, attitudes, and lifestyles -Uses principles to solve problems when individual's and society's rules conflict
Postural drainage
a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It aids in improving secretion clearance and oxygenation. Positioning involves draining affected lung segments and helps to drain secretions from those segments of the lungs and bronchi into the trachea. Some patients do not require postural drainage of all lung segments, and clinical assessment is crucial in identifying specific lung segments requiring it. For example, patients with left lower lobe atelectasis require postural drainage of only the affected region, whereas a child with CF often requires postural drainage of all lung segments
Autoimmune diseases
a group of inflammatory (often chronic) diseases in which the immune system is attacking the self. Stress has a causative role in autoimmune disease genesis. In rheumatoid arthritis, the immune system believes the cells of the tissue around joints are foreign invaders and attacks them. Inflammation, pain, and eventually disability result. Cancer is another example of an autoimmune disease. Stress management, self-care, meditation, guided imagery, yoga, music, and exercise are found to release endorphins as the sympathetic system is calmed. The immune system steps out of the emergency mode and back into maintenance of function.
Metabolic syndrome
a group of risk factors that increase the likelihood of significant chronic health problems, such as diabetes, stroke, and heart disease. There are five risk factors associated with metabolic syndrome and for an individual to be diagnosed with metabolic syndrome, he or she must have at least three of these risk factors. This syndrome is quite complex, but an underlying factor is low-grade inflammation. Prevention of metabolic syndrome will protect the individual from these major life-threatening diseases. Lifestyle changes, weight and stress management, lowering cholesterol with medication and diet, increasing activity, and self-care are all recommended for those at risk.
Thoracic Diaphragm
a huge layer of flat muscles right below the lungs (thoracic diaphragm). when it is relaxed is arched & the lungs don't have a lot of volumes. -when contracts, creates more space for lungs to fill with air -when relaxes, expels air
Coping
a person's cognitive and behavioral efforts to manage a stressor ( Can et al., 2017 ). It is important to physical and psychological health because stress is associated with a range of psychological and health outcomes ( Can et al., 2017 ). The effectiveness of coping strategies is influenced by a variety of factors, such as a person's age, cultural background, individual circumstances, and past use of coping strategies. Thus no single coping strategy works for everyone or for every stressor.
STAT orders
a single dose to be given immediately e.g. Apresoline 10mg IV STAT
Crisis Intervention
a specific type of brief psychotherapy and has two specific goals. First is patient safety. Use external controls to protect the patient and others if the person is suicidal or homicidal. Second is anxiety reduction using techniques that put a patient's inner resources into effect. It is more directive than traditional psychotherapy or counseling, and any member of the health care team who has been trained in its techniques can use it. The basic approach is problem solving, and it focuses only on the problem presented by the crisis -Crisis intervention aims to return the person to a precrisis level of functioning and promote growth.
Venipuncture
a technique in which a vein is punctured through the skin by a sharp rigid stylet (e.g., metal needle). The stylet is partially covered either with a plastic catheter or a needle attached to a syringe. General purposes of venipuncture are to collect a blood specimen, start an IV infusion, provide vascular access for later use, instill a medication, or inject a radiopaque or other tracer for special diagnostic examinations. It takes practice to become proficient in venipuncture. Only experienced practitioners should perform it for patients whose veins are fragile or collapse easily such as older adults.
Angina pectoris
a transient imbalance between myocardial oxygen supply and demand. The condition results in chest pain that is aching, sharp, tingling, or burning or that feels like pressure. Typically, chest pain is left sided or substernal and often radiates to the left or both arms, the jaw, neck, and back. In some patients, angina pain does not radiate. It usually lasts from 3 to 5 minutes. Patients report that it is often precipitated by activities that increase myocardial oxygen demand (e.g., eating heavy meals, exercise, or stress). It is usually relieved with rest and coronary vasodilators, the most common being a nitroglycerin preparation
Nebulization
adds moisture to inspired air by mixing particles of varying sizes with the air. Aerosolization suspends the maximum number of water drops or particles of the desired size in inspired air. When the thin layer of fluid supporting the mucous layer over the cilia dries, the cilia are damaged and unable to adequately clear the airway. Humidification through nebulization enhances mucociliary clearance, the natural mechanism of the body for removing mucus and cellular debris from the respiratory tract. This, in turn, improves the clearance of pulmonary secretions. Nebulization is also a method of administration for certain medications, such as bronchodilators and mucolytic agents
topical administration
administration of a substance directly onto the skin or mucous membrane -placed on skin surface, on mucous membranes, or in body cavities -usually require new applications every 24hrs -eyes, ears, nose, rectum, vagina, and lungs, skin -Cleanse skin prior to applying topical meds -Gloves and applicators are used to avoid absorption through nurse's skin during placement -Document body site where applied
PC, pc
after meals
Distribution of medication
after the medication is absorbed it is distributed to the tissues, organs and to its specific site of action.
Trade Medication name
also known as brand or proprietary name. This is the name under which a manufacturer markets the medication e.g. Tylenol.
Post-traumatic stress disorder (PTSD):
an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience Begins when a person witnesses a traumatic event
Stressors
any physical, psychological or social stimuli that are capable of producing stress and endangering homeostasis
transdermal administration
application of a drug in patch form, which is then absorbed into the blood through the skin -Meds designed to be absorbed through the skin for systemic effect -Patches are disposed of according to facility policy, especially if contains controlled substance -Placement sites rotated to avoid skin irritation -Placement of new patch and removal of old patch are both recorded on MAR -Cleansing the skin site is needed as skin oils may interfere with the adhesive on these products
Standing orders or routine orders
are carried out until discontinued by the doctor e.g. Acetaminophen 500mg q6h
Prescriptions
are ordered to be taken out of the hospital.
ad lib
as desired
prn
as needed
PRN orders
as needed e.g. Morphine sulfate 2mg IV q2h prn for incisional pain.
AC, ac
before meals
Hemorrhage
bleeding from a wound site, is normal during and immediately after initial trauma. Hemorrhage occurs externally or internally. -You detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. -A hematoma is a localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. -External hemorrhaging is obvious. Observe all wounds closely, particularly surgical wounds, in which the risk of hemorrhage is great during the first 24 to 48 hours after surgery or injury.
Psychoneuroimmunology
branch of research that seeks to understand the relationship between the mind and body
Sanguineous
bright red, indicates active bleeding
Pulmonary arteries
carry deoxygenated blood out of the right ventricle and into the lungs
Aldosterone
causes the kidneys to retain sodium and water
In order to use the nursing process...
critical thinking must be in place
Pulmonary Circulation
deoxygenated blood leaves the right ventricle, goes through a valve, and through the pulmonary trunk into the L & R pulmonary arteries towards the lungs. oxygenated blood then leaves the lungs through the few L & R pulmonary veins and into the left atrium
Therapeutic range
desired level
Incentive spirometry
encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is a commonly used intervention that promotes deep breathing and is thought to prevent or treat atelectasis in the postoperative patient. Recent evidence suggests that the use of the incentive spirometer is not as effective at preventing postoperative pulmonary complications as it once was thought to be. The AARC recommends that its use be reserved for patients with existing atelectasis or those with risk factors for developing atelectasis, such as those who have undergone thoracic or abdominal surgery, patients with prolonged bed rest, or patients with neuromuscular disease or spinal cord injuries (
FICA assessment tool
evaluates spirituality and is closely correlated to quality of life F—F aith or belief I—I mportance and Influence C—C ommunity A—A ddress (interventions to address)
q4h
every 4 hours
qh
every hour
q am
every morning
Respiration
exchange of oxygen and carbon dioxide during cellular metabolism
Full-thickness wound
extends into the subcutaneous layer and the depth and tissue type will vary depending on body location. -heal by hemostasis, inflammatory, proliferative, and maturation
Interstitial fluid
fluid that surrounds the cells (75% of extracellular fluid)
Intravascular fluid
fluid within blood vessels (20% of extracellular fluid)- Within the arteries, veins and capillaries (Plasma)
Cardiovascular Physiology
four cardiac chambers: two atria and two ventricles -right ventricle pumps deoxygenated blood through the pulmonary circulation and the left ventricle pumps oxygenated blood through the systemic circulation
QID, qid
four times a day
The cardiopulmonary system consists of
heart, lungs, airways, and blood vessels. They function to provide and deliver oxygen to the tissues and to remove carbon dioxide from the body.
oxyhemoglobin
hemoglobin bound to oxygen. -the formation of oxyhemoglobin is easily reversible, allowing hemoglobin and oxygen to dissociate (deoxyhemoglobin), which frees oxygen to enter tissues.
The four phases involved in the healing process of a full-thickness wound are:
hemostasis, inflammation, proliferation, and maturation.
Peak
highest level
Appraisel
how a person interprets the impact of a stressor
Sodium imbalances
hyponatremia/hypernatremia EXCESS SODIUM OR EXCESS WATER LOSS 1.Caused by change in intake or excretion of sodium 2.Caused by change in intake or excretion of water 3.Caused by shift in Na+ or H20
STAT, stat
immediately
Right-sided heart failure
impairment of the right ventricle. blood begins to back up into the systemic circulation as evidenced by weight gain, distended neck veins and peripheral edema.
Intraarticular
injection into a joint (usually limited to physicians)
Intravenous
injection into a vein
Intracardiac
injection into cardiac tissues (usually limited to physicians)
Intraarterial
injection into the arteries
Intraosseous
injection into the bone marrow
Intradermal
injection into the dermis just under the epidermis
Epidural
injection into the epidural space
Intramuscular
injection into the muscle
Intraperitoneal
injection into the peritoneal cavity
Intrapleural
injection into the pleural space
Intrathecal
injection into the subarachnoid space or one of the ventricles of the brain
Subcutaneous
injection into the tissues just below the dermis of the skin.
Intraocular route
inserting a medication similar to a contact lens into the eye. The medication remains in the eye for 1 week
Pursed-lip breathing
involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing out a candle. Patients need to gain control of the exhalation phase so that it is longer than inhalation. The patient is usually able to perfect this technique by counting the inhalation time and gradually increasing the count during exhalation. In studies using pursed-lip breathing as a method to improve exercise tolerance in patients with COPD, patients were able to demonstrate increases in their exercise tolerance, breathing pattern, and arterial oxygen saturation
Parenteral routes
involves injection of the medication into the tissues: Four major sites of injection: •Intradermal - injection into the dermis just under the epidermis •Subcutaneous - injection into the tissues just below the dermis of the skin. •Intramuscular - injection into the muscle •Intravenous - injection into a vein (there are others too)
Now orders
is a one time order to be given ASAP but not right away like a STAT order. A nurse has 90 minutes after receiving a now order to administer it.
Inspiration
is an active process, stimulated by chemical receptors in the aorta. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Patients with advanced COPD lose the elastic recoil of the lungs and thorax. As a result, the patient's work of breathing increases. In addition, patients with certain pulmonary diseases have decreased surfactant production and sometimes develop atelectasis. Atelectasis is a collapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide.
Positive expiratory pressure (PEP)
is an airway clearance technique that can be used with and without oscillation. Its use is typically reserved for patients with CF or other lung diseases in which sputum is retained. The Acapella and Flutter devices are commonly used PEP devices. PEP allows air to be inhaled easily but forces the patient to exhale against resistance. This action helps air get behind the mucus, which then makes it easier to expectorate the mucus. The patient must be physically capable of maintaining a seal with their mouth around the device.
Chest physiotherapy (CPT)
is external chest wall manipulation using percussion, vibration, or high-frequency chest wall compression (HFCWC). It is often used in conjunction with postural drainage and can help mobilize pulmonary secretions in a select group of patients. Box 41.7 describes the guidelines to determine whether CPT is indicated. The American Association for Respiratory Care (AARC) does not support the routine use of CPT with all patients. There is no evidence to support its routine use in all patient populations, instead reserving its use for patients with retained secretions who cannot expectorate those secretions, such as patients with cystic fibrosis (CF)
Regulation of ventilation
is necessary to ensure sufficient oxygen intake and carbon dioxide elimination to meet the demands of the body (e.g., during exercise, infection, or pregnancy). Neural and chemical regulators control the process of ventilation. Neural regulation includes the CNS control of respiratory rate, depth, and rhythm. The cerebral cortex regulates the voluntary control of respiration by delivering impulses to the respiratory motor neurons by way of the spinal cord. Chemical regulation maintains the appropriate rate and depth of respirations based on changes in the carbon dioxide (CO 2 ), oxygen (O 2 ), and hydrogen ion (H + ) concentration (pH) in the blood. Changes in levels of O 2 , CO 2 , and H + (pH) stimulate the chemoreceptors located in the medulla, aortic body, and carotid body, which in turn stimulate neural regulators to adjust the rate and depth of ventilation to maintain normal arterial blood gas levels
Wound infection
is present when the microorganisms invade the wound tissues. -The local clinical signs of wound infection can include erythema, increased amount of wound drainage, change in appearance of the wound drainage, warmth, pain, or edema. The patient has a fever, tenderness, and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is purulent, which causes a yellow, green, or brown color, depending on the causative organism.
Airway resistance
is the increase in pressure that occurs as the diameter of the airways decreases from mouth/nose to alveoli. Any further decrease in airway diameter by bronchoconstriction or the presences of excess mucus can increase airway resistance. Diseases causing airway obstruction, such as asthma, tracheal edema, or COPD, increase airway resistance. When airway resistance increases, the amount of oxygen delivered to the alveoli decreases.
Diaphragmatic breathing
is useful for patients with pulmonary disease and dyspnea secondary to heart failure. This type of breathing increases tidal volume and decreases respiratory rate, which leads to an overall improved breathing pattern and quality of life. Diaphragmatic breathing is more difficult than other breathing methods because it requires a patient to relax intercostal and accessory respiratory muscles while taking deep inspirations, which takes practice. The patient places one hand flat below the breastbone (upper hand) and the other hand (lower hand) flat on the abdomen. Ask him or her to inhale slowly, making the abdomen push out (as the diaphragm flattens, the abdomen should extend out) and moving the lower hand outward. When the patient exhales, the abdomen goes in (the diaphragm ascends and pushes on lungs to help expel trapped air). The patient practices these exercises initially in the supine position and then while sitting and standing. The exercise is often used with the pursed-lip breathing technique.
self-awareness
is viewed as the basic competency for influential leaders, recognizing that when learning about themselves, leaders are then able to serve as inspiring role models and supportive mentors for others. By learning about the self, leaders become comfortable with their internal thought processes, values, beliefs, preferences, and emotions. They become self-managers, careful about how they present themselves and respond to the outside world. A self-aware leader, then, is in a better position to collaborate and connect with others.
Collaboration
is viewed as the duty and a performance improvement strategy for influential leaders, with the understanding that creating a common goal through partnering with others allows for greater trust, accountability, and harmony. Collaborative action provides a climate for dynamic transformation from a competitive, power-over environment to a cooperative, power-with organizational culture. Sustainable collaboration draws on the expertise, knowledge, and strengths of each team member, allowing for collective decision making, cultivation of strong relationships, and acknowledgment that every person provides a unique talent and contribution to the creation of a high-performing organization.
Trough
lowest level
Red Blood Cells and Oxygen
made for the purpose of carrying around oxygen to the body. don't need oxygen, simply carry it around. -has no mitochondria so does not use oxygen
Inhalation route
medications absorbed throught the nasal passages, oral passage, or endotracheal or tracheostomy tubes
Medication forms
medications are available in a variety of forms: -Solid, liquid, other oral forms; topical, parenteral and forms for instillation into body cavities e.g. suppositories.
Simple Diffusion
movement of a solute from an area of high concentration to an area of low concentration Simple diffusion requires no energy. An example is oxygen and carbon dioxide can permeate through cell membranes and are distributed throughout the body. So...... Breathing is an example of diffusion!
Ventilation:
moving gases into and out of the lungs with air flowing into the lungs during inhalation and out of the lungs during exhalation
Diffusion:
moving the respiratory gases from one area to another by concentration gradients
Blanching
occurs when the normal red tones of the light-skinned patient are absent. When checking for pressure injuries in patients with dark pigmented skin, be aware that dark skin may not show the blanch response. Therefore inspect the pressure area with an adjacent or opposite area of the body for comparison. . Extended pressure occludes blood flow and nutrients and contributes to cell death. •The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.
clubbed nails
often occur when patients with chronic oxygen deficiency such as cystic fibrosis and congenital heart defects
Evidence-based knowledge
or knowledge based on research or clinical expertise, makes nurses better informed critical thinkers. Thinking critically and learning about the scientific concepts of deconditioning, comfort, and mobility prepare Tonya to better anticipate Mr. Lawson's needs, identify problems more quickly, and provide appropriate care.
Systemic Circulation
oxygenated blood leaves the left ventricle through the aorta (branches and splits) towards the body (brain, bones, liver, etc) and deoxygenated blood goes back to the heart through the inferior and superior vena cava and into the right atrium
Alkalosis
pH above 7.45 decreased acid or increased base
Acidosis
pH below 7.35 increased acid or decreased base
Wounds can be classified by the extent of tissue loss:
partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis).
Diffusion
passive movement of electrolytes or other particles down a concentration gradient from areas of higher concentration to areas of lower concentration. -Occurs within fluid compartment and from one compartment to another. -Example: When you pour a small amount of cream into a cup of black coffee, the cream mixes or spreads through the whole cup of coffee and diffuses throughout. (passive)
Buccal administration
placing the medication in the mouth against the solid mucous membranes of the cheek. -placed in side of mouth against inner cheek -Standard precautions used by nurse administering medications by sublingual or buccal route as the nurse's hand may come in contact with oral secretions -Warn patients not to chew or swallow the medication or to take any liquids with it (oral route)
Sublingual administration
placing the medication under the tongue e.g. nitroglycerin. -placed under tongue and allowed to dissolve -Standard precautions used by nurse administering medications by sublingual or buccal route as the nurse's hand may come in contact with oral secretions -Warn patients not to chew or swallow the medication or to take any liquids with it (oral route)
Goal of oxygen therapy
prevent or relieve hypoxemia by delivering the lowest amount of oxygen possible and achieving adequate tissue oxygenation
Chemical Medication Name
provides the exact description of medication's composition e.g. N-acetyl-para-aminophenolol which is commonly known as Tylenol. Nurses rarely use chemical names in clinical practice.
ego defense mechanisms
regulate emotional destress and give us protection from anxiety and stress -ex: compensation, conversion, denial, displacement, identification, dissociation, regression
Debridement
removal of foreign material and dead or damaged tissue from a wound Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. The method of debridement depends on which is most appropriate for a patient's condition and goals of care. It is important to remember that during the debridement process some normal wound observations include an increase in wound exudate, odor, and size. You need to assess and prevent or effectively manage pain that occurs with debridement. Plan to administer an ordered analgesic 30 minutes before debridement.
Myocardial ischemia
results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands -two common outcomes of this ischemia are angina and myocardial infarction
Partial-thickness wounds
shallow in depth, moist, and painful, and the wound base generally appears red. -heal by the inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
Isotonic Solutions
solutions separated by a membrane and containing an equal concentration of non-permeating solutes -Fluids with same osmolality as cell interior -0.9%NS; LR -Fluid shift? None -Expands only ECF, stays where it's administered, no net gain or loss from ICF
Alveoli: movement of o2 and co2
super small and have very thin walls. our circulatory system passes right next to them (arteries - come from the heart to the lungs) with deoxygenated blood. the air is flowing through the bronchioles and fill alveoli and the molecules of oxygen are allowed to cross the membrane of the alveoli and be absorbed into the blood. arteries from the heart release co2 into the alveoli to be exhaled. -o2 coming in and absorbed into alveoli -when we breathe out, we breathe out co2 that was in our blood that gets absorbed into alveoli and squeezed out about 1/5 mm in diameter
Pulmonary arteries and veins
supply blood and return blood to and from all segments of the lungs
Perfusion:
the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
Compliance
the ability of the lungs to distend or expand in response to increased intra-alveolar pressure. Compliance decreases in diseases such as pulmonary edema, interstitial and pleural fibrosis, and congenital or traumatic structural abnormalities such as kyphosis or fractured ribs.
Three things influence the capacity of the blood to carry oxygen:
the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the ability of hemoglobin to bind with oxygen.
Transcendence
the belief that a force outside of and greater than the person exists beyond the material world
Work of breathing (WOB)
the effort required to expand and contract the lungs. In the healthy individual breathing is quiet and accomplished with minimal effort. The amount of energy expended on breathing depends on the rate and depth of breathing, the ease in which the lungs can be expanded (compliance), and airway resistance.
Left-sided heart failure
the left ventricle is weakened and the amount of blood ejected drops significantly. resulting in decreased cardiac output. pulmonary congestion can occur as evidenced by crackles in the bases of the lungs, shortness of breath with exertion, hypoxia and cough.
Generic Medication Name
the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. drug book. Acetaminophen is an example of a generic name for Tylenol.
Humidification
the process of adding water to gas to keep airways moist. It is necessary for patients receiving oxygen therapy at high flow rates, typically greater than 4 L/minute (see agency protocols). Oxygen humidification via nasal cannula or face mask is achieved by bubbling oxygen through sterile water. Sterile water should be used to decrease the risk of hospital-acquired infection; agency protocols must be followed for changing the solution
What happens when we breathe out
the thoracic diaphragm relaxes and expels air with co2
Biological half life
the time it takes for excretion process to lower the serum of the medication concentration by half.
Chest physiotherapy is reserved for use in patients with
thick secretions to help them mobilize those secretions.
Hypertonic Solutions
those with higher solute concentrations and lower water concentrations; cells placed in these solutions undergo CRENATION -Fluid shift? From ICF to ECF - 3%NS; 50%Dextrose (inc. o.p. of ECF initially) H20 will rush out of cells, cells shrink, ECF volume increases. Too much, cell will die. -Hypertonic solutions pull fluid from the cells causing them to shrink and causing ECF to expand. -Solutions in which solutes more concentrated than cells
Hypotonic Solutions
those with lower solute concentrations and higher water concentrations; cells placed in these solutions gain water; and if they lack a cell wall, may burst -Where will fluid move? -Into cell-too much, cell will swell and burst -A hypotonic solution has < salt or more water than an isotonic solution. -Solutions in which solutes are less concentrated than the cells -0.45%NS; 0.33%NS -D5W -Fluid shift? Fluid will move from dilute ECF to ICF
TID, tid
three times a day
General adaptation syndrome (GAS)
three-stage reaction to stress, describes how the body responds physiologically to stressors. The GAS is triggered either directly by a physical event or indirectly by a psychological event. It involves several body systems, especially the neuroendocrine mechanism, which responds immediately to stress. When the body encounters a physical demand such as an injury, the pituitary gland initiates the GAS. A fundamental concept underlying this reaction is that the body will attempt to return to a state of balance, a process referred to as allostasis -Alarm stage (fight or flight) -Resistance stage -Exhaustion stage
Why does our body need oxygen?
to metabolize food our food, turn our food into atp to drive other cell functions
The primary function of pulmonary circulation
to move blood to and from the alveolar capillary membrane for gas exchange. Pulmonary circulation begins at the pulmonary artery, which receives poorly oxygenated mixed venous blood from the right ventricle. Blood flow through this system depends on the pumping ability of the right ventricle. The flow continues from the pulmonary artery through the pulmonary arterioles to the pulmonary capillaries, where blood comes in contact with the alveolar capillary membrane and the exchange of respiratory gases occurs. The oxygen-rich blood then circulates through the pulmonary venules and pulmonary veins, returning to the left atrium
Extracellular Fluid Volume Deficit (FVD)
too little isotonic fluid in the extracellular compartment CLINICAL DEHYDRATION
Epidermis
top layer of skin •The epidermis has several layers within it. The stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface.
Secondary traumatic stress:
trauma that health care providers experience when witnessing and caring for others suffering trauma Witnessing other people's suffering -common in healthcare workers and first responders
BID, bid
twice a day
Lung Volumes
when we breathe, the air in our lungs is in constant flux -lung volumes are determined by age, gender and height -tidal volume is the amount of air exhaled following a normal inspiration -residual volume is the amount of air left in the aveoli after a full expiration -forced vital capacity is the max amount of air that can be removed from the lungs during forced expiration
Implementing spiritual care into acute care settings
within acute care settings patient experience multiple stressors that threaten their sense of control. ongoing assessment of spiritual needs is essential because patients needs are often rapidly changing -Support systems -Diet therapies: offer food congruent to their religious observances -Supporting rituals: provide opportunities
Dressing Considerations
• Clean the wound and periwound area at each dressing change, minimizing trauma to the wound • Use a dressing that continuously provides a moist environment. • Perform wound care using topical dressings as determined by a thorough assessment. • No specific studies have proven an optimal dressing type for pressure injuries • Choose a dressing that keeps the periwound skin dry while keeping the injury bed moist. • Choose a dressing that controls exudate but does not desiccate the injury bed. • The type of dressing may change over time as the pressure injury heals or deteriorates. The wound should be monitored at every dressing change and regularly assessed to determine whether modifications in the dressing type are needed • Consider caregiver time, ease of use, availability, and cost when selecting a dressing.
Possible nursing diagnoses for patients with fluid, electrolyte, and acid-base alterations include the following:
• Fluid Imbalance • Dehydration • Electrolyte Imbalance • Acid Base Imbalance • Lack of Knowledge of Fluid Regimen
Nursing Assessment Questions: Life and Self-Responsibility
• How do you feel about the changes this illness has caused? • How do these changes affect what you now need to do?
Nursing Assessment Questions: Life Satisfaction
• How happy or satisfied are you with your life? • Which accomplishments help you feel satisfied with your life? • What is it that makes you feel dissatisfied?
Nursing Assessment Questions: Vocation
• How has your illness affected the way you live your life spiritually at home or where you work? • In what way has your illness affected your ability to express what is important in life to you?
Examples of patients who are at risk for the development of pressure injuries include the following:
• Older adults, those who have experienced trauma • Those with spinal-cord injuries (SCI) • Those who have sustained a fractured hip • Those in long-term homes or community care, the acutely ill, or those in a hospice setting • Individuals with diabetes • Patients in critical care settings
Focus on Older Adults Understanding Differences in Stress and Coping Among Older Adults
• Ordinary hassles of day-to-day living create a source of stress; older adults have more hassles with home maintenance and health than do younger people. • Older adults often use more passive, intrapersonal, emotion-focused forms of coping such as distancing, humor, accepting responsibility, and reappraising the stressor in a positive way. • Life experiences and perspectives of older adults make most problems seem insignificant, especially when older adults have acquired appropriate stress-management techniques • Older adults' coping improves based on earlier experience with coping with traumatic situations • Impaired coping affects overall health in older adults more than in younger adults • Because of the high incidence of depression in older adults, you need to assess for suicidal thoughts and intent. • When marital or partnership dyads are present, the perceived stress of one member has a greater effect on the other member than occurs with middle or young adults
Nursing Assessment Questions: Faith, Belief, Fellowship, and Community
• To what or whom do you look as a source of strength, hope, or faith in times of difficulty? • How does your faith help you cope? • What can I do to support your religious beliefs or faith commitment? Would you like me to pray with you or perhaps read from the Koran or Bible? • What gives your life meaning?
Nursing Assessment Questions: Connectedness
• What feelings do you have after you pray or meditate? • Who do you feel is the most important person in your life?
Nursing Assessment Questions: Spirituality and Spiritual Health
• Which experiences in the past have been most difficult for you? • What gives you hope during those difficult times? • Which aspects of your spirituality have been most helpful to you? • Which aspects of your spirituality would you like to discuss?
Wound classification
•A wound is a disruption of the integrity and function of tissues in the body. Understanding the etiology of a wound is important because the treatment for it varies, depending on the underlying disease process. •There are many ways to classify wounds. Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, and descriptive qualities of the wound tissue such as color. •Wound classification enables a nurse to understand the risks associated with a wound and implications for healing •Wounds can be classified by the extent of tissue loss: partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis). •Partial-thickness wounds are shallow in depth, moist, and painful, and the wound base generally appears red. •A full-thickness wound extends into the subcutaneous layer and the depth and tissue type will vary depending on body location.
Direct Care
•Activities of daily living (ADLs) Direct care measures usually performed during a normal day •Instrumental ADLs (IADLs) Activities that support daily life and are oriented toward interacting with the environment •Physical care techniques The safe and competent administration of nursing procedures •Lifesaving measures Ex: Counseling, Teaching, Controlling for adverse reactions, Preventive interventions
Nursing Considerations for Oral Administration
•Assess patient's ability to take medications by the oral route to prevent aspiration •Nurse should verify that the medication was swallowed •Special techniques are used for the patient who has difficulty swallowing large tablets. •Enteric-coated or sustained-release tablets should never be crushed •Antifungal liquid medications may need longer contact with mucous membranes and be prescribed as "swish and swallow." •May be administered through gastrointestinal tube. Liquid medication is preferred, although some tablets may be finely crushed and dissolved in water
Assessing Pressure Ulcers
•Assess pressure ulcers at regular intervals using systematic parameters to evaluate wound healing, plan appropriate interventions, and evaluate progress. Assessment includes wound location, depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. •Pressure ulcer staging describes the pressure ulcer depth at the point of assessment. Pressure ulcers do not progress from a Stage III to a Stage I. A Stage III ulcer demonstrating signs of healing is described as a healing Stage III pressure ulcer. •Use a disposable wound-measuring devices to obtain the measurement of width and length. Measure depth by using a cotton-tipped applicator in the wound bed. •Wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Examine the periwound area for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration.
After Medication Administration
•Clinical observation to evaluate effectiveness of medications •Subjective and objective data show evaluation of medication responses •Assess for adverse effects •Laboratory tests indicate the patient response to some medications •Significant patient deviations from normal response must be reported to the health care provider
Nursing Process: Assessment Skin
•Continually assess skin for signs of breakdown and/or ulcer development •Focusing on specific elements, such as a patient's level of sensation, movement, and continence status, helps guide the skin assessment. •Continually assesses the skin for signs of skin breakdown and/or ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. •Pay particular attention to areas located over bony prominences; next to medical devices; under casts, traction, splints, braces, collars, or other orthopedic devices. The frequency of pressure checks depends on the schedule of appliance application and the response of the skin to the external pressure.
Medications exit the body through the: (excretion)
•Kidney - main organ for excretion •Liver •Bowel •Lungs •Exocrine glands •Mammary glands •GI tract -The chemical makeup of medication determines the organ of excretion.
Critical Thinking in Everyday Nursing Practice
•Nurses must make accurate and appropriate clinical decisions or judgments. •Clinical judgment -Yields a well reasoned answer. -Influenced by a nurse's experience and knowledge. -Partly relies on knowing the patient. -Influenced by the context of clinical situations and the culture of patient care settings. -Nurses use a variety of reasoning approaches in combination. -Conclusion about a patient's needs or health problems.
Risk factors for pressure ulcers
•Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves. •Shear is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. •Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. •The presence and duration of moisture on the skin reduce the skin's resistance and may cause pressure ulcers •Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. •Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. •Patients who are unable to independently change position are at risk because they cannot change or shift off bony prominence areas.
Purposes of dressings
•Protects from microorganisms •Aids in hemostasis •Promotes healing by absorbing drainage or debriding a wound •Supports wound site •Promotes thermal insulation •Provides a moist environment
Factors that influence absorption of meds
•Route of administration •Ability of a medication to dissolve •Blood flow to the site of administration •Body surface area •Lipid solubility
Dermis
•The dermis provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. The dermis is made of collagen, blood vessels, and nerves. •Inner layer of skin •Collagen
