Exam 1 Blueprint PDF

What I think may be important to know!! Asepsis Principles & Sterile Technique ● Major mode of transmission for pathogens identified in health care settings is unwashed hands of a healthcare worker ● Asepsis: prevention of infection or breaking the chain of infection ○ Medical asepsis: clean techni...

What I think may be important to know!! Asepsis Principles & Sterile Technique ● Major mode of transmission for pathogens identified in health care settings is unwashed hands of a healthcare worker ● Asepsis: prevention of infection or breaking the chain of infection ○ Medical asepsis: clean technique, involves procedures and practices that reduce the number and transfer of pathogens ■ Ex. hand hygiene, wearing gloves, giving a flu shot, nasogastric tubes ○ Surgical asepsis: sterile technique, practices used to keep objects and areas free from microorganisms THINK: surgeries require STERILE environment ■ Ex. urinary catheter, IV catheter, sterile dressing change ○ Proper hand hygiene includes ■ Moment 1 – before touching patient ■ Moment 2 – before clean or aseptic technique ■ Moment 3 – after body fluid exposure risk ■ Moment 4 – after touching patient ■ Moment 5 – after touching patient surroundings ○ If hands are not visibly soiled → use alcohol based hand rubs for 15 seconds ■ Saves time, more accessible, and reduces bacterial count on hands ● Medical asepsis (clean technique) → reducing number of organisms present and preventing the transfer of organisms ○ Good hand hygiene techniques https://www.youtube.com/watch?v=G5-Rp-6FMCQ ■ Scrub for at least 20 seconds with 1 tsp of soap ■ Do not let your clothes touch the sink ■ Soap and water is the best technique!! ● Use when: ○ Hands are visibly dirty ○ Soiled with blood or bodily fluids ○ Before eating ○ After using the toilet ○ Exposure to spore-forming organisms ○ Start and end of shift ○ Carry soiled items away from the body to prevent touching ○ Do not place any soiled linen or other items on the floor – increases contamination ○ Avoid allowing patients to cough, sneeze, or breathe directly on others “cough etiquette” ■ Maintain separation of 3+ feet from person with respiratory infection (unless wearing PPE) ○ Dispose of soiled or used items directly into appropriate containers What I think may be important to know!! ■ Feces and urine → toilet ■ Contaminated items, such as blood → biohazard bag ○ Sterilize items that are suspected of pathogens ● Surgical asepsis (sterile technique) → the absence of all microorganisms “surgery requires sterile” https://www.youtube.com/watch?v=lumZOF-METc ○ The 7 principles of sterile technique ■ Sterile objects remain sterile only when touched by another sterile object ■ Only sterile objects may be placed on a sterile field ■ A sterile object or field out of range of vision or an object held below a person’s waist is contaminated (do not leave sterile environment) ■ Sterile objects become contaminated by prolonged exposure to air ■ When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action (think of what happens with a paper towel in water) ■ Avoid spilling fluids on a cloth or paper sterile field ■ The edges of a sterile field or container are considered to be contaminated (~1 inch) ○ Open sterile packages AWAY from you ■ Prevents accidental contamination ○ Consider an object contaminated if you have any doubt as to its sterility ○ Avoid talking, coughing, sneezing, or reaching over a sterile field PPE & Isolation Precautions ● Standard precautions ○ Standard use in the care of all hospitalized patients regardless of diagnosis; prevent and control infection ○ Applies to blood; all body fluids, secretions, and excretions, non intact skin, and mucous membranes ○ Protects patients AND healthcare worker ○ Follow hand hygiene (SOAP & WATER = BEST) ○ Wear clean, nonsterile gloves; change gloves between tasks on the same patient, as necessary, and remove gloves promptly after use ■ When encountering body fluids, mucous membranes, etc. ○ Wear PPE = mask, eye protection, face shield, gown ■ Use goggles with invasive procedures that may result in splattering of blood or bodily fluids ■ Remove PPE before leaving the room ○ Avoid recapping needles; always place needles, sharps, and scalpels in appropriate puncture-resistant containers after use ○ Follow respiratory hygiene/cough etiquette ○ Keep the room clean What I think may be important to know!! ■ CLEAN TO DIRTY ○ Use safe injection practices ● Transmission-based precautions https://youtu.be/EknQ4CudbEw ○ Used in addition to standard precautions for patients with suspected infection that can be transmitted by airborne, droplet, or contact routes ○ Airborne precautions: prevent transmission of pathogens through air via moisture or dust particles ■ THINK “MTV is on the Air” – Measles, Tuberculosis, Varicella (chicken pox) + COVID ■ Place patient in a private room that has monitored negative air pressure; keep door closed and patient in room ■ Transport patient out of room only when necessary and place surgical mask on the patient if possible ■ Healthcare workers wear a respiratory mask (N95 or higher) ○ Droplet precautions: prevent transmission through coughing, sneezing, talking, etc. by an infected person, creating large droplets that are inhaled by others ■ Diphtheria, Rubella, Adenovirus, Pneumonia (DRAP) ■ Private room required ■ Transport patient out of room only when necessary and place mask on the patient if possible ■ Keep visitors 3ft away from the infected person, must also wear a mask ○ Contact precautions: prevent transmission of infectious agents that are spread by the direct or indirect contact with the patient or the patient’s environment ■ For patients who are infected by MRSA, C. diff, VRE, etc. ■ In the presence of excessive wound drainage, fecal incontinence, or other discharges from the body ■ Place patient in private room if available ■ Wear gloves and a gown whenever you enter the room for all interactions; wash hands with an antimicrobial or antiseptic agent when leaving the room ● Use disposable equipment ■ Limit movement of the patient out of the room → patients MUST wear correct PPE when leaving ● Protective precautions: to protect the patient when they are immunocompromised ○ Positive-pressure airflow, no fresh flowers or plants, no sick visitors ○ PPE depends on the individual patient ○ Ex. transplants, chemotherapy What I think may be important to know!! ● Personal Protective Equipment (PPE) https://www.youtube.com/watch?v=iwvnA_b9Q8Y Type of Precautions PPE Required Gown Mask Goggles Gloves Airborne X X (N95) X Droplet X X (surgical) X Contact X X Safety ● Risk factors ○ #1 risk = history of falls ○ Primary cause of unintentional injuries throughout life → older adults (65+) and children are at highest risk ○ PRIMARY CAUSES OF FALLS ■ Age 65+ ■ History of falls ■ Impaired mobility ■ Cardiovascular changes (orthostatic hypotension) ● Dizziness, weakness, might pass out ■ Vision impairment ■ Confusion ■ Anesthesia ■ Toileting !! most falls occur here ● Factors affecting safety ○ Developmental considerations ■ Neonate → infection, falls, and SIDS ● Never leave infant unattended ● Use crib rails ● Choking hazards → toys, pillows, etc. in cribs ● Use car seats properly → rear facing car seats in the back seat ■ Toddler → falls, cuts, burns, suffocation/drowning, and inhalation or ingestion of foreign bodies ● Childproof environment ● Poison prevention control – always call PPC FIRST ● Use car seats properly ■ School-aged child → burns, drowning, broken bones, concussions, inhalation/ingestion, guns and weapons, substance abuse ● Interventions for safety at home, school, and neighborhood What I think may be important to know!! ● Bicycle safety ● Child abduction awareness ● Wear seatbelts ● Accidents and injuries are COMMON ■ Adolescent → motor vehicle accidents, drowning, guns and weapons, inhalation/ingestion ● Safe driving skills ● Avoidance of tobacco and alcohol ● Risk of infection with body piercing ● Guns and violence ■ Adult → stress, domestic violence, motor vehicle accidents, industrial accidents, drug and alcohol abuse ● Unsafe health habits and coping strategies ● Effects of stress on lifestyle and health ■ Older adult → falls, motor vehicle accidents, elder abuse, sensorimotor changes, and fires ● Accident prevention ● Orient person to their surroundings (call bell, restroom, etc) ● Safe home environment and medication safety ● Interventions ○ Assess your patient ○ Fall risk band (yellow) ○ No-skid socks ○ Keep room clear and clean ○ Call light and personal belonging need to be within reach ○ Beds locked and in lowest position ○ Use of side rails and assisted devices ● Fire Safety (RACE) ○ R – rescue anyone in immediate danger ○ A – activate the fire code and notify appropriate person ○ C – confine the fire by closing doors and windows ○ E – evacuate patients and other people to a safe area ● Seizure: an alteration in sensation, behavior, movement, perception, or consciousness that may be noticeable as abnormal, involuntary contractions and rapid shaking with loss of consciousness ○ RISK OF hypoxia, vomiting, and pulmonary aspiration ○ Reduce environmental stimuli (sound, light intensity) ○ Bed in lowest position – lowers risk for fall ○ Bedside equipment ■ Oral suction What I think may be important to know!! ■ Bite block or oral airway ■ Oxygen ■ Padded rails ○ Monitor therapeutic drug levels ○ ○ Safety precautions ■ Always provide a safe environment ■ Do not restrain the patient or put anything in their mouth ■ Support the head and place something soft under them ● Place them in side-lying position ■ Stay with the patient and CALL FOR HELP ● Physical restraint: any manual method, physical or mechanical device, material, or equipment that the person cannot remove easily, which immobilizes or reduces the person’s freedom of movement ○ LAST RESORT ONLY; all other alternatives must have been implemented and failed; must be documented ■ Encourage family visitation, offer distractions or a calm environment, move patient room near nursing station, games, TV, music ○ Must have an order from the primary care provider; last for 24 hours ○ Must remove restraints every 2 hours and perform ROM ■ Assess circulation every 15 min! and need for fluids or urination ○ Bed rails ■ 2-3 side rails up = safety ■ 4 side rails up = restraint ■ If patient asks for bed rails to be up → not a restraint ○ Extremity restraint (hands, wrist or ankles) ■ Ensure two fingers can be inserted between the restraint and patient’s extremity ■ Use a quick-release knot to tie the restraint to the bed frame, not side rail ■ Keep the call bell within reach ■ Steps for apply restraints ● Explain rationale for use to the client and the family ● Pad bony prominences What I think may be important to know!! ● Wrap the restraint around the client’s ankle and secure it with the hook-and-loop fastener ● Ensure that two fingers fit between the restraint and the client’s skin ● Position limbs in normal anatomic position ● Secure restraints to the bed frame with quick-release knots ■ SPECIAL CONSIDERATIONS ● Do not position patient with wrist restraints flat in a supine position due to an increased risk of aspiration ● Check restraints for correct size before applying ● Keep a pair of scissors for quick removal of restraints ○ Risks associated with restraints ■ Falls ■ Pressure ulcers ■ Delirium ■ Contractures and skin breakdown ■ Incontinence ■ Respiratory difficulties ● Assisted devices ○ Walker → improve balance by increasing support ■ Specified by arm strength and balance ■ Top of the walker should line up with the patient’s wrist ■ Elbows should be flexed about 30 degrees ■ Rubber tips should be intact to prevent slipping ○ Canes → widen support, providing improved balance ■ Held on the STRONG side ■ The cane’s tip is 4in to the side of the foot ■ Elbow should be flexed 15 degrees ■ Move cane and weak side together, then move strong side ○ Crutches → to help strengthen one or both legs ■ 2-3 fingers of space between axilla and rest pad ● Support needs to be on the hands and arms, not in the axillary areas → nerve damage and skin abrasion ■ Hand grips should be even with the hip-line; elbow flexed at 30 degrees ○ Considerations ■ Nurse stands on patient’s weak side to protect them ■ Use a wide stance when helping patients ■ Use hips and knees to assist ■ Keep heavy objects close to your body ■ Keep the bed at waist level What I think may be important to know!! ● Graduated compression stockings = used for patients at risk for deep vein thrombosis and pulmonary embolism and to help prevent phlebitis ○ Increase velocity of blood, promoting venous return to the heart ○ An order is required for use ● Effects of immobility on the body systems ○ Increased cardiac workload ○ Increased risk for orthostatic hypotension ○ Decreased rate of respiration ○ Impaired gas exchange ○ Altered digestion and utilization of nutrients ○ Increased urinary stasis ○ Decreased muscle size, tone and strength ○ Decreased joint mobility and flexibility ● Safety principles ○ Always work CLEAN to DIRTY ○ Expose only one section of the body at a time, maintain privacy, and ensure patient comfort ○ Bathing is a great opportunity for assessment and building trust and rapport ○ Encourage patient independence ○ Keep all dirty/soiled material away from your body ○ Do not put anything on the floor Medication Administration ● No medication can be given to a patient without a medication order from a licensed practitioner!! ○ The medication order MUST include (never guess!): ■ Patient’s name and date of birth ■ Date and time the order is written ■ Name of drug to be administered ■ Dosage of the drug ■ Route by which the drug is to be administered ■ Frequency of administration ■ Signature of the prescribing provider ○ If anything is missing → you cannot give the medication & you must call the provider ● Use medicines safely ○ Properly label medicines ○ Take extra care with patients on anticoagulants ■ Increased risk for bleeding!! ○ Give correct information about a patient’s medications What I think may be important to know!! ● ● ● ● ○ Give written information about medications the patient needs to take ○ Educate the patient on bringing an up-to-date list of medicine when going to the doctor Before giving medication ALWAYS KNOW ○ The action and purpose ○ Safe dose range ○ Contraindications ○ Drug to drug interactions ○ Precautions before administering ○ Nursing implications ○ Proper administration technique Rights of Medication Administration ○ (1) right Patient ○ (2) right Medication ○ (3) right Dosage/Amount ○ (4) right Time ○ (5) right Route ○ (6) right Documentation ○ (7) right Reason ○ (8) right assessment (allergies, complications, ability to swallow) ○ (9) right response from patient ○ (10) right to education ○ (11) right to refuse (assess the reason & address the concern) Nursing considerations ○ Three Checks ■ (1) In the med room: read the eMAR and select proper medication ■ (2) After retrieving medication: compare medication label with the eMAR ■ (3) At bedside: recheck labels after identifying patient and before administration ○ Check for allergies ○ Specific parameters (blood pressure drugs) ○ Check for 2 patient identifiers ■ If patient is in a coma – check their wristband ○ Insulin is a 2 nurse check ALWAYS ○ Do not open meds until at the bedside ○ Pull medications for one patient at a time ○ Assess the patient ○ Education Drug administration What I think may be important to know!! ○ Children → difficulty swallowing tablets and capsules; most medications are available in liquid form ■ Use a dropper for infants or very young children ■ Crush uncoated tablets or empty soft capsules and mix the medication with soft foods ○ Older adults ■ Allow extra time to administer medications ■ May have difficulty swallowing medications; easier to take it in liquid form or crushed ■ Assist in setting up a schedule for at home use ■ Monitor for adverse reactions ■ Teach the name of the drug, not just the color ● Process for drug administration ○ Perform assessments prior to administration ○ Provide effective medication teaching ■ Verify the medication is okay with the patient ○ Position the patient and assist as needed ■ Oral medications → high fowler’s position ○ Never leave the medications at bedside ○ Document medication administration on MAR ■ Always be detailed!!! ○ Medication refusal ■ Assess the reason why & educate ■ For time sensitive medications → encourage patient to take and explain the importance ○ Prepare medications for ONE patient at a time ○ Always review patient’s chart for allergies and contraindications before administration ■ Verify with the patient ● Oral Medications ○ More prolonged, less toxic effect ○ Know the purpose and adverse effects ○ Verify allergies ○ Assess the patient’s ability to swallow ○ CANNOT CRUSH enteric coated, extended release, capsules ● Topical Medications ○ Used for local effects; wear gloves ○ Patches ■ Assess patient’s skin for placement ● Do not place on hairy skin What I think may be important to know!! ■ Rotate the site to avoid irritation ■ Use palm to place firmly for 10 seconds ■ Initial and write the date on medical tape ○ Eye Drops ■ Pull down the lower lid to administer in conjunctival sac ● Avoids damage and pain to the eye ■ Avoid touching the eye with the dropper ■ Apply pressure to ensure proper administration ■ Don’t let the patient rub their eye after ■ Eye ointment → inner to outer corners of the eye; do not get tube into eye ○ Ear Drops ■ For adults – pull the ear up and back ■ For children – pull the ear down and back ○ Suppositories ■ Position patient in left-lying sim’s position ● Only expose the body part you are assessing ■ Wear gloves and lubricate suppository and finger ■ Tell the patient to take a deep breath ■ Insert suppository into anus ● 4 inches for adults ● 2 inches for children ● Inhalation medications ○ Inhalers ■ Metered-dose (MDI) ● Handheld uses aerosol spray to administer medication into the lungs for localized and systemic effects ○ Used primarily in children or patients with decreased lung capacity ● Educate the patient on how to use it properly ● Assess lung sounds and respiratory rate before administration ○ Provides baseline data for later assessment ● STEPS ○ Shake it ○ Place the spacer mouthpiece into mouth ■ Especially for children if they are unable to hold the inhaler ○ Release one puff and inhale slowly and deeply ○ Hold for 5-10 seconds ○ Exhale slowly ○ Wait 1-5 minutes between each puff What I think may be important to know!! ○ Rinse mouth after using – avoid accumulation of bacteria; yeast ● Injection medications ○ Intradermal injection: into the dermis, longest absorption time ■ Used for allergy tests, local anesthesia, tuberculosis ● Avoid massaging or putting pressure on the site ■ 25-27 gauge ⅜-⅝ in, less than 0.5 mL, 5-15 degrees ■ Pull skin taut, bevel UP, inject slowly ■ Most common in in forearm, scapula ○ Subcutaneous injection: into the adipose tissue, slow and sustained rate of absorption into the capillaries ■ Used for insulin and heparin ■ 25-27 gauge, ⅜-⅝ in no more than 1 mL, 45-90 degrees ● Pinch the skin, inject, release the skin ● Angle depends on amount of fatty tissue ■ Insulin → must be double checked by 2 licensed nurses; high-risk drug ○ Check the order, blood glucose level, correct dose, and correct insulin ○ Use the insulin syringe with units ○ Mixing regular insulin (R) and NPH insulin (N) “clear to cloudy” ■ NPH = long acting (cloudy) ■ Regular = short acting (clear) ■ Rapid = rapid acting (clear) ● Food must be at bedside to avoid hypoglycemic shock ○ Check the name and expiration date on the vial before mixing ○ NPH needs to be “rolled” in the palms of the hands ○ Wipe the tops of both vials with an antimicrobial swab and allow to dry ○ “Clear into Cloudy” ■ Apply air into the NPH (cloudy) vial FIRST ● Same amount as units prescribed ● Injection of air → prevents vacuum ■ Apply air into the regular (clear) vial NEXT ● Same amount as units prescribed ● Keep the needle in the vial and invert the vial What I think may be important to know!! ■ Withdraw the units prescribed from the regular vial ■ Withdraw the units prescribed from the NPH vial ■ Do not massage the site or apply pressure ■ Injections in the abdomen > arms > thighs > gluteal ■ ○ Intramuscular injection: into the muscles; slow, sustained release over hours, days, or weeks ■ Fastest rate of absorption due to larger and more blood vessels ● Good route for irritating medications ■ Used for antibiotics, hormones, vaccines ■ Z track technique prevents leakage of medication into the needle track ■ 22- to 25-gauge needle, 1-1 ½ in, up to 3 mL, 90 degree angle ● ● Kids, elderly = up to 2mL Infants = up to 1 mL ■ Locations for IM route ● Deltoid → fast absorption, less pain ○ 25 gauge 1 inch ○ ● Vastus Lateralis → large muscle, easily accessible (common for <2 years) ○ ● Ventrogluteal → tolerates large amounts, less painful (Z-track method) ○ 22 gauge 1 ½ inch What I think may be important to know!! ○ Skin Integrity ● Developmental considerations ○ Children ■ <2 years – skin is thinner and weaker ■ Skin and mucous membranes are injured easily ■ Becomes increasingly resistant to injury and infection ○ Older adults ■ Structure changes as a person gets older ■ Easily damaged skin ■ Circulation and collagen are impaired → increased risk for tissue damage ■ Healing time is delayed ● Wound = break or disruption in the integrity of the skin and tissues ○ Phases of wound healing (HIP Man) ■ Hemostasis → blood vessels constrict & blood clotting to control bleeding ● Occurs immediately after initial injury ● Exudate (fluid) is formed ■ Inflammatory → leukocytes and macrophages move to the wound and clean to allow healing ● Lasts 2-3 days ● Leukocytes ingest bacteria and debris ● Macrophages release growth factors and fibroblasts ● Characterized by pain, heat, redness, and swelling ● Patient may have elevated temperature, leukocytosis, and discomfort ■ Proliferation → new tissue fills wound space through the action of fibroblasts “new life” = “new tissue” ● Lasts for several weeks ● Capillaries bring oxygen and nutrients ● Blood flow is reinstituted ● Granulation tissue is formed ■ Maturation → final stage of healing ● After 3 weeks of healing ● Scar tissue begins to heal and is less elastic ○ Wound classification What I think may be important to know!! ■ Intentional (surgery) or unintentional (injury: increased infection & bleeding) ○ Factors affecting wound healing ■ Local factors ● Pressure (disrupts blood flow) ● Desiccation (dehydration, cells become dry) ● Maceration (softening of skin due to moisture) ● Trauma ● Edema ● Infection ● Excessive bleeding ● Necrosis ● Biofilm (decreases effectiveness of antibiotics and normal immune response; delays healing) ■ Systemic factors ● Age ○ Very young and old patients have sensitive skin ● Circulation and oxygenation ○ Inadequate nutrients needed for removal ○ Ex. diabetics – more likely to be chronic, poor circulation ● Nutrition (often forgotten) ○ Malnourished or NPO patients are at risk for wound complications ● Wound cause ● Medications ○ Corticosteroids decrease inflammatory response ○ Radiation depresses bone marrow function ● Immunosuppression ○ AIDS, lupus, chemotherapy ○ Wound complications ■ Infection ● Signs & symptoms ○ Increased purulent drainage, pain, redness, swelling, increased body temperature, increased WBCs, odor ● Can lead to chronic wounds, bone infection, and sepsis ■ Hemorrhage (highest risk after surgery) ● Check dressing frequently; including UNDER the patient ● If uncontrolled bleeding occurs → APPLY PRESSURE ● Can lead to a hematoma = internal blood clots ■ Dehiscence & Evisceration What I think may be important to know!! ● Most serious wound complications !! ● Dehiscence → muscle intact; due to increased abdominal pressure ● Evisceration → bowels protruding from wound; due to increased drainage; requires immediate surgery “something giving away” ○ Position patient in low Fowler’s ○ Cover area with saline moistened sterile gauze ○ NPO for surgery ● ■ Fistula ● Abnormal passage from an internal organ or vessel ● Can be purposeful or accidental ● Often results from an abscess (infected fluid that has not drained) ● Can lead to increased infection and skin breakdown ● ● Pressure injury: localized damage to the skin and underlying tissue that usually occurs over a bony prominence ○ Acute or chronic ○ Occur in older adults due to aging skin, chronic illness, immobility, malnutrition ○ Important to reposition patients every 2 hours ○ Factors in development ■ External pressure compressing blood vessels ● Occur mainly over the tailbone, heels, and hip bones ● Leads to ischemia (deficiency of blood in an area), hypoxia (inadequate oxygen to cells), edema, inflammation ■ Friction and forces that tear and injure blood vessels ● The skin over elbows and heels are affected ○ RISK FACTORS ■ Immobility What I think may be important to know!! ■ Nutrition and hydration ■ Moisture (incontinence, drainage) ■ Mental status ■ Age ○ RISK ASSESSMENT → Braden Scale (0-24) ■ MANSS ● M: moisture = skin exposure to moisture ● A: activity = degree of physical activity ● N: nutrition = usual food intake pattern ● S: sensory perception = ability to respond to pressure, discomfort, and pain ● S: shear and friction = shear is one layer of tissue sliced over another layer; friction is two surfaces rubbing against each other ■ Score less than 12 = increased risk ■ Prevention ● Turn every 2 hours ● Adequate hydration and nutrition ○ Protein, fatty acids, vitamins and minerals ● Keep skin DRY ○ Stages ■ Stage 1: Erythema of skin = red skin, changes in sensation, temperature, or firmness ■ Stage 2: Partial-thickness = partial loss of skin with exposed dermis; looks almost like a blister ■ Stage 3: Full-thickness = loss of skin, adipose tissue is visible ■ Stage 4: Full-thickness and tissue loss = exposed fascia, muscle, tendon, ligament, or bone in the ulcer ■ Obscured/Unstageable= tissue damage is obscured by eschar (necrosis) ● Remove necrotic tissue before staging ■ Deep tissue injury = purple, maroon area indicating tissue injury What I think may be important to know!! ○ ● Wound assessment ○ Assess old dressings – look for drainage, measure the size, determine location ○ BYR scale for color ■ Black (necrotic) = debris BAD – call provider ■ Yellow (sloughy) = cleaning ■ Red (granulating) = protect GOOD ○ Assess the color, odor, consistency ○ Palpate for firmness, temperature, and swelling ○ Assess for pain ○ Assess for signs of infection ● Types of wound drainages ○ Serous → clear and watery ○ Sanguineous → fresh bleeding, or darker old bleeding ○ Serosanguineous → serum and red blood cells; light pink to red ○ Purulent → thick, foul odor, may be yellow or green ○ What I think may be important to know!! Bowel Elimination + Skills ● CONSIDERATION ○ Valsalva cardiac effect → trouble defecating ■ Increased blood pressure, low HR ■ Take laxatives to help ○ Fecal impaction → breaking up fecal mass and removing it from the impaction ■ Usually seen in spinal cord injuries ■ Requires an order – invasive ■ Risk of triggering valsalva – monitor patient ○ Bowel incontinence ■ Requires proper cleaning to avoid skin breakdown ■ Educate on scheduled toileting and proper squatting ● Peristalsis: contraction and relaxation of GI smooth muscles facilitates in moving contents down GI tract ○ Patients may lose this ability due to: ■ Opioids, anesthesia, nerve/muscle damage, immobility ● Vili: increased surface area = greater nutrient uptake ○ Decreased absorption could be due to: ■ Celiac disease, IBS, necrosis, GI surgery, age ● Factors influencing bowel elimination ○ Age = aging → decreased ○ Diet = increase fiber intake – whole grains, dry peas and beans, fruits and veggies ■ Constipating food → processed cheese, meat, eggs, pasta, rice, white bread, iron and calcium supplements ■ Foods with laxative effect → prunes, dairy, fruits and veggies, spicy foods, alcohol, coffee ■ Gas producing foods → certain veggies, milk, carbonated drinks ○ Fluid intake = water and electrolytes ~2-3L a day ○ Physical activity = increase mobility ○ Psychological factors = stress and anxiety → decreased ○ Personal habits = patients in a new place are hesitant → decreased ○ Position = squatting ○ Pain = increased pain → decreased ○ Pregnancy = increased hormones and pressure on abdomen → increased ○ Surgery & anesthesia = slows down motility ○ Medications = ALWAYS ASSESS MEDICATIONS ○ Diagnostic tests ■ Fecal occult test – measures blood in stool ● Detects GI bleeding, ulcers, colon cancer ● Assess for hemorrhoids What I think may be important to know!! ● BLUE = POSITIVE ● Avoid vitamin C ■ C. diff – increased diarrhea, request an order ● Nasogastric tube: used to relieve pressure or drain unwanted contents in the GI system due to some type of blockage ○ ○ Correct way to measure ■ Nostril – tip of earlobe – xiphoid process ■ Check patency of nasal – looking for deviation ● Find the one they can breathe out better ○ Connected to suction or to gravity bag ○ Large bore is for gastric decompression – suction out extra content ■ Can be continuous or intermittent ■ Do not put gastric content back, test pH ■ Usually for overdose, after surgery, no bowel movements ○ Small bore for enteral feeding ONLY ■ Assess the tubing before feeding ● Aspirate for gastric secretions (note the amount and color) ● Flush with 30-50mL to avoid blockage ○ Would you suction and feed a patient through a NG tube at the same time? NO! Turn off suction for 30 minutes ○ When inserting the tube, always have water for the patient to swallow ○ Determine placement by aspirating and testing for pH ■ Gastric levels <5.5 ■ X-ray is needed to CONFIRM proper placement ● Enteral tube feeding = preferred method of meeting nutritional needs if a patient is unable to swallow or take nutrients orally ○ Requires a functioning GI tract ○ COMPLICATIONS → risk of aspiration due to food getting into the lungs ■ Must position patient in proper position (high-fowler’s) ○ When inserting the tube: ■ Tell the patient to keep swallowing while inserting ■ To assure proper placement, get an x-ray ○ Continuous feedings (feeding pump) ○ Intermittent feeding (regular intervals or through a syringe) What I think may be important to know!! ● Parenteral nutrition = nutrients are provided intravenously for patients unable to digest or absorb nutrition ○ Requires consistent evaluation ○ Crohn’s disease, short-bowel syndrome ○ Total parenteral nutrition → large veins, more nutrients ■ At risk for infection and increased glucose levels ○ Peripheral parenteral nutrition → peripheral veins, nutrients (more common) ● Constipation ○ Identify and manage contributing factors ○ Use laxatives, if appropriate ■ Only for short-term use ○ Enemas – inserting fluids into the rectum to influence bowel movement ■ PURPOSE ● Cleansing = before colonoscopy/surgery for a better visualization ● Oil retention = becomes slippery for the stool to come out ● Carminative = relieves gas ● Kayexalate = clears extra potassium from body ○ Educate about diet/fluid intake ○ Promote ambulation/exercise ● Ostomy: surgically created opening of part of an organ to the surface of the body to discharge wastes ○ Created when contents are unable to pass through normally ○ Ex. cancer – cancer and part of colon is removed ○ Stoma = the opening at the surface of the body ■ Should be beefy red, moist ■ Purple/blue color – NECROSIS ○ Ileostomy → part of small intestine is removed ■ Secretion will be liquidy and thin ■ EFFECT: loss of nutrients; dehydration ■ No control ○ Colostomy → part of the large colon is removed ■ More consistent with normal excretion ■ EFFECT: dehydration ■ Some control ○ What I think may be important to know!! ○ Ostomy care ■ Not sterile ■ Assess newly creates ostomies frequently ● Color, frequency, output ■ Report any complications immediately ■ Monitor nutritional, electrolyte and fluid balance ■ Educate patient on care of the ostomy when he or she is ready ● Can be emotional or embarrassing for the patient ● Consider how it affects the patient ○ Inform the patient about certain foods that cause odor/gas and increase fluid intake ○ Patients with ostomies can still have constipation and diarrhea Urinary Elimination + Skills ● Factors affecting urination ○ Food and fluid intake ■ Increased sodium → decreases urine formation ■ Alcohol → diuretic effect, increasing urine production ○ Developmental considerations ■ Child – toilet training 2-3 years old ● Enuresis → incontinence of urine past the age of toilet training ■ Aging ● Nocturia ● Increased frequency (due to decreased muscle tone) ● Urine retention and stasis ● Voluntary control affected by physical problems (weakness) ● AT RISK FOR DEHYDRATION ○ Pathologic conditions ■ Renal impairment affects urine output ○ Medications ■ Diuretics → increased urine production ■ Pyridium → turns urine orange ■ Nephrotoxic → toxic to the kidneys (analgesics) ○ Psychological variables ■ Stress → decrease in urination ■ Level of comfort – make sure patient has privacy ○ Activity and muscle tone ■ Exercise is GOOD for the bladder ■ Decreased muscle → increased urine in the bladder → increased infection ● Frequency of urination What I think may be important to know!! ○ Amount In = Amount Out ○ Measuring intake and output (mL) ○ Frequent intervals – void at first early urge to urinate, usually measured every 3-4 hours ○ Infrequent intervals – greater risk of UTI and kidney disorders ● Common Urinary Elimination Problems ○ Urinary retention – due to medications, muscle tone, enlarged prostate; when urine is not completely excreted from the bladder ■ Causes ● Enlarged prostate ● Urethral stricture ● Kidney stones ● Stroke or spinal cord injury ○ Urinary tract infection (UTI) – may be caused by indwelling catheters, urinary retention, urinary/fecal incontinence, poor hygiene practices increase risk ■ S&S ● Dysuria, cystitis, urgency, frequency, incontinence, foul-smelling cloudy urine, hematuria ● Flank pain (more serious) – pain in the kidneys ■ Patients AT RISK for UTI ● Women ● Sexually active ● Women who use diaphragms for contraception ● Postmenopausal women ● Individuals with indwelling urinary catheter ● Individuals with diabetes mellitus ○ Why? Increased glucose in urine → attracts bacteria ● Older adults ■ Catheter-associated UTI ● Usually from hospital procedures; most common ● IMPORTANT TO USE STERILE TECHNIQUE ● Regular perineal and catheter care is required ● Never let the drainage bags get full, empty when half full ○ Why? Urine will backtrack leading to infection ● Check for kinks or occlusions ● Keep drainage bag below the bladder to work with gravity ● Do not let tube or bag touch the floor ○ Urinary incontinence ■ Overflow = signal to empty bladder underactive or absent resulting in overdistention and overflow of bladder. Never fully empties What I think may be important to know!! ■ Urge = strong urge to urinate when bladder is not full (i.e. overactive bladder) ■ Functional = aware of the need to urinate, but cannot due to factors outside the urinary tract (i.e. inability to reach toilet, environment, physical limitations, memory loss) ■ Reflex = emptying of the bladder without sensation of need to void (i.e. spinal cord injury) ■ Stress = involuntary loss of urine related to an increase in intra-abdominal pressure (i.e. coughing, sneezing, exercise) ■ Total = continuous, unpredictable loss of urine (usually a result of surgery, trauma, anatomic abnormality) ■ Transient = appears suddenly and lasts 6 months or less ■ Mixed = urine loss with features of two or more types of incontinence ● Nursing Process ○ Assess data about voiding patterns, habits, past history of problems ○ Physical examination of bladder; assessment of skin integrity and hydration; and examination of the urine (can also assess pain in the kidneys) ■ Kidneys – any flank pain or tenderness? ■ Urinary bladder – palpate and percuss the bladder for distention or use a bedside bladder scanner ● Bedside bladder scanner = uses ultrasound technology to determine how much urine is in the bladder or how much urine has been retained ○ No order is required ○ Do this BEFORE catheterization ○ If there is no urine present → problem with kidneys ■ Skin – assess skin breakdown and exposure to moisture, skin turgor for hydration status ● Incontinence-associated dermatitis = infection from lack of skin care ○ Correlation of findings with results of procedures and diagnostic tests ● Urine assessment ○ Assess for amount (intake and output), color, odor, clarity, and sediment ■ Certain medications can affect the color of urine ○ Specific gravity = density of urine NORMAL 1.015-1.025 ○ Presence of abnormal constituents = sign of infection or kidney problem ■ Glucose ■ Protein ■ Ketone bodies ■ Bacteria What I think may be important to know!! ■ Blood, pus, casts ● Assessing a problem with voiding ○ Examples of questions to ask: ■ Do you urinate at regular times throughout the day? ■ Do you drink water? ■ Are you limiting your sodium intake? ■ Is your urine volume constant? ● Indwelling/foley catheter = double lumen; extracts urine and injects saline to inflate balloon ○ Used for continuous urinary drainage ○ Monitor intake and output, volume, and character of urine ○ Empty the bag at HALFWAY ○ Keep drainage bag below the bladder and off the floor at all times ○ Insert catheter until urine is seen and then continue to insert ■ No urine? You may be in the wrong spot ○ Avoids blocking/damaging the sphincter with the balloon ○ ● Straight/intermittent catheter = single lumen; drains bladder for urine ○ Used for a one time use ○ Lowers risk of CAUTI and complications ○ Patients can use clean technique at home ○ Used for patients with spinal cord injuries or other neurological conditions ○ ● Condom catheter ○ Patients who are at high fall risk or unable to hold a urinal ○ 1-2 inches away from the tip of the penis; leave flexible room around the penis (not too taught) ○ Assess the skin often!! What I think may be important to know!! ● Patient goals ○ Maintain fluid, electrolyte, and acid-base balance ○ Empty bladder completely at regular intervals without discomfort ■ Consequence = infection ○ Provide care for urinary diversion ○ Develop plan to modify factors contributing to current or future urinary problems ○ Correct unhealthy urinary habits ● Promoting normal urination ○ Promote fluid intake ○ Strengthening muscle tone ■ Pelvic floor exercise for urinary incontinence ■ Practice urinating and stopping (kegels) ○ Assisting with toileting ■ EMPOWER ■ ENSURE PRIVACY ● Maintaining normal voiding patterns ○ Regular schedule ○ Urge to void ○ Privacy ○ Position ○ Hygiene ● Patient education for UTI ○ Increase fluid intake ○ Promote good hygiene – wiping from front to back ○ Urinate after sex ○ Urge to urinate – GO RIGHT AWAY ○ Drink cranberry juice ○ Wear loose, breathable underwear ○ Increase activity ○ Take antibiotics as prescribed ● Reasons for catheterization ○ Used as a last resort!! ○ Straight catheter FIRST before indwelling catheter ○ Relieving urinary retention ○ Prolonged patient immobilization ○ Obtaining a sterile urine specimen when patient is unable to void voluntarily ○ Accurate measurement of urinary output in critically ill patients ○ Assisting in healing open sacral or perineal wounds in incontinent patients ○ Emptying the bladder before, during, or after surgical procedures ○ Providing improved comfort for end-of-life care What I think may be important to know!! Nutrition ● ADPIE ○ Assessment – nutritional screening ■ Ask for 24 hour diet recall ■ Alcohol consumption, food allergies ○ Diagnosis – imbalanced nutrition ○ Planning – nutritional education and counseling ○ Implementation – meal planning, educating ○ Evaluation – effectiveness of interventions ● BMI ○ Underweight = less than 18.5 ○ Healthy = 18.5-24.9 ○ Obese = 30-34.9 ● Therapeutic diets ○ Consistent-carbohydrate diet = type 1 and type 2 diabetes, gestational diabetes, impaired glucose tolerance ■ High-fiber and heart-healthy fats are encouraged ■ Sodium intake is limited ○ Fat-restricted diet = cardiovascular disease to help prevent atherosclerosis ■ Intended to lower the patient’s total intake of fat ○ High fiber diet = prevent or treat constipation; IBS, diverticulosis ○ Low-fiber diet = before surgery, ulcerative colitis, Crohn’s disease ○ Sodium-restricted diet = hypertension, heart failure, renal disease, liver disease ■ “Heart-healthy” diet ○ Renal diet = nephrotic syndrome, kidney disease, diabetic kidney disease ■ Reduces the workload on the kidneys to delay or prevent damage ● Post-surgery diets (diet progression) ○ NPO – nothing, sips of water with meds may be allowed ○ Clear liquid – clear broth, coffee, tea, fruit juice, gelatin ○ Full liquid – cream soup, custard/pudding, vegetable juice, yogurt ○ Pureed – scrambled eggs; pureed meat, vegetables, fruit; mashed potatoes ■ For patients who can chew, but cannot swallow ○ Mechanically altered – pasta, casseroles, tender meat, cooked fruit/vegetables ■ Makes it easier for the patient to consume ○ High fiber – fresh fruit, oatmeal, dried fruit ■ Patient needs LOTS of fluids!! ● Enteral tube feeding = preferred method of meeting nutritional needs if a patient is unable to swallow or take nutrients orally; short-term ○ Requires a functioning GI tract ○ COMPLICATIONS → risk of aspiration due to food getting into the lungs What I think may be important to know!! ■ Must position patient in proper position (high-fowler’s) ■ Ensure proper placement with x-ray ○ When inserting the tube: ■ Tell the patient to keep swallowing while inserting ■ To assure proper placement, get an x-ray ○ Types of feeding administration ■ Continuous = feeding into intestines to avoid dumping syndrome ■ Intermittent = feedings delivered at regular intervals ○ Enteral tube bags must be changed every 24 hours ● Diabetes ○ Type 1: the body makes little or no insulin ■ Glucose monitoring ■ Insulin dependent ■ Exercise ○ Type 2: the body is resistant to insulin ■ Diet, exercise, weight management ■ Glucose monitoring ○ Gestational: high blood sugar that develops during pregnancy Oxygenation, Circulation, Perfusion ● Gas exchange is made possible by: ○ Ventilation = movement of air into and out of the lungs ■ Contraction → inhaling ■ Relaxing → exhaling ■ Factors ● Condition of the musculature ○ Weak muscles = less effective inhalation and exhalation (OLDER ADULTS) ○ Signs of difficulty breathing ■ Nasal flaring ■ Retractions ■ Use of accessory muscles ● Compliance of the lung tissue ○ The ability of the lungs to distend or expand ○ Decreased compliance = decreased oxygenation ○ Surfactant = decreases surface tension, prevents alveoli from collapsing ○ Conditions that decrease compliance ■ Emphysema and fibrosis ■ Older adults have decreased surfactant What I think may be important to know!! ■ Premature babies do not have enough surfactant to breathe on their own ● Airway resistance ○ When the diameter of an airway decreases, the airway resistance increase and limits the amount of oxygen delivered to the alveoli ○ Conditions that increase resistance ■ Asthma ■ Sleep apnea ■ Edema ■ Increased secretions ■ Obstruction ○ May hear wheezing, high pitched sounds, crackling ○ Respiration = exchange of oxygen and carbon dioxide between the atmospheric air in the terminal alveoli and blood in the capillaries ■ Moves from high pressure/concentration to low pressure/concentration ■ Factors influencing diffusion ● Change in surface area ○ Removal of the lung, emphysema ○ Reducing the surface area, reduces diffusion ● Thickening of the alveolar-capillary membrane (Pneumonia) ● Partial pressure ○ Increased altitude pressure, decreased respiration ■ Atelectasis → collapse of the alveoli; prevents normal gas exchange ● Usually due to hospitalization/post-op complication ● Nursing interventions ○ Deep breathing exercises ○ Ambulation – better circulation ○ Semi-fowler’s position ○ Perfusion = process by which oxygenated capillary blood passes through the body tissues ■ Factors ● Amount of blood flowing through lungs ● Activity level ○ Increased activity → increases demand for O2 → increases perfusion ● Adequate blood supply and proper cardiovascular functioning ● ABG normal values for ventilation ○ PaO2 (partial pressure O2) = 80-100 mm Hg ■ Measures pressure of oxygen moving in and out of the body What I think may be important to know!! ○ PaCO2 (partial pressure CO2) = 35-45 mm Hg ■ Measures pressure of carbon dioxide moving in and out of the body ○ SpO2 (peripheral O2 saturation) = 95-100% ■ Measures concentration of oxygen in circulation ● Alterations in respiratory functioning ○ HYPOventilation = decreased respirations; body retains CO2 and can lead to respiratory acidosis ■ Can occur with atelectasis, sedation, and drug overdose ■ S&S: changes in mental status, low respiration rate, potential cardiac arrest, death ■ Intervention: give O2, encourage deep breathing and coughing, may need respiratory treatment ○ HYPERventilation = increased rate/depth of respirations; lungs remove CO2 faster than it is produced and can lead to respiratory alkalosis ■ Can occur with severe anxiety ■ S&S: lightheadedness, loss of consciousness ■ Interventions: patient breathe into brown paper bag, help calm anxiety ○ Hypoxia = inadequate tissue oxygenation; life threatening condition ■ S&S: restlessness, anxiety, tachycardia, bradycardia, extreme restlessness, dyspnea “RATBED” ■ Causative factors ● Decreased O2 carrying capacity (anemia, carbon monoxide poisoning) ● Hypovolemia – decreased circulating blood volume (shock, severe dehydration) ● Decreased O2 concentration (airway obstructions, decreased environmental oxygen from high altitude, hypoventilation) ● Increased metabolic rate – demanding more O2, persistent fever (needs O2 to fight infection), exercise ■ Give O2 ASAP ○ Chronic Obstructive Pulmonary Disorder (COPD) = chronic airflow limitation ■ #1 cause SMOKING ■ S&S: dyspnea, increased RR, barrel chest, use of accessory muscles to breathe ■ Interventions: breathing exercises, tripod positioning, encourage rest What I think may be important to know!! ● Cardiovascular system ● ○ Regulation of the cardiovascular system ■ Conduction system ● ■ Alterations in conduction Rhythm HR SV CO BRADYCARDIA <60bpm ↓ ↑ ↓ TACHYCARDIA >100bpm ↑ ↓ ↓ ATRIAL FIBRILLATION 100-175 bpm ↑ ↓ ↓ VENTRICULAR FIBRILLATION >175 bpm ↑ ↓ ↓ ● Atrial fibrillation is at risk for blood clots ○ Deep vein thrombosis – swelling, erythema, warmth ○ Patients will most likely be on blood-thinners (i.e. warfarin, heparin) ● Ventricular fibrillation is deadly ■ Blood flow to the cardiovascular system What I think may be important to know!! ● ● ● ● ● Myocardial ischemia = decreased blood flow to the heart ○ Stable angina – temporary imbalance; often due to an increase in myocardial oxygen demand ■ Often relieved with rest and vasodilators ■ Reduce alcohol, no smoking, activity is limited ○ Myocardial infarction – medical emergency; usually due to decrease in O2 blood flow ■ Accompanied by chest pain ■ Can only be relieved through surgery Heart failure → inability to pump sufficient blood leading to inadequate perfusion and oxygenation of tissues ○ Causes ■ Chronic HTN – heart was to work harder ■ Coronary artery disease ■ Incompetent valves Deep Vein Thrombosis (DVT): blood clots form in the deep veins, usually in the legs ○ Requires IMMEDIATE attention → can lead to pulmonary embolism ○ Risk factors: impaired circulation, decreased motility, prolonged bed rest, smoking, obesity ○ Symptoms: unilateral swelling in legs/calf, inflammation, redness, pain, warmth ○ Intervention: ambulate!!!!!!, encourage hydration, ROM, compression stockings, elevate the extremity ○ DO NOT massage the leg Factors affecting cardiopulmonary functioning ○ Level of health ○ Development ■ Infants-adolescents → immature immune system ● At risk for upper respiratory infection ■ Older adults → cardiac output decreases, cannot handle stress ○ Nutrition ○ Exercise ○ Smoking ○ Substance abuse ○ Stress ○ Environmental factors Nursing process ○ Assessment ■ Health history ■ Physical assessment ■ Vital signs What I think may be important to know!! ○ ○ ○ ○ ■ Diagnostic tests ■ Pulse oximetry monitoring ● Assess and read the patient FIRST, not the number ● COPD/chronic lung disease O2 level 88%-92% is normal Diagnoses ■ Ineffective airway clearance ■ Impaired gas exchange ■ Decreased cardiac output Planning ■ Demonstrate improved gas exchange ■ Preserve cardiopulmonary function ■ Demonstrate coping methods and self-care behaviors Implementation ■ Promote healthy lifestyle ■ Maintain good nutrition ■ Adequate hydration ■ Promote lung expansion ● Breathing exercises !! ○ Pursed lip breathing for COPD ● Ambulation → preventative for DVT ● Incentive spirometer → inhaling deep and slow ● Semi-fowlers, high-fowlers ■ Promoting and controlling cough ● Effective coughing – helps clear the airway clear of secretions ■ Loosen and mobilize secretions ■ Meeting oxygen needs with medication (inhalers) ■ Providing supplemental oxygen ● Humidifier requires an order → DO NOT HOLD IN EMERGENCY ● In patients with COPD, the administration of excessive oxygen causes them to hypoventilate ○ Can lead to respiratory acidosis ■ Suctioning ■ Thoracentesis (removal of fluid in pleural space) ■ Chest tubes ● Never clamp the tubing Evaluation ■ Ask about improvement ■ Auscultate lung sounds ■ Evaluate pulse oximetry changes What I think may be important to know!! ■ Use diagnostic results ● Oxygen delivery devices – least invasive to most invasive ○ Nasal Cannula ■ 1-6L/min 24-44% ■ Can dry mucosa and needs humidification ■ Patients can eat with this ○ Simple face mask ■ 5-8L/min 40-60% ■ Contraindicated for patients who retain CO2, may induce claustrophobia ○ Venturi mask ■ 4-6L/min 24-60% ■ Has flow-control meter on the mask ○ Partial/non-rebreather mask (emergency use) ■ 10-15L/min 80-95% ■ Should never be deflated ○ Always assess the skin ○ Humidify at 4L and above ■ Can dry out mucosa ○ Administering oxygen greater than 28% can damage patient’s stimulus to breathe deeper with COPD ● Complete Blood Count ● Coagulation “#s are TOO HIGH → patient will DIE; #s are TOO LOW → clots will GROW” What I think may be important to know!! ● Patients on anticoagulant therapy should expect longer bleeding times → takes longer to build clots ○ On heparin/warfarin – aPTT should be 1-2X longer ● In emergency situations: ABCs ○ Maintaining an airway is a priority ○ Administer oxygen ○ Interventions will vary ○ Always have emergency supplies ready ○ Activate appropriate emergency response ● Cardiopulmonary resuscitation ○ Permanent heart, brain, and vital organ damage occurs within 4-6 minutes ○ CPR ■ Maintain circulation ■ Establish airway ■ Initiate breathing ■ Early defibrillation What I think may be important to know!! JUST FOR REVIEW ○ Sitting position = evaluation of head, neck, lungs, vital signs ■ ○ Supine position = flat on back, head slightly elevated; anesthesia, surgery, abdomen exam ■ ○ Sims’ position = rectal, perineal, and pelvic exams; rectal temperatures, enemas ■ Left-lying – rectal and vaginal area ■ Alternative for elderly patients ■ ○ Dorsal recumbent position = best for patients with pain in back or abdomen ■ ○ Standing position = posture, balance, gait, male genitalia ■ ○ Prone position = hip joint, back exams; cardiac and respiratory problems cannot tolerate ■ What I think may be important to know!! ○ Knee-chest position = rectal, vaginal exams ■ Small pillow for comfort ■ Embarrassing for patient – reduce time ■ ○ Lithotomy position = female genitalia, reproductive tracts, and rectum ■ ○ High-fowler’s position = head, neck, and upper body (60-90 degrees) ■ ○ Fowler’s position (30-45 degrees) = promotes lung expansion ■