NUR 112 Exam 4 Review - Mobility, Oxygenation, Elimination, and Infection Control PDF

Exam 4 Review session By: Ashley Hotaling  Overview Mobility Elimination Gas Exchange Infection Control  Mobility Refers to acts of MOVEMENT Levels of Mobility Mobility: state or Impaired physical...

Exam 4 Review session By: Ashley Hotaling  Overview Mobility Elimination Gas Exchange Infection Control  Mobility Refers to acts of MOVEMENT Levels of Mobility Mobility: state or Impaired physical mobility: limitation Immobility: inability quality of being in physical to move mobile or movement but is moveable not immobile MOBILITY Disuse syndrome: predictable adverse Deconditioned: effect on body loss of physical tissues and fitness functions r/t inactivity  Key Terms Muscle Contraction a shortening or tensing of a muscle the ability of a muscle to contract or shorten and thereby Contractility exert force the tissue's ability to return to normal resting length when Elasticity a stress that has been placed on it is removed Substance that results from metabolism in anaerobic Lactic Acid (lacking O2) causes muscle weakness  Types of Movement Main difference is the size of muscles used GROSS MOTOR FINE MOTOR MOVEMENT MOVEMENT Uses large muscles to Uses smaller muscles perform general to perform smaller, movements precise movements Walking, crawling, Hands, fingers, wrists, sitting ankles, feet, toes Writing, drawing  sternum skull Bones are Storage spine scapula Centers humerus ribs radius pelvis BONES SERVE AS STOREHOUSES FOR TWO MINERALS: CALCIUM AND ulna PHOSPHORUS. femur tibia patella fibula Functions of Bone Movement BLOOD FORMATION: RBC, Protection WBC, PLATELETS ARE MADE IN BONE MARROW Support Bone Regulation WHAT DOES BONE STORE AGAIN? Calcium and Phosphorus also to a lesser extent Magnesium + Fluoride WHY IS VITAMIN D NEEDED FOR BONE HEALTH? It helps your body better absorb Calcium → ↑Ca2+ → stronger bones WHAT IS PARATHYROID HORMONE (PTH)? Secreted by the parathyroid glands. PTH levels are inverse to Calcium levels. So, if ↓ calcium levels → ↑PTH → Bone Resorption (breakdown) → Calcium leaves bone → ↑Calcium levels in the blood  Types of Bones Bones are classified according to their shapes. LONG BONE SHORT BONE Cylindrical Acts as a lever and Small and compact helps support the Designed for strength weight of the body and stability Lengthen in Bones in wrist, ankles carpal femur childhood bone Bones in arms, legs  Types of Bones Bones are classified according to their shapes. FLAT BONE IRREGULAR BONE Has a flat surface Has a complex shape Serves as a protector Has a variety of and a point of muscle functions, such as attachment protection and providing support scapula vertebra  Fractures Interruption in the continuity of a bone  Atrophy Hypertrophy Loss of muscle mass An increase in total (weakening) mass of a muscle  TYPES OF MUSCLES Voluntary control Skeletal muscles that are attached to the skeleton, provide movement + posture Smooth Located in walls of hollow visceral organs (liver, pancreas etc.), involuntary movements Involuntary control Cardiac Located in the walls of the heart, pump blood  what are Joints? FORMED WHERE TWO OR MORE BONES MEET AND PROVIDE A VARIETY OF RANGES OF MOTION allow movement between bones  What is cartilage softer and more flexible than bone RESILIENT, FLEXIBLE CONNECTIVE TISSUE FOUND IN VARIOUS PARTS OF THE BODY, INCLUDING JOINTS, EARS, AND NOSE CARTILAGE FACTS: 1.SERVES AS A CUSHION BETWEEN BONES → FLEXIBLE + SHOCK-ABSORBING 2.PROVIDES STRUCTURE 3.AVASCULAR (NO BLOOD SUPPLY)  Tendon vs ligament TENDON LIGAMENT Connects muscle to bone Connects bone to bone T= Two= connects TWO DIFFERENT BBL= Bone, Bone, Ligament structures  Strain vs Sprain STRAIN SPRAIN Excessive stretching of a muscle or Excessive stretching of a ligament tendon MSK + Nervous System Overlap The MSK and Nervous System work together! ⚬ The nervous system sends signals to muscles through nerves ⚬ This triggers the muscle to contract, which results in physical movement Balance is controlled by the cerebellum + inner ear  Is their gait steady 1 OBSERVE GAIT AND Normal: Ambulate with even, POSTURE smooth, painless gait Inspect joints, muscles, and 2 INSPECT extremities for size, symmetry, and color. MSK PHYSICAL ASSESSMENT Palpate joints, muscles, and 3 PALPATE extremities for tenderness, heat, nodules, or crepitus Test by having the person push or 4 MUSCLE STRENGTH pull against resistance and grade their ability to overcome it Active: person moves the joint 5 RANGE OF MOTION Passive: movement applied to a (ROM) joint by another person  Posture abnormalities KYPHOSIS LORDOSIS SCOLIOSIS Increased thoracic curvature of the spine Exaggerated lumbar curve Lateral curvature of the spine may be normal for older adults often seen during pregnancy or in obesity often seen in children Types of joints based on mobility DIARTHROIDAL (SYNOVIAL) Characteristics: ⚬ Lined with Synovium: Unique to synovial joints, this membrane secretes synovial fluid. ⚬ Function of Synovial Fluid: Provides lubrication and shock absorption. Bursae: ⚬ Definition: Sacs filled with synovial fluid. ⚬ Purpose: Facilitate smooth movement of joint structures and allow tendons to slide easily during bone movement. SYNARTHROIDAL AMPHIARTHROIDAL Completely immovable Slightly Moveable  Ball-and-Socket Ball-and-socket joints consist of a spherical head of one bone fitting into a cup-like depression of another bone. The shoulder joint is a classic example of a ball-and-socket joint; the head of the humerus forms the "ball" part of the joint, while the shallow, cup-shaped glenoid cavity of the scapula serves as the "socket."  Hinge Joints Hinge joints allow movement primarily in one plane, like a door hinge, permitting only flexion and extension. The elbow joint is a hinge joint formed by the articulation of the humerus (upper arm bone) with the ulna and radius (forearm bones). It allows for movements like flexion and extension of the arm.  Pivot Joints Pivot joints, also known as rotary joints, are a type of synovial joint in the human body that allow rotational movement around a central axis. The atlantoaxial joint between the first and second cervical vertebrae (C1 and C2) is a pivot joint. It allows for rotation of the head from side to side, such as when shaking the head "no."  Condyloid Joints Condyloid joints allow movement in two planes, primarily flexion and extension, as well as some abduction and adduction. The radiocarpal joint in the wrist is a condyloid joint formed by the articulation of the radius and a row of carpal bones. This joint allows for flexion, extension, abduction, and adduction movements of the hand.  Saddle Joints Saddle joints are similar to condyloid joints but have a greater range of motion. They allow for flexion, extension, abduction, adduction, and circumduction. The carpometacarpal joint of the thumb is a saddle joint, where the trapezium bone of the wrist articulates with the first metacarpal bone of the thumb. This joint allows for various movements.  Gliding Joints A gliding joint is a type of synovial joint in the human body characterized by the sliding or gliding movement of the articulating surfaces of bones. Intertarsal joints allow for subtle gliding movements between the tarsal bones. These movements contribute to the flexibility of the foot, facilitating actions such as walking, running, and balancing. Neurovascular Assessment  Expected MSK Changes in Children Expansion of the Need adequate Spinal changes during Skeletal Muscle Fibers ↑ Epiphyseal Plate in Calcium for bone infancy from a C-Shape in Circumference and Long Bones increases growth to toddler years S- length child's height Shape  Bone Density decreases as Bone Resorption increases, and Bone Growth decreases throughout adulthood. Expected MSK Muscles atrophy with age, reducing muscle Changes in contraction strength and speed, ↓size Older Adults Tendons and Ligaments lose elasticity, strength, and hydration leading to reduced range of motion and flexibility of the joints  Body System Effects of Immobility System Effects of Immobility Risk for orthostatic hypotension, Blood flow and oxygenation, Risk for Cardiovascular System venous thrombosis Respiratory System Pooling of secretions, Rate of CO2 excretion, Impaired gas exchange Altered protein metabolism, Altered digestion and utilization of Gastrointestinal System nutrients, Peristalsis Urinary stasis, Efficiency in maintaining fluid/acid-base balance, Risk for Urinary System renal calculi Muscle atrophy, Bone demineralization, Endurance, stability, Risk for Musculoskeletal System contracture formation Risk for electrolyte imbalance, Efficiency of body temperature Metabolic System regulation, Altered exchange of nutrients and gases Integumentary System Risk for skin breakdown and formation of pressure injuries Psychological Well-Being Sense of powerlessness/Risk of Depression, Altered sleep-wake pattern  BODY SYSTEM EFFECTS OF EXERCISE EFFECTS OF IMMOBILITY ↑ Efficiency of heart ↑ Cardiac workload Cardiovascular System ↓ Resting heart rate and blood pressure ↑ Risk for orthostatic hypotension ↑ Blood flow and oxygenation ↑ Risk for venous thrombosis ↑ Depth of respiration ↓ Depth of respiration ↑ Respiratory rate ↓ Rate of respiration Respiratory System ↑ Gas exchange at alveolar level Pooling of secretions ↑ Rate of CO2 excretion Impaired gas exchange Disturbance in appetite Gastrointestinal System ↑ Appetite Altered protein metabolism ↑ Intestinal tone Altered digestion and utilization of nutrients ↓ Peristalsis Urinary System ↑ Blood flow to kidneys ↑ Urinary stasis ↑ Efficiency in maintaining fluid/acid–base balance ↑ Risk for renal calculi ↑ Efficiency in excreting body wastes ↓ Bladder muscle tone ↑ Muscle efficiency ↓ Muscle size, tone, and strength ↑ Coordination ↓ Joint mobility, flexibility Musculoskeletal System ↑ Efficiency of nerve impulse transmission Bone demineralization ↓ Endurance, stability ↑ Risk for contracture formation ↑ Efficiency of metabolic system ↑ Risk for electrolyte imbalance Metabolic System ↑ Efficiency of body temperature regulation Altered exchange of nutrients and gases Integument Improved tone, color, and turgor r/t improved circulation ↑ Risk for skin breakdown and formation of pressure injuries Energy, vitality, general well-being ↑ Sense of powerlessness/Risk of Depression Improved sleep ↓ Self-concept Improved appearance  Friction Shear Mechanical force Mechanical force when skin is dragged exerted parallel to to across a coarse the skin or body’s surface Forces that can surface. Ex. Rug burn damage skin Ex. HOB elevated and causes sliding lower spine presses down compromising blood supply  Key Assessments for immobility Metabolic Assessment: Monitor anthropometric measurements and intake/output to check for dehydration. Respiratory Assessment: Inspect chest movement and auscultate for breath sounds (decreased, crackles, wheezes). Cardiovascular Assessment: Measure vital signs, peripheral and apical pulses, and assess for orthostatic hypotension, DVT, and edema. Watch for embolus risks impacting circulation and oxygenation (tachycardia, shortness of breath). Musculoskeletal Assessment: Evaluate muscle strength, tone, mass loss, contractures, and range of motion (ROM). Skin Assessment: Check for integrity and early changes in skin condition. Elimination System Assessment: Monitor intake/output, bowel sounds, and bowel/bladder habits.  Nursing interventions for immobility Respiratory Needs Cough and deep breath every 1 to 2 hours, Incentive Spirometer Sit up ASAP Provide chest physiotherapy Metabolic/Nutritional Needs Provide high-protein, high-calorie diet with vitamin B and C supplements Assist with toileting Serve a diet rich in fluids, fruits, vegetables, and fiber Cardiovascular Needs Compression Devices Dangling Progress from bed to chair to ambulation Restraints  Instrumental Activities of Daily Basic Activities of Daily Living Living (IADLs) (ADLs) Basic self-care tasks More complex, require thinking skills Usually learn as a young child Usually learn as teenagers Include: Include: Bathing Shopping Dressing Cooking Toileting Cleaning Grooming Banking Transferring Using the telephone Feeding Managing medications  Nursing interventions for immobility Respiratory Needs Cough and deep breath every 1 to 2 hours, Incentive Spirometer Sit up ASAP Provide chest physiotherapy Metabolic/Nutritional Needs Provide high-protein, high-calorie diet with vitamin B and C supplements Assist with toileting Serve a diet rich in fluids, fruits, vegetables, and fiber Cardiovascular Needs Compression Devices Dangling Progress from bed to chair to ambulation Restraints  Compression devices Purpose: DVT Prevention: Both graduated compression stockings and Sequential Compression Devices (SCDs) exert pressure on lower leg veins, promoting blood return to the heart and reducing the risk of blood clots. Care Tips: Regularly check feet and toes for color, temperature, mobility, sensation, swelling, and pain. (Neurovascular assessment= 6Ps) ⚬ Every 8 hours or 2x/day Make sure the patient has been sitting or lying down for 15 mins before putting them on. ⚬ Make sure legs are dry Contraindications: Avoid in clients with ulcers, dermatitis, or impaired arterial circulation. Safety: Lock bed wheels and lower side rails during application.  Application of Compression Devices Applying Graduated Compression Stockings 1.Lock bed wheels; raise bed to a comfortable height; lower side rails. 2. Position client supine and expose one leg. 3.Steps: ⚬ Turn stocking inside out to heel; slip over foot, ensuring heel pocket is positioned. ⚬ Pull up the stocking, checking for twists or wrinkles. 4.Repeat on the other leg. Applying SCDs 1.Remove sleeves from cover; unfold them. 2.Position sleeve under leg, aligning openings with ankle and knee. 3.Wrap sleeve and ensure fit (two fingers should fit between leg and sleeve). 4.Plug into air pump and activate; check for proper inflation/deflation.  Transfer from bed to chair Preparation: Lock bed brakes + lower bed to lowest position Place the chair next to the bed (on the patient’s stronger side) Positioning: Raise the bed to promote a standing position. Patient can place hands on the side rail or your shoulders. Your Position: Face the client with feet spread apart and knees flexed, maintaining a straight back. Patient Action: Instruct the patient to slide their buttocks to the edge of the bed until their feet touch the floor. Foot Placement: Place one of your feet outside of the patient’s feet. Standing: On the count of three, rock and assist the patient to stand. If the patient has a weak extremity, place your knee against it for support. Assess stability—if weak or unsteady, have them sit back down. Pivoting: Pivot on your back foot (opposite direction of the chair). Lift the patient’s foot in the direction of the chair. Seating: Back up until the patient’s legs touch the chair. Ask the patient to grasp the chair handles and lower themselves into the chair.  Gait Belts Purpose Function: A gait belt aids in transferring clients and assisting with ambulation, enhancing safety and stability. Application: Placed around the client’s waist over clothing to help with stability and repositioning in chairs or wheelchairs. Important Considerations Weight Bearing: Only use with clients who can bear weight; those who cannot require mechanical lifts. Contraindications: Avoid use with clients recovering from abdominal surgery or with severe cardiac or respiratory conditions. Applying the Gait Belt Positioning: Assist the client into a sitting position with legs hanging over the edge of the bed. Belt Placement: Wrap the belt around the waist, ensuring it’s not too tight and allows for finger clearance underneath. Safety Grip: Use an underhand grasp when holding the belt. Supporting the Client Stand on the client's weaker side, placing both hands on their waist for stability. Maintain an erect posture to prevent leaning to one side. Walk behind and slightly to the side of the client for better control.  Crutches Proper Fit Gap: 2-3 finger width (1-1.5 inches) between the axillae and crutch rest pad to prevent resting weight on the pads and avoid nerve damage. Elbow Position: Flexed at about 30 degrees when hands are on hand grips. Types of Gaits Tripod Position: Start position with crutch tips about 6 inches diagonally (in front and to the side) from feet. 1.Two-Point Gait: ⚬ Move injured crutch and non-injured leg simultaneously. ⚬ Then move non-injured crutch and injured leg together. 2.Four-Point Gait: ⚬ Move each crutch and leg separately: ￭ Right crutch → Left leg → Left crutch → Right leg.  Crutches Up and Down Stairs Going Up: ⚬ "Good = UP": Move the non-injured leg first, then crutches and injured leg. Going Down: ⚬ "Bad = Down": Move crutches down first, then the injured leg, followed by the non-injured leg.  Canes Purpose Balance Improvement: Canes widen the base of support, enhance stability during ambulation, and support the patient's weight, but they are not intended for full weight- bearing. Proper Fit Placement: Position the cane 4 inches to the side of the foot. Elbow Position: Flexed at 30 degrees when holding the cane. Posture: Stand erect and hold the cane in the hand on the strong side. Ambulation Technique 1.Advance Cane: ⚬ Move the cane forward 4-12 inches while supporting weight on the strong leg/hand. 2.Move Weak Foot: ⚬ Bring the weak foot forward parallel to the cane. 3.Weight Shift: ⚬ Support weight on the weaker leg and cane. ⚬ Advance the stronger leg ahead of the cane (heel slightly beyond the tip of the cane). 4.Repeat: ⚬ The weaker leg is moved forward until even with the stronger leg, then advance the cane again. Memory Trick "Cane Comes First": Remember to advance the cane before the weaker leg.  Positioning Turn every 2 hours to prevent pressure ulcers Maintain body in alignment Provide skin care  Pressure Ulcers Injuries to the skin and underlying tissue caused by prolonged pressure, restricting blood flow. Contributing Factors: Poor nutrition Impaired blood flow Lack of mobility Old age Decreased sensation Stages: Inflammation: The ulcer begins with redness and swelling, particularly over bony prominences. Ischemia: ⚬ Occurs when external pressure exceeds the pressure within small peripheral blood vessels. ⚬ This restricts blood flow to the skin and underlying tissues.  ANALGESICS: Opioids Depressants → SLOW everything down Examples: ⚬ Morphine ⚬ Meperidine (Demerol) ⚬ Hydromorphone (Dilaudid) ⚬ Oxycodone (Percocet) ⚬ Hydrocodone (Lortab) Side Effects: ⚬ Slows GI system → Constipation. ⚬ Slow vital signs → bradycardia, hypotension, bradypnea ￭ Depress respiratory system → watch for respiratory depression ￭ Hypotension: sit or lie down if dizzy; make position changes slowly ⚬ Sedation: caution with activities that require alertness; avoid alcohol  ANALGESICS: Non-Opioid Examples: ⚬ NSAIDs (Ibuprofen, Naproxen, Ketorolac/Toradol) ⚬ Acetaminophen (Tylenol) Key Considerations: ⚬ Nephrotoxicity → N in NSAID → Nephrotoxic ⚬ NSAIDs → watch for GI bleeds ￭ Caution if have gastritis, GI ulcers ⚬ Limit acetaminophen intake to 4000 mg per day d/t liver toxicity ￭ Assess if for alcoholism  ANALGESICS: Muscle Relaxants Examples: ⚬ Gabapentin (Neurontin) ⚬ Cyclobenzaprine (Flexeril) ⚬ Carisoprodol (Soma) ⚬ Baclofen Key Considerations: ⚬ Watch for respiratory depression, dizziness, and drowsiness. ￭ Diaphragm is the muscle that helps support breathing → too relaxed → no breathing!!!!!!!  Restraints Types: Physical restraints: restrict client movement through the application of a device. Chemical restraints are medications given to inhibit a specific behavior or movement. Nursing Assessment: Every 15/30 mins 1.Assess skin 2.Assess neurovascular status 3.heck need to urinate 4.check ROM 5. offer fluids Key Considerations: LAST RESORT Must have an order specifying or have DR assess within 1 hour of application All patients with restraints= fall risk Do not attach the restraint to a side rail, bed rail, mattress, head/footboard, or anything that does not move with the patient.  GAS EXCHANGE Ashley Hotaling What is Gas Exchange? Gas exchange is the process by which oxygen is transferred from the lungs to the bloodstream and carbon dioxide is removed from the bloodstream to the lungs. Role of the Respiratory & Cardiovascular Systems in Oxygenation The respiratory system brings oxygen into the body and removes carbon dioxide through breathing. ⚬ The respiratory center in the brain: Medulla The cardiovascular system transports oxygen to tissues and removes carbon dioxide through the bloodstream. Involuntary process that is signaled because of CO2 and Hydrogen concentrations. ⚬ Interesting: O2 can signal breathing but to lesser extent Breathing Mechanism Inhaling: The diaphragm contracts and moves down, and the muscles between the ribs pull the rib cage up and out → ↑space/ volume in the chest cavity → ↓ pressure in chest cavity → pulls air into nose/mouth Exhaling: The muscles relax → ↓ space/ volume in chest cavity → ↑ pressure in chest cavity → air is forced out Breathing Mechanism Breathing Mechanism Breathing Mechanism  Ischemia Definition: Insufficient flow of oxygenated blood to tissues. Consequences: Can lead to hypoxemia, resulting in cell injury or death. Note: -EMIA= BLOOD!!!!!!  Hypoxemia Deficiency of oxygen in the blood. ↓O2 in BLOOD Impact: Insufficient oxygenation of tissues, leading to potential organ dysfunction. Note: -EMIA= BLOOD!!!!!!  Hypoxia + ANoxia Hypoxia Definition: Inadequate amount of oxygen available to cells/tissues. Effects: Can impair cellular metabolism and function. Anoxia Definition: Complete lack of oxygen to body tissues. Severity: More critical than hypoxia, often resulting in rapid cell death. Tips for Skin Jaundice First Spot to See: Sclera of the eyes. Colors ↑ bilirubin Darker Skin Tones= look for yellowing in the sclera, oral mucous membranes, palms, and soles yellow to yellow-orange → appear Pallor First Spot to See: Lips, nail beds, mucous membranes, ↓ amount of blood or conjunctiva. hemoglobin/ lack of Darker Skin Tones: May appear ashen gray or yellowish in areas such as lips, nail beds, and mucous membranes. blood flow Cyanosis First Spot to See: Nail beds, lips, ears, and inside of the ↓ O2 in the blood mouth. Darker Skin Tones: May be observed as dullness rather than a blue tinge; check nail beds and mucous membranes. Breathing Patterns  Pulse Oximeter Provides an indirect measurement of oxygen saturation Arterial Oxygen Saturation: ⚬ Percent of hemoglobin bound with oxygen in the arteries. Normal Range: 95% to 100%; ≤90% indicates inadequate oxygenation. Considerations: ⚬ Assess hemoglobin levels; low levels can give false normal SpO2. ⚬ Adjust expectations for patients with chronic lung diseases (e.g., COPD). Early Signs of Respiratory Distress Tachycardia Tachypnea Hypertension (potentially) Restlessness, anxiety, confusion Pale skin, mucous membrane Use of accessory muscle, nasal flaring, adventitious lung sounds LATE Signs of Respiratory Distress Body is struggling to compensate!!! Bradycardia Bradypnea Hypotension Stupor/ Somnolence Cyanosis Dysrhythmias Everything ↓ slows down RESP DISTRESS: Pursed lip breathing Like blowing out of a straw Keep alveoli open longer and slow expiration→ combat air trapping COPD, asthma, emphysema, or CHF RESP DISTRESS: NASAL FLARING Common symptom of respiratory distress in CHILDREN Trying to open airway as much as possible RESP DISTRESS:TRIPOD POSITION  Chronic Gas Exchange Issues: Clubbing SCHAMROTH’S SIGN  Chronic Gas Exchange Issues: Barrel Chest Transverse > Anteroposterior Normal anteroposterior-transverse ratio = 1:2 Barrel Chest: 1:1 → COPD, Cystic Fibrosis  Oxygen Arterial pH Alert/Oriented Eupnea saturation 7.35-7.45 >94% Capillary refill Skin Color WNL Adequate thin respiratory secretions 2-3 L/ day ⚬ Contraindicated: ppl with heart issues, heart failure etc. Humidification Adding moisture to the air to prevent drying of the respiratory passages Vaporizers or Cool-Mist Humidifiers ⚬ prevent burns in children Must keep clean  Common Respiratory Meds Corticosteroids Name: Fluticasone propionate (Flonase) MOA: ↓ swelling or inflammation Mucolytics/Expectorant s Name: Guaifenesin (Mucinex) MOA: thinning, loosening and clearing out secretions from lungs Antihistamines Name: Diphenhydramine (Benadryl) MOA: to treat certain respiratory allergy symptoms Decongestants Name: Pseudoephedrine (Sudafed) MOA: shrink swollen nasal mucous membranes thereby increasing airway patency and reducing nasal congestion Bronchodilators Name: Albuterol PO & Inhalation MOA: Dilate or open up the airways SE= tremors, anxiety, insomnia, HA, palpitations, HTN, vomiting Nebulizers Delivers medication through high-flow oxygen or compressed air. Disperses fine particles for deep respiratory tract absorption. Treatment continues until the nebulizer cup is empty. Metered Dose Inhaler (MDI) 1.Twist canister > Shake well 2.Patient exhales 3.Place the mouthpiece into the mouth 4.Depress the MDI to dispense medication and immediately inhale slowly and deeply. 5.Holds breath for 5-10 seconds 6.Wait 1-5 mins b/w puffs 7.Repeat 8.Rinse MDI with soap and water or water after each dose Metered Dose Inhaler (MDI) Wait 1-5 mins between puffs Can use a spacer if have trouble Benefits of Spaces ⚬ Improve drug delivery ⚬ acts as a reservoir > makes it less complicated, dose more predictable > longer time to inhale ⚬ Remove after each use Dry Powdered Inhaler Patient Instructions Breathe Out: Exhale slowly and completely without inhaling into the DPI. Positioning: Place teeth over and seal lips around the mouthpiece. ⚬ Avoid blocking the opening with tongue or teeth. Inhale: ⚬ Breathe in strongly, steadily, and deeply through the mouth for 2-3 seconds. Breath Hold: ⚬ Remove inhaler from mouth and hold breath for 5-10 seconds, then exhale slowly through pursed lips. Post-Administration ⚬ Wait: 1-5 minutes as indicated before the next dose. ⚬ Replace Cap: After all prescribed puffs. ⚬ Rinse Mouth: Gargle with tap water. Diaphragmatic breathing Purpose: Strengthens the diaphragm, maximizes inhalation, and slows respiratory rate. Technique: 1.Sit upright or lie down. 2.Place one hand on the abdomen and one on the chest. 3.Inhale slowly through the nose, letting the abdomen rise. 4.Exhale gently, allowing the abdomen to fall. Benefits: Enhances lung capacity, promotes relaxation, improves oxygenation. Chest Physiotherapy Purpose: Techniques to eliminate secretions and improve respiratory function. Methods: Cough Assist: Helps patients expel mucus. Postural Drainage: Positions the body to promote mucus clearance. Chest Percussion: Clapping on the chest to loosen secretions. Vibration: Manual shaking to aid in secretion mobilization. Benefits: Loosens and mobilizes secretions. Increases mucus clearance, especially in patients with ineffective cough. Who requires Suctioning? Unable to expel or cough out secretions Increased respiratory effort Obvious secretions → moist lung sounds Hypoxia Reduced breath sounds How to suction? 1.Hyperoxygenate patient with 100% O2 2.Position: a. Unconscious: Side-lying b. Conscious: Semi-fowler 3.Insert 4.Withdraw while applying negative pressure (hold down valve) 5.Assess and give O2 Suctioning Guidelines 1.Max Suction Time: 10-15 seconds 2.Wait Time Between Passes: 30 seconds 3.Total Passes: Up to 3 times Indications to STOP Suctioning 1.Hypoxemia signs: 2.Cyanosis 3.Slow or rapid heart rate 4.Mucosal damage: 5.Bloody secretions Side Effects of Suctioning: Hypoxemia (removes O2 from airway) Hypotension Dysrhythmias Trauma to airway/mucosa Yankauers Suction = Mouth Only Artificial Airways Oropharyngeal and nasopharyngeal airway Endotracheal tube Tracheostomy tube Tracheostomy Definition: A surgical procedure where a hole is created in the neck and trachea. Process: ⚬ A tracheostomy tube is inserted into the opening. ⚬ The tube connects to a ventilator for breathing support. Duration: The tracheostomy tube can remain as long as necessary. It is not permanent and can be removed when no longer needed. Manual Resuscitation Bag AKA Ambu Bag Used during respiratory arrest Functions to provide high levels of oxygen concentration Consist of mask and inflating bag Promotion of Lung Expansion Ambulation Positioning Incentive Spirometry Incentive Spirometer Position: Sit in semi-Fowler’s or high Fowler’s. Seal: Cover the mouthpiece tightly. Inhale: Breathe in slowly through the mouth. Hold: Hold for 5 seconds. Duration: Use for 5-10 minutes every 1-2 hours. Exhale: Breathe out normally. If Lightheaded: Pause, take normal breaths, then resume.  Oxygen Therapy FiO2= Fraction of inspired oxygen in a gas mixture ⚬ Room air FiO2= 21% Oxygen Therapy (supplemental oxygen) increases the amount of oxygen that is transported to the blood. Oxygen is considered a medication. ⚬ Typically, an order is needed to apply oxygen. ⚬ An exception would be in an emergent situation where the patient’s oxygen saturation is rapidly decreasing.  Types of Oxygen Therapy Device Flow FiO2 Nasal Cannula 1-6 L/min 25-40% Face Mask 5-10 L/min 40-60% Face Tent 10-15 L/min 40% Venturi Mask 2-15 L/min 24-60% Non-Rebreather 10-15 L/min 80-95% High Flow Nasal Cannula up to 60 L/min 21-100%  Oxygen No smoking Safety Keep oils, grease, alcohol, and other flammable liquids away Keep oxygen at least 6 feet away from any source of fire and electric motors, heaters, hairdryers, etc. Do not use electrical equipment near oxygen Secure the oxygen tank in an upright position Avoid fire Monitor for oxygen toxicity  Partial and Nonrebreather Design: Contains 3-4 one- way valves. Function: Prevents exhaled carbon dioxide from entering the reservoir bag. Purpose: Ensures the patient inhales only oxygen, providing high concentrations for those in respiratory distress. Venturi Mask https://www.medsourcelabs.com/wp-content/uploads/2018/07/VENTURI-MASK.jpg http://www.non-change.com/en/product-413830/Venturi-Mask-Kit.html High Flow 4-6 L/min = 24-40% https://opentextbc.ca/clinicalskills/chapter/5-5-oxygen-therapy-systems/ Oxygen Toxicity SUBSTERNAL pain CRACKLES Non-productive cough Use lowest FiO2 possible Non-Invasive Ventilation CPAP= Continuous Positive Airway Pressure ⚬ Inhale/ Exhale: Constant set pressure BIPAP= Bi-Level Positive Airway Pressure Bi=Two= 2 pressure settings Inhale= Constant set Pressure Exhale: Lower pressure  Choking Complete Obstruction: ⚬ Client unable to speak or cough; may show universal choking sign. Immediate Action: Ask if choking. ⚬ Perform Heimlich maneuver (abdominal thrusts). If Unconscious: ⚬ Perform CPR Administering Cardiopulmonary Resuscitation Check victim for response Activate EMS Get external automated defibrillator Begin CPR ⚬ Chest compressions ⚬ Airway ⚬ Breathing ⚬ Defibrillation ASH LEY HOTAL IN G  Small Intestine Main site of nutrient absorption Digestion: Continues the process of breaking down food using enzymes from the pancreas and bile from the liver. Absorption: Nutrients, vitamins, and minerals are absorbed through the intestinal walls into the bloodstream. Structure: Composed of three parts: the duodenum (initial digestion), jejunum (nutrient absorption), and ileum (final absorption and connects to the large intestine).  Large Intestine Main site of water reabsorption Cecum: The first pouch of the large intestine, connecting the small intestine to the colon. It receives almost fully digested food. Colon: The longest part of the large intestine, responsible for absorbing water and nutrients, and passing waste to the rectum. It consists of four parts: ⚬ Ascending Colon: Located on the right side of the abdomen, leading to the hepatic flexure. ⚬ Transverse Colon: Crosses the upper abdomen, ending at the splenic flexure. ⚬ Descending Colon: Found on the left side of the abdomen. ⚬ Sigmoid Colon: Connects to the rectum, forming the last section of the colon. Rectum: The lower part of the large intestine (about 15 cm long) that stores waste until elimination through the anus. Anus: The opening at the lower end of the rectum, through which stool is expelled from the body.  Pancreas: Produces digestive enzymes (e.g., amylase, lipase, proteases) that help break down carbohydrates, fats, and proteins. ⚬ It also secretes bicarbonate to neutralize stomach acid in the duodenum. Liver: Produces bile, which aids in fat digestion and absorption. ⚬ Bile is stored in the gallbladder and released into the common bile duct, where it combines with pancreatic enzymes before entering the duodenum.  Vocab Defecation Constipation Diarrhea Peristalsis Process of bowel Passage of dry, hard Increased frequency Involuntary, wave- elimination; bowel fecal material and/or change in like movement of movement. stool consistency. gastrointestinal musculature  Vocab Fissure Fecal Impaction Flatus Occult Blood Linear break on the Collection of Intestinal gas. Blood present in margin of the anus hardened feces in minute quantities, the rectum that undetectable by the cannot be passed. naked eye Vocab Valsalva Maneuver 1 2 Paralytic Ileus Forcible exhalation against a Paralysis of intestinal peristalsis. closed glottis, increasing intrathoracic pressure.  Factors Affecting Bowel Elimination Age: Infants: ⚬ Breast milk stools: Watery and yellow-brown. ⚬ Formula stools: Pasty and brown. Toddlers: Bowel control typically achieved by ages 2 to 3. Adolescents: Increased gastric acid secretion and accelerated growth of the large intestine. Older Adults: Decreased peristalsis and relaxation of sphincters.  Factors Affecting Bowel Elimination Diet: Fiber Requirement: 25 to 38 g/day for healthy digestion. Constipating Foods: Cheese, lean meat, eggs, pasta, rice, white bread, iron, calcium. Laxative Effect Foods: Fruits, vegetables, bran, chocolate, spicy foods, alcohol, coffee. Fluid Intake: Requirement: ⚬ 2 L/day for females ⚬ 3 L/day for males Sources include both fluids and foods. Physical Activity: ⚬ Stimulates intestinal activity and enhances muscle tone → easier to defecation. Psychosocial Factors: ⚬ Emotional Distress: ↑ peristalsis → diarrhea Depression: ↓ peristalsis peristalsis → constipation  Tips to Increase Bowel Movements 25-35g of fiber Hydration: 2-3L Physical activity: at least 15 minutes Assessment Check for fluid deficit Inspect skin integrity around the anal area Collect a detailed history of diet, exercise, and bowel habits Monitor for constipation and/or diarrhea Perform a specimen collection for diagnostic testing as indicated  Aspirin & Anticoagulants: Pink, red, or black stool Iron Salts: Black stool. Effects of Bismuth Subsalicylate: Black stool. Medications Antacids: White discoloration or speckling. on Antibiotics: Green-gray stool Stool Fiber Indigestible part of plant foods that passes through the digestive system relatively intact Function: Unlike fats, proteins, or carbohydrates that are absorbed by the body, fiber: Increases stool size and weight, softening it for easier passage and reducing constipation. Absorbs water, helping to solidify loose stools and maintain overall bowel health.  Insoluble fiber Soluble Fiber Does not dissolve in water and Dissolves in water to promotes regular bowel form a gel-like movements by increasing stool substance. bulk. Benefits: Lowers Benefits: Helps alleviate blood cholesterol and Types of Fiber constipation and irregular stools. glucose levels. Sources: Whole-wheat flour, “Bulk” Sources: Oats, peas, wheat bran, nuts, beans, vegetables (cauliflower, green beans, apples, citrus beans, potatoes). fruits, carrots, barley Assisting with Fracture Pan Use: Bowel Raise the head of the bed to 30° for comfort. Movements If the client is unable to lift their hips, assist by rolling them onto one side, placing the bedpan, and rolling them back. Comfort Measures: Encourage clients to reduce stress by using an elevated toilet seat or a footstool. Safety Tip: Never leave a client lying flat on a regular bedpan. Post-Defecation Care: Always provide skin care to the perianal area after use. Fecal Occult Occult blood = blood not visible in stool but detectable with test. Blood (Guaiac) Test Use wooden applicator to place small stool samples on test card. Add developer ⚬ Blue color = positive for blood (cancer, hemorrhoids, ulcers). False positives: caused by red meat, citrus fruits, raw vegetables, certain medications. Stool for Culture, Culture= sample of the bacteria (e.g., from sputum, cell scrapings, urine, Parasites, and Ova stool) to be grown in a laboratory to determine the species of bacteria that causes an infection Wear gloves, use tongue depressor to transfer stool to container. Add developer ⚬ Blue color = positive for blood (cancer, hemorrhoids, ulcers). False positives: caused by red meat citrus fruits, raw vegetables, certain medications.  Constipation Symptoms: decreased bowel movements (BM), straining, pain, bloating, dry/hard feces, and irregular BM patterns. Causes: opioids, low fiber/fluid intake, inactivity, stress, anesthesia, dairy intake. Risks: can lead to increased intracranial/intraocular pressure, reopen wounds, trauma, arrhythmias. Nursing Care: Use bulk-forming products before stool softeners, stimulants, or suppositories. Enemas are a last resort. Laxative overuse weakens bowel response, leading to chronic constipation.  Types of Laxatives 1 2 3 Lubricants Bulk Stimulants Chemical Stimulants Increase stool size → Add Irritate the GI tract to push Lubricate the Intestines → bulk things along help stool pass smoothly Docusate sodium (Colace) Lubricating Laxative Stool softener, not a stimulant. Detergent action softens stool by increasing water and fat penetration. Takes 1-3 days to produce a bowel movement. Don’t use longer than 1 week without provider knowledge Common Uses: Patients who have constipation or need to avoid straining (heart conditions, surgery, hemorrhoids). Adverse Effects: Mild cramping, diarrhea, throat irritation (if oral). Stop if have severe cramping Magnesium Citrate Osmotic Laxative Indications: ⚬ Bowel evacuation for procedures ⚬ Removing ingested poisons Adverse Effects: ⚬ GI issues (diarrhea, cramping) ⚬ Dizziness, headache, sweating Contraindications: ⚬ Heart damage, heart block ⚬ Intestinal obstruction/perforation ⚬ Acute abdominal disorders Cautions: ⚬ Renal disease ⚬ Rectal bleeding Important Reminders Take with at least 8oz water Monitor for fluid/electrolyte imbalances Valsalva Maneuver Bears down to defecate ↑ pressure in abdomen & thoracic cavities, → ↓ blood flow → ↓ cardiac output, bradycardia Contraindicated if you have CV problems ⚬ Post-MI Random Fact: It can be used to treat a cardiac dysrhythmia called SVT (Supraventricular Tachycardia)! Impaction where hardened stool lodges in the rectum, causing discomfort and inability to pass stool Signs and Symptoms of Impaction: Loss of appetite Abdominal distention Cramping Continuous ooze of diarrheal stool Rectal pain Digital Rectal Examination: Position: Place the client on their left side with knees flexed. Procedure: Use a gloved, lubricated finger to loosen stool around the edges. Remove in small pieces, allowing rest as needed. Monitoring: Stop if heart rate drops significantly or if heart rhythm changes. Interventions: Manual Removal: If necessary, manually remove fecal impactions. Medications: Administer prescribed enemas, suppositories, or stool softeners to facilitate relief. Enemas A procedure that involves introducing fluid into the rectum to stimulate bowel movement. Procedure: 1.Perform hand hygiene and warm the enema solution. 2.Prepare the enema bag, fill tubing, and close the clamp. 3.Provide privacy and quick access to a commode. 4.Place absorbent pads under the client. 5.Position client on left side with right leg flexed. 6.Wear gloves, lubricate the rectal tube, and insert 3-4 inches (2-3 for children). 7.Open the clamp, raise the bag 12-18 inches above the anus. a. The HEIGHT of the enema determines how fast the enema enters the anus and the depth of cleaning 8.Ask the client to retain the solution as long as possible. Note: Have bedpan, portable toilet ~nearby~ Hemorrhoids Increased frequency or change in consistency of stools (loose) Pathophysiology: Increased stool frequency and liquid consistency due to rapid intestinal transit. Can lead to dehydration, acid-base imbalances, and skin breakdown. Nursing Interventions: Remove the cause of diarrhea when possible (e.g., medications like amoxicillin, metformin). Respond to call bells promptly. Administer medications to slow peristalsis and protect skin integrity. Effects of Diarrhea Dehydration ⚬ Weak, rapid pulse; hypotension; poor skin turgor; elevated body temperature Electrolyte Imbalance Fecal Incontinence Inability to control defecation, often due to diarrhea Determine causes (medications, infections, impaction). Provide perineal care after each stool and apply a moisture barrier. Consider a fecal incontinence pouch or bowel management system. Loperamide (Imodium) Antidiarrheal Short-term relief of diarrhea: slow peristalsis Adverse Effects: Constipation, abdominal pain, flatulence, N/V