Fundamentals Final Exam Review Fall 2022 PDF

FUNDAMENTALS FINAL EXAM REVIEW FALL 2022 Baldia’s In-Class Review: page numbers may be 1-2 pages off due to edits being made to the doc A lot about spirituality and ethics (page 62) KNOW THE LAB VALUES! → Sodium, potassium, magnesium, calcium, and BUN (page 21) ○ Sodium 136-145 ** (these values is based on the values she shared via email) If sodium is 150: Hypernatremia You could see high sodium in patients who are dehydrated ○ Calcium 9-10.5 ** (these values is based on the values she shared via email) Hypocalcemia - (PAGE 67) Chvostek and Trousseau sign Look at the muscle cramps, laryngospasm (respiratory system) Hyperkalemia - peak/tall T wave, widened QRS (page 68) ○ BUN (lab value: 8-20) → blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working amount of urea nitrogen found in blood. The liver produces urea in the urea cycle as a waste product of the digestion of protein ○ Magnesium: 1.5-2.4 Hypernatremia = Dehydration (page 68) 3 Parameters for Dehydration (page 69) ABGs and Acid Base Balance (simplified version on page 69) There is an INVERSE relationship between calcium & phosphorus (page 68) Hematocrit (lab value: 36-51%) → the percentage by volume of RBCs Pain (page 56) Fluid Volume Excess and Fluid Volume Deficit (page 22) PCA - Patient-controlled analgesia (PCA) is a type of pain management that lets you decide when you will get a dose of pain medicine (PAGE 56) ○ What are the responsibilities of a nurse with a patient with pca? Types of masks for oxygenation (page 45) ○ Non rebreather How much percentage of oxygen does it deliver? 90-100% What are you looking for as a nurse (how do you know it is functioning)? Bag should be partially inflated, NEVER DEFLATED. Monitor o2 sat so that it's going up. How do you know it’s a nonrebreather mask? Look for the rubberized flap, as the pt breaths and breaths out, air goes through the bag 100%, Flap open to get total oxygen (100%), make sure rubber flap is present. Two flaps: one on the side and one on the outlet for the oxygen. ○ Venti mask ○ Simple mask ○ Partial non rebreather mask KNOW ABGS (simplified on page 69, also on page 27) CHEST TUBES → HOW do you know its working?? (page 71) ○ Look at the water seal chamber ○ Looking for a rise, look for tideling, look for bubbling Delegation (PAGE 65) PATIENT CENTERED CARE Maslow's Hierarchy ABC’s (airway, breathing and circulation) are physiological needs !!!! Critical Thinking/Clinical Reasoning Critical thinking skills → interpretation, analysis, evaluation, inference, and explanation to be able to make clinical judgements. Clinical reasoning → process in which judgements lead the nurse to choose actions and interventions. Critical thinking → active, orderly, well thought out reasoning process that guides a nurse in various approaches to making a nursing judgment by applying knowledge and experience, problem solving, logic, reasoning, and decision making. Components of critical thinking include: knowledge, experience, critical thinking competencies, attitudes, and intellectual and professional standards. Follows a systemic process or pattern, not jumping to conclusions but using reason to guide decisions. Nurses make inferences when making clinical decisions by pulling pieces of information together to determine a relationship between the data. Concepts of Cultural Diversity and Respect Cultural Diversity is the coexistence of different ethnic, biological, sex, racial, and socioeconomic groups within one social unit. Nurses must be sensitive to cultural factors in order to provide culturally respectful care to people from diverse backgrounds. The concept of cultural respect enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Nurses need to understand actions and behaviors that are acceptable to a patient. ASEPSIS/INFECTION CONTROL Infection Control An infection occurs when the presence of a pathogen leads to a chain of events. A nurse uses infection control practices (medical asepsis, surgical asepsis, standard precautions) to break the chain and stop spread of infections. Medical Asepsis: clean technique; involved procedures and practices that reduce the number and transfer of pathogens; Commonly used continuously within and outside of health facilities Surgical Asepsis: sterile technique; includes practices used to render and keep objects and areas free from microorganisms; procedures include inserting an indwelling urinary catheter or inserting an IV catheter Standard and Transmission Based Precautions Standard Precautions: used in the care of ALL hospitalized patients regardless of diagnosis or possible infection status Apply to blood, all body fluids, secretions, and excretions except sweat, non-intact skin and mucous membranes Hand hygiene using alcohol based waterless products is recommended after contact with clients when hands are NOT visibly soiled or contaminated w/ blood or bodily fluids and after removal of gloves. Wash hands w/ soap and water if contamination with spores is suspected. Hand hygiene using nonantimicrobial soap or an antimicrobial soap and water when visibly soiled or contaminated w/ blood or body fluids. Use soap and water for C diff Remove gloves and perform hand hygiene between each client Masks, eye protection, and face shields are required when care might cause splashing or spraying of body fluids Use sturdy, moisture-resistant bag for soiled items. Transmission-based precautions: used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet or contact routes Airborne : infections smaller than 5 mcg such as measles, tuberculosis, varicella. Require private room with negative pressure. Door remain closed, health care workers wear respiratory mask ( N95 ) Droplet : infections larger 5 mcg and travel 3 to 6 ft from client. Adenovirus, diphtheria (pharyngeal), epiglottitis, influenza (flu), meningitis, mumps, parvovirus B19, pertussis, pneumonia, rubella, scarlet fever, sepsis, streptococcal pharyngitis Private room or client whose body culture contains the same organism. Wear a surgical mask. Place a mask on the client when they leave the room. Contact : used for colonization or infection with multidrug resistant organism, enteric infections (C. diff), respiratory infections (RSV, influenza), wound and skin infections (cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, and varicella zoster), eye infections (conjunctivitis) PATIENT SAFETY Factors Affecting Safety Developmental considerations Neonate and infant: never leaving the infant unattended, using crib rails, monitor choking hazard, infant carriers and car seats are mandate in all 50 states Toddler and preschooler: home accidents such as poisoning (Must call poison control center immediately; Call 911 if unconscious; Never induce vomiting), falls, drowning School-aged children: head injuries with bicycle accidents, helmet must be worn!! Adolescent: automobile accidents, suicide, alcohol use, substance abuse, tobacco, body piercing, use of guns, internet Adult: lifestyle habits, domestic violence Older patient: falls, motor vehicle accidents, medication overdose, elder abuse, fire Lifestyle: occupation, social behavior Environment Impaired mobility Sensory perception or communication impairment Knowledge -- lack of safety awareness Ability to communicate Physical & psychological health state Elderly Patients and Risk for Accidents Vision alterations, less sensitive to hot and cold, decreased hearing Alterations in posture, balance Decreased range of motion Slower reflexes Nocturia (frequent urination during night), incontinence Polypharmacy (antihypertensive medications) (e.g. Benzodiazepine) Implementing: Teaching to Promote Safety Acute care safety – fall risk prevention Orientation & explain how to use call light, place call device within easy reach Respond quickly to call lights/bed/chair alarms, personal items within reach, use nightlight instead of fluorescent lighting at night, avoid diuretics in the evening Keep environment free from clutter, no spills or scattered/ throw rugs Safe patient transfers Ambulation with assistance, assistive aids placed at bedside, non slip footwear Safety bars near toilets, bath seat, locks on beds and wheelchairs Apply color-coded wristbands (yellow) Frequent observations, low safety bed, mattress sensor, ambularm Lighting Changing the environment: remove obstacles, place necessary objects on bedside table, secure rugs and carpeting, wear safety alert device Accidental home fires – stop, drop and roll Reduce risk of accidental poisoning Preventing Falls in Health Care Facility - Explain how to use call light, place call button within easy reach - Respond quickly to call lights/bed/chair alarms, personal items within reach, use nightlights at night, avoid diuretics in the evening - Keep environment free from clutter, no spills or scattered/ throw rugs - Safe patient transfers - Ambulation with assistance, non slip footwear, assistive aids placed at bedside - Safety bars near toilers, bath seat, locks on beds and wheelchairs - Apply color coded wristbands - Frequent observations RACE in case of fire 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 safe area Using a Fire extinguisher: PASS Pull Aim Squeeze Sweep Using Restraints in Health Care Facilities Serious complications associated with restraints Hazards of immobility – Inadequate/improper turning & positioning -> pressure ulcers, pneumonia, constipation, incontinence, restricted breathing and circulation -> death!! Skin breakdown under restraint Decreased circulation to involved extremity -> neurovascular impairment Risk of falls Psychological implications – patient/family teaching re: restraint purpose, & precautions in place Purpose – the use of restraints must meet the following objectives: Reduce the risk of patient injury from falls. Reduce the risk of injury to others by the patient. Prevent the interruption of therapy, e.g. artificial airways, life support equipment, IV infusions, NG tube feedings, traction, Foley catheters, surgical drainage The use of restraints is a temporary, last resort measure. Used only when alternative, less restrictive measures have been tried & have been unsuccessful Used to ensure immediate safety Applied according to institution’s policy & procedure Discontinued as soon as possible **Use slipknot, tie to the bedframe Check on pt every 30 minutes and document Release restraints every 2 hours, check skin, offer toileting, offer drink/food Need new order from provider every 24 hours Alternatives to Restraints Goal: Maintain a restraint-free environment ○ Orient patient and family to surroundings ○ Assess frequently & respond promptly to call bell ○ Encourage family to stay ○ Use companions, adjust staffing, use trained sitters ○ Move patient to room closer to nurses’ station ○ Offer reassurance, de-escalate, redirect from inappropriate behavior ○ Educate patient regarding unsafe behaviors ○ Provide visual stimuli – familiar items, pictures, clock ○ Promote relaxation – music, books, back rub ○ Disguise/protect tubes, lines, & dressings ○ Ambulation as indicated ○ Toileting rounds ○ Offer food/snacks ○ Pain management ○ Medication review & lab results check ○ Bed alarm/ambularm Restraint Standards Nursing assessment comes first!! Use least restrictive measure Must be clinical justification based on face-to-face evaluation, must be time dated & signed by physician, must state the type of restraint, justification for the restraint, the intended duration of use, and criteria for removal. Restraints may be applied without a physician’s order in an emergency. However, the order must be obtained immediately afterward. (obtain within the hour) Must comply with agency policy Must have tried alternate strategies Preserve patient’s rights & dignity Written order, renewed q 24 hr. Cannot be ordered as prn. Remove restraint q 2 hrs Must be reassessed by staff every hour at least or according to agency policy; specific assessments q 15 inpt psychiatric pt. Patient Monitoring Signs of injury associated with the application of restraint or seclusion Nutrition/hydration Circulation and range of motion in the extremities Vital signs Hygiene and elimination Physical and psychological status and comfort Readiness for discontinuation of restraint or seclusion Unlicensed assistive personnel (nursing assistants) may monitor and document. Report changes to RN. RN must assess the patient and must do so regularly based on the patient’s need and per hospital policy Documenting Use of Restraints Indicate reason why pt. needed restraint – “clinical justification” Mental status/level of consciousness Patient’s behavior before restraint applied – e.g., agitated, attempting to climb out of bed or pull out tubes, combative, is patient threat to self &/or others Restraint alternatives attempted & patient’s response – e.g., medicated for pain/reports relief but behavior not improved; hand mittens applied but continues repeated attempts to pull out NG tube; one to one companion at bedside but continues to climb over side rails Pt./family teaching re: need for restraint & verbalized understanding of same Name of healthcare provider notified, order received & what type restraint & time applied Baseline – vital signs & neurovascular assessment of involved site: skin intactness, color, temp., perfusion (capillary refill check) & strength of pulses, sensation (any complaints of numbness, tingling, diminished tactile perception); any swelling? Restraint monitoring protocol initiated – document required 15-30min. checks & q 2 h actions such as release of restraints for skin/neurovascular assessment, skin care, nutrition/hydration needs, toileting, range of motion, reassessment for need &/or least restrictive method. Typically recorded on a flowsheet, but must be documented in progress note if flowsheet not in use. Pt.’s response – verbal, nonverbal behavior indicating outcomes of restraint use Application of Extremity Restraint Choose the least restrictive type of device that allows the greatest possible degree of mobility. Pad bony prominences. Wrap the restraint around the extremity with the soft part in contact with the skin. If hand mitt is being used, pull over hand with cushion to the palmar aspect of hand. Secure in place with the Velcro straps or reverse clove hitch. Ensure that two fingers can be inserted between the restraint and patient’s wrist or ankle. Maintain restrained extremity in normal anatomic position. Use a quick-release tie to secure the restraint to the bed frame, not side rail. The restraint may also be attached to chair frame. The site should not be readily accessible to patient. Keep call bell within easy reach. HYGIENE Factors Affecting Personal Hygiene Culture - People from diverse cultures practice different hygiene rituals. Avoid forcing changes unless hygiene practices affect health. Spiritual Practices - A person’s religious beliefs Health State - May lack physical energy and dexterity to perform self-care Socioeconomic Class - Influences the type and extent of hygiene practices used Developmental Level - Affects the patient’s ability to perform hygiene care Personal preferences - Dictate hygiene practices A clear threat to health must exist before a nurse decides a person’s hygiene practices are inadequate Assisting with Bathing and Skin Care Therapeutic: sitz, medicated - hemorrhoid patient will drink warm medicated water Complete bed bath, shower – assess the patient’s physical tolerance Partial bed bath – use long strokes on the extremities from distal to proximal ○ Disposable bath – decrease risk for infection related to contaminated washbasins and washcloths. No rinsing is required. ○ Perineal care Bathing Guidelines: Maintain safety - priority Provide privacy Maintain warmth Promote independence Anticipate needs Bathing a Patient w/ Dementia: Shift focus away from the “task” to needs and abilities of pt. Individualize patient care. Consult with family and other caregivers Observe behavior, is there an unmet need? Ensure privacy and warmth Be creative and set priorities: towel baths, washing under clothes, bag baths Be relaxed, talk in a calm, soothing tone Encourage independence Explore the need for routine analgesia before bathing. Notice triggers for agitation: washing face, being cold (Wash face or hair at the end or at a separate time) Massaging the Back effleurage, contraindicated in pts with #ribs, heart surgery. Encourages blood circulation Assisting with Oral Hygiene Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes. Brushing teeth at least twice a day with fluoride toothpaste. Use of chlorhexidine gluconate oral spray or dental gel for critically ill pts reduces the incidence of health care associated pneumonia. Do not use lemon-glycerin sponges and undiluted hydrogen peroxide Flossing removes tartar at the gum line. Flossing at least once a day. Rinsing removes particles and excess toothpaste. Patients with special needs: Diabetes – periodontal diseases Artificial airways (endotracheal or tracheal tubes) – xerostomia, ventilator-associated pneumonia ○ Unconscious – pooling of saliva, absence of gag reflex – Aspiration Precautions!! (Turn pt on side; Yankauer suction; oral airway if indicated) Chemotherapy – stomatitis, avoid alcohol, commercial mouthwash, stop smoking, encourage intake of soft foods ACTIVITY/IMMOBILITY Type of Exercises Two major types: muscle contraction during exercise and type of body movement occurring Isotonic: muscle shortening and active movement. Ex: carrying out ADL’s, independently performing ROM exercises, swimming, walking, jogging, bicycling. Increased muscle mass, tone, and strength; improved joint mobility; increased cardiac and respiratory function; increased circulation, and increased osteoblastic Isometric: muscle contraction without shortening. (no movement or only minimum of shortening of muscle fibers) Ex: palm press, holding a yoga pose, make a fist, foot flex Isokinetic : muscle contraction with resistance. Resistance is provided at a constant rate by an external device. Application of Ergonomics to Prevent Injury Face the direction of movement and avoid twisting your body. Maintain a wide, stable base with your feet spreading to shoulder width, lower center of gravity, flex at the knee level, use stronger muscle groups (e.g. legs). Put the bed at the correct height (waist level when providing care; hip level when moving a patient) Try to keep the work directly in front of you to avoid rotating the spine; face direction of movement when lifting patient up in bed Keep the patient as close to your body as possible to minimize reaching Use two hands to lift rather than one, even with light objects and tasks Avoid lifting with forearm in full pronation or supination Slide, roll, push or pull objects instead of lifting Push rather than pull equipment when possible. Keep arms close to your body and push with your body, not just your arms. Carry objects close to body at waist level Tighten the abdominal muscles & tuck the pelvis Break up heavy loads into smaller loads. Alternate periods of rest and activity Get assistance if needed!! BODY MECHANICS ALONE are NOT ENOUGH Ensuring Safe Patient Handling and Movement Assess patient, know patients medical diagnosis, capabilities, and any movement not allowed. Apply braces or any device the pt wears before helping from bed. Assess pt’s ability to understand instructions and cooperate w/ staff to achieve the movement. Ensure that enough staff are available and present to safely move the patient. Assess area for clutter, accessibility to the patient, and availability of devices. Remove any obstacles that may make moving and lifting inconvenient. Use handling aids, transfer equipment, and assistive devices whenever possible to help reduce risk of injury to yourself and patient. Positioning Patient in Bed Assessment to determine staff or equipment needed Assess for presence of tubes, incisions and equipment Check orders for positioning contraindications Maintain body alignment & use correct body mechanics Position the patient in the opposite direction of the turn first, on the edge if side rails are up. Avoid friction & shearing; avoid pressure points by supporting patient with pillows/use special mattress or bed Use individualized turning schedule Assistive devices: trochanter roll, trapeze bar ROM exercises ** MAKE SURE BED LOCKS ARE ON WHEN MOVING PATIENT ** Turning and Moving a Patient in Bed Reposition every 1 to 2 hours Assisting with ROM Exercises Active ROM exercises ASAP – incorporate into ADL, sitting in chair, lying in bed Passive ROM exercises ASAP – incorporate into bathing activities; CPM (continuous passive motion) Perform in head-to-toe sequence Slow & rhythmically ONLY to point of resistance & NEVER beyond point of pain; support joint 3-5 repetitions, 2-3X/daily Helping Patients Ambulate Bed to Chair/wheelchair – Involve patient Assess the patient endurance level, pain level, body weight, weight bearing status, use of assistive devices, determine staff required for safe transfer Elevate head of the bed Supine → sitting → DANGLE Provide non slip footwear Place chair on stronger side at 45-degree angle to bed Lock wheelchair, raise foot plates Mechanical lift device PRN Bed to stretcher – Pt who receive opioid pain medications need additional assistance, transfer board PRN Safety in ambulation – assistive walking devices Walker: device with four legs or rolling Canes: should be held on patient’s stronger (non-affected) side - COAL (cane opposite affected leg) ○ Weight evenly distributed between feet and cane ○ First advance the cane -> move weaker leg forward parallel to cane -> move stronger leg forward to finish step Crutches: crutch pad should be 3 finger widths below the axilla (weight should not be supported by axilla) MEDICATIONS Mechanism of Drug Action Interactions between medications and target cells, body systems, and organs to produce effects. Results in functional changes that are the mechanism of action of the medication. How the medication produces its therapeutic effect. Agonist: Medication that mimics the receptor activity that endogenous compounds regulate. Ex: morphine is an agonist because it activates the receptors that produce analgesia, sedation, constipation, and other effects. Antagonist: Medications that can BLOCK the usual receptor activity that endogenous compounds regulate or the receptor activity of other medications. Partial Agonists: Medication that acts as an agonist and an antagonist, with limited affinity to receptor sites. Adverse Drug Reactions Therapeutic Effect: Expected or predicted physiological response Adverse Drug Effects (ADE): Reportable serious ADEs to FDA MedWatch program Undesirable Side Effects – some are expected and tolerated. Ex. Constipation as side effect of Morphine Sulfate Allergic Effect ○ Anaphylactic Reaction (BP drops and airways narrow, blocking breathing) Drug Tolerance Toxic Effect – cumulative effect – more drug is taken before it is metabolized Idiosyncratic (paradoxical effect) – over-response, under-response or the opposite of what is expected Medication Reconciliation Process in which a patient's medication order is compared to all medications that the patient has been taking. This is to avoid medication errors such as wrong drug, wrong dose, drug given to wrong patient, etc. Anytime paperwork is handed off Using Safety Measures While Preparing Drugs 1. Check doctors orders against MAR: assure accuracy in the transcription, call doctors to verify the order if needed. Nurses are accountable for giving an ordered medication that is knowingly inappropriate or giving an unclearly written medication. 2. Check allergies 3. Know why patient is getting the medication 4. Be aware of precautions/contraindications/side effects/toxic effects 5. Ascertain vital signs/lab results if necessary BEFORE medication administration 6. Avoid distraction when preparing medications 7. Pour medication one at a time 8. Check drug name as you take from drawer, as you prepare to open and then after opening consistently with the MAR 9. Assure the right route/time/?can be crushed? 10. Administer medication at bedside with MAR 11. Assure right patient: check MAR against arm band-- Name, DOB (MRN# multiple births) 12. Stay with patient until all meds given 13. Do not leave any medication at bedside 14. Do not administer any medication prepared by another nurse, unless the unit dose label clearly identifies the drug and the seal has not been broken 14. Sign off the MAR right after medications are given and not before 15. Monitor for effects of drugs Administering Medications Through an Enteral Feeding Tube Head of bed elevated at least 30o during and after Liquid preparation available? Can pill be crushed? Verify tube placement prior to administering Add enough H2O (15-30 mL) to mix crushed medication. No tap water Using oral/enteral syringe, flush before, between, & after last medication with 15-30 mL (5-10 mL for children) water Turn off suction for 20-30 minutes after Discontinue a continuous tube feeding and leave the tube clamped for a period of time before and after the medication has been given, according to the facility protocol. Record intake of fluid Closed tubing should be replaced every 48 hours Open tubing is every 4 hours Preventing and Responding to Medication Errors ► Report all medication errors – more common than realized ► Patient safety is top priority when an error occurs. ► Documentation is required. ► The nurse is responsible for preparing an incident report: an accurate, factual description of what occurred and what was done. Do NOT document in the patient’s record the fact that an incident form was filled. ► Steps to take: 1. ASSESS patient 2. Notify prescribe and nurse manager/supervisor to discuss possible courses of action, depending on the patient’s condition. 3. Write a description of the error on the pt’s medical record, including remedial steps taken. 4. Complete special event or unusual occurrence reports – Do not document in the pt’s record the fact that an incident report was filed. Nurses play an essential role in medication reconciliation – helps prevent errors from occurring when patients change settings, HCPs, in-house transfers, or discharge PRINCIPLES OF IV THERAPY Initiation and Transfusion of Blood Typing and compatibility screening Temperature considerations ○ Blood warmers must be used to prevent hypothermia and adverse reactions ○ (e.g. cardiac dysrhythmia) when several units of blood administered ○ Only use devices tested for this purpose ○ Do not warm blood products in microwave or hot water Infusion pumps ○ These may be used to administer blood products if designed to function with opaque solutions ○ Always consult manufacturer guidelines for controller or pump ○ Special manual pressure cuffs may be used to increase flow rate, but pressure should not be higher than 300 mm Hg ○ Standard sphygmomanometer cuffs not to be used to increase flow rate HCP’s order required & consent form signed Assess IV access; 18 – 20 gauge for adults; 22-24 gauge for neonate or pediatric pt; ?additional IV needed Use special tubing (Y tubing w/ inline filter) that contains a blood filter to transfuse PRBCs. Platelets transfusion often require different tubing from that used for other blood products. Transfuse as soon as possible after being received from blood bank, within 30 minutes Check blood bag for date of expiration; inspect bag for leaks, abnormal color, clots, bubbles Only two licensed professionals may check blood bag/label & pt. ID band: RIGHT BLOOD – RIGHT COMPATIBILITY – RIGHT PATIENT No medications should be added to blood bag or piggybacked into blood transfusion Only Normal Saline infused or added to blood components Infused over 1-2 hrs. for RBC Prior to start of transfusion: ○ Have pt. void or empty Foley bag ○ Measure vital signs (priority assessment), temp (notify HCP if >100o), & lung sounds before, 15 minutes after start of transfusion, then q 30 min until 30 min to 1 hr post-transfusion. Report if baseline temperature is elevated!! Remain with pt. during first 15 min. of transfusion Discontinue blood that has been infusing for more than 4 hrs.; Blood administration sets changed every 4 hours or per facility policy Complications of IV Therapy Air embolism (systemic complication) Air enters the vein through IV tubing; Prime tubing with fluid before use to prevent air embolism Signs of air embolism: Dyspnea, chest pain Tachycardia Hypotension Cyanosis Decreased level of consciousness If suspected, clamp tubing to prevent air entry, turn client to left side in Trendelenburg’s position, notify physician, monitor vital signs & pulse oximetry Circulatory/fluid overload or speed shock (systemic complication) Administration of fluids too rapidly (fluid volume overload) Signs: Increased blood pressure Distended neck veins Tachypnea Dyspnea (SOB) Moist cough; crackles Pound headache If suspected, decrease IV flow rate to keep vein open, elevate head of bed, keep client warm, assess respiratory status and edema, notify physician, monitor vital signs. Electrolyte overload (systemic complication) Monitor for signs of electrolyte imbalance; notify physician if present Infection (systemic complication) The longer therapy continues, the greater the risk of infection; always assess for drainage at site At-risk clients include immunocompromised clients, clients receiving chemotherapy, older clients Signs: Erythema, edema, induration, drainage at the insertion site, redness Fever, malaise, chills, VS changes, tachycardia, nausea and vomiting ❖ Maintain strict asepsis when caring for IV site to prevent development of infection ❖ Change tubing and site dressing as per device protocol/follow agency policy ❖ Do not allow IV solution to hang for more than 24 hours or follow agency policy ❖ If infection occurs, discontinue IV and send device in sterile container to laboratory for culture (possible antibiotic administration) Infiltration (local complication) IV fluid leaks into surrounding tissue Form of tissue damage secondary to IV – escape of fluid into subcutaneous tissue due to dislodges catheter that penetrates vessel wall Signs: coolness, pallor or blanched skin, swelling, decrease in flow rate, pain around infusion site, numbness Extravasation If present, remove IV device immediately, restart in opposite extremity Do not rub infiltrated area; can lead to hematoma If present, elevate extremity, apply warm or cold compresses over site Phlebitis/ thrombosis (local complication) Inflammation of a vein/ blood clot that develops in vein Signs – warmth, redness (may be red streak), swelling (usually above insertion site), tenderness (may be able to palpate cord), heat If burning at the IV site, no signs of phlebitis or infiltration, indication of rapid infusion If present, discontinue IV device immediately, remove the catheter, restart in opposite extremity Apply warm, moist compresses as prescribed or per agency policy, and notify physician Do not rub or massage the affected area Hematoma (local complication) Collection of blood in the tissues At the site : blood, hard and painful lump, ecchymosis If develops, elevate extremity, apply pressure and ice or warm compresses as prescribed. NURSING PROCESS Collecting Data Subjective (symptoms or covert data): what the pt. says/ feels; self-report - how they describe their problems; cannot be verified by another person Objective (signs or overt data): observable and measurable data; can be seen, heard or felt by someone other than the patient; can be verified by another person Sources of Data: Patient - primary source. If data obtained from patient is not validated by objective data, must further explore. Secondary sources – ○ Family members, significant others – helpful when pt. is unable to give history ○ Patient record - Chart/ Computer record ○ Assessment technology - bedside monitors, vital signs ○ Other health care professionals ○ Scientific literature ○ Nurses’ experience – expertise & critical thinking develops with practice; learn how to ask right questions, make accurate assessments, anticipate & quickly recognize pt. Responses Identifying and Writing Outcomes Guidelines for Writing Goals and Expected Outcomes: Patient centered - “the patient will…” Singular goal or outcome Observable Measurable Time limited Mutual factors Realistic SMART (specific, measurable, attainable, realistic, time-bound) Identifying Nursing Interventions Nurse-initiated interventions ○ Independent—Actions that a nurse initiates Physician-initiated interventions ○ Dependent—Require an order from a physician or other health care professional Collaborative interventions ○ Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals (e.g. pharmacists, respiratory therapists or PAs) Six Factors to Consider: Characteristics of nursing diagnosis Research base for interventions Feasibility of the interventions Acceptability to the patient Nurses competency FLUIDS & ELECTROLYTES Major Electrolytes Serum “Chem” or “Metabolic profile” or “SMA” Sodium (Na+) 135 – 145 mEq/L Potassium (K+) 3.5 – 5.0 mEq/L Chloride (Cl-) 97 - 107 mEq/L Calcium (Ca2+) 8.6 – 10.2 mg/dL Phosphate (PO4-) 2.5 – 4.5 mg/dl Magnesium (Mg2+) 1.3 -2.3 mEq/L Blood urea nitrogen (BUN) 10 – 20 mg/dL Creatinine 0.7 – 1.2 mg/dL Glucose 70 – 110 mmol/L The Nursing Process for Fluid, Electrolyte, and Acid-Base Balance - Assessment Fluid Volume Deficit (Hypovolemia) Assessment Cardiovascular: Decreased BP & orthostatic hypotension Diminished peripheral pulses; quality 1+ (thready) Increased HR - tachycardia Flat neck veins when supine Elevated Hematocrit (Hct) - hemoconcentration Gastrointestinal: Thirst Decreased motility; diminished bowel sounds, possible constipation Neuromuscular: Decreased CNS activity (restlessness, confusion, lethargy to coma) Possible fever Skeletal muscle weakness Hyperactive deep tendon reflexes Renal: Decreased output – oliguria, anuria Increased urine specific gravity (normal SG 1.015-1.025) Weight loss Integumentary: Dry mouth/oral mucosa & skin Poor turgor Sunken eyeballs Third-spacing signs Respiratory: Increased RR Interventions: Prevention Oral rehydration therapy (fluids containing sodium) IV therapy Monitor electrolytes – possible supplement treatment Medications – e.g. antiemetics, antidiarrheals Monitor HR & BP (postural BP changes), Resp, Renal, GI status Assess for signs of hypovolemic shock Assess skin & maintain skin integrity Monitor daily weights (most effective) & strict I & O Fluid Volume Excess (Hypervolemia) - Assessment Fluid overload is an excess of isotonic fluid – overhydration Common causes: kidney diseases, heart failure Excess fluid volume in the intravascular area - hypervolemia Excess fluid volume in interstitial spaces – edema Types of edema: Localized Generalized – anasarca Third spacing (ascites, pitting edema, pulmonary edema) Causes: Increased Na/H2O retention Excessive intake of Na (PO or IV) Excessive intake of H2O ( PO or IV) (Water intoxication) Syndrome of inappropriate antidiuretic hormone (SIADH) Renal failure, congestive heart failure FVE Assessment : CV: Elevated pulse – 4+ bounding, elevated BP & CVP, distended neck & hand veins, ventricular gallop (S3) Decreased hemoglobin and hematocrit Resp: Dyspnea, Moist , wet lung sounds Crackles, tachypnea, SOB Integumentary: Periorbital edema Pitting or non-pitting edema GI: Increased motility Stomach cramps Nausea & Vomiting Renal: Weight gain Increased urine output & decreased specific gravity of urine (normal SG 1.015-1.025) Neuromuscular: Altered LOC, headache, skeletal muscle twitching FVE Interventions ↓Interstitial Fluid ► Low Na diet, ↓H2O intake ► Diuretics: Furosemide, Bumetanide ► Intravenous hypertonic therapy: Albumin Promote Circulation ► Avoid constricting clothes, positions ► Exercise ► TEDs, pneumatic, compression stockings Maintain Skin Integrity ► Protect from injury ► Keep skin clean & dry ► ↑ protein diet ► Use draw sheet Other ► Semi-Fowlers position ► Accurate I & O ► Daily weights critical!! ► Monitor electrolytes Modifying Fluid Intake Variations in Fluid Content ACID BASE BALANCE Normal arterial blood pH is 7.35 to 7.45 Blood pH < 6.8 or > 7.8 usually fatal Acid Base Balance Regulatory systems: acid production, buffering, and excretion to create balance Acid production: ► Carbonic acid (H2CO3) CO2 +H2O ↔ H2CO3↔ H+ + HCO3− (Carbon dioxide + water ↔ Carbonic acid ↔ Hydrogen ion + Bicarbonate) ► Metabolic acids: any acids that are not carbonic acid Acid buffering: Buffers are pairs of chemicals that work together to maintain normal pH of body fluids ► A base traps H+, as follows: HCO3− + H+↔ H2CO3 (Bicarbonate base traps hydrogen ion to form carbonic acid) ► An acid releases H+, as follows: H2CO3↔ H+ + HCO3− (Carbonic acid release hydrogen ion to form bicarbonate base) Acid excretion systems: lungs excrete carbonic acid & kidneys excrete metabolic acids Lungs: when you exhale, you excrete carbonic acid in the form of CO2 and water. PaCO2 reflects level of CO2in blood: Normal = 35 - 45 mmHg If PaCO2increases, pH falls (acidosis) -> respiratory rate & depth increase to exhale acids If PaCO2 decreases, pH rises (alkalosis) -> respiratory rate & depth decrease to qretain acids Lungs are the primary controller of carbonic acid level. Kidneys: excrete all acids except carbonic acid. ○ Normal HCO3 blood level = 22 – 26 mEq/L If HCO3−levels decrease, pH falls (acidosis) If HCO3−levels increase, pH rises (alkalosis) Renal regulation of acid base balance by absorption or excretion of acids & bases, & can produce HCO3−to restore losses. Kidneys are the primary controller of bicarbonate level. Potassium: compensates for hydrogen ion level changes ○ In acidosis, potassium moves out of cells to make room for hydrogen ions and serum potassium level increases – serum K increases ○ In alkalosis, potassium moves into cells and serum potassium level decreases serum K decreases Acid Base Summary: Kidneys Controls H+ & HCO3 H2CO3 ↔ HCO3− + H+ (Carbonic acid ↔ Bicarbonate + hydrogen ion) HCO3− + H+ ↔ H2CO3 (Bicarbonate + hydrogen ion ↔ Carbonic acid) When pH acidotic ( increase H+) - H+ excreted, HCO3−reabsorbed When pH alkalotic (decrease H+) - H+ retained, HCO3− excreted decrease HCO3−(< 22) -> pH decrease (acidotic) increase HCO3−(> 26) -> pH increase (alkalosis) pH moves in same direction as HCO3− Slow process – takes 1-3 days. The response is long term. HCO3− on ABG report Normal HCO3− = 22 - 26 Lungs Controls CO2 CO2 + H2O ↔ H2CO3 (Carbon dioxide + water ↔ Carbonic acid) increase CO2 (> 45) -> pH decrease (acidotic) decrease CO2 (< 35) -> pH increase (alkalotic) pH moves in opposite direction of CO2 Fast process – w/in minutes to hrs. The response is short term. PaCO2 on ABG report Normal PaCO2 = 35 - 45 Normal ABG’s: pH 7.35 – 7.45 PaCO2 35 – 45 mmHg HCO3− 22 – 26 mEq/L PaO2 80 – 100 mmHg Oxygen saturation >95% Acid Base Imbalance - Respiratory acidosis/alkalosis; Metabolic acidosis/alkalosis Respiratory Acidosis The lungs are retaining too much CO2, the kidneys excrete excess hydrogen and retain bicarb pH < 7.35 PaCO2 > 45 mmHg HCO3− 22-26 mEq/L normal if not compensated; > 26 mEq/L if compensated Causes: Hypoventilation -> hypercapnia (excess carbon dioxide), pneumonia, atelectasis, pulmonary edema, pulmonary emboli, bronchial asthma, COPD, emphysema, respiratory failure, airway obstruction, chest wall injury, respiratory center depression (narcotics, benzos, barbiturates, anesthesia, head trauma, brain lesions, neuromuscular diseases), inadequate mechanical ventilation, alcohol intoxication (CNS depressant) Nursing assessment: mental changes (apprehension, confusion, decreasing LOC –unresponsiveness), ashen color, dyspnea with rapid, shallow, SLOW respirations, tachycardia/.< BP diminished DTRs dysrhythmias/increase K (hyperkalemia) Nursing interventions Protect airway: respiratory assistance, bronchodilators. supplemental O2, antibiotics *COPD low flow O2 Cough & deep breathing, chest tube Alert for Resp. failure Respiratory Alkalosis Lungs are losing too much carbon dioxide, kidneys excrete excess bicarb and retain hydrogen pH > 7.45 PaCO2 < 35 mmHg HCO3− 22-26 mEq/L normal if not compensated; < 22 mEq/L if compensated Causes: Hyperventilation-> hypocapnia, anxiety, fever, sepsis, heart & liver failure, excessive mechanical ventilation, hypoxia, thyrotoxicosis, early salicylate poisoning, lesions, CNS affecting resp center, hysteria, pain, pregnancy Nursing assessment: lightheadedness, dizziness/faintness, anxiety, confusion, Restlessness, blurred vision, dry mouth, diaphoresis, dyspnea with increased rate & depth, (tachypnea) Tachycardia paresthesia, spasms of extremities tetany hyperactive DTR, decrease K (hypokalemia) Nursing interventions Goal is to raise the CO2 -> Treat underlying cause Supplemental O2, sedation Seizure precautions Monitor for respiratory fatigue/failure ○ Ex; have patient breathe into paper bag Metabolic Acidosis Kidney has too much hydrogen, too little bicarb, lungs will blow off CO2 pH < 7.35 HCO3− < 22 mEq/L PaCO2 35-45 mmHg normal if not compensated; < 35 mmHg if compensated Causes: Base (HCO3−) deficit or Excess acids (other than CO2) -- diarrhea, intestinal fistulas, parenteral nutrition, excessive intake of acids (e.g. salicylates), DKA, renal failure, starvation ketoacidosis Nursing assessment: Decreasing LOC: Lethargy -> coma, dull headache, Kussmaul breathing – deep, regular & rapid respirations (increase resp. rate) (to compensate) warm, dry, flushed skin, anorexia, nausea, vomiting, abd. cramps, diarrhea, muscle weakness, diminished DTRs, Hypotension increase K - hyperkalemia. Metabolic Acidosis -> CNS depression: if untreated, can lead to dysrhythmias, coma, cardiac arrest Nursing interventions Tx underlying cause: reverse DKA w/ insulin; dialysis for renal pts. or drug toxicities; antidiarrheal agents Support Airway – assist work of breathing Support BP Monitor Neuro status Monitor serum K IV NaHCO3 – closely monitored because too much can cause metabolic alkalosis; NS flush required because NaHCO3 can precipitate other drugs Metabolic Alkalosis Kidneys have too much bicarb, too little hydrogen, lungs will retain CO2 pH > 7.45 HCO3− > 26 mEq/L PaCO2 35-45 mmHg normal if not compensated; > 45 mmHg if compensated Causes: Excess base (HCO3−)(excess ingestion of antacids/bicarbonate) or loss of acids (hypokalemia causes – inadequate intake; HCL & K losses from excess/prolonged vomiting or NG suction; Potassium wasting diuretics; Other causes: licorice, chewing tobacco, renal loss of H+ from steroid or diuretic use) Nursing assessment: decrease K (hypokalemia), apathy, Confusion anorexia, nausea, vomiting shallow respirations (to compensate) cyanosis hypotension muscle twitching paresthesia tetany hyperactive DTRs seizures dysrhythmias coma Nursing interventions KCL supplementation IV Fluids (Hydrochloric acid) Diamox- diuretic that increases HCO3− excretion Supplemental O2 Monitor K & muscle activity Seizure precautions Tx underlying causes IF pH and PaCO2 opposite relationship -> RESPIRATORY if pH and HCO3 corresponding relationship -> METABOLIC IMBALANCE Arterial Blood Gasses Pyramid Points In acidosis, the pH is decreased In alkalosis, the pH is elevated The respiratory function indicator is the PaCO2 The metabolic function indicator is the HCO3− Pyramid Steps 1. Look at the pH. Is it increased or decreased? If increased -> alkalosis, if decreased -> acidosis 2. Look at the PaCO2. Does the PaCO2 reflect an opposite relationship to the pH? If yes -> respiratory imbalance. If no -> Step 3 3. Look at the HCO3−. Does the HCO3− reflect a corresponding relationship with the pH? If yes -> metabolic imbalance 4. Full compensation has occurred if the pH is 7.35 – 7.45 (pH normal, PaCO2 & HCO3− abnormal) If the pH is not within normal range, does the PaCO2 or the HCO3− go the opposite direction of pH? (pH, PaCO2 & HCO3− abnormal) In respiratory imbalance, look at the HCO3−to determine the sate of compensation In metabolic imbalance, look at the PaCO2 to determine the state of compensation 5. Look at the PaO2 and the SpO2 to determine if hypoxemia has occurred ASEPSIS / INFECTION CONTROL PT 2 Basic Principles of Surgical Asepsis Medical vs. surgical asepsis, principles of surgical asepsis Medical Asepsis: reduces the number of organisms and prevents their spread Surgical Asepsis: procedures to eliminate micro-organisms from an area Donning vs Doffing - Donning 1. Gown 2. Mask 3. Goggles 4. Gloves - Doffing 1. Gloves 2. Gown 3. Goggle 4. Mask Hand Hygiene 1. Moment 1 – Before touching a patient 2. Moment 2 – Before a clean or aseptic procedure 3. Moment 3 – After a body fluid exposure risk 4. Moment 4 – After touching a patient 5. Moment 5 – After touching patient surroundings Principles of Surgical Asepsis: A sterile object remains 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 the range of vision or an object held below a person’s waist is contaminated. A sterile object or field becomes 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. Fluid flows in the direction of gravity. Hold sterile objects above the waist level. The edges (outer 1 inch) of a sterile field or container are considered to be contaminated. SKIN AND WOUND CARE Classification of Wounds by RYB Color Red: beef red, puffy, or mounded healthy granulation tissue Yellow: tan, brown gray, thin, wet, stringy nonviable slough exudate & fibrous debris Black: usually dry, thick and hard nonviable necrotic tissue The goal of wound care: Protect (cover) red granulation Cleanse yellow slough Debride black eschar R=Red=Protect Y=Yellow=Cleanse B=Black=Debride Wound Healing by Intention (Primary, Secondary, Tertiary) Primary intention Minimal tissue loss, wound edges are well approximated by sutures, clips or tape. Minimal scarring (e.g. surgical incision, clean laceration) Secondary intention Wound edges are not well approximated. Healing is delayed and occurs through granulation, contraction and epithelialization, scarring results (e.g. burn, major trauma, pressure injury) Tertiary or delayed primary intention Wound is infected or contains foreign bodies or fluids and requires cleaning or drainage prior to closure 3-5 days later (e.g. severe bite wound) Wound Complications Hemorrhage: normal during and immediately after initial trauma. Hemorrhage prolonged if coagulation problem or large vessels involved; risk greatest during 1st 24 to 48 hrs. post-op; internal or external; assess internal by noting distention or swelling of involved body part, change in type or amount, drainage from dressing or drain, or signs of hypovolemic shock. Hematoma: localized collection of blood underneath tissues; seen as swelling, change in color, sensation, or warmth, or a bluish tinged mass Infection: wound infection is 2nd most common HAI; presence of purulent drainage = infection; higher risk if wound contains necrotic tissue, foreign bodies, or diminished blood flow to site; may be seen within 2-3 days post-op in contaminated wounds; on th th 4 -5 post-op day in surgical incision. Complete assessment before report. Dehiscence: partial or total separation of wound layers; typically involves abd surg. site & occurs after sudden strain like vigorous coughing, vomiting or sitting up & site is unsupported (teach splinting); c/o “something has suddenly given way”; pts. at risk include obese, poor nutritional status. Be alert to serosanguineous fluid from a previously dry wound!! Evisceration: total separation of wound layers & protrusion of organs through wound opening—SURGICAL EMERGENCY. Actions to take: 1) call for help; stay with the pt. & instruct the pt. remain quiet. 2) place the pt. in low-Fowler’s position with knee bent 3) cover wound with sterile saline soaked sterile towels. No ice packs!! 4) monitor vital signs closely for signs of shock 5) keep NPO, prep for emergency surgery 6) document Fistula formation: abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another Pressure Injury Staging Stage 1: intact skin with non blanchable redness Stage 2: partial thickness skin loss involving epidermis, dermis, or both; may also present as open ulcer or rupture/intact fluid/serum-filled blister Stage 3: full thickness skin loss, may be visible fat; slough may be present without obscuring depth of tissue loss; may see undermining and tunneling Stage 4: full thickness tissue loss with exposed bone, cartilage, ligament, tendon, fascia or muscle; slough and eschar may be present; often includes undermining and tunneling; osteomyelitis possible Unstageable: full thickness tissue loss in which base of ulcer is covered by slough and/or Eschar, stage cannot be determined Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue Wound Assessment Type – surgical incision, pressure injury, diabetic, venous stasis Location Dimension/size – L X W X D (cm) Presence of undermining or tunneling Tissue viability – type & percentage of granulation, slough, or eschar in relation to wound base Exudate/drainage – COCA Peri-wound condition – inspect & palpate within 4 cm. of wound edge Pain – medication for pain 30-45 minutes prior to dressing change Drains – presence, type, amount, location. Report sudden change in drainage amount to HCP Wound closures – staples, sutures, tissue adhesive Wound cultures – cleanse or irrigate wound prior to obtaining specimen, require HCP’s order Type of Wound Drainage Serous - clear, watery Serosanguineous - pale, pink, watery - mixture of clear and red fluid Purulent - thick yellowish-green, foul odor, may indicate infection Sanguineous - bright red blood, indicates active bleeding Preventing Pressure Injury Topical skin care and incontinence management Inspect skin during bathing or daily personal care. Avoid strong soap & hot water when cleansing. Do not scrub. Gentle, thorough drying with attention to skin folds/creases Apply moisturizer – do not massage reddened/discolored pressure points; Use skin barrier ointment & film sprays Assess skin around drain sites – body fluids on the skin are a risk for skin breakdown Evaluate and manage urinary and fecal incontinence. Bowel and bladder training when appropriate. Use absorbent pads as the last resort!! Positioning: HOB to 30 degrees or less to minimize shearing force; individualized turning schedule, minimally q2h. Heels off pressure!! Support surfaces: Decrease the amount of pressure exerted over bony prominences. No foam rings, No donuts. !!!!!! Use of appropriate devices to ensure safe patient handling and movement Patient & family education Wound care/wound management Wound management ○ Goals: prevent & manage infection, irrigate the wound (with N/S or sterile water, not hydrogen peroxide; a wound cleanser, an antiseptic or an antibiotic solution may be used depending on wound condition & physician’s order), remove nonviable tissue, manage exudate, maintain wound in a moist environment, protect the wound ○ Debridement – removal of nonviable, necrotic tissue ○ Mechanical: wet to dry saline gauze dressing, wound irrigation with N/S ○ Autolytic: use of synthetic dressing ○ Chemical: use of topical enzyme preparation (e.g. sterile maggots) ○ Surgical/sharp ○ Maintaining a moisture environment ○ Control or eliminate contributory factors Education of the patient and caregiver Wound healing diet – high in protein, fat, carbohydrates, vitamins (especially A, C, E), minerals (including zinc) Protein status, hemoglobin Dressings Types of dressings Dry gauze dressings – have 3 layers, allow drainage to move to overlying absorbent layers (wick) Nonadherent gauze (petrolatum and Telfa) – prevent sticking to the wound Transparent film dressing - semi-permeable membrane are adhesive and waterproof are occlusive (Tegaderm, Op-site) Hydrocolloid—protects the wound from surface contamination (Duoderm) Hydrogel—maintains a moist surface to support healing (Aquasorb) Changing dressing Evaluate pain, pre-medicate the pt. if indicated – Initial action! Explain the procedure to reduce anxiety Perform thorough hand hygiene before & after wound care Wearing sterile gloves before directly touching an open or fresh wound Removing or changing dressing over closed wounds when wet or infected Packing a wound: not too tight or over the wound edges HEAT AND COLD THERAPY The Nursing Process for Heat and Cold Therapy Assessment for temperature tolerance ○ Assess the skin and skin integrity. ○ Assess the patient’s response to stimuli. ○ Assess the equipment being used. ○ Identify any contraindications. Bodily responses to heat and cold Local effects of heat and cold Factors influencing heat and cold tolerance Application of heat and cold therapies: require HCP’s order The Do’s : Do check the order – type, frequency, & duration of application; body site to be treated; temperature Do refer to the agency’s policy and procedure manual for safe temperatures Do assess & protect the pt.’s skin q 5-10 min Do know your pt.’s risk for injury from heat or cold Do know the effect that heat or cold has on VS & peripheral circulation, cover the application with pillowcase, towel or sheet. Do place a heating pad anteriorly or laterally to, not under the body part. Do explain to the patient sensations to be felt during the procedure Do instruct the patient to report changes in sensation or discomfort immediately Do provide a timer, clock, or watch so that the patient can help the nurse time the application Do keep the call light within the patients reach Do check the condition of the equipment The Dont’s: Do not microwave towels or medical products used for heat application Do not allow the pt. to adjust the temperature Do not use a heating pad with a selector switch that can be turned up beyond safety temp. Do not use pins to secure a heating pad Do not cover the heading pad with anything that might be heavy Do not allow the pt. to move an application, or place hands on a wound site Do not place the pt. in a position that prevents movement away from the temperature source Do not leave a pt. unattended if they are unable to sense temperature changes or move away from the temperature source Do not allow the pt. lie on an application Do not leave an application for over 30 mins unless ordered by HCP OXYGENATION Physiology of the Respiratory/cardiovascular System (gas exchange) Cardiovascular Physiology: Myocardial Pump ○ Stroke Volume (SV): quantity of blood forced out of the left ventricle with each contraction ○ Frank-Starling’s law: as the myocardium stretches, the strength of the subsequent contraction increases Myocardial Flood Flow ○ Unidirectional through four valves ○ S1: mitral and tricuspid close ○ S2: aortic and pulmonic close Coronary Circulation ○ Coronary arteries supply the myocardium with nutrients and remove wastes. Systemic Circulation ○ Arteries and veins deliver nutrients and oxygen and remove waste products. Respiratory Physiology: Lung Volumes ○ Common pulmonary function tests: tidal, vital capacity, residual, forced vital capacity (FVC) Pulmonary Circulation ○ Moves blood to and from the alveolar capillary membranes for gas exchange Oxygen Transport ○ Lungs and cardiovascular system 1. Amount of dissolved O2 in the plasma 2. Amount of Hgb 3. Ability of Hgb to bind with O2 (carbon monoxide poisoning) Carbon Dioxide Transport ○ Diffuses into RBCs and is hydrated into carbonic acid Regulation of Respiration Neural regulation by pons/ medulla Chemical regulation: central chemoreceptors respond to CO2 and pH levels & peripheral chemoreceptors respond to pO2 levels Promoting Proper Breathing Dyspnea Management Treat underlying cause Positioning: high-Fowler’s O2therapy Medications – bronchodilators, mucolytics, inhaled steroids, anti-anxiety agents Breathing exercises ○ Deep breathing and cough (DB/C) ○ Pursed-lip breathing ○ Diaphragmatic breathing Relaxation, biofeedback & meditation Mobilization of Pulmonary Secretions Hydration – 1900 – 2900 mL (2-3 quarts) daily, unless contraindicated by renal or cardiac status Humidification of O2 – necessary when flow rate > 4 LPM; hoods & tents for pediatric pts. Nebulization – moisture or medications added to inhaled air; used for bronchodilators & mucolytics; enhances mucociliary clearance DB/C Techniques – at least q 2 h while awake; if large amts- q1h while awake & arouse at night q 2 h; q 2-4 h for post-op & teach splinting to prevent hospital-acquired pneumonia Chest physiotherapy (PT) – percussion, vibration, postural drainage Maintenance and Promotion of Lung Expansion Ambulation ○ Positioning – Reduces stasis of pulm. secretions & decreased chest wall movement, maintains ventilation and oxygenation Initial nursing action for pts experiencing hypoxia, dyspnea, or SOB Good lung down – for pts. with unilateral lung involvement to promote perfusion of healthy lung Affected lung down – pulm abscess/hemorrhage to prevent drainage toward healthy lung Minimal Q 2H – need to asses & determine frequency for pt.'s needs ○ Incentive spirometry (IS) – provides visual feedback re: inspiratory volume; encourages voluntary deep breathing Noninvasive ventilation - CPAP, BiPAP Maintains positive airway pressure and improves alveolar ventilation Complications – facial/nasal skin breakdown, dry oral mucosa, thick secretions, gastric content aspiration Promoting Comfort (maintaining adequate fluid intake) Dyspnea management Hydration (2000 - 3000 ml/day) Airway maintenance Mobilization of pulmonary secretions ○ Humidification ○ Nebulization ○ C/D/B techniques ○ Chest physiotherapy (postural drainage) Oxygen Delivery System Administered to prevent or relieve hypoxia Is a medication – Follow “rights for medication” Must be ordered by provider – Order includes type of O2 delivery system (e.g. nasal cannula) and rate of oxygen delivery (e.g. 2 liters/min) Effect is assessed by ABG analysis, pulse oximetry (SpO2) and improvement in pt.’s clinical status Safety precautions ○ No smoking! O2in use sign; all electrical equipment grounded; store cylinders securely & upright ○ Avoid wearing and using synthetic fabrics ○ Avoid using oils in the area ○ Make sure transport tanks are full before transporting pt. ○ Teach pts. home safety re: oxygen safety Dosage expressed as liters/minute (LPM) or FiO2. Humidification must be added if flow rate is greater than 4 L/min Methods of O2 delivery: ○ Nasal cannula/prongs (low flow) – most commonly used O2 delivery device, up to 6L/min, 24%-44% O2 (every 1 LPM increase raises O2 by 4%); allow pts to eat, drink and speak. Used for COPD pts. Apply water-based lubricant or saline nasal spray nares to reduce dryness and irritation. No petroleum. Disadvantage: easily dislodged, dryness to mucosa, difficult for pt breathing through mouth ○ Nasal cannula (high flow) – aerosolized oxygen and warmed N/S, up to 15 L/min (90% O2). Often better tolerated by children. ○ * Face masks: impede eating & talking * Simple face mask (low flow): 5-8 LPM/40-60% – must be at 5 LPM to prevent rebreathing CO2 Partial rebreather (low flow) delivers ~ 8-11 LPM/50-75% – set flow high enough to keep reservoir bag remain 2/3 full when pt. inhaling Non-rebreather (low flow) - delivers from ~ 10-15 LPM/80-95% – bag should never totally deflate; set flow rate to keep reservoir bag full and collapse only a little during inspiration. Mask has flap so as pt breathes in and out; flap opens (make sure (2) rubber flaps are there) Venturi mask (precise concentration) (high flow) – delivers between 4-6 LPM/24-40% O2 Mechanical ventilation (ETT/trachs: trach collar) Managing Chest Tubes Patient Assess & manage pain; assess VS, resp. pattern, breath sounds, SpO2 C/DB, Incentive spirometer, Position q 2 h OOB/chair, ambulate as ordered Assess insertion site for crepitus (SQ emphysema) Assess dressing for leakage Equipment Secure tube to chest wall with adhesive tape Securely tape connection from chest tube to system with adhesive, allowing visual area for observation Monitor consistency in drainage in collection chamber Ensure recommended level of H2O in water-seal chamber – refill prn, maintain water level at 2-cm mark or recommended by manufacturer Observe water seal chamber for * tidaling (normal resp. fluctuations) * – fluid rises on inspiration, falls on expiration in spontaneously breathing pt.; opposite directions in mechanically ventilated pts. Temporarily disconnect suction to observe for tidaling. Continuous, excessive bubbling (abnormal) – air leak anywhere from pt. through system Maintain prescribed suction in suction control chamber – refill prn ► Typically ordered at – 20 cm. H2O pressure (adult range -15 to -20cm. H2O pressure) ► Ensure continuous gentle bubbling only in suction control chamber when connected to wall suction Equipment (cont’d) Avoid kinking & dependent loops in drainage tubing – lay tubing horizontally on top of bed mattress Mark level of drainage on outside of collection chamber q shift. Never empty drainage from the collection chamber. Assess, measure & record color, amount, consistency of drainage q 15 min. x 2 hrs. post insertion. Expected drainage ○ Grossly blood drainage during 1st 3 hrs post-op changing to serous. Gush of blood drainage when cough or position change immediate post-op. ○ 100 – 300 mL/hr from a posterior chest tube in 1st 3 hrs.; 500 – 1000 mL/24 hr. ○ little to no output from an anterior chest tube inserted for a pneumothorax Notify HCP ○ Sudden or unexpected cloudy, opaque or bright red bloody drainage ○ Bright red drainage > 250 mL/hr during 1st 3 hrs post-op or > 100 mL/hr after 1st 3 hrs. post-op Equipment (cont’d) ○ Maintain position of chest drainage unit upright & below level of pt.’s chest ○ Maintain occlusive dressing ○ If the chest tube disconnects from the drainage unit, instruct pt. to exhale as much as possible & cough. Immerse open end of the chest tube in bottle of sterile saline or water immediately to maintain water seal, then call HCP. ○ Keep 2 padded Kelly clamps at bedside No routine clamping, milking or stripping chest tube Removal of chest tube Administer analgesics to pts. 30 min. prior to removal Pt. instructed to perform Valsalva maneuver (deep breath in & keep mouth & nose closed while exhaling forcibly, bear down) immediately prior to removal Maintain occlusive dressing Monitor site for drainage & crepitus Assess pts’ respiratory status, vital signs, SpO2, pain NUTRITION Metabolic Requirement Amount of energy required to carry out involuntary activities of body Factors which increase BMR: infection, fever, emotional tension, extreme environmental temp; excess thyroid hormone Factors which decrease BMR: aging, sleep, cold temp, decreased thyroid hormone, prolonged fasting BMI – ratio of weight (in Kg.) to height (in meters) BMI – estimate of risk for diseases: Heart disease, Diabetes, Hypertension Underweight 40 inches o Women > 35 inches Biochemical Data - Hemoglobin (normal = 12–18 g/dL) ↓ anemia - Hematocrit (normal = 40%–50%) ↓ anemia ↑ dehydration - Serum albumin (normal = 3.5–5.5 g/dL) ↓ malnutrition (prolonged protein depletion), malabsorption - Prealbumin (normal = 23–43 mg/dL) ↓ malnutrition, protein depletion - Transferrin (normal = 240–480 mg/dL) ↓ anemia, protein deficiency - Blood urea nitrogen (normal = 17–18 mg/dL) ↑ starvation, high protein intake, severe dehydration ↓ malnutrition, overhydration - Creatinine (normal = 0.4–1.5 mg/dL) ↑ dehydration ↓ severe malnutrition, reduction in total muscle mass Monitoring Nutritional Status (Diet tolerance) Nutritional screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools: ○ Height ○ Weight & Weight change ○ Primary diagnosis ○ Comorbidities ○ Screening tools Anthropometry is a measurement system of the size and makeup of the body. ○ An ideal body weight (IBW) provides an estimate of what a person should weigh. ○ Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships. ○ Underweight if BMI < 18.5; Overweight if BMI 25-29.9; Obesity if BMI ≥ 30 ○ Waist circumference Modified Consistency Diets NPO – nothing by mouth Clear liquid diet – water, tea, black coffee, ice pops, clear broth, plain gelatin, popsicles, clear fruit juice without pulp (apple, grape, cranberry) Full liquid diet – clear liquid items; milk; puddings, ice cream, cream soup, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, milk and egg substitutes Soft diet – easily chewed & digested Pureed diet – blenderized liquid diet Mechanically altered diet – regular diet with modifications for texture, excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits. Dysphagia – thickened liquids Diet as tolerated/Regular Low residue – low fiber, easily digested – roast lamb, buttered rice, sponge cake, “white” processed foods. High residue – high fiber Sodium-restricted, fat-restricted (e.g. fruit, vegetables, cereals, lean meat), renal diet (protein, sodium, potassium and fluid restrictions dependent on patient situation) Consistent Carbohydrate Diet - Diabetic Promoting Patient Safety (Gastric Residual) MD will order: formula, rate of feeding, type. Secure all connections in the tubing to prevent injury. Always check expiration dates of formula. Administer at room temperature Elevate HOB at least 30 degrees. Verify correct tube placement before checking GRV, ensure normal digestion of the GI tract Flush feeding tube with 30 ml water or sterile water ( for immunocompromised pts.) Systems are open (containers must be filled) or closed (ready to hang). Feeding must infuse within 8 hours if open system Disposable tubing & container change every 24 hrs; closed system can be used up to 48 hrs. Never add fresh formula to formula hanging Never administer meds while a feeding is being infused. Never add meds directly to the formula. Feedings are initiated at full strength. Do not dilute feedings! Assess bowel sounds, abd. status before & PRN Assess feeding tolerance (no abd. distention, diarrhea, c/o N/V, bloating, flatus, excess GRV). Starting feeding at a slower rate improves tolerance (rate may be ordered at 25mL – 50mL/hour then advanced by 10 – 25 mL/hr every 8 – 12 hours). Elevate HOB at least 30 degrees, preferably upright during feeding and 1 hr afterward. Assess insertion site & tube insertion site care, mouth care Fingerstick blood glucose every 6 h. Record on I/ O sheet Parenteral Nutrition Solutions and Administration Used for pts with non functioning GI tracts Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states: ○ Sepsis ○ Head injuryBurns Total Parenteral Nutrition (TPN): infusing a nutrient rich hypertonic solution intravenously through a central line (25% glucose, lipids, insulin, vitamins, etc.) ○ Expensive, high potential for complications especially infections. ○ TPN can promote tissue and wound healing ○ TPN used to “rest” the bowel Change every 24 hours If bag runs out, replace with D10 ○ Peripheral Parenteral Nutrition (PPN): infusing isotonic solution through peripheral vein (not as concentrated – 10% glucose) ○ Moderate nutritional deficiencies ○ May be done for short term 2 weeks or less. Administering TPN Use same lumen of catheter Always use pump; use filter on tubing Read label & double check against order for all ingredients Use strict aseptic technique when changing bag, tubing q 24 h Sterile dressing change procedure Check all connections Can hang only for 24 hours; lipids only hang for 12 hrs. Refrigerate solution unless using immediately If 3-in-1 TPN (contains lipids) – do not hang if oil droplets or oily or creamy layer observed & return it to the pharmacy; No fat emulsions (lipids) if allergic to egg – essential!! Never add meds to parenteral nutrition solutions Baseline labs; check VS q 4 h, especially temp. per policy; glucose levels q 6 h; daily I/O & weights; serum protein and electrolyte levels Monitor IV site – dedicated line; label line Don’t catch up or suddenly discontinue – gradually reduce TPN rate Must wean off TPN using 10% Dextrose; reduce infusion gradually to prevent hypoglycemia; off TPN if pt tolerates at least 75% nutritional needs by enteral feeding URINARY ELIMINATION Assessment for Urinary Retention and Bladder Scan Characteristics of urine (Table 37-1 p. 1350) ○ Color: pale yellow, straw to amber color depending on its concentration ○ Clarity: transparent unless pathology is present ○ Odor: normal urine smells aromatic; ammonia odor as urine stands ○ Diabetes mellitus or starvation: sweet or fruity odor ○ UTI: foul odor ○ pH: 4.6-8 ○ Specific gravity: 1.015-1.025 Urine testing Specimen collection Measuring Urine Output ○ Void into bedpan or hat ○ Pour into graduated container ○ Urinary catheter – measure and empty urine per hospital policy – 8 hrs – med-surg ○ Urine output measured hourly in critical care setting Postvoid Residual (PVR) ○ Amount of urine remaining in bladder after voiding ○ PVR < 50 ml. normal ○ PVR > 100 ml. inadequate emptying Collecting Urine Specimens Random urinalysis: do not collect from a drainage bag; use a clean specimen cup. Clean catch or midstream (sterile specimen): urine culture & sensitivity; use a sterile specimen cup. Sterile: urine culture & sensitivity; obtained from catheter or urinary diversions; do not collect from a drainage bag; use a sterile specimen cup. Specimen from a urinary diversion Timed: 24- hour urine (e.g. measure creatinine clearance, protein quantity tests) Post a sign on the pt’s bathroom door Time period begins after the pt. urinates (discard the urine) and ends with a final voiding added to the container at the end of the time period. Special container Must save all urine or start over Check procedure manual for maintaining the collection (e.g. on ice, in a fridge, or with a preservative) Assisting with Diagnostic Procedures Noninvasive procedures (Box 37-2, page 1355) Abd x-ray (KUB) – simple film, no prep, determines size, shape, location & symmetry Computed tomography – detailed images of structures. Tumors and obstructions may be visible. Must assess for shellfish (iodine) allergy if contrast is ordered. IVP (intravenous pyelogram)/ excretory urography – views collecting ducts, renal pelvis, ureters, bladder and urethra ○ Must assess patient’s allergy to iodine and shellfish ○ Prep: bowel cleansing ○ Post: priority is to monitor for delayed allergic reactions (e.g. rash, fever, difficulty in breathing) ○ Encourage fluids; monitor I & O Renal ultrasound – identify gross renal structures and structural abnormalities ○ No prep required ○ Simple ultrasound (bladder scan) can be done on the nursing unit to evaluate retained urine (post voided residual – PVR) Invasive procedures Cystoscopy – direct visualization, specimen collection, and/or treatment of the bladder & urethra Consent required Done using conscious sedation Post procedure: monitor VS, I&O, urine characteristics; encourage fluids Angiography – visualization of renal arteries to detect narrowing or occlusions via catheter placed in femoral artery Consent required Must assess for allergy to iodine Post procedure: monitor VS, I&O; encourage fluids; neurovascular check of involved extremity; check catheter site for bleeding, swelling, increased tenderness, hematoma Renal biopsy – obtaining a small piece of renal tissue for microscopic examination Consent required Obtain coagulation studies and hematocrit, VS, withhold food & fluid before procedure, sedation may be necessary Post procedure: lie quietly for 4 hrs, monitor urine for hematuria, VS, avoid strenuous activities or heavy lifting for several days. Report flank pain, hematuria or dizziness. Caring for Patients with UTI’s Risk of CAUTI increases the longer a catheter stays in place Avoid unnecessary use of catheters and remove ASAP ○ Reasons for urinary catheterization: acute urinary retention, obtaining a sterile urine specimen, spinal cord injury, accurate intake and output measurement in critically ill patients, perioperative preparation for select surgeries, healing of open sacral or perineal wounds in incontinent patients, patients requiring prolonged bedrest, and comfort for end-of-life care. Not routinely used for urinary incontinence! Daily reminder – Can the Catheter be Removed? Drink 8 – 10 glasses of H2O Clean perineal area from front to back after bowel movement or urination Drink 2 glasses of water before and after intercourse, void immediately after intercourse Take showers not baths Wear underwear with a cotton crotch Drink 10 oz cranberry juice daily Caring for an Incontinent Patient Behavioral interventions (e.g., Kegels, biofeedback, timed voiding): first line of therapy Pharmacologic interventions (e.g., anticholinergic or antispasmodic for urge incontinence) Surgical interventions (e.g., stress or urge incontinence not responding to other interventions) Adequate fluids Frequent changes of absorbent pads (e.g., cognitive functional incontinence) Help clients with feelings of embarrassment, hopelessness and stigma Prevent complications Catheterizing the Patient’s Bladder Types: Indwelling: Foley, Suprapubic (when injury, stricture, prostatic obstruction, gynecologic or abd surgery has compromised flow of urine through the urethra) Intermittent: Straight catheter; No touch catheterization Sterile insertion Nursing care ○ Handwashing ○ Frequent peri care q8h & prn ○ Clean 4” of catheter ○ No powder, lotions, antibiotic ointments ○ Maintain closed system, prevent reflux, do not place collection bag above waist ○ Encourage fluid intake unless contraindicated ○ Spigot clamped except during emptying ○ Tape in place (velcro band) ○ Don’t routinely change BOWEL ELIMINATION Factors affecting Bowel elimination Developmental considerations Daily patterns Food and fluid - 2 to 3 L /day Activity and muscle tone Lifestyle Psychological variables Pathologic conditions Medications: Cathartics and Laxatives (habitual use may be the cause of chronic constipation), Aspirin (Pink, Red Black), Iron (Black), Antacids (White), Antibiotics (Green-Gray) Diagnostic studies Surgery and anesthesia – direct manipulation of bowel; anesthesia can cause paralytic ileus (normally lasts 3-5 days) Bowel elimination assessment Nursing history ○ Usual elimination pattern: include frequency and time of day; characteristics of stool; rectal bleeding/blood in stool; recent changes ○ Routines followed to promote normal elimination; use of artificial aids at home ○ Presence and status of bowel diversions ○ Changes in appetite/weight loss or gain ○ Diet hx: food preferences; type & amount of fluid intake ○ Hx of surgery or illnesses affecting the GI tract ○ Medications Hx - ask about prescribed & OTC medications that alter defecation or fecal characteristics ○ Emotional state: the pt’s emotions significantly alter the frequency of defecation ○ Activity/Exercise/Mobility ○ Pain/discomfort: abdominal or anal pain; N/V/D, constipation Physical assessment ○ Mouth, abdomen, and rectum ○ Bowel sounds ○ Palpation – tenderness, distention, firmness or tautness Stool characteristics- Bristol stool form scale & color change White or clay – absence of bile Black or tarry – upper GI bleed or iron ingestion Red – lower GI bleeding, hemorrhoids Pale, greasy – fat malabsorption Translucent mucus – colitis, excessive straining bloody mucus – blood in stool, inflammation, infection Warning signs of colon cancer: rectal bleeding; change in the bowel elimination pattern; blood in the stool; cramping pain in the lower abdomen. Diagnostic studies ○ Fecal specimens – stool culture; fecal occult blood test Diagnostic Studies Abdominal X-ray – no prep Upper GI series and small-bowel series/Barium swallow – examines structures & motility via series of films taken after pt. drinks barium contrast; NPO after midnight; a post-test laxative is usually prescribed. Barium may lighten stool color for several days. Large intestine/Barium enema – examines structures & motility via series of films taken with administration of barium enema; dietary modifications and a bowel prep; force fluids after test, a post-test laxative may be prescribed. Barium may lighten stool color for several days. Encourage rest post test. Abdominal ultrasound – high frequency sound waves echo off body organs; NPO for at least 8 hrs. May resume normal diet and fluids post test unless contraindicated by test results. Abdominal Computed Tomography (CT) - multiple angle cross-section x-ray visualization; contraindicated for pregnant pts; NPO for 4-6 hrs, assess for pt allergies to iodine, IV contrast and/or shellfish, assess for renal impairment, discontinue Metformin at the time of study and for 48 hrs after the study. Magnetic Resonance Imaging (MRI) - bounce off of magnetic & radio waves from body tissues; contraindicated for pregnant pts; no metallic objects (e.g. metal implants, cardiac pacemaker, implanted surgical clips, cochlear implants, drug infusion pumps), may need to fast or consume only clear liquids prior to study, claustrophobia problematic Esophagogastroduodenoscopy (EGD) & Colonoscopy– direct visualization of upper GI tract or entire colon via lighted fiber-optic tube; can obtain biopsy; NPO 6-12 hrs for EGD; diet modifications several day before colonoscopy, may be NPO for 6-8 hrs with sips of water for meds, and nothing for 2hrs before colonoscopy; sedation given for both -- close monitoring & crash cart must be present. Withhold food & fluids until gag reflex returns after EGD, usual diet may be resumed once pt recovers from sedation after colonoscopy. Observe for flatulence, gas pain, signs of bowel perforation post test. Flexible Sigmoidoscopy – examines interior of sigmoid colon with lighted tube; light meal the night before and 2 fleet enemas to prep bowel before test. Observe for flatulence, gas pain, signs of bowel perforation post test. Preventing and Treating Diarrhea Cathartics and laxatives Oral, tablet, powder, and suppository forms Excessive use increases risks for diarrhea and abnormal elimination – impairs normal defecation reflex Used for bowel prep Bulk-forming (high fiber)– safest; use first; metamucil, miralax Emollient (stool softeners) – colace (vitamin C) Saline – for acute & quick need; not for renal or fluid restricted pts; Magnesium citrate Stimulant cathartics – intestinal mucosa irritant; cause severe cramping, fluid & electrolyte imbalances with chronic use; dulcolax, senokot Lubricants – coat fecal contents; decrease absorption of fat soluble vitamins; pneumonia with aspiration; increased risk of fat embolism if taken with emollients; mineral oil Antidiarrheal agents ○ Rehydration is essential with acute diarrhea ○ Opioid-receptor agonists: Loperamide, Diphenoxylate and atropine ○ Antisecretory/antimicrobial: Bismuth subsalicylate Emptying the colon of feces Pouching ostomies ○ An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. ○ A colostomy normally starts to produce drainage within 2-5 days postop. ○ An ileostomy drains within 24 to 48 hrs because of the liquid contents in the small intestine. ○ Healthy stomas are protruding from the skin, dark pink to red in color and moist. Report pale, purple-blue, brown or black color immediately. ○ Most stomas protrude ½ to 1 in from adnominal surface. Nutritional considerations ○ Consume low fiber for the first weeks. ○ Eat slowly and chew food completely. ○ Drink 10 to 12 glasses of water daily. ○ Patient may choose to avoid gassy foods. Keep the patient as free of odors as possible; empty the appliance frequently when it is approx. one third full. Replace the pouch every 3-7 days. Inspect the patient’s stoma regularly. ○ Note the size, which should stabilize within 6 to 8 weeks. ○ Keep the skin around the stoma site clean and dry. Measure the patients fluid intake and output. Explain each aspect of care to the patient and self-care role. Encourage patient to care for and look at ostomy. Meeting the needs of patients with bowel diversions Temporary or permanent artificial opening in the abdominal wall – stoma ○ Ostomies created in the ileum (Ileostomy) or colon (colostomy) to treat various bowel disorders, including Ca, obstruction, inflammatory bowel disease, ruptured diverticulum, ischemia (compromised blood supply), or traumatic injury, familial polyps ○ The standard bowel diversion creates a stoma (incontinent type) OR reconstructive bowel surgery to create a continent pouch Location of the ostomy determines consistency of stool output or effluent ○ Ileostomy – frequent & liquid to pasty; contains caustic digestive enzymes ○ Ascending colon – frequent & liquid ○ Transverse colon – semisolid & formed ○ Descending to sigmoid colon – more solid to near normal ○ No blood should be seen in the stool. PERIOPERATIVE NURSING Informed Consent and Advanced Directives Health care provider performing the procedure must obtain the consent and includes: ○ Understandable language ○ Procedure and alternatives ○ Underlying disease process and natural course ○ Name of the person performing the procedure ○ Risks including risk for damage, disfigurement, and death ○ Patient has right to refuse the procedure ○ Expected outcome, recovery and rehabilitation plan Involves discussion and signing the form with all of the previous points Nurses may witness pt’s signing of the consent, but must be sure that the pt. has understood the surgeon’s explanation of the surgery. Must document the witnessing of the signing of the consent form. Must be written and attached to pt. medical record. Must be voluntary and pt. must be competent. Consent form is not legal if patient is confused, unconscious, sedated, mentally incompetent or a minor No sedation should be administered to the pt. before signing informed consent. Minors may need a parent or legal guardian. Older pts. may need a legal guardian. Psychiatric pts. have a right to refuse treatment until a court has legally determined pts’ incompetency. Use an interpreter when required and document Must notify the surgeon if the patient expresses concerns Consent may be given by health care proxy, parent , spouse, next of kin, legal guardian Nursing Role in Advanced Directives: The purpose of advanced directives is to communicate a client’s wishes regarding end-of-life care should the client become unable to do so. Provide written information about advanced directives Providing Preoperative Patient Care: Hospitalized patient Prepare the pt psychologically through communicating & teaching: encourage pt & family participation Teaching about surgical events & sensation, PACU environment, monitoring frequency, equipment, therapies Teaching about pain management Teaching about physical activities Deep breathing and coughing – 1-2 X / hr for the first 24 hrs postop. Prevent pneumonia & atelectasis; Contraindicated for pts. after eye, intracranial or spinal surgery. Incentive spirometry – 10 X / hr. while awake. Prevent atelectasis. Leg and foot exercises – each exercise 5 X / q 2 h. Prevent venous stasis of blood & increase venous blood return. Mobility instructions – early ambulation is key. Splinting of wound when C/DB & moving to prevent incisional pain Turning & positioning – q 2 h when awake. Prevent skin breakdown. Prepare the pt physically Hygiene & skin Prep – shower only, or shower with chlorhexidine sponges 1-3x; pt. instructed NOT to shave hair at site Elimination – enemas, laxatives/cathartics as prescribed for bowel surgeries, or other lower abd. organs (GU); IDC may be ordered before surgery Nutrition & fluids – regular meals should be finished 8 hrs before surgery; light meals such as tea and toast may be consumed up to 6 hrs before surgery; clear liquids (e.g. water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee) allowed up to 2 hrs before surgery. Medications ○ Routine meds usually withheld: NSAIDS (e.g. Ibuprofen) (1 week) anticoagulants, antiplatelet (e.g. Aspirin) (3-5 days) ○ Metformin withheld (2 days ) ○ Routine Meds (given- instructed to take): BP meds, synthroid, insulin (may decrease dose) Rest & sleep Preparation on Day of Surgery Vital signs (slight increase in BP, pulse is expected) & Documentation (use preoperative checklist) Hygiene & oral care. Verify adherence to food & fluid restrictions (clear liquids up to 2 hrs before surgery) Hair and cosmetics; Removal of prostheses, jewelry, body piercing, nail polish Safeguarding valuables Have patient empty bladder before surgery Other procedures (e.g. IV, IDC, NG) Administering preoperative medications. Pt. must not leave the bed/ stretcher after receiving preoperative medications. Side rails up & Instruct the pt. how to call for assistance. Safety is key!! Eliminating wrong site and wrong procedure surgery: MOST IMPORTANT to make sure the operative site is marked!! Preoperative verification Marking the operative site “Time Out” Time Out Post-surgical Respiratory Complications Atelectasis: increased RR, dyspnea, fever, crackles & productive cough, occurs 1-2 days post Pneumonia: fever, productive cough, chest pain, purulent mucus, dyspnea, occurs 3-5 days post Hypoxemia/hypoxia: restlessness, confusion, dyspnea, diaphoresis, cyanosis Pulmonary Embolism: dyspnea, chest pain, cyanosis, tachycardia, drop in BP PAIN, COMFORT, AND SLEEP Responses to Pain Behavioral/voluntary responses – assess behavioral response to pain Physiologic/involuntary responses When pain is moderate (4-7) and superficial: Fight or flight ○ Stimulation of sympathetic nervous system: increased BP, increased HR, increased RR, dilated pupils, muscle tension and rigidity, diaphoresis, pallor, increased adrenaline output, increased blood glucose, decreased GI activity ○ When pain is severe and deep: Rest and digest ○ Stimulation of parasympathetic responses: decreased BP, decreased HR, rapid and irregular breathing, prostration, N & V, fainting or unconsciousness Affective/psychological responses ○ Weeping and restlessness, withdrawal, stoic, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness Pain Assessment of Special Populations Children and older adults need accurate assessment and treatment of pain. Effective pain management in children requires careful assessment; good communication among patient, family, and caregivers; and a thorough understanding of the actions and side effects of drugs used to relieve pain. Children and older adults are more sensitive to pain Older adults are less likely to have their pain managed because of drug-drug interactions Older adults in pain can become agitated, experience difficulty concentrating

Fundamentals Final Exam Review Fall 2022 PDF

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