Funda Day 2 PDF

PAIN a feeling of hurt or sensation caused by a noxious stimulus HIGHLY SUBJECTIVE ALL PAIN IS REAL 5th VITAL SIGN PHYSIOLOGY OF PAIN PAIN TRANSDUCTION PAIN TRANSMISSION PAIN PERCEPTION PAIN MODULATION ASSESSMENT OF PAIN OBJECTIVE CUES Physiologic signs Increased PR Increased depth a...

PAIN a feeling of hurt or sensation caused by a noxious stimulus HIGHLY SUBJECTIVE ALL PAIN IS REAL 5th VITAL SIGN PHYSIOLOGY OF PAIN PAIN TRANSDUCTION PAIN TRANSMISSION PAIN PERCEPTION PAIN MODULATION ASSESSMENT OF PAIN OBJECTIVE CUES Physiologic signs Increased PR Increased depth and frequency of respiration Increased BP Diaphoresis and pallor Dilated pupils Muscle tension Behavioral signs Rigid body position Restlessness Frowning Clenched teeth Clenched fists Crying OPIOID SIDE EFFECTS constipation nausea and vomiting sedation pruritus urinary retention circulatory depression respiratory depression NONPHARMACOLOGICAL PAIN MANAGEMENT Cutaneous Stimulation Thermal therapies: Distraction Transcutaneous Electrical Nerve Stimulation (TENS) Relaxation techniques Guided imagery Hypnosis Aromatherapy AcL pressure/ Acupuncture CONSIDERATIONS PRIOR TO PHYSICAL ASSESSMENT Prepare the client Provide privacy Prepare the environment Positioning INSPECTION observation, makes use of the sense of sight determines size, shape, color, symmetry, position, location, movement and abnormalities adequate lighting position and expose body parts to be viewed compare each area with the opposite side of the body use additional light (penlight) to inspect body cavities pay attention to detail PALPATION makes use of the sense of touch determines texture, temperature, moisture, mobility, still, deter palaced, is degree, mendernes, biling to, polis recy, dice, red shape client should be relaxed (deep breaths, proper positioning) done systematically from non-tender to tender area, light to deep palpation warm hands, short fingernails wear gloves when palpating areas lined with mucous membranes PERCUSSION lapping of lingers quickly and sharply against parts of the potients body usually the chest and abdomen locate, Identify the organ determine its size, shape and position determines density (if the organ is solid, fluid-filled or air-filled) determine tenderness elicits reflexes DIRECT AND INDIRECT PERCUSSION AUSCULTATION makes use of the sense of hearing eliminate distracting noises do not auscultate through the clothing uses a disinfected stethoscope diaphragm - high pitched; bell - low pitched to determine presence or absence of heart, breath, bowel sounds DIAGNOSTIC EXAM - Blood Tests Specimen Collection = Visualization Procedures Aspiration / Biopsy SPUTUM SPECIMEN COLLECTION Sputum analysis Sputum culture and sensitivity Sputum AFB STOOL SPECIMEN Routine Fecalysis Stool Culture and Sensitivity Determination of ova and parasite Fecal occult blood test (FOBT) URINE SPECIMEN COLLECTION Clean catch midstream urine specimen Timed urine specimen Indwelling catheter urine BIOLOGICAL THEORIES OF AGING Wear and Tear Theories Cross-Linking Theories Free-radical Theory Immunological Theories PSYCHOSOCIAL THEORIES OF AGING Erikson's Ego Integrity vs. Despair Disengagement Theory Continuity Theory Activity Theory INTEGUMENTARY Wrinkling and sagging of skin Dry skin Brown "age spots" or LENTIGO SENILIS Decreased subcutaneous fat SENSORY / PERCEPTION Presbyopia Arcus Senilis Presbycusis Diminished smell and taste Diminished pain perception RESPIRATORY GENITOURINARY Diminished lung expansion Diminished renal blood flow Barrel-chest Decreased bladder capacity Decreased alveolar function Decreased bladder tone Decreased cough efficiency Decreased hormone production in women Prostate enlargement in men CARDIOVASCULAR Decreased cardiac output Decreased vessel elasticity Orthostatic hypotension S4 heart sound MUSCULOSKELETAL Loss of bone mass Kyphosis & Joint stiffness Decreased power of muscle contraction Impaired balance GASTROINTESTINAL Decreased salivary production Diminished digestive juices Decreased peristalsis  HEALTH CARE-ASSOCIATED INFECTIONS Acquired in a hospital or other health care facility and were not present or incubating at the time of a client's admission Hospital-acquired infection is also known as nosocoral infection Can be transmitted by health care personnel who fail to practice proper standard precautions HOSPITAL-ASSOCIATED (NOSOCOMIAL) INFECTIONS Catheter-Associated Urinary Tract Infection (CAUTI) Surgical Site Infection (SSI) Ventilator-Associated Pneumonia (VAP) Central-Line-Associated Blood Stream Infection (CLABSI) STANDARD PRECAUTIONS STANDARD PRECAUTIONS Nurses must practice standard precautions with all clients DONNING PPE in any setting, regardiess of the diagnosis or presumed Wash hands infectiveness. Wear gown Wear mask These precautions apply to blood, all body fiuids (whether Wear eyewear/goggles or face shield or not they contain blood), secretions and excretions, Wear gloves nonintact skin, and mucous membranes. DOFFING PPE STANDARD PRECAUTIONS Remove gloves WASH HANDS Wash hands between client contacts Remave eyewear after contact with blood, body fluids, secretions or excretions, Disinfect hands nonintact skin, or mucous membranes Remove gown after contact with equipment or contaminated articles Disinfect hands immediately after removing gloves Remove mask Disinfect hands For routine decontamination of hands, use alcohol-based hand rubs when hands are not visibly soiled STANDARD PRECAUTIONS USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE) Wear gowns if soiling of clothing a 4 ands atter remi 0N4 Wear masks and eve protection, or face shields, & cel care actvites may gentrate splashes or sprays of blooil body hurd Wear gloves when touching ble od, body fluids: secreti excretions, nonintact skin, mucous membranes, pr contaminated iterns, ramove gloves and wash hands between client care contacts STANDARD PRECAUTIONS Clean and reprocess cient care equipment properly and discard single-use items Discard contaminated items in a yellow trash bin. Place contaminated linens in leak-proof bags and imit handling to prevent skin and mucous membrane exposure. Dispose according to agency policy Clean spills of blood or body fluids with agency-approved disinfectant. STANDARD PRECAUTIONS Use needleless devices or special needle safety devices: NEVER RECAP NEEDLES. Discard all sharp instruments and needles in a puncture-resistant container. TRANSMISSION-BASED PRECAUTIONS AIRBORNE PRECAUTIONS Single room is contained under negative airflow pressure, door remains rosed except upon entering and exting Ultraviolet gernicide irradiation or HEPA filter is used in the room. Healthcare workers wear a respratory mask (N95 or higher level). A surgical mask is placed on the client when the client needs to leave the room, the client leaves the room only if necessary. TRANSMISSION-BASED PRECAUTIONS DROPLET PRECAUTIONS Used for pts with known or suspected infection with pathogens transmitted by respiratory droplets, generated when coughing sneezing, or talking, Private room or cohort ellent (a client whose body cultures contain the same organism) Wear a surgical mask when within 3 feet of a client Place a mask on the client when the client needs to leave the room TRANSMISSION-BASED PRECAUTIONS CONTACT PRECAUTIONS Private room or cohort client Use gloves and a gown whenever entering the room Provide articles dedicated only for the patient. The primary indication of Oxygen Therapy is HYPOXIA Earliest sign: Restlessness Late sign: Cyanosis Chronic sign: Clubbing of fingers Oxygen Delivery Systems LOW-FLOW DELIVERY SYSTEM Delivers oxygen via small-bore tubing that varies depending on tidal volume and respiratory rate. Room air is inhaled. HIGH-FLOW DELIVERY SYSTEM Delivers a precise and consistent 02 via large - bore tubing. Safety Precautions Place precautionary sign "NO SMOKING, O2 IN USE" Remove articles that generate static electricity. Ensure that electrical devices are in good wurking under to prevent short circuits. Avoid the use of volatile and flammable marcrials. Electronic monitoring equipment or machines must be all grounded. Ensure availability of fire extinguishers.