Fundamentals Final Review.docx

Fundamentals Final Review Infection - Pathogens: Cause infection-such as bacteria (gram positive or gram negative), viruses, fungi - Common Cold, Hep (A, B, C), HIV are viruses and do not respond to antibiotics - Fungi are found in air, soil, water (mold and yeast) Infection cycle...

Fundamentals Final Review Infection - Pathogens: Cause infection-such as bacteria (gram positive or gram negative), viruses, fungi - Common Cold, Hep (A, B, C), HIV are viruses and do not respond to antibiotics - Fungi are found in air, soil, water (mold and yeast) Infection cycle 1. Infectious agent: Bacteria, Virus, Fungi 2. Reservoir: where the organism resides 3. Portal of exit from reservoir: How did the organism escape the reservoir 4. Means of transmission: How did the organism travel (toilet, shoes, bed) 5. Portal of entry: how did the organism enter into a new host 6. Susceptible host: people who are most likely Stages of Infection 1. Incubation period: organisms growing and multiplying 2. Prodromal stage: Most CONTAGIOUS, few symptoms (Non-specific to disease) 3. Full stage of illness: Harsh symptoms, disease at its peak, specific to disease 4. Convalescence period: Recovery stage The first line of defense is the skin and the mucous membranes and the body's normal flora Inflammatory response - Vascular phase: Vasoconstriction followed by vasodilation (redness and heat), the vessels get bigger so WBC can travel to site of inflammation, histamine (causes swelling, pain, loss of function temporarily), increases permeability (helps WBC) - Cellular phase: WBC travels to area, and exudate is released can be serous-clear, sanguineous-blood, serosanguineous-pink, purulent-infected pus Immunity - Risk for infections: pH of GU and GI, skin integrity is compromised, number and health of WBC, age, comorbidities, level of nutrition, stress level, presence of invasive medical devices such as Foley. - Active Immunity: Immunizations (introducing inactive part of an organism so the body can be tricked and create antibodies) - Natural immunity: Born with it (skin, WBC, mucous, flora) - Passive Immunity: Oneself did not create immunity it was passed onto (like breastfeeding. Types of Asepsis - Medical: clean technique, low number of pathogens (GI tube because stomach has bacteria) - Surgical: 100% sterile, free from microorganisms (Foley, trach suction) Sterile Field - Solutions upon opening are only sterile for 24 hours - Drop 6 inches above sterile field when adding more stuff - 1 inch border rule, new sterile field if contamination occurs - Do not reach over sterile field, do not turn back, do not drop hands below waist - If sterile becomes wet, it's contaminated DON 1. Gown 2. Mask 3. Face shield 4. Gloves DOFF 1. Gloves 2. Face shield 3. Gown 4. Mask (until leaving patient room) Precautions - Standard: with all patients, washing hands, gloves when contact with blood, sweat, open wounds. Gown is used to avoid splash of feces - Airborne: MTV (MMR (measles, mumps, rubella), Tuberculosis, Varicella), spread through air, negative air pressure, private room, N95 mask, patient will need surgical mask if need to move to another place. - Droplet: 3 feet away patient, large particle droplet. (Rubella, mumps, diphtheria). Surgical mask, if patient needs to move, they will need to obtain a surgical mask, keep in private room, if possible, visitors 3 feet away - Contact: MRSA, VRE, Hep A/E, C-diff; colonization of Multiple-Drug Resistant Organisms. If available, a private room. Where gown and gloves when in contact. Minimize sharing equipment. - Reverse isolation: For patients who are immunocompromised in order to protect them, restrict sick visitors, wear a mask, own equipment, no outside things like flowers and foods. (Neutropenic patients) Safety - Babies- high risk for suffocation, keep meds away - Some people can be at risk of their safety at work due to being exposed to chemicals, loud noise, old machinery-related accidents - Impaired sensory perception can cause incidents such as disturbed perception of hearing, smelling, taste, vision, touch - Hearing: not hearing fire alarms - Smell: not smelling foul smells or fires - Taste: risk of eating expired foods; ingesting harmful chemicals - Vision: not seeing something that can cause them to fall - Touch: inability to feel that something is hot or sharp - Always assess patient ability to communicate to receive information regarding safety - Psychosocial state affects patients. For example, if they have depression they are at higher risk for suicide, altering their safety (high risk for injury) - Falls are the leading cause of injury fatalities for 65 y/o or older. Always do a fall risk assessment - Morse fall scale (greater than 50 is HIGH RISK) - Fall prevention strategies: - Always apply breaks to all equipment - Bed in the lowest position - Call bell within reach (to avoid them from standing up) - Orient patients to their surroundings - Use of non-skid footwear - Avoid the use of restraints (4x side rails is restraint and can make patient want to get out of bed) - In case of fire: RACE: Rescue, Alarm, Contain, Evacuate. PASS: Pull pin, Aim at the base, Squeeze, Sweep side to side - In poison, call the poison control center. - Heimlich: When they can't speak, breathe, cough Restraints - Chemical restraints: meds such as sedative - Very tight blankets or sheets can also be considered restraints - Restraints only for safety of patient - Restraints: document why they were given, last resort, document previous used alternative methods to restraints, exhaust ALL other measures first. 4 hours max for adult patients, 2 hours for children and 1 hour for less than 9 YOA. MAX in total is 24 hours. Pad bony prominences, make sure 2 fingers fit underneath, QUICK RELEASE KNOT TO BED FRAME - Assess 1-2 hours: all systems toilet, water, mobility, nervous system, and skin. Incidents - Preventing procedure-related incidents - 5 nights of medication (follow it) - Be sure to know how to transfer patient (devices or not) to prevent falls/injuries - Follow aseptic techniques when doing dressing changes - Be careful with hot or cold therapies (do not exceed 30 min, place protective) - Incident report: Honest, objective, right after incident, patient's response, tell family and apologize) DO NOT put in patient chart, nurse notes Bioterrorism: deliberate spread of pathogenic organisms into a community (smallpox) Chemical terrorism: Release of chemical compounds to harm people. Immediate decontamination is crucial Nuclear terrorism: intentional introduction of radioactive materials (wear PPE) Mass Trauma Terrorism: Such as bomb threat Triage Class 1: life threatening injuries but high chance of survival Triage Class 2: Injuries that can wait 30 min-2hrs (Major injured) Triage Class 3: Non-life-threatening injuries. (minor injuries) Triage Class: Not expected to love Medication Administration - Absorption rate: oral(slow), subQ (less slow), IM (faster), IV (fastest) - Adverse reaction: not predicted, life-threatening - Toxic Effect: too much of the med that can affect greatly an organ if not excreted - Therapeutic range: desired level of a drug that completes the desired effect of the drug with no toxic effects - The PEAK of a med is drawn 1 hour after the dose of medication, and it indicates the highest plasma concentration - The TROUGH is drawn 30 min before the next dose, and it indicates the lowest plasma concentration, and how well the body is eliminating the drug. - If a telephone order is given: needs to be signed by provider in 24 hours another nurse needs to witness the call, need to repeat the order given back to the provider. ONLY in emergencies. - Enteral route means through an enteral tube such as NG tube, gastric tube, etc. - Buccal med route: between tongue and cheek. - When giving meds with a tube, make sure the HOB is at least at 30 degrees, the tube is in the stomach and not anywhere else, before giving meds 15-30ml flush, in between meds and at the end after last med flush. Do not resume suction of the tube until about 30 min to prevent suctioning of meds. - Intradermal injection is given in the corium (under the epidermis-top layer of skin) Usually 25-27 gauge, angel 5-15 degree and less than 0.5ml - Subcutaneous injection given in the adipose tissue. Usually 25-30 gauge, less than 1ml, and 45-90 degree, 2 inches around umbilicus - Intramuscular injection, sites are ventroguluteal, vastus laterals, deltoid muscle, Z-track technique. Usually 20-25 gauge or 18-21, 70-90 degree angle. Deltoid 1ml max, and ventrogluteal more than 1ml (no more than 4 ml in dosage because its too much) 10 seconds per mL HYGIENE - Skin is the first line of defense so if skin is intact it can indicate a less trouble for pathogens to enter. - Assess culture preferences when regarding personal hygiene such as shaving preferences, if they would like to be helped by someone their own gender, etc. - Developmental level can be a factor that affects hygiene because as babies and children they might need help with basic hygiene activities, and with this they will also keep learning regarding hygiene the way their parents teach them how to. - Adult's health can be affected due to if they have a condition that prevents them being able to help themselves into a hygiene routine. (Vision problems, dizziness, sick, pain, diabetes needs to maintain skin clean and intact to prevent ulcers and amputations) - Put patients to the side if you are doing oral care with patients who are comatose. Patients who are intubate; we should be doing oral care every 4 hrs because their mucous membrane get dry. - Glossitis: is a condition where the tongue gets swollen when there is a vitamin b12 deficiency - Start bathing from cleanest area (face) and end in the dirtiest part (perineal area) - With eyes, remember if they are comatose may need hydrating drops and more eye care - Clean around the area of piercing with warm water, if signs of infection let provider know. - As a nurse back massage are okay, as it improves circulation, gives the opportunity to assess skin, helps patients sleep, decrease pain. Skin Integrity - Brown pigmentation changes with venous insufficiency, shiny and translucent changes with no hair on the toes and foot indicate arterial insufficiency. - Skin can help with first line of defense, body temp regulation, psychosocial (to feel better when out with people), sensation (because it help us feel pain and avoid further damage), vitamin d production (because it help when the sun is being absorbed and helps with calcium), immunological (because if there is a tear it send to our immune system to help us solve it), elimination and absorption (sweat). - Babies and older adults have thinner skin which put them at risk for skin breakdown and more tears. - Existing illnesses can also affect the skin due to the fact that it affects the sensation of the skin causing more prone to have tears. Such as diabetes. - Diuretics which can cause patients to be dehydrated, when skin is dehydrated can make skin more prone to tears. Types of Wounds - Intentional: planned like surgery, IV access - Unintentional: accidentally created like scrape from fall - Open wound: skin if broken (portal of entry to organisms) like stabbing - Close Wound: blow or blunt trauma (skin is not broken but tissue is such as a cerebral bleed. - Acute wound: moved through the healing process in acute manner (closing as intended) - Chronic: healing process is impaired and prolonged, like diabetic ulcers. - Phases of Wound Healing: - 1\. Hemostasis phase: blood stays, blood vessels constrict by platelet aggregation, then after vasoconstriction comes vasodilation, in which is going to allow the WBC to go into the site of injury (when we get the exudate of WBC and other blood components) - 2\. Inflammatory Response: this is where there is going to be inflammation at the injury site, last 2-3 days, mild elevated temperature, the WBC start to fight bacteria, macrophages barely arrive. - 3\. Proliferative Phase: (reproduction phase), lasts a few weeks, it generates a new tissue which is the granulation tissue that is the foundation of scar tissue. - 4\. Maturation phase: which is when collagen is remodeled making wound like adjacent tissue, 3 weeks after the injury usually and lasts up to months, this is where the scar becomes thinner. - Wound healing: - Primary intention: surgical wounds with sutures - Secondary intention: edges are not well approximated and form more scar tissue when healing, it can be in the case of trauma, burns or primary wounds that become infected. (wound cannot be closed due to needing to heal from bottom) - Tertiary intention: wounds left open for several days, such as wounds from extensive trauma, or wounds that need to be drained. (left open then they are closed) - Dehiscence: separation of incisional wound layers - Evisceration: protrusion of body organ from wound (a serious complication of dehiscence), place patient in low fowler with the knees and the hips bent, cover with moist sterile dressing in this case it happens (NPO patient due to going to surgery, never reinsert organs back, notify provider STAT, and stay with the patient). - With pressure ulcers they are cause due to bony prominences being pushed against or at like an elbow stuck in bed due to being paralyzed, this whole pressure causes the tissue to not get enough blood flow causing ischemia, and it starts breaking up into tears in the skin. - Friction: 2 surfaces rub against each other (rubbing but not doing down like in shear) - Shear: one layer of tissue (skin) slides over another- such as sliding the patient - Pressure Ulcers - Stage 1: skin is intact and nonblanchable (does not turn white), which is why its red - Stage 2: loss of dermis or serum filled blister - Stage 3: subcutaneous fat is loss - Stage 4: you can see bone or muscle - Unstageable: is when you are unable to see how deep the injury is and this can be when there is presence of slough: yellow, tan, brown dead tissue or when there is eschar: tan, brown and black dead tissue - Suspected DTI (deep tissue injury) can be when there is no visible trauma to the skin, but there is discoloration - Prevention of skin injury is important. - For Braden Scale we need to assess for - 1\. Sensory perception, moisture, activity, mobility, nutrition (if they are malnourished,) friction or shear. - In BRADEN scale for pressure ulcers: the highest score means low risk; the LOW score means a HIGH risk. 23 is low injury - Wound Assessment: COCA- color, odor, consistency, amount - RYB classification: - Red-protect - Yellow: cleanse (slough) - Black: debridement (eschar) - Heat Therapy: heat causes vasodilation, do not apply after trauma, hemorrhage, or non-inflammatory edema, localized malignant tumor, the testes, abdomen of a pregnant woman, over mechanical implants. Usually used for chronic conditions. When using place cover over pack (not too heavy) and don't apply for longer than 20 minutes - Heat Therapy increase blood flow, increases tissue metabolism, relaxes muscles, eases joint stiffness and pain - Cold Therapy: cause vasoconstriction, do not apply on open wounds, patients with impaired circulation, adverse effects to cold, commonly used for sprains - Cold therapy decreases inflammation, preventing swelling, reduces bleeding, reduces fever, diminishes muscle spasms, decreases pain by decreasing the velocity of nerve conduction. - Be sure to consider: - Use caution when very young fair-skinned or older adults because they have fragile skin - Clients who are immobile might not be able to move away from the application if it becomes too uncomfortable - Clients who have impaired sensory perception might not be able to feel numbness, pain or burning Oxygenation - Respiratory center is in the medulla oblongata and its trigger is high CO2 - Gas exchange happens in the alveolar system. Surfactant prevents alveolar from collapse. However, it can still collapse, and it is called atelectasis (collapse of the alveoli) - Pulse oximetry: measures pulse saturation in hemoglobin by infrared light - Early signs of hypoxia: anxiety, restlessness, low level of consciousness, and lung sounds. - Nursing interventions to promote respiratory function: encourage immunizations, teach about pollution-free environment, smoking cessation, clear air, promote comfort, teach pursed lip breathing, adequate position. Offer about 6 small meals, to prevent them from getting tired by eating big meals. - Teach ways for use of incentive spirometer (inhaling is what is being measured) 5-10 times and hour every 1-2 hours - Promote to control coughing, because as well as it can clear secretions, it can be a dry cough, and we would like to suppress it to avoid discomfort (non-productive cough) - 2-3L a fay to promote excretion of secretions of lungs (because if they are dehydrated, they can stick to the body) - On room Air the oxygen concentration is 21% - Nasal canula: 1-6L and gives 24-44% or high nasal canula 10-15L gives 65-90% - Simple mask 5-8L gives 45-60% - Partial rebreather mask: 8-11L give 50-75% (has exhalation port) - Non-rebreather: 10-15L gives 80-95% - Venturi mask: GIVES exact amount of air 4-6L 24-40% accurate to deliver amount of oxygen - For oxygen: avoid smoking, check electrical equipment, use distilled water for H2O humidifier, ensure a full tank of O2 tank is always available, avoid using synthetic clothing USE COTTON instead, evaluate effectiveness of O2 - Chest tubes can be given for pleural effusion (fluid in pleural cavity), hemothorax, pneumothorax - Chambers include close water seal, drainage collection, suction - Tracheostomy: used when patients are not able to breathe on their own, and need prolonged intubation or if they can't be orally intubated. Ensure potency, maintain asepsis when cleaning and suctioning, inner canula if disposable we can throw away if non-disposable, we need to clean it in sterile technique. Perioperative - From the point the patient says yes to surgery to where the patient is taken to surgery is pre, into and post. - Classes of surgery: - Urgency, elective, urgent within 24 hours or 48 hours, emergency need to happen immediately like a repair of a hemorrhage. - Minor surgery: tooth removal - Major surgery: hip replacement - Purpose of surgery: diagnostic (biopsy), ablative (remove a body part that is not working, like appendicitis), palliative to provide comfort to a patient or lessen pain, reconstructive aims to fix something like a breast reconstruction, transplantation is transplanting organs, and constructive is to restore the function of any abnormalities - General Anesthesia: patient will need to be intubated, will lose consciousness and reflexes. Produces CNS depression, will produce analgesia (brain will not respond to pain stimuli) - Moderate sedation: conscious sedation, used for short term, minimally invasive procedures, patient can maintain their own airway without needing to be intubated - Regional anesthesia: injected near a nerve, inhibits sensory stimuli to CNS, watch out for safety since loss of sensation - Topical or local anesthesia: used on mucous membranes, open skin, wounds, and burns. Like lidocaine - Informed consent: MUST be acquired with any procedure that is invasive (surgery, oscopys that require moderate sedation), surgery consent by surgeon, anesthesia by anesthetist. - HCP- provides alternatives, describes procedure, the risks, explains the right to refuse at any time, explain outcome, recovery time, course of action, risks of not performing the surgery. - Nurse role for informed consent: advocate for patient, witness that the patient was indeed the one who signed the informed consent, and that the patient is able to understand in the right language. - Nurses should only reinforce what the doctor said, and if a patient arises with new questions you must call the surgeon back to answer the rest of the questions. Nurses should advocate for patients if they have any barrier preventing them from understanding. - Patients should not be under the influence of anything, they need to be alert and oriented, competent. - Minors cannot sign consent unless they are emancipated, and they will need to present the court order. - Advance directive: living will: wishes for end-of-life medicated care is stated (do we intubate?) out in the chat the patient wishes as well as telling the HCP prior to any procedure - Durable power of attorney provides the power of attorney to another person in the case of incapacitating medical conditions (only medical decisions) - In the case that there is no durable power of attorney it will be the next of kin, which is the legal spouse if not children are next. (Eldest), if not eldest sibling, and if no family the hospital must go to the court with the information so that the court can make a decision. - Pre-surgery: get PMH, baseline data, allergies, fluid and electrolyte status, current meds, prior surgical issues, NPO status (8hr prior to surgery-only give water with needs that are needed and should not be skipped even the day of surgery), review diagnostic tests, complete CBC, cardiac clearance, weight baseline, document the whole head-to-toe assessment prior to surgery. Check glucose level - Teach patients how long the surgery would last, what type of equipment they will have after surgery, what care would be needed at home after surgery. Teach to ask for pain meds prior to the pain level getting to the worse level, teach about alternative methods to control pain, use incentive spirometer and to cough and splinting (with the pillow) due to prolonged anesthesia avoiding them to hold their own airway on their own. Teach about ambulation. Teach about the use of ted hoses to promote venous return, teach about moving, hydrating and teach that after surgery the diet would change, and teach them to keep skin dry and clean. - Post-operative: ABCs every 15 minutes, vital signs. Color and temperature of skin, make sure the patient is hydrated (measure intake and output, at least 30 mLs per hour), assess surgical site, in case a lot of bright red blood on gauze do not remove it just reinforce it. Assess pain level, make sure patient is in the position that was ordered if not fully conscious patient should be on the side to prevent aspiration. - Post-operative alerts/concerns: dyspnea, cyanosis, bleeding/hemorrhage (tachycardia first, them BP will go down and skin will turn pale), LOC, paralytic ileum (normal for the first 24-48 hours the patient will have hypoactive bowel sounds) assess bowel every 4 hours, assess wound such as COCA, s/s of infection of wound: foul odor, high WBC. - Make sure when the patient is discharged that they have all the instructions regarding their care: nutrition, diet, wound care, mobility, restrictions. Have the client repeat the info back so that you can assess how much they understood. Activity/Mobility - Abduction: away from the body - Adduction: adding to the body - Isotonic: any activity of ADL - Isometric: muscle contraction but no shortening of muscle (like planks) - Isokinetic: muscle contraction with resistance; with weight or resistance (physical therapy) - PUSH is easier than pulling - Effects of immobility: lower ventilation, high secretions that if not being excreted or moved can lead to pneumonia. DVT because not moving, orthostatic hypotension because they are used to staying in one position (blood stays), high workload on the heart (because the heart will word harder to provide oxygenation everywhere). Assess for s3 sounds. Move patients every 2 hours, teach ROM exercises, SCDs (contraindicated if they already have DVT because it can dislodge a clot). Enoxaparin if patients are not moving. Avoid putting pillows underneath the knees. - Osteoblast: regenerates/generates bone - Effects of immobility: because they are not moving, they will begin to get constipation, the urine stasis can lead to UTI, if they are just gaining calories but not moving, they are most likely gain weight. Urinary stasis leads to UTI which can lead to calculi. Lack of mobility can lead to pressure ulcers, so this is why we need to reposition q2hr, and assess hydration status because if they are dehydrated skin is more prone to breakdown. - SCDs require a doctor's order, measure calf and tight circumference to see which size are adequate for TED stockings. Need to be removed q8hr to assess the skin, document when you applied them and when you took the off. - Fowlers: high fowler is 90 degrees, semi fowler is 30-45 degrees, for high fowlers make sure you don't have them for long periods because this can put a lot of weight on the sacral area which may cause bed ulcers, - Prone: on the stomach (contraindicated for patient with spinal problems) - Supine: back on the bottom, face up - Trendelenburg: head down, feet up - Reverse Trendelenburg: head up, feet down - After prolonged bed rest, sit them at bed, and dangle first, then you can reassess to see if they get orthostatic hypotension. Ensure skid-floor wear - Walker: 30 degrees angle for the elbows, advance walker first then walks into the walker - Cane: must go on the stronger side, elbow at 15 degrees, good leg goes up and bad leg stays down when going up the stairs. When standing up from sitting, put pressure on the cane and support on chair. - Crutches: properly fitted, 20-30 degrees on elbow, do not put on axillae area, advance 15 cm. - 4-point gait: bear weight on both feet, client alternates each leg with the opposite crutch (right leg, left crutch), so 3 points of support are at the floor all time. - 3-point gait: bear weight on 1 foot - 2-point gait: partial weight on both feet; moves a crutch while moving the opposite leg at the same time (mirror leg and arm motion when walking) Other - Hypokalemia: alkalosis - Hyperkalemia: acidosis - IV tubbing can be changed every 72-96 hours - The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. - Intestinal tumor: ribbon like stooled - Upper GI bleed is black since the blood has been digested - Lower GI bleed is bright red - If patient present with too much diarrhea take contact precautions - Barium contrast: causes constipation 8-10 stools and bloody in IBS - Cast oil: soap solution for enema - Stomas should appear shiny, moist, beefy red - 200-250 NGT residual volume risk for aspiration - Pregnancy they have slower peristalsis Rest and Sleep - There are 2 stages of sleep NREM which accounts for 75% of total sleep and the REM which accounts for 25% - Deep sleeps happens in REM it is very important for cognitive restoration (learning, adaptation of a new sleep schedule) - REM is also helpful for an emotional equilibrium, if not going into full REM it can affect mood of the person (such as being moody) - Circadian rhythm: is our biological clock, that tells our body when to wake up and when to go to sleep, works with the sun and the darkness. Works with the hypothalamus that sends the signal to our brain, and the hormone released to tell our body to go to sleep is melatonin. - What happens with lack of sleep: obesity, affects normal growth in children, hypertension, cardiovascular diseases, increased risk for CVA, diabetes, depression, increased risk for accidents - What factors affect sleep: motivation (like if something exciting is going to happen the next day it will prevent sleep), developmental considerations like age, dietary habits (like caffeine intake), physical activity (its best to do it earlier in the day, not within 3 hours of bedtime because it causes endorphins to be released; the environment factors like if the room is too hot or too cold; seizures can also prevent peaceful sleep, illness like acid reflux can cause nocturia - Insomnia: difficulty falling asleep, intermittent sleep, early awakening from sleep, you want to tell them to limit fluids 4 hours before falling asleep and to avoid caffeine - Hypersomnia: characterized by excessive sleep during the day, high meals in protein with small amounts (in order to be able to process it and so that the brain does not need a lot of activity to process food) - Narcolepsy: high in complex carbs, uncontrollable feeling to sleep, falls asleep standing up or during conversation. Tell them to avoid activities that require a lot of energy to mental alertness in order to avoid accidents - Obstructive sleep apnea: meaning the patient does not breath for 5-10 seconds, and the oxygen level in the body goes down and it increases the heart rate and the blood pressure and can lead to cardiovascular diseases in a long term, and they are usually put on a CPAP to lead airway open. - Restless leg syndrome causes patients to constant move their legs, can happen with electrolyte imbalances or it can be unknown. Can be resolved by non-pharmacological measures (like cold and hot therapy, avoid nicotine or caffeine), or can be treated with muscle relaxants. - Nursing actions: promoting a restful environment, promote bed rituals, offer appropriate bedtime snack, promote relaxation, promote comfort, respect normal sleep-wake pattern, avoid unnecessary disturbance while patient is asleep (make sure to assess their sleep patterns and everything related to their sleep). Comfort and Pain management - Transduction: conversion of painful stimuli to electrical impulses (it will translate it to the brain) - Transmission: from the local site to the spinal cord then travels to the thalamus then into the cortex where we can start the pain modulation - Self-analgesia: endorphins (natural protectant) - Pain threshold: the point where our body start to feel pain - Pain tolerance: amount of pain a person tolerates - Acute pain: fast, protective, temporary, resolves with tissue healing, fight or flight response activated (sympathetic), its like when we get stung or when we hit ourselves - Chronic Pain: over 6 months, long-term (patients who have cancer, RA) it can be idiopathic, and management is for long-term treatment. Patient can have depression or anxiety; however vital signs can appear normal (because the body will not be able to keep altering the VS every time for chronic pain) - Referred pain: perceived pain from the point of origin (like heart attack that move in the shoulder) - Intractable pain: pain that is resistant to therapy - Psychogenic: no physical cause but pain can still be present (pain is real they just don't find a physical cause) - Idiopathic: unknown cause - Nociceptive pain: damage of inflammation of tissue (cutaneous, visceral or somatic) like stubbing your toe - Neuropathic pain: due to damage or abnormal pain nerves (like diabetic neuropathy) - Nociceptive: cutaneous (superficial), somatic (bone, muscle tissue), visceral pain (intestines) - Neuropathic: due to damaged or abnormal pain nerves; s/s are intense, shooting, burning often described as needles. It can also cause phantom pain: the pain is real because the nerve in the end were damaged - Pain is whatever the patient says - Location (where), quality (what makes the pain better or worse, what causes it? Is it dull, sharp, crushing, throbbing?), radiation (does it go anywhere else?), severity (1-10 scale), timing: how often does the pain last - Objective data for assessment of pain: high HR, RR, patient guarding site, high BP, nasal-labial folds. - Factors that can affect pain experience: past experience, spirituality, anxiety, fear, age, culture, religious beliefs - Pain scales: numeric children older than 9 y/o or adults; FLACC 2 months to 7 years old; Wong-baker non communicative patients or less than 7 years old - Non-pharmacological therapies: distractions, imagery, humor, music, arranging bed, relaxation, breathing exercises, acupuncture, hypnosis, biofeedback (many of these are outpatient and need someone who is licensed) - Acetaminophen for mild pain, do not exceed 4g a day - For intractable pain, pain management should be around the clock not PRN because you want to keep the therapeutic level at a safe range that the patient can hold pain. Nutrition - Nutrition is vital for health - 6 main types of nutrients: carbs, protein and fat are macronutrients and vitamins, minerals are micronutrients. Water is sill vital for the body - Carbs, fats and protein give energy and help build tissue - Vitamins and minerals don't give energy but are required for some functions that the body needs such as metabolizing, cell functioning, etc. - BMI Formula: kg/m\^2 or lbs/inches\^2 x 703 - Normal BMI: 18 to 24.5; overweight is 25 to 29.9, obesity is 30 to 34.9, obesity 2 is 35 to 39.9 and obesity 3 is above 40 - Carbohydrates: primary source of energy, they give a total of 4kcal per gram, and should be 45-65% of our total food - Complex carbs are better: like potatoes, bread - Simple carbs are like candy and sugar - Any excess of carbs is processed by the liver and stored as glycogen - Protein: 4kcal per gram, 10-35% of our diet, its needed for formation of all body structures (build and repair body tissue) and excess is store as fat in the liver - Vitamins can be divided by water and fat soluble; fat soluble we store it in the body and water soluble we need to ingest them with meals or supplements, BODY takes what it needs and gets rid of the extra - Fat Soluble Vitamins: A,D,E,K - Water Soluble Vitamins: B,C - Vitamin A: helps with vision - Vitamin B: helps with cell maintenance, and energy - Vitamin C: absorption of calcium - Vitamin E: helps as antioxidant - Vitamin K: helps with clotting - Anorexia nervosa: fear of gaining weight deprive self of not eating - Anorexia: depriving self of eating (lack of appetite) - Bulimia: vomiting after binge eating - Anthropometric data: height, weight, waist circumference - High risk: waist above 40 inches in male, and women above 35 inches (for cardiovascular problems or diabetes) - Assess for dysphagia (people who have suffered strokes). Can put them at risk for aspiration - Assess mouth health, because for example they don't have enough teeth they are more prone to not being able to chew - Hemoglobin and hematocrit can indicate anemia - Albumin is a good indicator for malnutrition, dehydration, or overhydration - Malnutrition assessment: weak, poor tone, dry and brittle nails and hair, dry skin - Decreased metabolic rate (like older adults, resting mode) - Increased metabolic rate like when sick, when growing like pediatrics more calories - Metabolic rate is the amount of energy and calories our body burns when doing certain activity (therefore if the metabolic rate is increased, we will need more food to compensate those energy and calories wasted) - NPO: nothing by mouth not even ice chips - Clear liquid: no residue, clear broth, juice, water, clear at room temperature - Full liquid: clear and liquids that can be poured at room temperature like liquid yogurt, coffee with milk, milk is full liquid diet - Pureed: food thrown into blender, for dysphagia patient - Mechanical soft: soft and cut it into pieces, fully cooked veggies, no seeds, no nuts - Soft diet: modified easy to digest low in fat, low in fiber, or seasoning. - Cardiac diet: low salts, less than 2 grams of salt a day - Diabetic diet: 1800 calories (low carbs and low calories) - Low residue: low fiber - High residue: high fiber - Weight reduction diet: 500 calories less in a day ( so if you were eating 2,500 calories now you will be eating 2000 and that will give you 1lb lost per week) - Enteral nutrition: into the GI system (NPO) the most accurate way to verify placement is through x-ray - PH gastric content is 4 to 5 higher than 6 is close to the lungs, or 7 pH means low intestine, then after doing CXRAY then PH, then length of the tube measure (only after CXRAY) - NGT is for no more than 4 weeks, if needed nutrition longer than that tube should be replaced for a gastric-tube (G-tube) - Position for enteral feeding 30-45 degrees of bolus make sure at least they are like this for 1 hr, before administering food make sure to measure the length to be sure it has not moved, 200-250 residual means the patient is not tolerating the feeding and that the patient is at risk for aspiration, flush before, during, and after medication administration. Assess for residual every 4-6 hours - CXRAY verification only the first time, after that we need to measure length and test pH - Do not neglect oral hygiene just because they are NPO, if tube is dislodged the patient has to go back to an OR to get it replaced - Parenteral nutrition into vascular system (vein)- when their GI system does not work and they need to give nutrition directly into the blood - TPN: hypertonic (highly concentrated), high concentration solution that should be given through a central line= large vessel or a PICC - PPN: partial parenteral nutrition, only for less than 2 weeks can be given through a peripheral vein. - TPN: can cause hyperglycemia, check glucose every 6 hours or hypoglycemia (if we stop the TPN for long periods of time) if they don't have the TPN ready for the patient to make sure you always have some concentration of dextrose to give the patient in order to avoid hypoglycemia - Solutions and tubing must be changed every 24 hours (TPN AND PPN) - Pneumothorax can happen with this type of parenteral nutrition because central lines are close to the chest which can put patient at risk of poking a lung (SOB, low oxygen, tachypnea) - Do not give or connect anything with TPN, no meds unless its insulin or heparin but pharmacy usually combines them prior - Nephrons filter the contents in the kidneys. Kidneys filtrate and excrete - 1-2L of urine a day for normal adult - 200-250mls can be held in an adult bladder, when it reaches about 150 the bladder starts to stretch, and the receptor activates and start to send the signal to go pee to the brain - Anuria: less than 50 mls in 24 hours or no pee - Oliguria: less than 400ml in 24 hours - Dysuria: pain when urinating - Nocturia: pee at nigh (frequent) - Hematuria: blood in urine - Proteinuria: protein in urine - Polyuria: too much urine - Urgency: the feeling of needing to go - Frequency: how often you go pee - Retention: not being able to excrete pee - Incontinence: not being able to hold pee - Enuresis: wetting bed at night (its involuntary) - Children are able to control pee until they are about 3-5 years old - Adults: bladder loses muscle tone, causing the bladder to feel fuller when less pee, causing them to go stasis the urine (more prone to UTI), they also have more health problems which can prevent them to going to the restroom easily and causing them to have incontinence. - If you are dehydrated urine is more concentrated - If you are overload, more urine is produced because the body will want to get rid of the excess fluid - High salt equals low urine which means water retention (this is why patients are placed on cardiac diet) - Because the bladder is a muscle as well it needs to be exercised continuously, however because many patients are at bed rest or comatose this puts them at high risk of urine stasis, which they usually resolve with the foley catheter, however this puts them at risk for infection. Foley does not let bladder hold a lot of urine or be distended which makes muscle tone to be lost. - Kidney produces bicarb - Anticoagulants can cause hematuria - Phenazopyridine can turn urine orange - Levodopa can turn urine brown - Antihistamines can cause urinary retention - Aminoglycosides: mucin antibiotics can affect the kidneys as well as NSAIDS, lodine can also affect the kidneys. - Assess urine pattern of patient, in case of babies we need to count how many diapers they wet usually 6-8 per day - Assess costovertebral angle and with this is that if it hurts it may indicate UTI complication (like pyelonephritis) - For bladder scan make sure they are in supine position, if you are going to palpate for distention make sure to do it after the patient has voided because otherwise it can be very uncomfortable (bladder is not usually palpable but if its distended you will be able to palpate it) - Assess skin of the patient if they have problems with kidneys, it can be uremic frost or in end stage renal disease it can cause uremic pruritus which are deposits of calcium and phosphorus that lie on the skin causing itchiness - Normal color of urine is yellow to amber depending on the concentration - Ammonia level can indicate that the patient can have an infection - High glucose can give a sweet odor of the urine - Normal urine pH is 5-6 - For measurement of intake and output 1g of wet choux equals 1ml so 1g=1ml. Always assess COCA for urine - UA does not need to be sterile, you can collect from foley, bed pan, as long as you follow medical asepsis (1.005 to 1.030) the higher the number the higher the urine is concentrated the lower the number the less concentrated the urine is - If a clean-catch or midstream method specimen (sterile technique is required) - Sterile technique from indwelling catheter: have to collect through port - Urinary diversion: ostomy for the pee, if sterile specimen for the ostomy (need to Cath the stoma and get the specimen from there) - 24 hour urine collection, placed on ice (needs to be preserved), it can be done to see the function of the kidney, need to do patient teaching regarding so they don't throw any urine, the 24 hour urine collection starts after the first void after the order was done (if ordered at 5pm and they pee at 6p, they will throw that one and start after that) - Diagnostic tests: cystoscopy is used to see any problem or can crush the stones so that patient can urinate them (required informed consent due to being invasive) - Intravenous pyelogram: to see the structures better, prior to this assess renal function and allergies (shellfish and iodine). BARIUM causes constipation - NPO 8 hours prior to IV pyelogram - KUB (kidneys, ureter and bladder) this is done without contrast. - UTIs: women are prone, sexually active, postmenopausal women (loss of estrogen), foley catheter, clients with diabetes mellitus (due to high concentration of sugar, and bacteria multiplies due to liking sugar), elderly (urine stasis, less usage of restroom to empty bladder) - Patient education to avoid UTIs: wipe front to back, take showers not bath, void after sex, increase fluid intake, wear cotton and loose underwear, avoid bubble baths, avoid perfume. - Cystitis: inflammation of the bladder - If UTI travels to kidneys it can cause flank pain on CVA - Treatment: analgesics, antibiotics, patient education, fluids (hydration) - Condom Cath: not invasive, does not require doctor orders has to be applied on a daily basis (so check skin integrity everyday) - Intermittent: for short drainage (like after surgery, for specimen, or neurological disorder-like spinal cord injuries) - Indwelling: long periods, continuous drainage, can measure strict I&O, higher risk for CAUTI - 3 WAY- catheter for irrigation: helps with getting rid of the urine as well as flushing of blood clots that can stay in the bladder - Suprapubic: for long term, catheter is directly placed onto bladder, for use of patient who have had any trauma or anything preventing them from urinating through the urethra - For prevention of CAUTI of foley: make sure that the need of using the foley is critical everyday (we want to get rid of it). Keep drainage bag below bladder, do not open the close system it can cause a risk of bacteria going in. - Nursing care for incontinence: assess skin integrity, maintain skin dry and clean, and have a baseline of skin. - Encourage fluid intake to avoid constipation, maintain I&O - Treatment for incontinence: Kegel exercises to tighten pelvic muscles, oxybutynin (lessens the detrusor muscle, teach bladder retaining programs (try to do it on intervals so that you promote a more accurate timing of pee. Hourly rounds to see if they want to go to the restroom. - For patients with renal failure they have to go into dialysis in order to remove excess fluid in the body (peritoneal is done at daily basis at night, and the fluid gets drained this needs to be a surgical asepsis technique because its going into the peritoneal cavity), hemodialysis is directly placed onto a graft or fistula so that blood is circulated and the rest of the fluid gets excreted, done 3 times a week and patient has to go to a center. - Patients on dialysis are usually on a fluid restriction, and make sure to not take BP on the arm that the patient has the fistula or the graft for the dialysis. - Empty ostomy bag 1/3 full, so when bag reaches 1/3 you need to empty it, ostomy should look beefy red, moist and clean. Sensory Function - Keep client safe and free from injury - Vision loss can be partial or total - Risk factors: glaucoma (increase IOP), presbyopia (loss of vision with age), cataracts (opacity of lens), diabetic retinopathy (nerve damage), macular degeneration (central vision loss) - S/S of poor vision: eye strain (pain). Blurred vision, poor judgement of depth, poor hand-eye coordination - Snellen chart: used for visual acuity, held away at 20 feet - Tonometry: used to measure eye pressure - Ophthalmoscopy: used to detect and evaluate symptoms of retinal detachment or eye diseases - Nursing interventions for vision problems: keep a clear walking pathways, ensure the room is well lit, keep their belongings close, stairs should have secure handrails, ensure the patient is using their corrective devices, provide enlarged print (so the ones with partial vision loss can still see something - Ophthalmologist visits every year - Hearing loss: conductive (outer or middle ear), sensorineural (inner ear-such as cochlea, 8^th^ cranial nerve) - Otosclerosis: fusion of bones in the middle ear - S/S of hearing loss: tinnitus, dizziness, speaks loudly, does not respond to verbal sounds - Diagnosis: audiometry, tympanogram (assessing the middle ear), otoscope (color of the tympanic), RINNE (mastoid to see if air or bone conduction), or WEBER to see where it lands - Nursing interventions: provide visual aids and written, minimize background noises, check hearing of clients receiving ototoxic medications, ask for a sign language if needed (when asking for informed consent), speak slowly and clearly (not loudly). - Teach clients to cover their ears if going into shower, and to open their mouth when sneezing so no pressure is created into the ear. - Decrease sense of touch, s/s numbness, tingling, lack of sensation, burning sensation - Risk factors for decreased sense of touch: stroke, diabetes, age, limb, amputation, trauma, spinal injuries, meds - Diagnosis: nerve function test, blood test, monofilament testing (done to test nerve damage, with a little string touching the sole of the foot) - Nursing intervention: assess for injuries and breakdown of skin, label the faucets in order to prevent burning or extreme cold, teach patients regarding diabetic foot care, encourage use of assistive devices if needed. - Decrease smell: can be due to exposure to chemicals, nasal polyps, irritation, allergies, disease - Nursing interventions: remove unpleasant odors, protect nose from toxic fumes, avoid HCP using strong perfumes; make sure smoke and carbon monoxide alarm is placed at home and work, follow up with HCP if alterations in smell. - Decrease taste: the smell and taste go hand by hand, can be caused by meds, smoking, diseases chemo (can cause blisters in mouth), decrease in b12 deficiency (glossitis) - Provide good oral care 2-3 times a day because it can help with appetite, make sure they read expiration dates to avoid ingesting rotten meals, enhance taste with use of spices, encourage patient to visit the dentist at least 2 times a year - Sensory overload: excessive, sustained multi-sensory stimulation, can lead to anxiousness, stress, panic, rapid mood changes and restlessness - Nursing interventions: try to avoid environmental noise, avoid crowding the patient, don't schedule a lot of activities in short periods of time, speak calmly, provide periods of rest, reduce stimuli, provide simple explanations prior to doing something. - Sensory deprivation: we need sensory stimulation for our brain to keep working, processing and functioning. This can be when patients are not alert or awake or are isolated. Some risk factors are isolation, patients with spinal cord injuries, brain damage, patients with monotonous environment, patients with sensory alterations, medications that depress the CNS. Can lead to confusion, anxiety, hallucinations or depression - Nursing interventions: we want the patient to be alert in order to get stimulation, talk to them, read to them, orient them to the environment, self-stimulation like reading, maintaining sufficient sensory stimuli, provide emotional support - Patients with altered cognition: patients that receive a different message than the rest. - In case of confused patient: speak calmly, slowly, face to face contact, reorient them, assist the patient in anything they are not able to do. - In case of unconscious patient: do not assume patient is unable to hear you, speak to the patient in normal voice and use sense of touch often, speak to patient before touching (tell them what is happening), keep environment low of noise Bowel elimination - Chyme is partially digested food - Small intestine: digestion of food, and absorbs the nutrients into the blood stream - Large intestine: absorption of water, make some vitamins, K and B, formation of feces and expulsion of feces - Parasympathetic stimulates the movement - Sympathetic prevents the movement - Peristalsis: squeezing the intestines trying to push out the contents into finally being excreted, normal peristalsis is every 3-12 minutes - Infants have a lot of stools during the day - Breastfeed infant: 1-10 stools a day yellow and liquidly - Formula fed infant: 1-2 stools and stools are pasty and brown - 2-3 years old is when babies mature their GI and gain function of their anal sphincter - Bowel elimination, patterns depend on other factors - To promote stools: 25-35 grams of fiber a day, and 2-3 liters of water to promote elimination (walk, water, fiber) - Psychological factors can affect the stools: like constipation or diarrhea - Ribbon like stool: tumor in the stomach - Cystic fibrosis can be indicated when there is steatorrhea - Diverticulitis can happen when episodes of diarrhea or constipation (alternating) - Irritable Bowel Syndrome (IBS): 8-10 bloody stools in a day - Contact precautions with c-diff - Upper GI bleed stools will be black - Lower GI bleed stools will be bright red - Antibiotics can cause change stool into a more greenish color, antacids containing aluminum can cause constipation - Chronic use of laxatives can weaken the intestines and in the long-term causing the patients to end up with more constipation - Barium can cause constipation - In colonoscopy we need the bowel clean we will use polyethylene glycol that can cause diarrhea to get rid of contents - Paralytic ileum: usually return 3-5 days after surgery, (if not resolved can lead into obstruction, or you can use metoclopramide to promote peristalsis - Assessment of bowel pattern: COCA assesses perianal area, IAPEP, medications, changes in pattern, appearance of stool, at what time do they usually use restroom. - Stool collection: too see for any pathogens, medical asepsis (do not collect urine poop or water from bathroom, soap, toilet paper) - Guaiac test: blue indicates positive (avoid cross contaminations, like for example if they have hemorrhoids, periods) - Endoscopic: EGD (esophagus, gastro and duodenum) - Sigmoidoscopy: goes into the lowest part of the colon (large intestine), which is sigmoid colon shaped like an S-section connects to the rectum - Endoscopy: goes into the upper portion of the colon (both need NPO 8 hours prior) - After oscopy: NPO until gag reflex has returned - Laxative after barium to get rid of it and avoid impaction - Enemas require doctor's order: assess anal and for rectal surgeries, and check for trauma - Cleansing enema: to clean colon, relieve constipation or impaction, during bowel training programs, to promote visualization of intestinal tract. Examples: tap water, normal saline, soap solution, hypertonic - Oil retention enema: to lubricate stool, "retain solution" often used with digital removal of fecal impaction, medicative, purpose is just to retain and lubricate. - Sims, on the left side right leg forward - Lubricate rectal tip - Do not do it to fast - Bag 12-18 inches above hip level, the higher the bag the higher the rate - Assess HR and vital signs during enema insertion to see vagus nerve stimulation - NGT can also be used for relieving of bowel obstruction; irrigation 30-60mL every 4 to 8 hours; stomach pH is 4-5.5 - Ileostomy: stool liquidly, does not need to be irrigated; colostomy is formed - Ostomy care: empty when it gets 1/3 full, keep odor-free, note color, size and consistency, maintain skin around the stoma dry and clean. COCA should normalize within 6-8 weeks, avoid fiber the first 6-8 weeks because it can cause the stoma to get overloaded; encourage fluid intake, ONLY 1/8 of inch should be exposed. - Inverted or protruded stoma is NOT okay (can only be protrude ½ an inch out) - They should also avoid anything that can make them gassy, when after surgery I&O measure every 4 hours the first days after - Patient education regarding ostomy, make sure they are able to look at their stoma. Fluid and electrolytes - ICF: 2/3 (intracellular) - ECF: 1/3 (intravascular-blood, interstitial- around the cell like lymph, and transcellular fluid-around the organs like pericardial pleural, biliary, peritoneal, synovial) - Dehydration: not enough intake, or the body is excreting too much water - Hypovolemia: loss of electrolytes and fluids; all labs are going to go upo, hypothalamus activates the thirst instinct, ADH signals the kidneys to stop retaining water and the urine starts to get concentrated. - Causes: diuretic therapy, burns (3^rd^ spacing coming out of the cell-like ascites that lodges into the tissue), patient is not eating or drinking enough - Hypovolemic = hypothermia - Hyperthermia = overload - Severe dehydration can lead to seizures, thirst, weight loss, decreased cap refill, poor skin turgor, HCT increased, BUN increased, glucose is increased and protein as well - Nursing interventions for dehydration: check temperature, ABCs, weight 1kg= 1L of fluid, weight patient daily, accurate I&O, control nausea vomiting and diarrhea to avoid further dehydration, provide IV hydration, monitor LOC (in dehydration they will be confused) - Thirst mechanism is decreased in older adults. - Overhydration: not getting rid of it, or intaking too much - ADH hormone will be: lessen causing the fluid to buildup since it's not being excreted. - BNP hormone released by the heart to tell kidneys to excrete - BUN is a waste product of the kidneys to remove products. Indicates function of the kidneys - Overhydration labs would go down: BUN, hct, UsG, osmolality, sodium goes down (labs are diluted) - Nursing interventions with over hydration: assess vital signs, heart sounds (crackles), lung sounds, daily weight, edema, accurate intake and output, restrict fluids, restrict sodium, (too avoid more retention), administer diuretics, turn them every 2 hrs, avoid diuretics at night and assess BP to see they are not dropping - ABG's: lungs work by excreting or retaining CO2 (respond faster to compensation) - Kidneys work by excreting or retaining bicarb - Metabolic alkalosis: when you vomit too much (losing acid), then the body will compensate by retaining bicarb which means the lungs will retain CO2 - Metabolic acidosis: the body is not having enough bicarb which means the lungs will have to excrete CO2 - Respiratory alkalosis: the body will need to retain CO2 TO COMPENSATE, kidneys will need to release bicarb - Respiratory acidosis: the body needs to get rid of CO2 TO COMPENSATE the kidneys will need to keep bicarb - SODIUM: 135-145 level - Hyponatremia: diluting sodium, diarrhea, excessive water intake, vomiting. Manifestation is confusion, cerebral edema (because the water will try to compensate with fluids the vital organs) They will have anorexia, muscle cramp, seizures, dry skin, low BP. You should give them hypertonic solutions and iv fluid solutions and salt - Hypernatremia: excessive salt intake, not excreting fluids, fever, burns, diaphoresis, diarrhea. Manifestations: thirst (because they have so much salt-think when like eating popcorn). They will also have seizures, decrease loc, high temperature, red swollen tongue. You should give them water (to dilute), low sodium diet and diuretics to excrete. - POTASSIUM 3.5 TO 5 - hypokalemia: not enough vitamin k intake, vomiting, gastric - suctioning, alkalosis (because they are getting rid of the potassium in the suctioning). Manifestations: muscle weakness and cramps, CARDIAC dysrhythmias, paresthesia (burning sensation). You should give them: foods high in K, sodium IV (NEVER IV PUSH POTASSIUM) - Hyperkalemia: eating too much K, renal failure (not excreting), use of Aldactone (potassium-sparing diuretics) Manifestations: skeletal muscle weakness, paralysis, nausea, CARDIAC DYSRHYTMIAS. You should give them: loop diuretics (to get rid of it). sodium polystyrene sulfate (causes the GI system to combine and exchanges sodium with potassium) - Calcium 8.9 to 10.2 - Hypocalcemia: eating too low vitamin D or malabsorption (like Crohn's disease) Manifestations: numbness or tingling in toes and fingers, MUSCLE CRAMPS or twitching. You should give them iv calcium, vitamin d supplement, foods high in calcium. Tests: Chvostek (face nerve), tetany (intermittent muscle spasms, trousseau sign (when they take bp the hand twitches) - Hypercalcemia: usually due to cancer or hyperparathyroidism. Manifestations: lethargy, high risk for kidney stones (due to calcium deposits). You should restrict them in calcium, increase fluid intake to get rid of the calcium by urine. - Magnesium 1.3 to 2.3 (neuromuscular function) - hypomagnesemia: excreting too much, not consuming enough, nasogastric suctioning, sepsis, burns. WITHDRAWAL OF ALCOHOL (alcohol gets rid of your - magnesium). Manifestations: hyperactive DTR (magnesium is neuromuscular-inverse relation). You should: give mg replacement in iv or foods high in magnesium - Hypermagnesemia: usually with renal failure, or excessive intake (like milk of magnesia). Manifestations: absent DTR, n/v, cardiac arrest. You should: give loop diuretics, calcium gluconate (if severe cardiac changes) - Solutions: isotonic: same equal as the concentration of particles as plasma D5W, 0.9% NS, and lactated ringers - Hypertonic: high concentration of particles than plasma - such as D5NS, D5 0.45NS, TPN - Hypotonic: lesser concentration of particles than the plasma 0.33%NS, 0.45% NS - Implanted ports: for continuous usage, like people who are on chemo and need constant iv access (so they don't poke them every time) - Phlebitis: redness, warm to touch - Infiltration: cool to touch, pallor - Extravasation: edema, burning sensation - We can't give blood without doctors' orders, witness informed consent. Only normal saline to prime - 2 nurses should check that everything regarding a blood transfusion is fine - Nurse needs to stay the first 15min when giving blood (look for fevers, low back pain- this is sign of hemolytic reaction meaning blood given did not match the antigens of RH + and they probably had Rh - of vice versa, shivers, anxiety) - ONLY HANG BLOOD for 4 hrs, discard and document the rest. LOSS - Grief: internally expressed - Mourning: outside expressed - Bereavement: period od time the person spends grieving or mourning Kubler Ross Model 1. Denial 2. Anger 3. Bargaining 4. Sadness 5. Acceptance LOSS - Medical criteria for death: No activity in ECG, no reflexes, no breathing, no response to pain stimuli - Impending death: dysphagia, dysphasia, Low body temperature, low BP, nausea, flatus, incontinence, cyanosis, weak and irregular pulse, restlessness and agitation, Cheyne-Strokes respiration - Good death: less pain as possible, controlling symptoms, stopping labs, comfort measures, assess for any spiritual concerns (following patient wishes at the end so that they are able to die in peace) family education od s/s of impending death - Palliative care: providing comfort, emotional support - Hospice Care: Less than 6 months, stop treatment that is curative only comfort measures - Advanced directives: durable power of attorney - After the client has been pronounced dead, the nurse is responsible for preparing the body. Family members may need to see the client\'s body to accept the death fully; allow them to see the client\'s body before discharging to the mortician. The body is placed in a normal anatomic position (flat) to avoid pooling of blood. In most cases it is unnecessary to wash the body, and some religions strictly forbid it. The nurse is legally responsible for placing identification tags on either the shroud or garment that the body is clothed in, and on the ankle to ensure that the body can be identified even if separated from its shroud. - The taking of all opioids and stimulants is prohibited in the Adventist religion because it is believed that the body is the temple of the Holy Spirit and should be protected. The other religions allow opioid use. - Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people. - Some groups, such as Christian Scientists and the Amish, have been legally exempted from immunizations; however, many medical decisions are reviewed on a case-by-case basis depending on the client\'s age and imminence of death.