Foundation of Care PDF

Foundation of care ‫اح م د ا لس ي د‬ 0503327640 0503327640 ‫احمد السيد‬ Page 1 Intracellular compartment Fluid inside the cells. Extracellular compartment Fluid outside the cells includes: Intravascular compartment  (fluid inside a blood vessel) Interstitial fluid: (Sometimes called the third s...

Foundation of care ‫اح م د ا لس ي د‬ 0503327640 0503327640 ‫احمد السيد‬ Page 1 Intracellular compartment Fluid inside the cells. Extracellular compartment Fluid outside the cells includes: Intravascular compartment  (fluid inside a blood vessel) Interstitial fluid: (Sometimes called the third space)  Fluid between cells blood ,lymph, bone, connective tissue, water, and trans cellular fluid Accumulation of fluid in the interstitial space Types Localized edema Occurs as a result of traumatic injury from accidents or surgery, local inflammatory processes, or burns. Generalized edema (anasarca) An excessive accumulation of fluid in the interstitial space. Osmotic pressure the force that draws the solvent from a less concentrated solute into a more concentrated solute 0503327640 ‫احمد السيد‬ Page 2 Isotonic solutions Isotonic to human cells Hypotonic solutions contains a lower concentration of salt or solute hypotonic to the cells Hypertonic solutions has a higher concentration of solutes than another  The client with diarrhea is at high risk for a fluid and electrolyte imbalance.  A client with acute kidney injury or chronic kidney disease is at high risk for fluid volume excess. 0503327640 ‫احمد السيد‬ Page 3 Types of pain 1. Acute:  associated with an injury, medical condition, or surgical procedure.  Lasts hours to afew days 2. Chronic:  Usually associated with long-term or chronic illnesses or disorders.  may continue for months or even years 3. Phantom:  Occurs after the loss of a body part (amputation)  may be felt in the amputated part for years after the amputation Pharmacological Interventions A. Nonopioid analgesics  Nonsteroidal antiinflammatory drugs (NSAIDs) and acetylsalicylic acid (Aspirin)  These medication types are contraindicated if the client has gastric irritation or ulcer disease  Bleeding is a concern with the use of these medication types. 0503327640 ‫احمد السيد‬ Page 4  take oral doses with milk or a snack to reduce gastric irritation.  NSAIDs can increase the effects of anticoagulants.  Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent.  A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker. Acetaminophen(Tylenol)  contraindicated in clients with hepatic or renal disease, alcoholism, or hypersensitivity.  Monitor the client for signs of hepatic damage(e.g., nausea and vomiting, diarrhea, abdominal pain).  Monitor liver function parameters.  The antidote to acetaminophen is acetylcysteine. The major concern with acetaminophen is hepatotoxicity. Opioid analgesics  medications suppress pain impulses but can also suppress respiration and coughing by acting on the respiratory and cough center, located in the medulla of the brainstem.  Opioids, which produce euphoria ‫ نشوة‬and sedation, can cause physical dependence.  Administer the medication 30 to 60 minutes before painful activities. Before adminstration monitor: respiratory rate; if it is slower than 12 breaths/min in an adult, withhold the medication and notify the HCP. if bradycardia develops, withhold the medication and notify the HCP. hypotension and assess before administering pain medications to decrease the risk of adverse effects. 0503327640 ‫احمد السيد‬ Page 5  Encourage activities such as turning, deep breathing, and incentive spirometry to help prevent atelectasis and pneumonia.  Instruct the client to take oral doses with milk or a snack to reduce gastric irritation.  Have an opioid antagonist (e.g., naloxone), oxygen, and resuscitation equipment available 2. Codeine sulfate Should be used in low doses as acough suppressant. It may cause constipation. Common medications in this class are hydrocodone and oxycodone (synthetic forms). Hydromorphone  The primary concern is respiration depression.  Other effects include drowsiness, dizziness, and orthostatic hypotension.  Monitor vital signs, especially the respiratory rate and BP. 4. Morphine sulfate uses      myocardial infarction or cancer, dyspnea resulting from pulmonary edema, preoperative medication. The major concern is respiratory depression, postural hypotension, urine retention, constipation, and pupillary constriction may occur Contraindication     Severe respiratory disorders head injuries, severe renal disease Seizure activity, increased intracranial pressure. urine retention. 0503327640 ‫احمد السيد‬ Page 6  constipation  Monitor the pupil for changes; pinpoint pupils may indicate overdos pressure injury and impaired skin integrity (Bony prominences are areas most affected by pressure injury)  Atelectasis: Collapse of the alveoli  Hypostatic pneumonia: inflammation of the lung from the pooling of static secretions,  Orthostatic hypotension, thrombus formation  The distance between the axillae and the arm pieces on the crutches needs to be 2 to 3 finger widths in the axilla space  The elbows should be slightly flexed, 20 to 30 degrees, when the client is walking.  When ambulating with the client, stand on the affected side. Two-point gait  For clients who can bear weight on both legs and have mastered the four-point gait Three-point gait For clients who can bear weight on only one leg. 0503327640 ‫احمد السيد‬ Page 7 four-point gait For clients who can bear weight on both legs Swing-through gait For clients who have adequate muscle power and balance in the arms and legs commonly used by clients with paraplegia who wear weightsupporting braces on their legs Going up the stairs a. The client moves the unaffected leg up first. b. The client moves the affected leg and the crutches up. Going down the stairs a. The client moves the crutches and the affecte d leg down. b. The client moves the unaffected leg down 0503327640 ‫احمد السيد‬ Page 8 Skin is the large organ in the body and provides protection against disease Factors affecting skin integrity  Nutrition Protein, vitamins, and trace minerals are important for healing Serum albumin is frequently measured as an indicator of nutrition for clients who need support with wound healing.  Tissue perfusion Clients with diabetes mellitus and poor tissue perfusion are at increased risk for impaired skin integrity and delayed wound healing Indications of infection include redness in the tissue, pain, fever, change in the volume or character of wound drainage, purulent drainage, and odor.  Immobility  Incontinence a. Inflammatory: Begins at the time of injury and lasts 3 to 5 days; manifestations include local edema, pain, redness, and warmth. b. Fibroblastic: Begins the fourth day after injury and lasts 2 to 4 weeks; scar tissue forms, and granulation tissue forms in the tissue bed. c. Maturation: Begins as early as 3 weeks after the injury and may last for 1 year; scar tissue becomes thinner and is firm and inelastic on palpation 0503327640 ‫احمد السيد‬ Page 9 Primary (first) intention wound is easily closed and dead space is eliminated. Second (second) intention: occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue. c. Tertiary (third) intention: involves delayed primary closure occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by first intention. Serous ■ Clear or straw-colored and watery Serosanguineous ■ Pale, pink, and watery Sanguineous ■ Red drainage that is abnormal and indicates active bleeding Purulent ■ Yellow, gray, tan, brown, or green drainage due to infection in the wound 0503327640 ‫احمد السيد‬ Page 10 Risk factors 1. Skin pressure 2. Skin shearing and friction 3. Immobility 4. Malnutrition 5. Incontinence 6. Decreased sensory perception Interventions  reposition the immobile client every 2 hours or more  Avoid direct massage to a reddened skin area,  ensuring adequate nutrition, and developing a plan for skin cleansing and care.  Keep the client’s skin dry and the sheets wrinkle free  Use creams and lotions to lubricate the skin and barrier protection ointment for the incontinent client.  provide active and passive range-of-motion exercises at least every 8 hours. 0503327640 ‫احمد السيد‬ Page 11 Stage 1 Skin is intact. Area is red (not purple or maroon) and does not blanch with external pressure. Stage 2 Skin is not intact. Partial-thickness skin loss with exposed dermis. Wound bed is viable, pink or red, and moist. Presents as an intact or open/ruptured serum-filled blister Stage 3 Full-thickness skin loss. Granulation tissue and rolled wound edges are often present. Subcutaneous tissue may be damaged or necrotic. Stage 4 Full-thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. 0503327640 ‫احمد السيد‬ Page 12 1) Obtaining informed consent The surgeon who will be performing the surgery is responsible for explaining the surgical procedure to the client and answering the client’s questions. the nurse is responsible for obtaining the client’s signature on the consent form for surgery the nurse must be sure that the client has understood the surgeon’s explanation of the surgery. Minors (clients younger than 18 years) may need a parent or legal guardian to sign the consent form. Clients who are not alert or oriented may need their power of attorney for health care or a legal guardian to sign the consent form. Psychiatric clients have a right to refuse treatment until a court has legally determined that they are unable to make decisions for themselves. No sedation would be administered to the client before the client signs the consent form. Nutrition NPO (nothing by mouth) status before surgery. Withhold solid foods and liquids as prescribed to avoid aspiration, usually for 6 to 8 hours before general anesthesia and for approximately 3 hours before surgery with local anesthesia Insert an intravenous (IV) line and administer IV fluids, (fluids are also administered to protect the kidneys during anesthesia Elimination If the client is to have intestinal or abdominal surgery an enema, laxative, or both may be prescribed for the day or night before surgery Insert an indwelling urinary cathete 0503327640 ‫احمد السيد‬ Page 13 Deep-Breathing and Coughing Exercises Incentive Spirometry If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or one hand with the other hand on top, over the incisional area. Leg and Foot Exercises Gastrocnemius (calf) pumping: Instruct the client to move both ankles by pointing the toes up and then down. Foot circles: Instruct the client to rotate each foot in a circle. Hip and knee movements: Instruct the client to flex the knee and thigh and to straighten the leg, holding the position for 5 seconds before lowering (not performed if the client is having abdominal surgery or if the client has a back problem). Psychosocial preparation Be alert to the client’s level of anxiety. Answer any questions or concerns that the client may have regarding surgery. Provide support and assistance as needed 0503327640 ‫احمد السيد‬ Page 14 Guidelines to prevent wrong site and wrong procedure surgery The surgeon meets with the client in the preoperative area and uses a surgical marking pen to mark the operative site. In the operating room, the nurse and surgeon ensure and reconfirm that the operative site has been appropriately marked. Just before starting the surgical procedure, a time out is conducted with all members of the operative team present to identify the correct client and appropriate surgical site again. Postoperative Care The goal of postoperative care is to prevent complications, to promote healing of the surgical incision, and to return the client to a healthy state.  Monitor airway patency and ensure adequate ventilation  Monitor vital signs per agency policy  Encourage deep-breathing and coughing exercises as soon as possible after surgery  Monitor circulatory status, such as skin color, peripheral pulses, and capillary refill  Monitor for bleeding.  Assess the pulse for rate and rhythm  Encourage the use of antiembolism stockings  Encourage ambulation if prescribed;  Unless contraindicated, place the client in a lowFowler’s position after surgery to increase thesize of the thorax for lung expansion.  Avoid positioning the postoperative client in asupine position until pharyngeal reflexes have Returned  turn the client every 1 to 2 hours unless contraindicated.  Assess level of consciousness.  Assess neurological status, 0503327640 ‫احمد السيد‬ Page 15  Assess the surgical site, drains, and wound dressings (serous drainage may occur from an incision, but notify the surgeon if excessive bleedingoccurs from the site).  Assess the skin for redness, abrasions, or breakdown  Maintain the NPO status until the gag reflex and peristalsis return. Monitor urine output (urinary output needs to be at least 30 mL/hr).  ask the client to rate the degree of pain on a scale of 1 to 10. Postoperative Complications      Pneumonia and atelectasis Hypoxemia Pulmonary embolism Hemorrhage Skin breakdown Wound infection 0503327640 ‫احمد السيد‬ Page 16 ‫‪Page 17‬‬ ‫احمد السيد ‪0503327640‬‬