Exam 1 Blueprint Foundation PDF

hi 🌈🦠🥽😷Exam 1 blueprint🩺🧤🤓🌈 Covers modules 1-3 60 questions, combination of multiple choice, multiple answer, true/false, dosage and calculation %15 of final course grade Review module outcomes, reading assignments and activities, module summaries. NCLEX style questions: comprehens...

hi 🌈🦠🥽😷Exam 1 blueprint🩺🧤🤓🌈 Covers modules 1-3 60 questions, combination of multiple choice, multiple answer, true/false, dosage and calculation %15 of final course grade Review module outcomes, reading assignments and activities, module summaries. NCLEX style questions: comprehension, application, analysis *Please note this review guide is not all-inclusive and you are responsible for all content covered in modules 1-3 Module 1 Critical Thinking Module Outcomes 1.​ Examine the relationship between clinical judgment, clinical reasoning, and the nursing process. ★​ Clinical Judgment are influenced by a nurse’s experience and knowledge and a reliance on knowing the patient and his or her typical pattern of responses, as well as engaging with the patient and his or her concerns ★​ Clinical Reasoning= ○​ Ask question to understand things occur ○​ As much relevant info as possible to understand the situation clearly ★​ Nursing Process= ADPIE ➔​ The Nurses’ responsibility in making clinical decisions ★​ Using your experience ➔​ Reflection and how it can improve a nurse’s ability to problem solve (i.e., how do we reflect on our actions) ★​ Reflection, a part of critical thinking that involves purposefully reviewing a situation to discover its purpose or meaning. ★​ The reflection allows you to gain new knowledge and raise questions about your practice, which can lead to a search for better ➔​ Subjective vs objective data and be able to identify examples of each  ★​ Subjective data are your patients’ verbal descriptions of their health problems. Subjective data include patient feelings, perceptions, and self-reported symptoms.(PAIN) ○​ For example, Mr. Lawson’s self-report of pain at the area where his incision slightly separated is an example of subjective data ★​ Objective data are the findings resulting from direct observation or measurement, including what you see, hear, and touch ○​ Inspecting the condition of a wound, observing a patient walk down the floor, measuring blood pressure, and describing specifically an observed behavior (patient seizure) are examples of objective data ➔​ Critical thinking and how it is used in the scientific method 2.​ Develop a plan of care using the nursing process ★​ Steps of the nursing process ➔​ NANDA approved nursing diagnoses ★​ A nursing diagnosis is 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 NANDA International North American Nursing Diagnosis Association, organized in  1973. It formally identifies, develops, and classifies nursing diagnoses. NANDA-I categorizes nursing diagnoses into three types: problem-focused, risk diagnosis, and health promotion (NANDA-I, 2018b). ★​ Impaired body image takes off boob, pt complains of boob being gone ○​ Patient has impaired body image ★​ LACK OF KNOWLEDGE CONCEPT MAP (new diabetes) ➔​ Critical thinking and the nursing process (i.e., when to implement nursing interventions) ★​ Choosing suitable nursing interventions involves critical thinking and applying the best evidence for a patient’s health problems. ➔​ Standing orders vs. protocols A preprinted documentation containing medical orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific  patients which identified clinical problems. It directs patient care in a specific clinical setting. (These orders reflect health care provider treatment preferences) ➔​ Task delegation to a UAP for all topics covered (i.e., can vital signs be delegated to a new post op patient to your unit? - answer is no) Delegation: Allows you to use your time more wisely and to have other care providers assist. When you delegate a task to an AP, you are responsible for ensuring that you assign each task appropriately and that the AP completes each task according to the standard of care. This requires ongoing supervision to be sure the AP has performed the task on time without difficulty. You must be sure that any delegated action was completed correctly, documented, and evaluated UAP LPN NURSE Module 2 Foundations of Nursing Care Module Outcomes 1.​ Identify factors which negatively impact patient safety. Safe patient care (i.e., falls, safe home environment, fires, seizure precautions, etc.) a.​ Maslow’s hierarchy of basic needs that influence a person's safety are : i.​ Oxygen- O2 is flammable ii.​ Nutrition- if someone doesnt store or clean right- risk for infection iii.​ Temperature- if it's too cold may cause frostbite or hypothermia, too hot may cause hyperthermia A-Airway​ B-Breathing​ C-circulation​ b.​ Fall precaution - i.​ Construction worker vibes (working @ heights) ii.​ Druggies and alcoholics iii.​ Socioeconomic factors (poverty)  iv.​ Underlying medical conditions v.​ On lots of meds vi.​ Immobile and imbalanced vii.​ Poor mobility (old ppls) viii.​ Unsafe environments ( throw rugs) ix.​ Bad feet/bad shoes (chancla, high heels) -call light in reach Physical hazards that threaten a person’s safety : or -​ Motor vehicle accidents, Falls, Poison, Disasters, Fire Which one of these is safe for kids? ALL AGES UNDER 12 SHOULD SIT IN THE BACK SEAT!!!!!! - born -> tween Birth-2- look at wall (sent to corner) 2-5- terrible 2 (mom wants to see you) 5- until seat belt fits- school time (57 inches tall) ​ -8 year old that 4 feet tall needs booster seat bc they small asf Fire ( use the RACE acronym) BOX 27.14 ○​ P.A.S.S. (PASSing extinguisher after Pulling-pin, Aiming-at-base, sweeping Side-to-Side) NURSING CONSIDERATIONS  ★​ Fire Exits (Fire Exit used) ★​ Do Not Use Elevators (Elevator Not Used) ★​ Manual Ventilation (Manually Ventilating) -​ R- Rescue/ remove all patients in immediate danger (rescuing pt from fire) -​ A- Activate alarm before attempting to extinguish (alarm) -​ C- Contain fire by closing doors/ windows & turn off oxygen equipment (confine the fire - slam the door) -​ E- extinguish fire with appropriate extinguisher (extinguisher) Seizure Precautions - must protect a patient from traumatic injury, to position adequate ventilation drainage of oral secretions, and then provide support and privacy after seizure. Look for adults and older adults! need order for restraints Pressure Injury  ➔​ Proper body mechanics for safety and know active vs. passive ROM ( Chapter 38) -​ Proper body mechanics: (jayla working) -​ Widen your base of support by separating the feet to a comfortable distance. -​ Bring the center of gravity closer to your base of support to increase balance. -​ Bend your knees and flex the hips until squatting, and maintain proper back alignment to keep the trunk erect. -​ Active (AROM) exercises : patient moves specific joints independently based on their muscular weakness and the type of activity that needs strengthening. -​ Passive (ROM) exercises: are indicated when a patient is able or permitted to move Patient intubated what time of movement would you to -​ a body part, as in the case of a paralyzed extremity or healing fracture. Chapter 40: Hygiene :) -Wipe front to back -wash your hands to prevent infection -USE TEACH BACK METHOD! -USE PRINCIPLES OF BODY MECHANICS AND SAFE PATIENT HANDLING 2.​ Apply nursing knowledge to meet the hygienic care of patients. Quality Hygiene care requires a complete awareness of the patients’s hygiene preferences and needs NURSING ASSESSMENT QUESTION: -Cultural and/or Religious Practices (do you feel comfy with this stuff?) -Tolerance of Hygiene Activities (do u have pain when cleaning yourself) -Assistance with Hygiene (do you need chair when bathing?, do u want male or female helper?) -Skin Care (do you bathe often, seen skin changes or nah) -Mouth Care (do you have tooth pain, or dentures) -Foot and Nail Care (do you take care of ur feet?) -Hair and Scalp Care (do you have dandruff?) ➔​ Hygiene needs and factors that influence personal practices (i.e., skin, hair, oral cavity, feet, etc.) - Normal versus abnormal assessment findings -​ FACTORS that influence hygiene: -​ Social practices - social groups (culture) -​ Personal preference (mom and dad teach u) -​ Body image - emotional/mental status may reflect hygiene (depression) -​ Socioeconomic status - poverty (can't afford) -​ Health beliefs and motivation (small minded?) -​ Culture (using deodorant or not) -​ Developmental stage - aging affects (old or young) -​ Skin - development/bathing (young and old- thin skin) -​ Feet and nails - older adults/mobility -​ Mouth - development (british mout) -​ Hair - distribution (lice) (Bald) -​ Eyes, ears, nose - sensory alterations (u deaf?) (can u see me?) -​ Physical condition - physical limitations/disabilities (needs extra help) Knowing regular old aging stuff STERILE- NO PATHOGEN (NOTHING) (FOLEY) (SURGERY) ASEPTIC- clean 3.​ Describe the mechanisms for the spread of infection. ➔​ Infectious agent (gold digger) ➔​ A reservoir or source or source for pathogen growth (GD already got a rich man but she wants more) ➔​ Port of exit for the reservoir (GD leaves her man to find a better one) ➔​ A mode of transmission (GD gets in her lil Nissan) ➔​ A port of entry to a host (GD goes to River Oaks to find a new man) ➔​ A susceptible host (GD finds a better, richer man) ➔​ Modes of transmission -​ Contact -​ Direct (person 2 person) MRSA , C.Diff , Influenza -​ Indirect (lice) Droplet -​ Pertussis and Meningitis , COVID , Pneumonia Airborne (cough, cough) NEGATIVE PRESSURE ROOM -​ (Nontuberculous mycobacteria or Aspergillus , chickenpox) Vehicles (needles) -​ Sharp objects can lead to -> HIV, HBV, HCV  -​ Vector (mosquito) TB COVID​ FLU -(MASK) HIV- (MASK) (MRSA in the NARSE) CONTACT BUT IT NOW DROPLET (MASK) ➔​ Course of Infection by Stage 1.​ Incubation Period a.​ Basically the interval entrance of the pathogen in da body to when you first see a symptom b.​ You win the lottery *woot woot* 2.​ Prodromal Stage a.​ Interval from onset of nonspecific sign and symptoms (fatigue) to a specific symptoms b.​ Half of the money is for taxes *tears* 3.​ Illness Stage a.​ Interval when patient manifests signs and symptoms specific to a type of infection (strep throat) b.​ You finally have the money *play “Money in the Bank by Lil’ Scrappy ft. Young Buck* 4.​ Convalescence a.​ Interval when acute symptoms of infection disappear b.​ Buy ya momma a house with that moolah WHAT CAN BE A R FOR PATHOGEN  ➔​ Methods to reduce transmission of pathogens and break the chain of infection -​ Proper PPE (gown, gloves, face shield, mask, gloves, booties) -​ Proper hand hygiene -​ Personal Hygiene (nurse and pt) (including bathing, dressing changes) -​ Immunization -​ Cough etiquette -​ Clean stethoscope between pts -​ Never put soiled linens on the floor ORDER ON 1.​ GOWN 2.​ MASK (face shield??) 3.​ GLOVES ORDER OFF 1.​ GLOVES 2.​ MASK 3.​ GOWN ➔​ Identify patients most at risk for infection -​ Older adults - less capable of producing lymphocytes -​ Infant -​ Under intense stress -​ Immunosuppressed (Diabetes, Leukemia, AIDS, Lymphoma, Anemia, HIV) -​ Poor nutrition status -​ SEX related differences ( estrogen in women vs men) ➔​ Events of the inflammatory response  -​ The cellular response of the body to injury, infection, or irritation is inflammation. It is a protective vascular reaction that neutralizes and eliminates pathogens or dead (necrotic) tissue to establish a means of repairing body cells or tissues. Chapter 29: Vital Signs :) Temperature Range Pulse Avg temp range: 36° - 38°C / 98.6° to 100.4°F 60 - 100 beats/min Avg oral/tympanic: 37°C / 98.6°F Strong and regular Avg rectal: 37.5°C / 99.5°F Axillary: 36.5°C / 97.7°F Respirations Pulse Oximetry (SpO2) 12 - 20 breaths/min Normal: SpO2 ≥ 95% Deep and regular Blood Pressure Capnography (EtCO2) Systolic: < 120 mmHg Normal: 35 - 45 mmHg Diastolic: < 80 mmHg Pulse pressure: 30 - 50 mmHg Thermoregulation: physiological and behavior mechanisms regulate the balance between heat lost and heat produces Look what you would do if pulse ox in under 95 4.​ Discuss how alterations in sensory function impact care of patients. -​ An older patient comes in and his history says that he doesn't taste well anymore, that he puts a lot of seasoning in his food. -​ Diminished sensory function is regular with age ➔​ Sensory deficits (i.e., visual deficits, hearing deficits, etc.), sensory deprivation, & sensory overload -​ Sensory overload: too much stimulation (jumbled mind, too much going on and you cannot process it) -​ CLOSE THE DOOR -​ PUT ALARM ON LOWEST VOLUME -​ ASK PATIENT IF THEY WANT HEADPHONES -​ Sensory deprivation: not enough stimulation (anti-social behaviors, bored) -​ Sensory deficit: no stimulation (blind, deaf, autism) Depression with delirium if they are sensory deprived and you sudden come up to them- they may have stronger (exacerbated) delirium ➔​ Common causes and effects of sensory alterations, how to assess for sensory function, and common nursing diagnoses -​ Common Sensory Deficits - presbyopia, Cataract, Computer vision syndrome/digital eye strain, dry eyes, glaucoma, diabetic retinopathy, macular degeneration, presbycusis, dizziness, Xerostomia, Peripheral neuropathy, stroke -​ Assessment -​ Physical Assessment (neuro) -​ MMSE - assessing emotional and mental status -​ Ability to perform self-care -​ Environmental Hazards -​ Health Promotion Habits -​ Communication Methods -​ Use of Assistive Devices -​ Social Support 5.​ Describe the importance of sleep in relation to health. -​ Sleep is a time of restoration, memory consolidation. Achieving the best sleep is important for the promotion of good health and recovery from illness. -​ Usually ppl who are sick, need more sleep than healthy ppl, but the sickness sometimes causes the sick pts not to be able to sleep. Examples of people with physical illness that may struggle with sleep are people with: -​ Respiratory Problems -​ Hypertension -​ Hypothyroidism -​ Nocturia -​ Restless Leg Syndrome -​ People with peptic ulcer disease -​ What’s regular to see in adults while sleeping 🛌 -​ HR: 70-80 BPM or less, and other function may decrease -​ During Stage 3 of sleep 💤 the body releases a human growth hormone for the repair and renewal of epithelial and specialized cells like brain cells. Also, protein Synthesis and cell division happen here too :)  -​ ➔​ Sleep stages and the mechanisms that regulate sleep -​ N1: lightest level of sleep, a few minutes, gradual fall in vital signs/metabolism, noise can arouse sleeper, if awakened it feels like daydreaming -​ N2: sound sleep (relaxation increases), still can be awakened easily, brain/muscle activity slow down -​ N3: slow-wave sleep, deepest stage of sleep, difficult to awaken and does not move, brain/muscle activity significantly decreased, vital signs lower than when awakened -​ Rem Sleep: important for early brain development, cognition, and memory. Associated with changes in the brain ( cerebral blood flow and increased cortical activity) that deal with learning and memory storage. ➔​ Normal sleep patterns and requirements for all age groups -​ Neonates - up to 3 months = 16 hours of sleep -​ Infants- 3 months to 1 ½ = several naps during the day , 8-10 hours during the night total 15 hours. -​ Toddlers- By 2 , total sleep 12 hours a day , by age 3 daytime naps are incorporated. -​ Preschoolers- 12 hours a day -​ School aged children- varies during the school years. 6 yo averages 11-12 hours , 11 yo average 9-10 hours -​ Adolescents- average 7 hours, recommended 8-10 -​ Young Adults- 6-8 ½ at night , Approximately 20% of sleep time is REM sleep. -​ Middle Adults- recommended 7-9 per night -​ Older Adults- 40% report sleep issues. Tend to have lighter sleep. ✨The major sleep center in the body is the hypothalamus. It secretes hypocretins (orexins) that promotes wakefulness and rapid eye movements (REM)✨ Age group requires the most amount of sleep! Chapter 38 Activity tolerance -​ The type and amount of exercise a person is able to perform without undue exertion or injury Body mechanics -​ Coordinated efforts of the musculoskeletal and nervous system The best program of physical activity is a combination of what exercises? a.​ Isotonic exercises i.​ Causes muscle contraction and changes in muscle length ii.​ ex) walking, swimming, jogging, bicycling b.​ Isometric exercises i.​ Involves tightening or tensing muscles without moving body parts ii.​ Ideal for patients who do not tolerate increased activity, such as a patient who is immobilized in bed iii.​ ex) quadrieps set exercises and contraction of the gluteal muscles (wall sits) c.​ Resistive exercises i.​ Contracts muscles while pushing against a stationary object or resisting the movement of an object ii.​ ex) push-ups, hip lifting Helping a Patient Walk - postpone walking if you determine the patient cannot walk safely 1.​ Help the patient to a sitting position 2.​ Dangle legs for 1-2 minutes before standing (monitor for orthostatic hypotension) a.​ If the patient develops dizziness lasting 60 sec, return pt to bed 3.​ For patients who can bear weight easily: a.​ Provide support at the waist with a gait belt so that the patient’s center of gravity remains midline (helps you stabilize the pt if they lose their balance) 4.​ If the patient has a fainting (syncope) episode or begins to fall: a.​ Do NOT try to stop a fall  i.​ Use a wide base of support with 1 foot in front of the other (this supports the pt’s body weight) ii.​ While holding the belt, try to extend one leg, let the patient slide against the leg, and gently lower him or her to the floor Module 3 Basic Physiological Concepts Part 1 Module Outcomes 1.​ Identify the physiological and psychosocial effects of immobility on patients. I made a new section -​ Physiological: skeletal abnormalities , muscular impairments, endocrine/metabolic illnesses, hypoxemia, decreased cardiac function, decreased endurance, impaired physical stability, pain, sleep pattern disturbance. ( activity & exercise but can apply here to :) -​ isolation -​ irritability -​ Apathy -​ Depression -​ Sensory alterations -​ Changing in coping -​ The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3%/day -​ Cardiovascular, skeletal, and other organ changes -​ Disuse Atrophy -​ The tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage -​ LORDOSIS-EXAGGERATION OF CURVE BACK “OH LORD” ​ KYPHOSIS- HUNCHBACK ➔​ Pressure ulcer (Physiological) ➔​ Impaired function and use of assistive devices (i.e., canes, walkers, hearing aids, etc.) Walkers: for patients with lower extremity weakness or had problems with balance. ​ Requires people to lift device up and forward ○​ How to use: ​ Hold the hand grips on the upper bar ​ Take a step ​ Move the walker forward ​ Take another step NEVER lean over the walker or walk behind it Should not be used on stairs Cane: ○​ Provide less support than a walker and is less stable ○​ Keep the cane on the stronger side of your body ​ How to use: ​ Place the cane forward 15-25 cm (6-10in) ○​ Body weight on both legs ​ Move the weaker leg forward to the cane ○​ Body weight is divided between the cane and stronger leg ​ Advance the stronger leg past the cane ○​ Bodyweight and weaker leg supported by the cane and stronger leg Crutches: ​ Used to increase mobility; often temporary but some patient need it permanently ○​ Measurements for crutches i.​ Patient height ii.​ The angle of the elbow flexion (15-30*)  iii.​ The distance between the crotch pad and the axilla ​ Length of the crutch 2-3 fingers widths from the axilla (1.5-2 in) ​ Position the tips about 2 inches lateral and 4-6 inches anterior to the front of the patient shoes ○​ Basic Crutch Stance/ Tripod Position i.​ Place crutches 15 cm in front and 15 cm to the side of each foot ii.​ Erect head and neck, straight vertebrae, extended hips and knees iii.​ Axilla should NOT bear any weight ○​ 4 Main Types of Crutch Gait: i.​ Four- Point alternating gait= weight bearing on both legs and each leg is moves alternately with each opposing crutch ii.​ Three- Point alternating gait= put all your weight unto one foot iii.​ Two-Point gait = partial weight barrier on each foot iv.​ Swing through gate ​ A physical therapist in collaboration with the health care provider will determine the appropriate gate ➔​ Using Crutches to ASCEND stairs: ​ Have the patient hold the handrail for support with one hand ○​ Strong leg next to railing ​ You carry the crutch positioned next to the handrail as the patient places the other crutch under the axilla of affected side ​ Have the patient transfer their body weight to the crutch while holding the handrail with one hand ​ Stay behind the patient, holding onto the gait belt ​ Have the patient support their weight evenly between the handrail and crutch ​ The patient places some weight on crutch and then steps up the first step with weight-bearing food (stronger leg) ​ Have patient get their balance learning forward with weight on good leg ​ Ask the patient to straighten the good knee, push down on crutches and lift their body weight, bringing the affected leg and then the crutch up the stair ​ Repeat for each step.  ​ Using Crutches to DESCEND Stairs: high risk of falling! :( 1.​ Have the patient stand close to the edge of the top step 2.​ Have the patient hold the handrail with one hand (weak leg next to railing) 3.​ You carry the crutch positioned next to the handrail as the patient places the other crutch under the axilla of the strong side. 4.​ Stand above the patient while holding the gait belt. 5.​ Have the patient lower the crutch down to the step below 6.​ Then have the patient move their affected leg down 7.​ Patient brings the strong leg down the step and supports their weight evenly between the handrail, good leg, and crutchstanding ○​ Caution the patient NOT to hop! Make sure the crutch tip is completely on the stair. Ascending: lead with the stronger leg Descending: lead with the affected leg Hearing Aids: ​ -​ Make sure you keep them clean, accessible and functional. Make sure a family member is educated on the correct use and care for the device. Older adults are usually reluctant to use hearing aids due to cost, appearance, insufficient knowledge, amplification of competing noise and unrealistic expectations. Older adults may have a harder time putting in their hearing aids because of stiff fingers and enlarged joints, and decreased sensory perception. -​ Common types of hearing aids: -​ Compleyely-in-Canal (CIC) -​ In-the-ear (ITE) -​ Behind-the-ear (BTE) -​ Digital hearing aid -​ Hearing aid care: -​ Initially wear hearing aids for -​ Avoid storing your device in extreme heat or cold or in a damp environment, like a bathroom. Keep the hearing aids away from moisture, like sweat. Don't wear them in the shower or when swimming. ➔​ Effects of impaired mobility by age group  -​ Infants, toddlers, preschoolers: delays a child’s gross motor skills, intellectual development, musculoskeletal development -​ Adolescents: behind in gaining independence, accomplishing certain skills (getting a driver's license), social isolation is a concern (teenage) -​ Adults: all physiological systems are at risk, role of the adult changes in the family/ social structure (ex: dad becomes bedridden, mom has to become the breadwinner) -​ Older Adults: increases physical dependence on others, accelerates functional losses, can be a result from degenerative disease/neurological trauma/chronic illness (grandma and grandpa) ➔​ Nursing interventions -​ collaboration with other qualified staff (if needed), use assistive devices if pt. needs them (walkers, canes), small intervals of daily exercise (don’t overwhelm the pt. or they might faint/pass out), take breaks before proceeding EXERCISE/ POC -​ Key points: patient movement algorithms are assessment tools for developing individualized approaches for safe patient handling, correct positioning techniques (if pt. has impaired body alignment/mobility) 2.​ Apply the nursing process to the care of persons with impaired wound healing. Assessment -asses for skin abnormalities, wounds/pressure injuries, wound appearance, drainage, wound closures, pt mobility, nutritional status, pain, if they’re stable or in need of aid rn, assess how the wound is influencing pts self perception Diagnosis - includes: risk for infection, acute/chronic pain, impaired mobility, impaired peripheral tissue perfusion, impaired skin integrity Planning - plans should promote wound healing and prevent complications of any existing wounds. Some goals (within a 2wk period) could be: Increase in the percentage of granulation tissue in the wound base, no further skin breakdown, Increase in caloric intake by 10% Implementation - Improve nutrition, prevention/management of pressure injuries, topical skin care (baths), incontinence management, positioning (elevate head of bed 30 degrees and reposition q2h), support surfaces (cushions/pillows), wound management, (debridement), consistent dressing changes (cleaning skin and drain sites), heat and cold therapy Evaluation - Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified? Did the plan of care decrease these components? Was wound healing supported by providing the wound with a moist protected environment? Was nutrition assessed and a plan of care developed that provided the pt with the calories to support healing? Types of wounds -​ Partial thickness wounds : are wounds that involve only a partial loss of skin layers ( the epidermis/superficial dermis layers) -​ Full thickness wounds: involve total loss of skin layers (epidermis/dermis) Blanching -​ Occurs when the normal red tones of the light skinned patient are absent Types of Wound Drainage terms:KNOW WHEN YOU SEE THESE -​ Serous ( clear, watery plasma) -​ Serous drainage is a clear, thin, and watery exudate that typically appears during the inflammatory stage of wound healing. -​ Purulent ( thick, yellow, green, tan, or brown)  -​ A wound giving off purulent drainage usually indicates it has acquired an infection -​ Serosanguineous ( pale, pink, mix of clear/red fluid) watermelon ish color (know after surgery time period) -​ usually appears during the inflammatory stage of the wound healing process -​ Sanguineous ( bright red, indicates active bleeding) (know after surgery time period) -​ usually appears during the inflammatory stage of the wound healing process If a wound drainage patient still got out of surgery and that had…. Which one of these description is a normal finding -after surgery will improve color (go upward)  ➔​ Pressure injuries, identify risk factors for development (i.e., shear, friction, moisture, etc.), prevention strategies, and associated nursing diagnoses -​ Deep Tissue pressure injury: Persistent nonblanchable deep red,maroon/ purple -​ Unstageable Pressure Injury: Obscured full thickness skin and tissue loss Risk factors for wound healing : -​ Nutrition -​ tissue perfusion ( ability to perfuse adequate amounts of oxygenated blood) -​ Infection -​ Age Prevention strategies: -​ Risk assessment - assessing pt who are at risk for developing a pressure injury -​ Economic Consequences - affordability/availability Shear  -​ The sliding movement of skin and subcut tissue while the underlying -​ muscle and bone are stationary -​ SKIN STRETCHINGcan cause pressure injury -​ 60 degree sitting you can slide (do less than 60 to avoid) -​ Example: (Patient in hospital bed pilling down) Friction -​ Force of two surfaces moving across one another -​ Example: chaffing Branden Scale ➔​ Pressure ulcer staging system and be able to describe and identify all stages with defining characteristics Stage 1 : Nonblanchable erythema of intact skin Stage 2: Partial-thickness skin loss with exposed dermis Stage 3: Full thickness skin loss Stage 4: Full thickness skin and tissue loss 3.​ Explain factors that impede and promote wound healing. Impeding wound healing: -​ Hemorrhage- indicates a dislodged surgical suture, a clot, infection or erosion of blood vessels by foreign objects. -​ Infection- when microorganisms invade wound tissues -​ Dehiscence is when an incision fails to heal properly, the layers of skin and tissue separate -​ Evisceration is the total separation of wound layers ( protrusion of visceral organs through a wound opening) ➔​ Process of wound healing, the four phases of full-thickness wound repair, and nutrition needs for wound healing. -​ Phase 1- Hemostasis: Injured blood vessels constrict/platelets gather to stop bleeding which forms clots that becomes the framework of cellular repair -​ Phase 2- Inflammatory: Damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and wbc into the damaged tissue. ( edema, warmth,throbbing occurs as a result) -​ Phase 3- Proliferative: Begins and lasts from 3 to 24 days, filling of a wound with granulation tissue, wound contraction and wound resurfacing by epithelialization -​ Phase 4- Maturation: can take more than a year depending on the wound The collagen scar continues to reorganize and gain strength for several months. -​ 4.​ Differentiate common alterations in urinary elimination. -​ Urinary retention: inability to partially or completely empty the bladder (got a some left in the tank) -​ Urinary tract infection (UTI): an infection in any part of the urinary system (kidneys, bladder, urethra) - E. Coli is the Culprit -​ Pyelonephritis: kidneys (upper) -​ Ureteritis: ureters (upper) -​ Cystitis: bladder (lower) -​ Urethritis: urethra (lower) KIDNEY STONES= build u -​ Prostatitis: prostate (lower) -​ Urinary incontinence: involuntary leakage of urine -​ Urinary diversions: stoma (divert urine to the outside of the body through an opening in the abdominal wall), nephrostomy tubes (small tubes that are tunneled through the skin into the renal pelvis) ➔​ Urinary alterations including common symptoms and associated causes (i.e., dysuria, polyuria, hesitancy, etc.) ◆​ Urgency: fast and strong desire to pee ​ Caused by: Full Bladder, UTI, Inflammation or irritation of bladder, overactive bladder ◆​ Dysuria: pain or discomfort with peeing ​ Caused by: UTI, Inflammation of the prostate, urethritis, trauma to lower urinary tract, urinary tract tumors ◆​ Frequency: peeing more than 8 times during day ​ Caused by: high volumes of fluid intake, bladder irritants (like caffeine), UTI, pregnancy, prostate enlargement, overactive bladder ◆​ Hesitancy: delay in peeing ​ Caused by: anxiety (peeing in public restroom), bladder outlet obstruction (prostate enlargement, urethral stricture) ◆​ Polyuria: peeing a lot of pee ​ Caused by: high volumes of fluid intake, uncontrolled diabetes mellitus, diabetes insipidus, diuretic therapy ◆​ Oliguria: low pee (urinary output) in relation with what you drink (fluid intake)  ​ Caused by: fluid and electrolyte imbalance (dehydration), kidney dysfunction 👵 or failure, increased ADH, Urinary tract obstruction ◆​ Nocturia: waking up in the night bc you have to pee ​ Caused by: excess intake of fluids (coffee or alcohol), bladder outlet obstruction (prostate enlargement), overactive bladder, medications (diuretics), cardiovascular disease (hypertension), UTI ◆​ Dribbling: leaking small amount of pee ​ Caused by: bladder outlet obstruction, (prostatic enlargement), incomplete bladder emptying, stress incontinence ◆​ Hematuria: blood in pee (can easily be seen or can be seen in a urinalysis) ​ Caused by: tumors (kidney, bladder), infection (glomerulonephritis) urinary tract calculus, trauma do the urinary tract ◆​ Retention: can’t pee when bladder is full ​ Caused by: bladder outlet obstruction (prostatic enlargement), absent or weak bladder contractility, side effects of medications ➔​ Urinary incontinence, characteristics, and common nursing interventions -​ Involuntary leakage of urine -​ Characteristics: leakage of urine when coughing/sneezing/laughing, urgency, dribbling, nocturia (ex: overflow UI and urgency UI) Types: -​ Transient : incontinence caused by medical conditions that are usually treatable/reversible INTERVENTION - look for reversible causes -​ Functional : Direct result of caregivers not responding in a timely manner, also can be related to functional deficits INTERVENTION - adequate lighting in bathroom, toileting program, mobility aids, clear toilet area, elastic pants without buttons/zippers, nurse call system within reach -​ Overflow : involuntary loss of urine caused by an overdistended bladder INTERVENTION - depend on severity - mild: timed voiding, double voiding, intermittent catheterization severe: intermittent/indwelling catheterization -​ Stress: involuntary leakage of small volumes of urine INTERVENTION - instruct pt in pelvic muscle exercises -​ Urge incontinence- could be UTI, but is a strong urge that you need to pee. INTERVENTION- don’t drink alcohol or irritant, exercises, -​ Reflex Incotinence- you pee but you know when INTERVENTION- schedule pee  ➔​ Laboratory and diagnostic tests used, methods of collections, and any nursing considerations -​ Lab/diagnostic tests: -​ NONINVASIVE: abdominal roentgenogram, CT of the abdomen/pelvis, intravenous pyelogram (IVP), ultrasound of renal bladder -​ INVASIVE: cystoscopy - Methods of collection: random (routine urinalysis), clean-voided or midstream, sterile specimen for culture and sensitivity, timed urine specimens Side side middle Circular for pepe 24 hour - FRIDGE, record, don't mess up READ THE CHART!!!!  ➔​ Types of catheterization (i.e., urethral, suprapubic, intermittent, etc.) and nursing considerations LOOK BACK!! Which one do you need for this patient Straight cath= single lumen Indwelling cath =doulke lumen -​ Intermittent catheterization means one time catheterization for bladder emptying -​ Indwelling catheterization means it remains in place over a period of time -​ Single lumen catheter used for intermittent/straight catheterization -​ Double lumen designed for indwelling catheters, provide 1 lumen for urinary drainage while the other inflates a balloon that keeps catheter in place. -​ Triple lumen is used for continuous bladder irrigation or to instill meds into the bladder -​ Suprapubic catheter: urinary drainage tube inserted surgically into bladder through abdominal wall above the symphysis pubis.  5.​ Describe common physiological alterations in bowel elimination. _________________ ➔​ Common bowel elimination problems (i.e., constipation, diarrhea, etc.) and nursing considerations (i.e., dietary effects, interventions) -​ Constipation: difficulty emptying bowel movements (intervention: encourage fluid intake, encourage activity, eat more fiber, provide stimulant laxatives and softeners) -​ Sick, stress, inactive, opioids can cause constipation, old women What do you do with a patient with constipation?!!! LOOK BACK - laxative -​ Impaction: unrelieved constipation and is unable to expel the hardened feces in the rectum -​ DIGITAL STOOL REMOVAL!!! (last resort) -​ Diarrhea: increase number of stools and the passage of liquid, unformed feces -​ Incontinence: inability to control passage of feces and gas -​ Flatulence: gas accumulates in the lumen of the intestines, the bowel wall scratches and distends -​ Hemorrhoids: dilated, engorged veins in the lining of the rectum (can be internal or external) ➔​ Bowel diversions (i.e., ostomies) and associated nursing care -​ Stoma - created surgically by bringing part of the intestine out through the abdominal wall -​ Red -​ Pink -​ Moist  -​ (malodorous and farting (gas)) -​ Mucus and Blood is normal -​ Sigmoid colostomy: easiest, temporary, more formed stool -​ Transverse colostomy: easiest, temporary, thick liquid to soft consistency -​ Loop colostomy: reversible, two openings, proximal end drains fecal effluent, distal end drains mucus -​ End colostomy: permanent or reversible, rectum is eother left intact or removed Ileostomy Urostomy ➔​ Bowel training, enemas (temperature for enemas), nasogastric tubes  -​ Bowel training (habit training): the tracing program involves setting up a daily routine, by attempting to defecate at the same time each day and using measures that promote defamation. ( like potty training in hospital) Know how to do enema -​ Enemas: an enema is an instillation of a solution into the rectum and sigmoid colon -​ Cleansing Enemas -​ complete evacuation of feces from the colon -​ Tap Water -​ Normal Saline!!!! -​ Physiologically normal saline is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving saline enemas lessens the danger of excess fluid absorption. -​ Hypertonic Saline -​ Soapsuds!!!! -​ You add soap suds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in a liquid form, included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they could cause electrolyte imbalance or damage to the intestinal mucosa.. -​ Oil retention -​ Other types of enemas: (carminative enemas provide relief from gaseous distention) -​ KEEP ROOM TEMPERATURE (not too hot or cold)  -​ Nasogastric tubes: is a pliable hollow tube that is inserted through the patients nasopharyngeal into the stomach -​ Small bore tubes: used for medication administration and enteral feedings -​ Large bore tubes: used for gastric decompression or removal of gastric secretions Decompression (remove gas from GI) (prevents relief of abdominal detention) (Salem sup 11 LVIN MILLER ABBIT) Internal Feeding (Food) (Impaired swallowing) Compression (Internal application of pressure by means of inflating balloon to prevent internal esophageal or GI Hemorrhage) LAVAGE (irrigation of starch in case of active bleed or gastric dialation) 6.​ Distinguish the nutritional needs of patients with nutritional deficits. -​ Anorexia nervosa/ Bulimia nervosa: (if you had an eating disorder) -​ Carbohydrates: 55%-60% of total daily kilocalories -​ Proteins: increase 1-1.5 g/kg/day -​ Fats: does not increase -​ Adequate hydration -​ Vitamin and mineral supplements are not required -​ IRON-RICH FOODS to prevent anemia (we want that good blood) -​ Pregnancy: -​ Proteins: increase to 60 g daily -​ Calcium intake important in third trimester -​ Iron supplements (meet mothers increased blood volume, fetal blood storage, and blood loss during delivery) -​ FOLIC ACID: 400 mcg daily, increased to 600 mcg daily during pregnancy  ➔​ Energy expenditure including energy requirements in relation to weight The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy you need to consume over a 24-hour period for your body to maintain all of its internal working activities while at rest. Factors that affect metabolism include illness, pregnancy, lactation, and activity level. When the kilocalories (kcal) of the food we eat meet our energy requirements, our weight does not change (Nix, 2017). When the kilocalories ingested exceed our energy demands, we gain weight. Likewise, if the kilocalories ingested fail to meet our energy requirements, we lose weight. BMI CHART PUT IN!!!!!!  ➔​ Sources of energy (i.e., carbohydrates, proteins, etc.) and the role they play in dietary needs of patients with certain conditions (i.e., diabetes mellitus, cancer, etc.) Carbohydrates: one of the main chicks for energy. 4 kcal/g Proteins: used for growth, maintenance, and repair of body tissue. 2nd main chick; 4 kcal/g Fats: important side chick, can be good or bad. 9kcal/g Water: cells are always thirsty asf ( depend on fluid to function) (60-70% water in body) Vitamins : essential to normal metabolism Mineral  ➔​ Therapeutic diets are needed -​ CLEAR LIQUID- BROTH, COFFEE, TEA, SODAS, CLEAR FRUIT JUICES, JELLO, POPSICLES -​ FULL LIQUID- DAIRY, ICE CREAM, CREAMY SOUP (BROCCOLI CHEDDAR), OATMEAL, V8 JUICE, YOGURT -​ DYSPHAGIA STAGES- THICKENED LIQUID, PUREED - MASHED POTATO, SCRAMBLED EGG (BABY FOOD) (wisdom teeth out) -​ MECHANICAL SOFT (DICED/GROUND MEAT) ALL CREAMY SOUPS, LIGHT BREADS, COOKED VEGGIES, CANNED FRUITS -​ SOFT/ LOW RESIDUE LOW FIBER, EASILY 2 EAT (PASTAS, CASSEROLES, MOIST/TENDER MEAT, CANNED FRUITS, VEGGIES, CAKES) -​ HIGH FIBER ADDITION OF FRESH UNCOOKED FRUITS, STEAMED VEGGIES, OATMEAL -​ LOW SODIUM 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets -​ LOW CHOLESTEROL 300 mg/ day cholesterol, CHILL WITH THE OILS and frying stuff DIABETIC Balanced diet of carbs, fats, and proteins ( my plate type of diet) -​ GLUTEN FREE- NO WHEAT, BREAD STUFF, OATS -​ REGULAR- NOTHING CHANGES EAT IT ALLLLLLLLLLL Look up what dysphgia eats ➔​ Enteral tube feeding, parenteral nutrition and associated complications of both Enteral nutrition: `Provides nutrients into the Gi tract. Used if the pt can't swallow or take in nutrients orally. Comes in nasogastric, jejunal, or gastric tubes. Complications- -​ Pulmonary aspiration, Diarrhea, Constipation, Tube occlusion, Tube displacement, abdominal cramping , N/V, delayed gastric emptying, Fluid overload, serum electrolyte imbalance, Hyperosmolar dehydration Parenteral nutrition: specialized nutritional support through IV. For patients in highly stressed physiological states such as sepsis, head injury, or burns. Requires constant monitoring. Complications -​ pneumothorax from initial catheter insertion, air embolism , electrolyte imbalance, hypoglycemia, hyperglycemia Tutoring session Immobolity - pneumonia, clots, orthostatic hypotension (dangle feel off the bed a bit - helps prevent falling), ambulate ASAP, risk for kidney stones (hypercalcemia), Braden Scale used to asses skin on immobilized pt Look at pg 1239 Wound Care - pressure ulcers, keep skin dry, rotate the pt, smooth beds (creasing can increase friction) Certain religions that cannot eat certain foods talking to meg ​ Car Seat with kid (safety) ​ DIET QUESTIONS ​ Nursing Diagnosis vs Medical Diagnosis ​ Roles (UAP, LPN…) Scope of Practice ○​ (SELECT ALL THAT APPLY) ○​ Look at next ​ Safe patient care- What can you do with FALL RISK! ○​ LIGHTS ON ○​ Frequent Urination (noturia) ○​ No obstacles  ○​ Home- not rugs that are slippery ○​ This patient has frequent urination? What can you do to prevent falls? ○​ TEXTBOOK ○​ Occupations at elevated heights or other hazardous working conditions. ○​ Alcohol or substance use. ○​ Socioeconomic factors, including poverty, overcrowded housing, sole ○​ parenthood, or young maternal age. ○​ Underlying medical conditions, such as neurological, cardiac ○​ (orthostatic hypotension), or other disabling conditions. ○​ Polypharmacy and side effects of medications. ○​ Physical inactivity and loss of balance, particularly among older adults. Poor mobility (impaired balance, gait, coordination), cognition, and ○​ vision, particularly among those living in an institution, such as a ○​ nursing home or chronic care facility. ○​ Unsafe environments (e.g., broken stairs, icy sidewalks, inadequate ○​ lighting, throw rugs, exposed electrical cords, barriers along walking ○​ paths, and improper equipment for ambulation). ○​ Foot problems that cause pain and unsafe footwear, such as backless ○​ shoes or high heels. ​ HYGIENE ○​ Perineal care (NEVER BACK TO FRONT) ​ Active and Passive ROM ○​ A patient is unconscious. What can a nurse do to move them? ​ PRESSURE ULCERS!!!! ○​ BED BOUND ○​ Look over Stages ○​ If you see a new patient with a pressure ulcers, DOCUMENT!!! ​ Risk for Infection ○​ Diabetes ​ Know all of the urine alterations - all types ○​ Later-know numbers ​ I and O - vomiting -> recording it in the out ​ Which would be a good diet with a person with dysphagia? ​ -soft foods (liquid??) ​ Look at boxes, vocab, and practice questions ​ Clear Liquid ​ Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles ​ Full Liquid ​ As for clear liquid, with addition of smooth-textured dairy products (e.g., ​ ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt ​ Dysphagia Stages, Thickened Liquids, Pureed As for clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy ​ Mechanical Soft ​ As for clear and full liquid and pureed, with addition of all cream soups, ​ ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried) ​ Soft/Low Residue ​ Addition of low-fiber, easily digested foods such as pastas, casseroles, ​ moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut ​ High Fiber ​ Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits ​ Frequent urination, what do you do before anything ​ Have a route of there bowel or urine schedule ​ ENEMA-not to hot (can cause everything to come out?), not to cold (can cause cramps) Not too important ​ Know the difference between Enteral vs Parenteral Feeding!!!! ​ Enteral Tube feeding- how to verify that it is in the stomach !!! PH strip to verify if that doesn't work that do an X RAY!! ​ CLEANING PRIVATE AREAS ​ Penis- 2 toilettes on the tip ​ Vulva- side, side, middle, (one wipe) spread it ​ What is the first thing you should do when a patient is constipated!! ​ -enema, laxative, massage stomach, digital if those don’t work ​ Nutrition needs for wound healing ​ -HIGH PROTEIN​ -HIGH CALORIE ​ -LOTS OF FLUIDS ​ Which is good to give patience when.. ​ Eggs? ​ -BASICALLY KNOW FOODS!! ​ Energy ​ Requirements in relation to weight ​ Look up ratio ​ Food and activity  ​ How much exercise to actual;y have to do to lose weight or gain weight ​ -Look up in book ​ Shear friction and Moist Friction ​ -shear- skin separates from friction (skin moves and everything below or in the body stays the same) Example:back and bed ​ -What was a way to prevent shear- gently lift the patient ​ MOISTURE LAZERATION- shower (prune hands) more likely to get friction or cut ​ Bed baths give to patient that were immoble ​ Communication- if a patient hears a noisy background and you are taking patient history, you would do something to make it quieter. ​ What don you do to better look like a actively listening, sit with patient make eye contact (some cultures don't like to make eye contact) ​ A mom comes in and she doesn't make eye contact with her son. What do you do? ​ -Keep talking to mom!!! ​ Look for later test ​ LOOK UP CRUTCHES FOR LATER​ GATE BELTS- ​ Properly moving patient with left sides and right side stroke and move to wheelchair UN AFFECTED SIDE OF BODY GETS IN WHEELCHAIR FIRST ​ TYPES OF CATHETERIZATION!!!!-straight cath Lab stuff: ​ 24 HR URINE COLLECTION ​ First collection starts after the first void, the void doesn’t count but the rest do. Record the time ​ If you miss the drop you gotta start over ​ REFRIGERATE IT (URINE) !!!