NURS 202 Digital Notes

[10^TH^ SEPTEMBER]: CRITICAL THINKING AND THE NURSING PROCESS. - Critical thinking means that when we learn, we observe and train ourselves so that we think things out for ourselves. - Characteristics of critical thinkers: raise questions, show a willingness to search for answers, are...

[10^TH^ SEPTEMBER]: CRITICAL THINKING AND THE NURSING PROCESS. - Critical thinking means that when we learn, we observe and train ourselves so that we think things out for ourselves. - Characteristics of critical thinkers: raise questions, show a willingness to search for answers, are curious, eager to learn, consider multiple perspectives, are open-minded, explore ideas/problems in new ways, etc. - Character + knowledge + skills = CRITICAL THINKING - Critical thinking is a high-level cognitive process that can involve problem-solving. - The Nursing process is intertwined with critical thinking. They are all intertwined, and they go in a circle. It follows the acronym ADPIE. - The Nursing process is as follows: - Assessment--- - This involves gathering and analyzing information about the patient and the context from their perspective. It is literally establishing a database. - There are types of data: subjective data (what the patient says) and objective data. Quote subjective data verbatim. - The patient (primary source) and others (patient records, formal care providers, literature, etc.) are sources of data. - Data clustering is grouping the most pertinent data. You need to decide what data can help you reach a diagnosis. - Nursing Diagnosis--- - NANDA International (READ UP ON THIS) - The nursing diagnosis is as follows: the problem is related to the reason. You can add extra information. We are looking at the whole person, not just the cause. It might not even be related to the actual illness. - For example, impaired comfort r/t to blood glucose tests, as evidenced by grimacing. This might be diabetes mellitus. - Types of nursing diagnoses: - Problem-focused dx: This is not just a diagnosis, it\'s a solution. It describes an existing problem and provides a clear path for patient care. It\'s about identifying and addressing the patient\'s immediate health issues. - Risk dx: This type of diagnosis describes a potential problem that the patient is at risk of developing. It helps us identify and address issues before they become serious health problems. - Health promotion dx: This is not just about treating an illness; it\'s about promoting overall health. It focuses on the patient being as healthy as possible, e.g. effective breastfeeding. It\'s a proactive approach to patient care. - Syndrome dx: based on a group of signs and symptoms that go together, e.g. post-trauma syndrome. - Planning--- - Occurs from first contact and continues until discharge. - Examples of planning include initial, ongoing and discharge. - These result in a care plan. - Priority setting - Classification of properties: - High: ABC'S ("S" is safety) - Mid: not critical when they\'re in the hospital - Low: Affects future well-being - Maslow's hierarchy of needs can help with the priority setting. - Set a SMART patient-centred goal. - When planning goals, we combine a verb with the condition and criterion (usually time periods). - You also need to plan out nursing interventions that *you*, as the nurse, need to carry out alone. The three different nursing interventions are independent, dependent and collaborative. - Implementation--- - This is initiating appropriate nursing interventions after reassessing the patient, organizing resources or assistance and anticipating/preventing complications. - Rationale required\*. Check the textbook to start utilizing scholarly resources. - Evaluation--- - This is about whether the interventions were effective and whether the goal was achieved. If not, what can you do better? - The Nursing process is truly dynamic and interactive. - Normal limits of blood pressure are [12^TH^ SEPTEMBER]: CASE STUDY - Write the goal but in the past tense when at the evaluation stage. - When you write an evaluation, it's just one statement. For example, goals are met, goals are partially met, or goals are not met. - Review of "typical" care plan: - Data Cluster (Assessment) -- Compile r/t data - Nursing Diagnosis (Diagnosis)- problem r/t reason - Goal (planning)- patient will... \[goal+ outcome+ criteria\] - Proposed nursing intervention (implementation) -- (NURSE WILL...) List actions you will do, and state the rationale for your choices - Evaluation- Is the goal achieved or not? Revise as necessary. - Nursing diagnosis evaluates the patient\'s response to actual or potential health problems. - ADLs -- assistance with stuff that would usually be easy. - JOANNE CASE STUDY: - Data Cluster: - Physical data (PH): MS, assistance with ADLs, obese, increased need for care and support, poor diet, predisposed to diabetes because of treats, limited mobility, pressure injury, sleeps well. - Psychosocial data (PS): She loves music, is upset because of tension with her husband and staff, misses her children, spends more time in bed, and believes she should move. - Pressure injury is a priority because of decreased circulation as well as her MS and diabetes. - Family situations could affect recovery as well as anger. - Written out, it looks like P injury (stage 1), R hips MS, assistance with ADLs/care, limited mobility - Written out, it looks like Two children (husband), upset with staff, ++time in the room, quick to anger/low mood - Cluster to display the relevant information that you want to focus on. - Diagnosis: (LOOK THROUGH ACKLEY'S) - Psychosocial: anger, family problems/process, stress, possible depression, some anxiety. A formal diagnosis could be powerlessness. - Written out, it looks like powerlessness r/t LTC (Long-term care) environment, ineffective coping strategies, and possible low self-esteem. (Cite Ackley or Potter when required.) - Planning: - For PS, how can we, as nurses, support Joanne to regain power? - The client will state feelings of powerlessness, identify factors and participate in her care plan. Make SMART goals. - Written out, it looks like Joanne will state feelings of powerlessness and other feelings by Sept 15/24. - Implementation: - For PS, does Joanne agree? How do I support Joanne? If she disagrees, revise the plan. Interact with patients to figure out how to create the best care plan possible. - Written out, it looks like this: 1.) Note factors contributing to powerlessness 2.) Engage with Joanne using respectful listening and questioning to understand the perspective of Joanne 3.) Encourage Joanne to identify her role in her care and her sense of purpose. - When writing an implementation method, be clear, specific and concise. Don't be vague. - Don't forget to cite each implementation. - For implementation, five interventions are too few, and twenty are too many. - Evaluation - As you approach the end of the timeframe, check if she is meeting the goal. If not, revise. - Written out, it looks like if the goal is met, Joanne stated being frustrated with the current situation on Sept 15/24. If the goal is partially met, she shared being upset but did not state her feelings properly by 'date' (probably needs more time). If the goal is not met, she did not engage by the 'date,' so revise it to advocate support from a counsellor. - When teaching patient education, you always want them to teach it back. - TRY YOUR HAND AT THE PHYSICAL CARE PLAN WHEN YOU GO THROUGH THIS. \* 17^TH^ SEPTEMBER: DOCUMENTATION - If the care wasn't documented, it was not given. - Charting and documentation are the same action. - But the chart is the health care record. It encompasses everyone who provided care to the patient, i.e., all the disciplines. - Confidentiality is paramount. Mind your business/patient and do what is in your power to protect your patients\' information. - The importance of the chart is communication, but it is also a legal document, auditing, education and research. - TYPES OF RECORDS - Electronic Health Record: This is not to be confused with an EMR. (Electronic Medical Records are used to document one specific complaint.) EHRs are beneficial because they are efficient and allow continuity of and ready access to information. - Medical Administration Record: Time and who gave it. - Source-oriented record: This is the traditional chart. - Problem-oriented record: Only one of the patient\'s problems. All disciplines are documented on the same record. - WAYS OF DOCUMENTATION AND ORGANIZATION - Narrative charting: Long hand charting. It describes everything that happened. A detailed record of the care that you provided. Keep it as objective as possible. - - Progress notes organized: When documenting, be as systematic as possible. You can use this to manage your documents. SOAP (**S**ubjective, **O**bjective, **A**ssessment, **P**lan). SOAP comes after the ADPIE and is more linked to the Nursing process. ADPIE is for care plans, while SOAP is for organizing your documentation. You may add IE (**I**ntervention, **E**valuation) or even R (**R**evision) to make SOAPIE or SOAPIER. PIE is another organizational method you can use. PIE stands for **P**roblem, **I**ntervention and **E**valuation. There is no assessment because the assessment (for example, it has been documented on a separate flow sheet) has been documented somewhere else. - Focus charting: This method is based on the patient's concerns rather than what might typically be identified as the priority. DAR (**D**ata, **A**ction, **R**esponse) is used here. - Charting by exception (CBE): We only document deviations from ordinary. This approach assumes that if something is not documented, it is normal. It includes observations, nursing interventions, and patient response. - Case management (interdisciplinary): These are care maps. They are helpful only if the patient has only one disease; they are not beneficial for comorbidity. They are pre-made to deal with common illnesses. - The nursing process (ADPIE) guides all the acronyms. - FORMS: - Admission database: to organize information upon patient's entrance to give the most holistic care. - Standardized (individualized) care plan - Kardex (temporary record): This is part of the patient's record but not kept on their chart. It contains pertinent information on the patient. - Flowsheets: graphic record. Documents data in a more concise manner. E.g. MAR - Progress notes: specific to nurses - Discharge summary: It is given to the patient. - Incidence/work safety reports: These document unusual occurrences. - Guidelines - Do your documentation as it happens. Be timely. - Use 24-hour clock time. - Don't document in pencil. Write legibly. - Use accepted abbreviations. - Sign all entries: Name, school, and title- T. Idiong, Usask, NS. - Stick to the facts. Be accurate and objective. Don't be vague. 19^TH^ SEPTEMBER: Medical terminology - abd- abdominal - ABD- abduct - Types of medical terminology Latin and Greek word parts: Gastroenteritis, Hyperalgesia, etc Eponyms: named after a person (Isle of Langerhans) Modern English words (Fetal viability) - Elements - Word roots: Foundations of most terms. (Cardi=heart, neuro=nervous system, Anthro=joint, etc) - Suffixes: It always ends a medical term. (-ectomy=to cut out, -itis= inflammation, -pathy=disease, -gram=record/picture, -ac=pertaining to, etc) - Prefixes: It is at the beginning of a medical term. (Dys-=painful, abnormal or difficult, etc.) - Combining words: Usually an 'o' to make the word flow better. 24^TH^ SEPTEMBER - The chain of infection must have all the components linked for an infection to occur. - As nurses, we need to break as many links in the chain of infection as possible, ensure we don't infect the patients again, and protect ourselves from infection. - Some factors that allow microbes to infect: - Number - Virulence (strong enough to overcome the host) - Entry and survival in the host - Susceptibility of host - Nosocomial/healthcare-associated infections (HAI) are infections you are exposed to in the hospital setting. You wouldn't usually be exposed to the outside world. They tend to be very aggressive infections. - A reservoir is a place where pathogens are stored. To survive, reservoirs must have food, sometimes oxygen, water, temperature, pH, and darkness. - The portal of exit is the path to leave the reservoir. This portal of exit includes body openings and breaks in the skin of the mucous membrane. They require fluid to leave. - Modes of infection transmission. - Contact (direct, indirect and droplet) - Air - Vehicles (things like food, water, etc) - Vectors - How to reduce the transmission of infection - Proper hand hygiene: There are key moments to wash your hands. These moments are before touching a patient, before a clean/aseptic procedure, after contact with body fluid, after touching a patient and after touching a patient's surroundings. - Do not share equipment. - Soiled items should not touch your clothing. - Personal Protective Equipment (PPE): Doffing (dirtiest to cleanest) and Donning (opposite). - The portals of entry and exit are the same. If any devices are used on a patient, more portals are available. - Host: This is the body\'s degree of resistance to a pathogen. - Body Defences - Normal flora - Immune system - Body defence mechanisms (skin, tears, cilia, stomach acid, etc.) - S + S (signs and symptoms) - Inflammatory response (Vascular and cellular response; inflammatory exudate {serous \[transparent\], continuous \[bloody\], purulent \[pus\], etc.} and tissue repair.) - Medical asepsis = clean technique - One of the ways we follow clean techniques is through routine practices. - These routine practices include handwashing, gloves, masks, eye protection, gowns that can be soiled, careful use of clean equipment, containing used linen, discarding sharp instruments correctly, and considering isolation in the right situation. 26^TH^ SEPTEMBER - Developmental considerations for safety - Infants/toddlers/preschoolers: Educating parents about keeping their young ones safe from falls, extra stuff in cribs, best temperature, etc. - School-aged children have a higher potential for injuries and worry about bullying. Protective equipment like helmets, elbow pads, kneepads, etc., is required. - Adolescents: A sense of identity, peers, and controlling risk-taking is essential. Possible ideas of suicide. Trying to figure out who they are. - Young Adults: Lifestyle habits and stress can jeopardize their safety. - Middle-aged adults: Responsibilities and possible accidents are endangerments. - Older adults: There are continued safety concerns from middle age, but they also deal with deteriorating physiological changes and chronic conditions. - Risks in healthcare environments - Chemicals- disinfectants, meds, etc. - Microorganisms- nosocomial infections (HAI) - Equipment- check regularly - Perceptions of safety- not realizing that hospitals are not completely safe and should be tightly controlled. - Risk for medical/procedural errors -- write up an incident report. - Possibilities of falls (caused by medications, delirium, limited mobility, etc.) - Restraints are a last resort and discouraged. - Side rails on the bed pose a risk of both entrapment and injury from falls. (BETTER READ UP ON BED-MAKING). 1^ST^ OCTOBER: GENERAL SURVEY, MEASUREMENT AND VITAL SIGNS. - Stuff on the midterm: units 1 to 5 from lectures, guest lectures, lab content or required readings. The midterm is on 17^th^ October. - Forty multiple-choice questions, using an op-scan sheet, only bring pencils, an eraser, student ID and a beverage container. Bags will be to the left at the front of the room. - 50-minute exam, lectures continue following the midterm exam (in preparation for next week's lab). You must come at your registered section time. - The general survey is the appraisal of the whole person, considering four areas- - Physical appearance: Age (compare stated age with how they appear), sex, level of consciousness (LOC, e.g. patient is alert), skin colour (consistency of skin colour throughout the body), facial features (response to the current situation, is their smile drooping to one side), etc. - Body structure: Stature (is it what we would expect considering age and sex), nutritional status; symmetry of body (are both sides the same or is maybe the right shoulder different from the other?), posture (slouching?), position (should be relaxed free and easy), body build. - Mobility: gait (is it easy, balanced, unbalanced), range of motion (is the ROM what we expect?), etc. - Behaviour: facial expression, mood (the overarching term for how the patients feel and look in general), affect (current expression on the face, flat affect (expressionless)), speech (it should be clear, articulate and easy to understand), dress (appropriate for the season), personal hygiene. - Objective measurements are weight and height. - Weight in kg and height in cm/m. Weight fluctuates throughout the day because of fluid retention. - BMI calculation: weight/height. Individuals who are overweight or obese are at risk for specific comorbidities. - Waist -- Hip ratio: This can be used to determine whether the patient is at risk for some conditions.  - SpO~2~ is oxygen saturation. - However, specific data can be acceptable regarding the range of data such as COPD, such as 90% for COPD patients. - Temperature: - The body likes a particular range and works hard to get it to that range. Temp may be influenced by diurnal/circadian cycle, menstruation/menopause, exercise (warmer), age (getting colder as we grow), environment, + stress. Infants have terrible body temperature regulation. - Routes to take temperatures: Oral (insert temperature probe in the mouth underneath the tongue, hold the probe in place, wait 2 minutes to take temperatures after smoking, 5 minutes after chewing and 20 minutes after any warm or cold thing to take temperatures), rectal (must wear gloves, closet to body temperature), axilla (underarm, most prone to inaccuracy, must be done on bare skin), tympanic (gently insert thermometer into ear) and temporal artery. - Compared to oral temperature, rectal temp is 0.50 Celsius higher, and axilla temp is 0.50 Celsius lower. You must use the disposable cover before taking the temperature. - Types of thermometers: electronic, disposable, etc - Pyrexia (or febrile) means fever or feverish. - Hyperthermia (increased T) - Hypothermia (decreased T) - Pulse: - Metric of the palpable feeling of blood flow (or stroke volume). - It can be influenced by age, exercise, temperature, emotion, pain (people with chronic conditions can have a lower heart rate in response to the pain), medications, body position, and hypovolemia (lower blood volume like haemorrhage). - 120 TO 160 beats per minute for infants. - Wait 5 to 10 minutes after any activity before checking their resting heart rate. - Critical points for a radial pulse: Pads of first three fingers, regular rhythm count 30 sec (x 2). If it\'s irregular, do it for a full minute instead. - Assessing the pulse, you need to look at the rate (the beats per minute), rhythm (is it regular or irregular?), force/strength (full/bounding (3 points), standard (2 points), weak/thready (1 point), absent (0); be sure to see /use 3-point scale in JARVIS, p.165), and equality (pulses on both sides on the body and that the same time). - Tachycardia (\> 100 beats/min) - Bradycardia (\< 60 beats/min) - Respirations - Can be influenced by age, exercise, temp, etc - Key points to measure respirations: do not tell the patients; observe the chest rise and fall; one inspiration and expiration is one respiration. - The ratio of pulse rate to respiration rate is about 4 to 1. - To assess respiration, you must look at respiratory rate (respiration per minute), pattern/rhythm (usually regular, laboured or not, what is the effort of breathing?), and depth (standard or shallow?). - Oxygen saturation (SpO~2~) is technically lumped in with respiration. - It is the percent of oxygen bound with hemoglobin in our arterial system. - It is measured by the digit probes or earlobe ones. They can also be disposable. The digit must be warm when putting probes on. - Blood pressure - It tells how our heart is functioning. - Systolic pressure is the ventricular contraction (when the heart/ cardiovascular system is under pressure) - Diastolic pressure is when the heart is at rest. - Pulse pressure increases as we grow. SP-DP - Mean arterial pressure= DP + 1/3 (PP). (LOOK A LITTLE MORE INTO THIS) - Our body is in diastole more than we are in systole. - Physiological factors: Cardiac output (directly proportional with bp, increasing and staying increased is terrible), Peripheral vascular resistance (vasoconstriction and vasodilation), the volume of circulating blood changes, Viscosity of blood (thick blood is difficult to pump) and elasticity of vessel walls. - Influenced by age, ethnocultural background, weight, emotions, gender, daily rhythm, etc. - Critical points to assessing blood pressure (for manual, you need a stethoscope and the manual BP machine): - The patient needs to be at rest for five minutes (if ingested caffeine or nicotine, wait for 60 minutes, wait 30 minutes after exercise). Caffeine and nicotine have vasoconstrictive properties. - If sitting, they need to be supported comfortably while their feet should be flat on the floor. They should also be lying supine. - Have the arm at the level of the heart with the palm upward. In semi-fowlers, this position naturally happens. It has to be on bare skin. - Select the appropriate size cuff for the patients. It should cover eighty percent of the arm\'s length and forty percent of the circumference. Place the cuff on the bare arm 2.5cm above the brachial artery. It should be snug but not constrict the arm - Two-step method: Palpate the radial (or brachial) artery, inflate the cuff until the pulse disappears, and look at the dial to know when the pulse goes away (this systole). Deflate the cuff, wait a minute, then inflate 30mmHg higher than the systole. Place a bell or diaphragm of the stethoscope on the brachial artery. Deflate the cuff slowly, 2mmHg per beat. Notice when the sound starts and stops - One-step method: You continue inflating the cuff after systole. Go 30mmHg higher, then continue with the stethoscope. - At the first phase of the Korotkoff sound, you hear a thud: the first mmHg you hear it at is your systolic pressure. - CHECK JARVIS AND ASTLE ET AL. FOR GUIDELINES FOR DIAGNOSING HYPERTENSION. - Hypotension is diagnosed through the mean arterial pressure. 8^TH^ OCTOBER - Germinativum is spinosum + basale. - Subjective data: previous hx of skin disease, change in moles, changes in pigmentation, excessive dryness or moisture, pruritus (itching), excessive bruising, etc. - The skin is the body\'s largest organ. - Two layers: outer layer epidermis and inner layer dermis; beneath this layer, there is the subcutaneous layer - Epidermis: - Thin but tough. - Inner basal cell layer: forms new skin cells. - The primary ingredient is the tough fibrous protein called keratin. - Melanocytes produce the pigment melanin, which gives skin and hair their tones; all people have the same number of melanocytes, but the amount of melanin they produce varies with genetic, hormonal and environmental influences. - From the basal layer, new cells migrate up and flatten into the outer horny cell layer, which consists of dead keratinized cells. - Epidermis is completely replaced every four weeks. - Palms and soles skin is thicker because of work and weight-bearing. - Epidermis is avascular but nourished by blood vessels in the dermis below. - Dermis: - The inner supportive layer is mostly CT or collagen; this tough fibrous protein enables the skin to resist tearing. - It has elastic tissue that allows skin to stretch with body movements. - Nerves, sensory receptors, blood and lymphatic vessels are in the dermis. - Appendages from the epidermis, such as hair follicles, sebaceous glands and sweat glands, are also in the dermis. - Subcutaneous layer: - Adipose tissue is made up of fat cells - It stores fat for energy, provides insulation for temperature control and aids in protection by its soft, cushioning effect - Hair: - The hair is a thread of keratin, the shaft is the visible part, and the root is below the surface. - At the root: bulb matrix is the expanded area where new cells are produced quickly. - Hair growth is cyclical, with active and resting phases; each follicle functions independently, so while some are resting, others are growing. - Arrector pili contract and elevate hair that resembles goose bumps during exposure to cold or in emotional states. - Two types of hair: - Vellus: everywhere except palms, soles and genitals. - Terminal: darker, thicker hair that grows on the scalp, eyebrows, and, after puberty, on the axillae, pubic areas, face, and chest. - Sebaceous glands produce sebum, secreted through hair follicles, and lubricate skin and hair everywhere except on palms and soles. They are most abundant in the scalp, forehead, face, and chin. - Sweat glands: - Eccrine glands open directly onto the skin surface, producing a dilute saline solution called sweat. The evaporation of sweat reduces body temperature and is widely distributed throughout the body. - Apocrine: thick milky secretion into hair follicles, located mainly in axillae, genital areas, and nipples, become active during puberty. - Nails: They are hard keratin plates on the dorsal edges of the fingers and toes. The nail plate is a clear pink colour from the underlying nail bed of vascular epithelial cells. Lunula at the proximal end of the nail, where new keratinized cells are formed. - Health history questions to ask (Subjective): - Previous history of skin disease (allergies, hives, psoriasis, eczema) - Change in pigmentation: Any change in skin colour or pigmentation? - Change in mole colour, size, shape - Excessive dryness or moisture, any change in the feel of your skin? - Pruritus, any skin itching? Is this mild or intense - Excessive bruising, any excessive bruising? - Rash or lesion, any rash or legions? - Medications: what medications do you take - Hair loss, any recent hair loss - Change in nails, any change in nail shape, colour, brittleness - Environmental or occupational hazards - Self-care behaviours - History for infants and children: - Birthmarks - Change in skin colour: Have any skin colour changes as a newborn? - Rashes or sores: have you noted any rash or sores - Diaper rash - Burns or bruises: does a child have any burns or bruises? - Exposure: has the child been exposed to contagious skin conditions, infectious diseases or toxic plants? - Erythema: An intense redness of skin from excess blood (hyperemia), expected with fever or emotional reactions such as blushing. - Cyanosis: Bluish, usually a lack of oxygen. - Jaundice: Yellow discoloration, indicating rising amounts of bilirubin in the blood. - Temperature: - Use the dorsal of hands to palpate and check bilaterally; the skin feels warm, and the temperature feels equal bilaterally. - Hypothermia: generalized coolness may be induced, such as for surgery or high fever. - Hyperthermia: occurs with an increase in metabolic rate, such as fever or after exercise. - Perspiration usually appears on the face, axilla and skinfolds in response to activity, warm environment, and diaphoresis, which accompanies an increase in metabolic rate. Look for dehydration in the oral mucous membranes. - Edema - Edema is fluid that accumulates in the intercellular spaces; it is not present usually to check for edema, imprint thumbs against the ankle malleolus or tibia; if pressure leaves a dent in the skin, edema is present. - Mobility and turgor: Pinch up a fold of the skin of the chest under the clavicle; mobility is the skin's ease of rising, and turgor is the ability to return to place promptly when released, reflecting the skin's elasticity. - Lesions - Palpate lesions: wear gloves if you anticipate contact with mucous, body fluids, or skin lesions. - Gently scrape to see if it comes off. - Note surrounding skin temperature. - Does the legion blanch with pressure or stretch? Stretching the skin between the thumb and index finger decreases the normal underlying red tones. - Use a magnifier and light for closer inspection of the lesion. - Inspect and palpate hair - Colour: Hair colour results from melanin production and may vary; greying begins as early as 3rd decade of life because of reduced melanin production - Texture: scalp hair may be acceptable, thick, straight, curly, etc. - Distribution: fine vellus fair coats the body while terminal hairs grow at the eyebrows, lashes and scalp. - Lesions: separate hair into sections and lift it, observing the scalp, behind the ears, as well. - Inspect and palpate the nails - Shape and contour: The nail surface is typically slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded. - Profile sign: view the index finger and not the angle of the base. It should be about 160 degrees; the nail base is firm on palpation. - Colour: translucent nail plate is a winder to even. - Capillary refill: press the nail edge to cause blanching and then release, noting the return of colour, should return instants; a sluggish colour return takes longer than 1 to 2 seconds. - Teaching self-examination: teach all adults to examine their skin once a month using the ABCDE rule to detect warning signals of any suspect lesions. 10^TH^ OCTOBER: - Types of baths: - Complete or total: The patient is dependent on care. - Assisted (self-help): The patient can bathe with some assistance. - Partial: areas prone to odour are washed. - Equipment: - Tub - Shower - Bag bath: disposable bath. - Steps to doing a bed bath. - Gather equipment together. - Explain what you're doing to the patient. - Move from clean to dirty: from face/neck to arms (axilla) to hands to chest (under breasts) to abdomen to legs to feet to back to peri-care (genital and anal cleaning). - Start with the eye. Use the corners of the cloth so that you do not contaminate the other. - Wash the arm further away first. Use strokes that go distal to proximal because they help bring blood to the heart (the veins) - When you're done with underarms, discard the cloth. - Soak hands in water. - Only expose as necessary. - Be sure to lean under pendulous breasts. You might apply a bit of powder. - Wash and dry the abdomen. - Wash the leg furthest away. - Dry as your wash because they could catch a chill. - Change the water after the dirtiest cleans. Change if it gets cold, too. - Assist the patient in rolling over. Wash off the back and buttocks. Wash and dry. Apply lotion and give the patient a massage (maybe). - If a patient is incontinent, do peri-care first. - For peri care, wash front to back. So that you don't introduce fecal matter. Do not use powder. Assess the area for rashes, especially if the person is incontinent. When cleaning men, return the foreskin to the original position so they don't develop an infection. - Ensure privacy during a bed bath (DUH!). - Use an IV gown if they have one. - Dress the affected side and undress it last. - The bath is your opportunity to assess a patient in their entirety. - Oral hygiene 15^TH^ OCTOBER - The immune system is dependent on the musculoskeletal system. - Major muscles: masseter, sternocleidomastoid, trapezoid, deltoid, pectoralis major, rectus abdominus, biceps brachii, triceps brachii, gluteus maximus, biceps femoris, latissimus dorsi, gastrocnemius, and quadriceps femoris (Vastus intermedius/lateralis\*/medialis, rectus femoris). - Major joints: synovial (ball and socket, hinge, etc), temporomandibular, spine, shoulder, elbow, wrist, hip and knees. - We expect to see the C- shape for the spine shape of infants. - Rotator cuffs are the tendons. - Subjective assessment (Probing questions): - Joints (pain, stiffness, edema?, movement) - Muscles (cramps + weakness) - Bones (pain, any fractures, deformities) - ADLs (functional assessment, whether you are independent enough) - Self-care behaviours (Does work involve heavy lifting? Amount of exercise? Medications?) - Objective Assessment (Inspection, palpation, ROM, muscle strength): - Be orderly (head to toe, proximal to distal, compare one side of the body to the other) - Inspection (Color, size, contour, edema, deformity - Palpation (any tenderness?) - Range of Motion (ROM): - Active vs passive (Can the patients do it themselves?). There are expected ROMs for each joint. - Crepitation (always abnormal) - Muscle testing 22^ND^ OCTOBER - Special diets: - A typical balanced diet for a pt consists of a variety of foods, 2000 calories per day, and regular. - NPO: Nil per ora, nothing by mouth. - DAT: Diet as tolerated; start with clear fluids to full fluids and - Clear fluid (don't want to stimulate the gut). You can see through the fluid. - Full fluids include juices, refined cereal, pureed vegetables, and thickened fluids such as nectar, honey, and pudding. - Soft/low residue diets: no need for teeth, etc. - Other diets are low sodium, low cholesterol, diabetic, allergic, gluten/lactose intolerance, etc. - Things to remember while assisting with nutrition - Stimulate their appetite, e.g. could possibly be a shot of sherry - Have equipment available, e.g., a shirt saver, special utensils, correct tray of food, etc. - Always sitting straight up. - Little bites of food and be sure to provide enough time for the patient to chew food. - Take precautions to prevent aspiration: observe for dysphagia (trouble with swallowing), offer small bites, observe for fatigue; the patient should remain upright for thirty minutes after eating, etc. - Assist with oral care. - Don't forget to document. 24^TH^ OCTOBER - Thyroid gland release T3, T4, and calcitonin. These help with metabolism. - Lymph nodes: There ten key lymph nodes (List in a way that is systematic). Most of the lymph nodes occur in pairs, except the submental. When palpating them you should really feel anything, except maybe the superficial cervical- - Preauricular - Posterior auricular - Occipital - Submental - Submandibular - Jugulodigastric (tonsillar) - Superficial cervical - Deep cervical {a chain of lymph nodes} - Posterior cervical - Supraclavicular - You can trace the pain through the lymphatic drainage to the infected lymph node. 29^TH^ OCTOBER - Male and female urinary systems are similar except for the position of the bladder. - In males, the unitary system works together with the genital system. - When assessing the genitourinary system, we look at the at: Condition of skin Passing urine Abnormalities - MALE GU - Externals: - Penis (contains glans, corona, urethra, foreskin (pretus), etc.) - Scrotum (rugae) - Internals: - Testes - Epididymis - Vas deferens - Spermatic cord - Cremaster muscle - Inguinal area or groin: (prone to developing hernias in this area) - Inguinal canal - spermatic cord - Femoral canal - femoral artery/vein - Subjective Data collection for the Male GU: - Frequency, urgency, and nocturia? - The pattern of voiding (Dysuria, polyuria, oliguria) - Hesitancy and straining (maybe while you start to micturate) - Urine colour (is urine cloudy? Bloody (hematuria)) - GU history - Pain, lesion and/or discharge of penis? - Sexual activity and contraceptive use - Objective Data collection - Position (male could be standing or laying supine): For the inguinal canal, the patient must be standing. - Gloves must be worn. - Inspection and palpation of the penis - Skin + pubic hair - Glans must be smooth and have no discharge except ejaculate. - Inspection and palpation of the scrotum - Skin - Testes (two separate, but the left side hangs lower; there should be no masses, and the scrotum must not transilluminate.) - Epididymis and such - Check for hernia - Inguinal lymph nodes - Female GU - External is collectively called the vulva: mons pubis, labia majora/minora, clitoris, frenulum, vestibule, urethral meatus, and Skene's/Bartholin's glands. - Internal: - Vagina - Cervix - Uterus - Fallopian tubes - Ovaries - Vagina has rugae to assist with childbirth. - Structure of the rectum + anus - Rectum: Valves of Houston - Anal canal: columns and Sphincters. - Prostate glands 31^ST^ OCTOBER - Promote healthy bowel habits--- with diet (fibre), fluids, exercise, positioning and timing (specific times a patient has a bowel movement). - Problems with bowel elimination: constipation, impaction (obstructions could cause intestinal ruptures), diarrhea, incontinence, flatus (oral and rectal), etc. - If patients can pass gas, they are not yet at the point of impaction. - Positioning can cause constipation. You can use a commode chair. - For bedpans, the bed must be completely flat. - Ways to support bowel care. - Medication: - Oral (antidiarrheals, cathartics/laxatives, etc.) - Rectal (Suppositories, enema, etc): you must use the Clean technique. - Enema adds bulk to the rectum to stimulate bowel movements. Hypertonic enema does not take much to work (it can dehydrate, so don't give much). Isotonic does not draw or release fluid; it just puts pressure on the rectum. Needs a lot. Hypotonic is tap water (a concern when you don't want the patient to have circulatory overload). It also needs a lot. - REMEMBER: Water wants to go where salt is. - The suppository and an enema require a doctor's order. - Digital removal of stool is possible. - A stool can be collected for occult blood, culture and sensitivity, steatorrhea (fatty stool), ova and parasites. - You cannot collect a specimen from a toilet because the water contaminates it. - We collect urine for culture and sensitivity (could be sterile; it should be midstream), analysis and could be a timed urine specimen (to maybe check for the function of the kidneys). 5^TH^ NOVEMBER - Complete Mental status exam: **A**ppearance, **B**ehaviour, **C**ognition and **T**hought processes. - Illnesses, medications, and educational/behavioural levels can slightly alter some mental status problems. - Developmental Considerations - Children/Adolescents: Emotional and cognition development functioning/ Suicide may become prevalent. - Young Adults: Mental health can be r/t academic or financial stressors. - Middle aged adults: Family/work stressors - Older adults: No necessarily age-related changes, check for sensory issues like turning up hearing aids, putting on glasses, etc. - Objective Data: - Level of consciousness - Facial expressions (Does it match the context?) - Speech (Quality is good? Does it make sense?) - Mood and affect (Affect is to mood as day is to season. Days in winter can vary in temperature but it is still winter) We want the mood and affect to match. - Appearance and Behaviour are observation. - When assessing Cognitive functions, look at: - Orientation - Gnosia - Attention Span - Immediate Memory - Recent Memory - Remote Memory