NURS 112 Study Guide PDF

NURS 112 Study Guide Hand hygiene - Wash hands with antimicrobial or plan soap and water - Use alcohol-based hand rub - Components o Soap o Running water o Friction - Rub hands together for at least 15s to 2m _____...

NURS 112 Study Guide Hand hygiene - Wash hands with antimicrobial or plan soap and water - Use alcohol-based hand rub - Components o Soap o Running water o Friction - Rub hands together for at least 15s to 2m ____________________________________________________________________________________ Standard precautions - Applies to all body fluids (except sweat), non-intact skin, and mucous membranes - Hand hygiene using alcohol-based waterless product o After contact, not visibly soiled or contaminated with blood or body fluids and after removal of gloves o More effective in removing microorganisms - Soap and water if contaminated with spores o Nonantimicrobial or antimicrobial for visibly soiled or contaminated o For C. dif - Gloves and gowns ____________________________________________________________________________________ Contact precautions - Protect against direct client and environmental contact infections (within 3 ft) - Requires o Private room or share with clients who have the same infection o Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag - PPE o Gloves and gowns  - Diseases o Respiratory syncytial virus, shigella o Enteric diseases caused by microorganisms, multidrug-resistant organisms o Wound infections o Herpes simplex, impetigo, scabies ____________________________________________________________________________________ Droplet precautions - Protect against droplets larger than 5mcg and travel 3 to ft from the client o Cough, sneeze, breathe - Requires o Private room or share with clients who have the same infection o Ensure clients have their own equipment o Mask for providers and visitors o Clients should wear mask outside the room / home - PPE o Mask and gown o Face shield, goggles, gown if in contact with blood / bodily fluids - Diseases o Streptococcal pharyngitis or pneumonia o Haemophiles influenzae type B o Scarlet fever, rubella, pertussis, mumps o Mycoplasma pneumonia o Meningococcal pneumonia and sepsis o Pneumonic plague o Bacterial meningitis, whooping cough, pneumonia, influenza ____________________________________________________________________________________ Airborne precautions - Protect against droplet infections smaller than 5mcg - Requires o A private room  o Negative pressure airflow exchange of at least 6 to 12 exchanges per hour - PPE o Wear full face protection (eyes, nose, mouth) ▪ For splashing and spraying o N95 mask or high efficiency particulate air (HEPA) ▪ For tuberculosis or Sars-CoV-2 - Diseases o Measles, varicella, SARS-CoV-2 o Pulmonary or laryngeal tuberculosis ____________________________________________________________________________________ Erikson's Stages of Development 1. Infancy Stage 0-1 (Trust vs Mistrust) 2. Early Childhood 2-3 (Autonomy vs Shame/Doubt) 3. Play Age 4-6 (Initiation vs Guilt) 4. School Age 7-12 (Industry vs Inferiority) 5. Adolescence 13-18 (Identity vs Role Confusion) 6. Young Adulthood Early 20s (Intimacy vs Isolation) 7. Adulthood Late 20s-Late 50s (Generativity vs Stagnation) 8. Old Age 60s (Ego Identity vs Despair) Infancy Stage 0-1 (Trust vs Mistrust) - Primary task is to develop trust without eliminating the capacity for mistrust - Learn to trust caregivers and environment - Basic needs given o Food, comfort, warmth - Positive o Caregivers are going to be reliable and affectionate ▪ Infants develop sense of trust in the world and themselves o Example ▪ Baby cries -> caregiver feeds, changes diapers, cuddles ▪ Overtime baby learns that their needs are met by caregivers ▪ Sense of trust in caregiver and world  - Negative o Neglectful and inconsistent ▪ Develop mistrust, suspicion, fear about the world o Example ▪ Baby cries -> left to cry without being comforted by parent ▪ Infant feels anxious and mistrustful ▪ Less likely to explore any kind of security Early Childhood 2-3 (Autonomy vs Shame/Doubt) - As toddlers begin to assert independence, they need to be encouraged to explore abilities - Task: achieve a balance of autonomy and shame and doubt - Positive o Encouraging, supporting toddlers ▪ Develop sense of autonomy, confidence, independence o Example ▪ Encourage toddler to dress themselves ▪ Offer guidance and celebrate effort of toddler ▪ Celebrate + encourage independent -> increase in confidence - Negative o Overly critical and controlling ▪ Feelings of shame and doubt ▪ Lack of confidence o Example ▪ Toddler is scolded and overly corrected when making a mess trying to feed themselves ▪ Doubt abilities and feel ashamed -> leading to reluctance to try new things Play Age 4-6 (Initiation vs Guilt) - Starts to take initiative, plan action, take responsibility - Eager to explore and do things on their own - Positive o Give child opportunity to develop sense of initiative, leadership, purpose o Example  ▪ Preschooler decides to organize a pretend tea party and assigns roles to friend ▪ Praise creativity and leadership of child -> develops sense of initiative - Negative o Criticized or controlled too much -> develops sense of guilt, unworthiness, lack of inhibition o Example ▪ A child is repeatedly told their ideas is silly or let others lead ▪ Child develops sense of guilt ▪ Hesitate to express ideas School Age 7-12 (Industry vs Inferiority) - Children begin to compare themselves among peers - Develop sense of pride in accomplishment - Positive o Encouragement of parents and teachers o Fosters industry and competence o Example ▪ Work hard on school project, receive praise and recognition ▪ Allows them to feel more competent and proud ▪ Encourage to do more challenging task - Negative o Ridiculed, restricted, not allowed to be o Develop sense of inferiority, lack of sense confidence o Example ▪ Child is trying, but parent and teacher criticizing, ignoring them ▪ Feel inferior with peers and doubt their own abilities ▪ Affects how they motivate themselves and sense of self esteem Adolescence 13-18 (Identity vs Role Confusion) - Crucial to develop sense of identity, personal identity - Explore different roles, beliefs systems, ideas coming from a single identity - Positive o Strong sense of self and direction in life o Example  ▪ Explore hobbies, social groups, try various styles with support of family and peers ▪ Clear sense of who you are as a person ▪ What is important for you – value system - Negative o Failure to establish clear identity o Role confusion -> insecurity, weak sense of self o Example ▪ Pressured to conform to other expectation ▪ Unsure about place in the world ▪ Struggle about who you are as an individual ▪ Make difficult decisions Young Adulthood Early 20s (Intimacy vs Isolation) - Major task is to form intimate, loving relationships with other people - Involved in building deeper relationships out of family - Positive o Fulfilling relationships, sense of connectedness, commitment o Enter a committed relationship, secure and supported by friends and partners o Fulfilling and long-lasting relationship - Negative o Feeling - failure that you are going to find committed relationship ▪ Result in loneliness and isolation o Fear or commitment and relationships ▪ Avoid close relationships ▪ Fear of getting hurt ▪ Previous experience – rejected, experienced loneliness and isolation ▪ Difficult to form meaningful bond Adulthood Late 20s-Late 50s (Generativity vs Stagnation) - Need to create and nurture things that will outlast them - Positive o Feelings of usefulness and accomplishment o Example  ▪ Mentoring, becoming a professor ▪ Becoming a parent ▪ Community involvement ▪ Contribution to society ▪ Sense of purpose - Negative o Feeling stuck, monotonous routine with no fulfillment o Resistant to change o Lack of interest in mentoring or guiding youth Old Age 60s (Ego Identity vs Despair) - Individuals reflects on their lives - Develops sense of integrity if satisfied and accomplished, - Sense of despair, unproductive, and filled with regret - Positive o Achieving integrity o Will feel they have wisdom, fulfillment, acceptance of life and death, sense of accomplishment, meaningful life - Negatives o Afraid to try things and take risks o May result in bitterness and regret o Fear of death o Going to experience despair ____________________________________________________________________________________ Cranial nerves Cranial Nerve Type of Number Name Nerve Function Smell (olfaction) I Olfactory Sensory - Ask them to describe what they’re smelling Vision II Optic Sensory - Visual acuity, visual fields  - Snellen chart Eye movement; pupil constriction; accommodation (adjusting lens of the eye III Oculomotor Motor for focus) - Pupillary reaction to light Eye movement (specifically, movement of IV Trochlear Motor the superior oblique muscle) Sensation in the face; strength muscles of mastication (chewing), corneal light reflex - Motor: clench teeth while palpating V Trigeminal Both masseter and temporal muscles -> listen to TMJ, should be smooth - Sensory: touch face with cotton ball and ask what they are and feeling Eye movement (specifically, lateral VI Abducens Motor movement via the lateral rectus muscle) Facial expressions; taste on the anterior 2/3 of the tongue; secretion of tears & saliva VII Facial Both - Motor: smile, frown, puff out cheeks, raise eyebrows, close eyes tightly, show teeth - Sensory: identify salty or sweet Hearing; balance - Whisper test: occlude one ear and test the other to see if client can hear VIII Vestibulocochlear Sensory whispered sounds without seeing your mouth move - Expected: can hear whisper from 30 to 60cm away (1 to 2 ft) Taste on the posterior 1/3 of the tongue; swallowing; salivation IX Glossopharyngeal Both - Test: Identify sour or bitter taste in the back of the tongue - Soft palate  Sensation and muscle movement in the throat; parasympathetic control of the heart, lungs, and digestive tract X Vagus Both - Checking speech for hoarseness - Gag reflex - What happens in vagus stays in vagus Movement of the trapezius and sternocleidomastoid muscles - Head and shoulder strength - Test: Place hands on client’s XI Accessory (Spinal) Motor shoulders and ask them to shrug against resistance - Turn head against the resistance of your hand Movement of the tongue XII Hypoglossal Motor - Strength of tongue, sticking out tongue "Some Say Marry Money, But My Brother Says Big Brains Matter Most." Here's the breakdown: 1. Some - Sensory - Olfactory 2. Say - Sensory - Optic 3. Marry - Motor - Oculomotor 4. Money - Motor - Trochlear 5. But - Both - Trigeminal 6. My - Motor - Abducens 7. Brother - Both - Facial 8. Says - Sensory - Vestibulocochlear (Auditory) 9. Big - Both - Glossopharyngeal 10. Brains - Both - Vagus 11. Matter - Motor - Accessory (Spinal Accessory) 12. Most - Motor – Hypoglossal "Oh, Oh, Oh, To Touch And Feel Very Green Vegetables, AH!" This corresponds to the order of the cranial nerves: 1.Olfactory 2.Optic 3.Oculomotor 4.Trochlear 5.Trigeminal 6.Abducens 7.Facial 8.Vestibulocochlear (sometimes referred to as Auditory) 9.Glossopharyngeal 10.Vagus 11.Accessory (also known as Spinal Accessory) 12.Hypoglossal ____________________________________________________________________________________ Neurological Assessment Mental Status 1. Alert: optimal level of consciousness, fully awake, aware, responsive o Opening eyes spontaneously, answering questions promptly correctly, maintain conversations 2. Lethargic: state where client is not fully alert o Drowsy or sleepy o Open eyes when they’re spoken to, but need prompting o Answering question slow or need repetition o Fall asleep if not stimulated 3. Obtunded: more difficult to arouse than one who is lethargic o Often seem confused when they respond o Observation: requires shaking pt lightly, use loud verbal cues for them to respond o Slow or delayed responses, confused or have difficulty comprehending 4. Stuporous: client unresponsive to light stimuli o Require painful stimuli to show any response o Press knuckle into the chest severely, / rub sternum if they wake up ▪ Can also pinch tendon o Response is brief, and is usually not verbal 5. Comatose: lowest level on consciousness o Complete absence of responsiveness o Will not respond even if given painful stimuli o Show abnormal posturing ▪ 1. Decorticate rigid Characterized by the flexion and internal rotation of upper extremity joins and legs Client's arm being pulled towards to body ▪ 2. Decerebrate Rigidity Client will have neck and elbow extension with wrist and finger flex Alert x4 o Person – what is your name? o Place – where are you? o Time – what day is it? o Situation – do you know why you’re here? Glasgow Coma Scale - Use scale to obtain baseline assessment of the client’s level of consciousness and for ongoing assessment o Assesses eye, verbal, motor response o Assigns a number value based on client’s responses - Highest value is 15 – full consciousness - Lowest value is 3 – no response Motor Function - Coordination o Have client extend arms and rapidly touch nose, alternating hands (eyes closed) o Expected: smooth, coordinated movements - Gait o Assess while client is unaware o Expected: smooth, steady, coordinated - Balance o Romberg Test ▪ Feet together, arms at both sides, eyes closed ▪ Expected: client can stand with minimal swaying at least 5 sec o Heel to toe walk ▪ Place the heel of one foot in front of the toes of the other foot ▪ Expected: walk in a straight line without losing balance - Muscle strength o Ask client to push or pull against resistance o Expected: strength is equal or slightly stronger on dominant side Sensory Functions (eyes closed) - Pain sensation o Alternating sharp and dull objects on skin o Ask client what they feel - Temperature o Two test tubes (warm and cold) o Identify which one is which  - Light touch o Cotton ball touching skin o Where they feel cotton ball touching skin - Vibration o Tuning fork handle on skin o Ask when and where they feel - Position o Reposition client’s appendages o Report whether each is positioned up or down - Discrimination o Two-point discrimination ▪ Paperclip, protractor ▪ Determine the smallest distance between the two points at which the client can still feel the two points on skin, not just one ▪ Compare bilaterally ▪ Minimal distance varies with the body part o Stereognosis ▪ Place familiar object in client’s hand (key, cotton ball) ▪ Ask them to identify object o Graphesthesia ▪ Trace number on client's palm with blunt end of pencil ▪ Ask them to identify number ____________________________________________________________________________________ Aspiration risk ____________________________________________________________________________________ Heimlich maneuver - First aid technique for choking and conscious - Applying series of sharp upward thrusts to the abdomen to expel a foreign object from the airway  - Place hands below ribcage and two inches above the belly button - Inward and upward 5x - If pregnant, preform over the sternum - Risks o Can cause injury o Brusing of the abdomen o Broken rib or xiphoid process ____________________________________________________________________________________ Diaphragmatic Breathing - Males and children are diaphragmatic breathers o Abdominal movements are more noticeable o Deep breathing that uses the diaphragm and abdominal muscles ____________________________________________________________________________________ Breathing Sounds Expected Sounds - Bronchial: wind blowing through big tunnel, loud, hollow, high pitch o Exhaling longer than inhaling, hearing over trachea (normal in trachea) - Bronchovesicular: sound of wind near the woods, medium pitched, heard over bigger pathways in the lungs o Hear better in the mid chest area, between the shoulder blades - Vesicular: soft rustling of leaves, low, gentle, inhaling is longer than exhaling o Hear vesicular sound in trachea, can indicate pneumonia ▪ Sound causing it to travel Unexpected or Adventitious Sounds - Crackles or rales: stepping on dry leaves, milk over rice krispies, bubbling sounds  o Air moving through wet areas of the lungs, tiny air ways are opening up o Disease or disorders: pulmonary edema, pneumonia, fibrosis o Fluid accumulation in the lungs - Wheezes: high pitched sound o Air is trying to squeeze into tiny space, hole o Asthma, COPD - Rhonchi: deep snore, someone playing cello o Air in moving through a thick mucus fluid o Can be cleared by coughing o Chronic bronchitis, cystic fibrosis - Pleural friction rub: two dry surfaces rubbing against each other, hair rubbing on each other o Two surfaces on pleura are irritating o Difficulty breathing o Pulmonary embolism – blood clot inside lungs causing it to inflate - Apylepsis: absence of breath sounds ____________________________________________________________________________________ Cyanosis Assessment - Cyanosis: o Light skin tones: Bluish o Darker skin tones: palms and soles, grayish skin o Brown skin tones: yellow brown skin - Location: nail beds, lips, mouth mucosa, palms - Indication: hypoxia or impaired venous return ____________________________________________________________________________________ Hypoxia Manifestations Early (Up) - Tachypnea - Tachycardia - Restlessness, anxiety, confusion - Pale skin, mucous membranes - Elevated blood pressure - Use of accessory muscles, nose flaring, adventitious lung sounds Late (Down) - Stupor - Cyanotic skin, mucous membranes - Bradypnea - Bradycardia - Hypotension - Cardiac dysrhythmias ____________________________________________________________________________________ Oxygen Saturation - Pulse Oximeter: A device that attaches to various body parts like the fingertip, earlobe, or forehead. - Function: Uses infrared light to measure oxygenation in arterial blood. Reliable for SaO2 values above 70%. - Oxygen: A colorless and tasteless gas comprising 21% of atmospheric air. - Goal: Maintain SpO2 levels between 95% to 100%, using minimal oxygen to prevent complications. - FiO2: Indicates the percentage of oxygen a client is receiving. ____________________________________________________________________________________ Types of Oxygen Delivery  Nursing System Description FiO2 Advantages Disadvantages Actions - Safe, simple, - FiO2 varies and easy-to- - Assess nares with flow rate apply. patency. Delivers an and client’s Tubing with two -Comfortable -Ensure proper FiO2 of 24% breathing. Nasal small prongs for and well- prong fit. to 44% at a -Can cause Cannula insertion into tolerated. -Use gel for dry flow rate of 1 skin breakdown the nares. -Enables nares. --Provide to 6 L/min. and dryness. eating, talking, humidification -Easily and above 4 L/min. dislodged. ambulating. - Easy to apply - Risk of CO2 - Ensure proper Delivers an and rebreathing at fit and seal. FiO2 of 35% comfortable. dorsal recumbent -> right lateral to ensure fluid reaches the large intestine ▪ Cleanses only the rectum and sigmoid colon ▪ Risks Older adults and pregnant women – increased risk of electrolyte imbalance and intestinal mucosa damage o Normal saline ▪ The safest enema because it’s equal to the osmotic gradient ▪ Volume stimulates peristalsis ▪ Best for infants and children because they’re at a greater risk for fluid imbalance o Low-volume / hypertonic ▪ Used by clients who cannot tolerate high-volume enemas ▪ Commercially prepared  ▪ Risks Don’t use with infants Don't used on those who are dehydrated o Draw water out of colon o Oil retention ▪ Softens rectum for easier passage of stool ▪ To enhance the action, patient retains for several hours o Medicated enema ▪ Delivering medication directly into the large intestine ▪ Need to have the patient retain the enema for a specific period 1 to 2 hours - Typically, cleansing enema, pt needs to be on left side, Sims positon, right leg flexed o Lubricate enema tubing o 3 to 4 inches for adults o 2 to 3 inches for children o Need to assist pt to go o the bathroom or use a bedpan o Monitor for any adverse reactions after enema o Cramping, bleeding, signs of fluid imbalance ____________________________________________________________________________________ Types of diet ie. Npo, full, liquid, etc. - NPO (nil per os): nothing by mouth o No food, fluid, ice chips o Need doctors’ prescription before resuming oral intake - Clear liquid o Liquids that leave little residue o Broths, gelatin, clear juices o Promoting hydration, giving bio nutrients, minimize residue in intestine - Full liquid o All liquids, milks, all kind of juices o Some facilities include pureed vegetables in a full liquid diet - Puree o Foods with smooth consistency, pureed meats, food, scrambled eggs o Thicker but smooth food o For swallowing difficulty - Mechanical soft diet o Foods that are soft o Diced / minced / grounded o Great for patients who have chewing difficulties ▪ Dental issues, post-oral surgery - Soft/low residue diet o Easily digestible food, low in fiber o Dairy, eggs, ripe bananas o Minimize work in digestive systems o Post-surgery, pt with digestive disorder - High fiber o Whole grains, raw vegetables, dried fruits o Promote regular bowel movements o Great for pt with constipation issue - Low sodium o Manage blood pressure, fluid retention o Can be restricted in varying degrees o No added salt or have gram limit of sodium ▪ 1 to 2 grams - Low cholesterol o Manage or prevent high cholesterol levels o No more than 300 mg per day - Diabetic o Balanced intake of protein, fats, and carbohydrates ▪ About 1800 calories ▪ Calories needs varies o Blood sugar levels  - Dysphagia (difficulty swallowing) o Pureed food, thickened liquid - Regular diet o Standard diet with no type of restriction o For pt with no dietary limitations - Gluten Free o Rye, barley, wheat ____________________________________________________________________________________ Pain assessment Acute Pain (transient) Nature o Temporary and protective o Serving as a warning of a disease or a threat to the body Duration o Last until the tissue going to heal o Short duration o Common after acute injury, disease, surgery Physio responses o Increase heart rate, elevated blood pressure, sweating, anxiety Behaviors o Observable signs: grimacing, moaning, flinching Treatment o Focused on addressing underlying cause of the pain o Will generally subside after addressed o Resolves with or without treatment o Able to treat aggressively as it has an identifiable cause o Complete pain relief is not always achievable, but reducing pain to a tolerable level is the realistic goal Transition o If not effectively treated, will transition into chronic pain Chronic pain (persistent) - cancer and noncancer Nature o Persistent and debilitating Duration o More than 3-6 months, beyond the healing o Unknown cause Physio responses o Not usually cause any vital sign changes o Dramatic effect on quality of life ▪ Emotional effects: depression, suicide, hopelessness, anger, apathy ▪ Physical: fatigue, insomnia, anorexia, weight loss ▪ Job loss, inability to perform simple tasks, sexual dysfunction, social isolation Behaviors o Not show any outward signs because they tend to adapt to chronic pain overtime Treatment o Symptom relief and improving quality of life o Chronic pain might not always be curable, but manageable o Encourage use of pharmacological and nonpharmacological management Transition o Malignant causes, cancer related o Non-malignant, arthritis related ▪ Arthritis, low back pain, headache, fibromyalgia, peripheral neuropathy o Idiopathic pain: Unknown of origin Nociceptive Pain Origin: damaged to body tissue or inflammation Mechanism: activate pain receptors o Sensing potentially harmful stimuli Described: sharp, throbbing, aching pain, pinpoint/localized to a specific area Treatment: opioid medication (morphine), non-opioid (ibuprofen) Types: somatic, visceral, and cutaneous o Somatic: skin, muscle, bones, joints, connective tissue, ▪ Well localized pain ▪ Constant, intermittent, aching, throbbing, cramping  o Visceral: internal organs, lining cavities of body ▪ Poorly localized pain ▪ Referred pain: sensation is felt at a different location than actual source o Cutaneous pain: skin, subcutaneous tissue, mucosal surface ▪ Sharp, burning, numbness or paresthesia without any visible signs Neuropathic Pain Origin: damage/disease of dysfunction of nervous system (somatosensory) Mechanism: damaged nerve Described: burning, stabbing, shooting, pins and needles o Persistent and resistant to typical pain medication Treatment: adjuvant medication o Helping medication, not necessarily designed for pain o Pain relieving properties o Anti-depressants, anti-seizure, muscle relaxants o Can be used to enhance the effects of pain medications Type: just one Pain Perception Start of process starts at: transduction --> transmission --> medulation --> perception Transduction: activated nociceptor converts energy produced by stimuli into an action potential o Painful stimulus converted into signal into nerve cell ▪ Stimulus is strong enough to meet the activation threshold of nociceptors o Turning on a switch that starts sending a message to the brain o Cut, burn on hand, exposure to heat, chemicals ▪ Thermal, chemical, or mechanical stimuli  Transmission o Signal of pain stimulus travel along nerve fibers, to spinal cord (spinothalamic tract), to brain (thalamus) ▪ Sending a message through wires o Rapid to ensure message reaches the pain o The point at which the stimulus becomes very painful when you start to feel pain o Threshold: is different for everyone, feel pinch sooner than others o Tolerance: how much a person can handle before they need to stop/take action before they need to relieve the pain Medulation: o Body can increase / decrease pain you are feeling ▪ Medication o Pain will have effects to care more or less o Inhibitory mediators: endorphins, serotonin, norepinephrine, GABA ▪ Hinder transmission Perception: travels to the cortex o How the brain interprets brain signal o Recognize and understand you are in pain ▪ Influenced by emotions, attention, past experiences, perception Asking questions: Where is your pain? Does it radiate anywhere else? Point to the pain. Quality of pain? How are they describing the pain? Intensity, strength, severity of pain. Rate of 0-11 Timing: onset, frequency, duration How is the pain affecting the patients daily life o Where are you when the symptoms occur? o What are you doing when they occur? o How does it affect sleep, work, interaction with others? Associated findings o Fatigue, anxiety, nausea Aggravating / relieving factors o Prescriptions? Herbal or over the conuter ____________________________________________________________________________________ Pitting edema assessments - Grade 0: No pitting, the skin bounces back immediately - Grade 1: Mild pitting, a barely visible dent that disappears within 10 seconds - Grade 2: Moderate pitting, a light dent that disappears within 15 seconds - Grade 3: Severe pitting, a deeper dent that takes up to 30 seconds to disappear - Grade 4: Very deep pitting, a deep dent that takes more than 30 seconds to disappear ____________________________________________________________________________________ Dehydration - Dehydration: lack of fluid in the body from insufficient intake or excessive loss o Relative dehydration involves a shift of water from the plasma (blood) to interstitial space - Hypovolemia or isotonic dehydration: lack of both water and electrolytes o Causes decrease in circulation blood volume o Also called fluid volume deficit - Compensatory mechanisms include sympathetic nervous system responses of increased thirst, antidiuretic hormone (ADH) release, and aldosterone release - Rapid or severe dehydration can induce seizures - FVD can lead to hypovolemic shock - Older adults have an increased risk due to o Decrease in total body mass o Total body water content o Decreased ability to detect thirst ____________________________________________________________________________________ Hypovolemia Assessment Causes of Isotonic FVD (Hypovolemia)  - Excessive gastrointestinal (GI) loss: vomiting, nasogastric suctioning, diarrhea - Excessive skin loss: diaphoresis without water and sodium replacement - Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency - Third spacing: burns - Hemorrhage or plasma loss - Altered intake: anorexia, nausea, impaired swallowing, confusion, nothing by mouth (NPO), decreased intake of water and sodium Causes of Dehydration - Hyperventilation or excessive perspiration without water replacement - Prolonged fever - Diabetic ketoacidosis - Insufficient water intake o Enteral feeing without water administration, decreased thirst sensation, dysphagia o Diabetes insipidus o Osmotic diuresis o Excessive intake of salt, salt tablets, hypertonic IV fluids Expected Findings Vital Signs - Hypothermia (hypovolemia) or hyperthermia (dehydration) - Tachycardia, thready pulse, hypotension, orthostatic hypotension - Decreased central venous pressure - Tachypnea: increased respirations - Hypoxia Neuromusculoskeletal - Dizziness, syncope, confusion, weakness - Fatigue, seizures (rapid/severe dehydration) GI - Thirst, dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, acute weight loss Renal - Oliguria: decreased production of urine Other findings - Diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of teats, decreased skin turgor - Assessment of skin turgor in older adults might not provide reliable findings due to a nature loss of skin elasticity Nursing Care - Checking how fast patient is breathing o Checking vital signs - Laboratory tests o Monitor lab tests to ensure they are at healthy levels – not losing blood volume - Oxygen therapy o Ensure it is the correct oxygen levels o Specific with someone with COPD ▪ Limitations of oxygen ▪ Maximum of 3L via nasal canula ▪ More than 3L, going to shut down how they’re going to process oxygen - Daily weight o Same time each day, using same scale o Subtle changes in weight, there might be changes in fluid balance - Watch for nausea and vomiting - Blood pressure and pulse - Neurological status of patient o Not alert, sign of fluid problems  - Heart rhythm o Put on heart monitor - IV access o Always need this to give them IV fluids, medications o Directing fluids inside the blood o Direct line to improve fluid balance inside body - Monitor I&O ____________________________________________________________________________________ Fluid Volume Deficit & Dehydration Lab Results - HCT: increased in both hypovolemia and dehydration unless the fluid volume deficit is due to hemorrhage - Blood osmolarity – dehydration: increased hemoconcentration osmolarity (greater than 295 mOsm/kg) - Urine specific gravity – dehydration: increased concentration (urine specific gravity greater than 1.030) - Blood sodium – dehydration: increase hemoconcentration (greater than 145 mEq/L) - BUN: increased due to hemoconcentration (greater 25 mg/dL) - Dehydration: increased protein, electrolytes, glucose ____________________________________________________________________________________ Over Hydration – Fluid Overload - Too much fluid inside the body - Causes o When someone is consuming too much salt, the body is holding on to more water ▪ Sponde soaking up too much water, get overly swollen  o - Severe fluid volume excess -> serious health issues o Pulmonary edema ▪ Too much fluid inside the lungs ▪ Going to make breathing harder for patient ▪ Can drown patient o Heart failure ▪ Struggle to pump blood because there's too much fluid inside the blood stream - Compensatory mechanism o Peptides inside the body will get rid of excess water in the body ▪ Released in the body and goes into the kidneys ▪ Tells kidneys to excrete the excess fluid ▪ Kidneys listen and start getting rid of sodium and water into the urine Nursing Care - Respiratory status o Looking at rate, symmetry, effort o Auscultate the breath sounds, listen o Shortness of breath, dyspnea - Check ABGs, SaO2, CBC, and chest x-ray - Semi-Fowlers and Fowler’s position - Daily weight measurements - Look for edema in lower legs, lower back, and around the eyes o Swelling on the thighs indicate heart failure - Fluid restriction - Dietary restriction o Sodium restriction - Supplemental oxygen - Diurectics o Remove excess fluids - Reposition patient - Support arms and legs ____________________________________________________________________________________ Electrolytes Levels Expected Reference Ranges - Sodium: 136 to 145 mEq/L - Calcium: 9 to 10.5 mg/dL - Potassium: 3.5 to 5 mEq/L - Magnesium: 1.3 to 2.1 mEq/L - Chloride: 98 to 106 mEq/L - Phosphorus: 3 to 4.5 mg/dL ____________________________________________________________________________________ Electrolytes Signs and Symptoms - Week 7 - ATI Chapter 57 & 58 ____________________________________________________________________________________ Electrolytes ie. Potassium, sodium, calcium, magnesium, nursing care Electrolytes - Minerals that carry out electrical charge inside the body fluids - Present throughout the body - Essential in many bodies function - Role o Control fluid balance o Enable muscle contraction – heartbeats o Transmit nerve signals - Types  o Sodium – maintaining acid-base balance, fluid balance, transport mechanism, good for nerve and muscle function o Potassium – cell metabolism, nerve impulse transmission, muscle and cardiac -- , acid-base balance o Chloride o Calcium – cardiovascular function, neuromuscular activity, involved in endocrine system, blood clotting, bone and teeth formation o Magnesium – nerve fucntion, regulating blood pressure, supporting immune system, maintaining bone health o Phosphate o Bicarbonate o Sulfate - Testing o Cations – positively charged o Anions – negatively charged - Hypernatremia: Muscle weakness, lethargy, swollen red tongue - Hypokalemia: Leg cramps, muscle weakness, nausea, vomiting, cardiac dysrhythmias. ____________________________________________________________________________________ Promoting thinning of secretions ____________________________________________________________________________________ Ankle injury nursing actions ____________________________________________________________________________________ Abdominal assessment Bowel sounds assessments ____________________________________________________________________________________ Constipation Common Bowel Elimination Problems - Fecal incontinence o Leading to unintended o Causes ▪ Diarrhea, medications, infections, impaction, hardened stool that is lodged is going to cause diarrhea o Ensure that perianal area is clean after each bowel movement to protect skin and protect barrier ointment o Might be prescribed incontinent pouch - Flatulence o Leading to discomfort, cramping o Observe for abdominal distention o Swelling due to gas accumulation ▪ Encourage to walk or move around to promote natural passage - Hemorrhoids o Enflamed, dilated blood vessels in the rectal area o Difficulty in defecating ▪ Pregnancy, increases pressure in rectal vessels ▪ Liver disease or heart failure o Itching in rectal area, pain or discomfort after bowel movement  o Might be rupture in hemorrhoids o Apply prescribed ointment or cream to alleviate ▪ SITZ bath, warm water bath to relieve discomfort ▪ Ice pack - Constipation o Hard dry stool, paralytic ileus o Bowel type of destruction when there is a lack of intestinal activities ▪ Electrolyte imbalances ▪ Aging ▪ Not enough water, low fiber diet, sedentary lifestyle ▪ Side effects of medications - Ostomies o Specific bowel disorder / diseases o Difficulty in eliminating feces ▪ Create a surgical opening in the abdomen to allow stool to exit o Different type of colostomies Causes of Straining While Defecating - Hemorrhoids and rectal fissures o Bradycardia, hypotension, syncope (fainting, passing out) - Valsalva maneuver (occurs with straining/bearing down) ____________________________________________________________________________________ Drainage tubes Ng tube ____________________________________________________________________________________ Vital signs Lab results levels Sterile dressing change ____________________________________________________________________________________ Subjective and Objective data Subjective - Patient verbal description of health problems - Gathered during interview with pt o Informal, formal - Patients' feelings, perceptions, self-reported symptoms - Example o Asking patient if they have any pain o Pt responds with where and the intensity Objective - Findings from observation of pt behavior - Clinical signs - What you directly measure, see, touch - Inspecting the condition of the wound - Observing pt walking - Describing an observed behavior o Pt seizing - Measured based on an accepted standard o F, C, inches, cm, pain rating scale ____________________________________________________________________________________ Antiembolic Stockings Equipment - Tape measure Procedure - Hand hygiene - Assess skin, circulation, presence of edema in legs - Measure calf and/or thigh circumference - Measure length of the leg to select the correct size stockings - Turn the stockings inside to the heel - Put the stockings on the feet - Pull remainder of the stocking over the heels and up the legs - Smooth any creases or wrinkles - Remove every 8 hours to assess o Redness, warmth, tenderness - Make sure they’re not too tight - Keep clean and dry - Document application and removal ____________________________________________________________________________________ Grade DTR responses as - 4+ = Very brisk with clonus - 3+ = More brisk than average - 2+ = Expected - 1+ = Diminished - 0 = No response ____________________________________________________________________________________ Cardiovascular assessment Heart Apical pulse or point of maximal impulse (PMI) - Can be visible just medial to the left midclavicular line at the fourth or fifth ICS. With clients who have large breast tissue, displace the breast with one hand to locate the PMI. - Palpate where you visualized it. Otherwise, try to palpate the location to feel the pulsations. - Heaves (or lifts): unexpected, visible elevations of the chest wall that indicate heart failure o Often along the left sternal border or at the PMI. - Thrills: palm of the hand to feel vibration like that of a purring kitten o This is an unexpected finding. ____________________________________________________________________________________ Pulse locations Positions  - Ask patient to sit and lean forward, able to hear sounds from the front of the heart more clearly - Lying flat, supine, basic position without emphasizing specific part - Turning patient inward, left side: heart come closer to chest wall, hear extra or unusual heart sounds (murmurs) - Aortic best area to hear aortic area Stethoscope - Diaphragm: high pitched S1 & S2 (normal) - Bell: low pitched, murmurs S3 & S4 (abnormal) Heart Sounds - S1: lub, contraction o Closure of the mitral and tricuspid valves o Beginning of ventricular systole o Place diaphragm at the apex - S2: dub, relaxation o Closure of the aortic and pulmonic valves o Beginning of the ventricular diastole o Place diaphragm at the aortic area - S3: like an echo, heart is filling up too fast o Can hear more in kids and young adults, pregnant women, well-trained athletes - S4: extra beat o Normal in older adults, athletes, kids - Gallops: additional beats o Ventricular gallop: sounds like a horse trotting o Atrial gallop: rhythm sounds like Tennessee - Murmurs: whispering and soft sound of water o A lot of blood in the heart, blood is not flowing correctly o Can be felt or heard (thrill)  ▪ A buzz or cat purring - Bruits: distant river rushing sound o Not form the heart, but tells us blood flow in the vessels o Blocked blood vessel, can pick up sound in artery Apical Pulse (PMI – Pulse of Maximal Impulse) - Found in mid left clavicular line in 4/5 ICS in the ribs - Clients with large breasts, use one hand to move breast out the way Jugular Venous Pressure - Distended, enlarged when sitting or standing - Underlying health condition - No such thing as elevated left jugular vein distention o It's only RIGHT – right sided heart failure o OR both together – complete heart failure ____________________________________________________________________________________ Indwelling urinary catheter assessment and care Straight or indwelling catheter insertion - Size and type of catheter o Children: 8 to 10 o Females: 10 to 12 o Males: 12 to 14 - Latex allergies – use silicon or Teflon - Catheterization kit with a sterile drainage bag - Soap and water - Collection container for straight catherization - Procedure o Explain procedure o Use sterile technique Routine catheter care - Equipment o Soap and water o Washcloth o Gloves - Procedure o Soap and water at the insertion site o Cleanse catheter 3x a day and after defecation o Monitor patency ▪ Reports of fullness in the bladder area ▪ Kinks in the tubing ▪ Check for sediment in tubing ▪ Collection bag should be below bladder to avoid reflux ____________________________________________________________________________________ Intermittent Self Catherization - Describe the process of regular catheterization which you carry out yourself to remove urine from the bladder ____________________________________________________________________________________ Wound healing assessment, wound care, prevention Classification of Pressure Injuring - Stage 1: non blanchable erythema of intact skin o Warmer or cooler compared to surrounding tissues o Experience discomfort o On darker skin, redness may not be as apparent o Non blanchable erythema: reddened area of skin that doesn’t turn white when you press on it ▪ Indicates onset of a pressure ulcer  - Stage 2: a partial thickness skin loss with exposed dermis o Affect dermis and epidermis layers o Reddish pink o Can resemble as an intact or ruptured blister o Treatment ▪ Maintain moist healing environment Saline or occlusive dressing Hydrocolloid dressing - Stage 3: full thickness skin loss o Skin loss is extending to the dermis to exposed subcutaneous fat o Some slough, eschar present o Possible undermining or tunneling - Stage 4: full thickness skin and tissue o Muscle, tendons, ligaments, cartilage, bones are exposed o Epibole, tunneling, undermining - Unstageable pressure injury o Cannot be determined due to obscured by eschar o Only way is for a wound doctor to surgically cut off or remove dark skin o Can only happen if patients aren’t turned every two hours, lack of nutrients, diabetic, dehydrated ▪ Can happen after 24 hours of patient being immobile Assessing Pressure Wounds - Braden scale: how we assess integumentary when it comes to the skin o Observe for warmth, breakdown, changes in color ▪ Fair skin: paleness, pallor, redness ▪ Dark skin: purple or blue, injury or reduced blood flow o Bony prominences ▪ Bones are close to the skins surface ▪ Elbows, heels, hips ▪ Prone to pressure injuries since there is less cushioning from muscles or fat o Check for skin turgor ▪ Pinch area of the skin, back of the hand ▪ Seeing quickly how it returns to normal position  ▪ Assess hydration level (slow return – poor, dehydrated) - Sensory perception, moisture, activity, mobility, nutrition, friction ____________________________________________________________________________________ Wound Dressing - Woven gauze or sponges o Absorbs wound exudate o Common dressing for the wounds o Drainage to the wound o Good for a wound that has moderate to heavy drainage - Nonadherent o Designed to not stick to wound bed o Making it less painful - Damp to damp o Utilized for mechanical debridement until granulation tissue starts to form in the wound bed ▪ Debridement: process of removing dead tissues from the wound o Moist protects the healing tissue ▪ Prevents pain and disruption of wound healing - Self-adhesive, transparent film o Acting as a temporary layer ▪ Second skin o Ideal for small superficial wounds o Allows to observe what the wound looks like o Transparent dressing maintains - Hydrocolloid o Occlusive dressing that reacts/swells with exudate to form gel ▪ Air and watertight dressing o Composed of gelatin and pectin that forms a seal at the wounds surface ▪ Prevents evaporation of moisture from skin ▪ Maintain moist environment o Can stay in place for several days (3 to 5 days) o Good for tissue granulation - Hydrogel o Primarily composed of water ▪ Rehydrates and fills dead space ▪ Requires a secondary occlusive dressing o Gel after contact with exudate to promote autolytic debridement ▪ Great to provide a cooling effect ▪ Moist wound bed that soothes and prevents pain and skin breakdown in high-pressure areas o Best for dry wounds, minimal drainage, soothing and reducing pain ▪ Infected, deep wounds or necrotic tissue - Alginates o Non adherent dressing, highly absorbent of exudate, conform to wounds shape o Ideal for patients with a lot of drainage ▪ Maintain moisture ▪ Packs wound ▪ Supports debridement - Collagen o Available in gel, powder, granules, sheets, gels, pastes ▪ promote healing, will stop wound from bleeding o Coagulant type of dressing - Vacuum assisted closure system o Uses negative pressure to promote healing by drawing the edges of the wound together  Type of Drainage (Exudate) Description What it might indicate Clear and watery, like the fluid from a Typical part of the early Serous blister or the clear part of blood healing process, seen in (serum). clean wounds. Active bleeding, often Sanguineou expected immediately Fresh blood, appearing bright red. s after an injury or surgical procedure. A mix of serous and sanguineous Serosangui Common in the early exudate; clear and blood-tinged, light neous stages of wound healing. pink to light red appearance. Thick, often green, yellow, or brown, Indicates infection in the Purulent resembling pus. wound. Suggests there may be a Purosangui Contains both pus and blood; can look small vessel rupture in an neous like blood-tinged or pink-tinged pus. infected area. ____________________________________________________________________________________ Care of wound infection  Perform wound cleansing and irrigation. - For clean wounds (a surgical incision), cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin). QS - Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. - Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents. - Never use the same gauze to cleanse across an incision or wound more than once. - Do not use cotton balls and other products that shed fibers. - If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19-gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer’s, or an antibiotic/antimicrobial solution. Hold the tip 2.5 cm (1 in) above the wound. Use continuous pressure to flush the wound, repeating the procedure until the irrigant flowing out of the wound is clear. - Remove sutures and staples. - Administer analgesics and monitor for effective pain management. - Administer antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count). - Document the location and type of wound and incision, the status of the wound and type of drainage, the type of dressing and materials, client teaching, and how the client tolerated the procedure. ____________________________________________________________________________________ Dehiscence and Evisceration - Dehiscence o Partial or total separation of a sutured wound ▪ Usually with the separation of underlying skin layers ▪ Visible separation of wound edges o Serus drainage o Patient “I feel or hear a popping sensation, I feel my wound has given away”  o If this happens – dehiscence ▪ Notify healthcare provider and stay with patient ▪ Thin blanket or pillow over the wound ▪ If they cough or coughing, press pillow against the wound - Evisceration o Severe form of dehiscence because the organs are protruding through the wound opening o Literally going to see visible organ protruding from the wound o Protruding organs – evisceration ▪ Cover the wound with a sterile saline soaked towel or dressings ▪ Prevent any bacteria ▪ Important to keep things at the bedside - Position o Supine position with hips and knees bent to reduce tension - Observe o For signs of shock o Color pallor o Clamminess o Rapid heartrate o Hypotension o Maintain calm environment and reduce anxiety o Keep patient NPO, anticipate surgical doctor is going to correct the patient quickly ____________________________________________________________________________________ Stages of Wound Healing and Management - Inflammatory Stage: begins with injury and lasts 3 to 6 days o Effects to the wound ▪ Controlling bleeding with vasoconstriction, retraction of blood vessels, fibrin accumulation, clot formation ▪ Delivering oxygen, WBC, nutrients to the area via the blood supply  ▪ Phagocytosis: macrophages engulf microorganisms o This phase is prolonged ▪ Too little inflammation (with debilitating disease) ▪ Too much inflammation - Proliferative Stage: 3 to 24 days o Effects to the would ▪ Replacing lost tissue with connective or granulated tissue and collagen ▪ Contracting the wound’s edges to reduce the area that requires healing ▪ Resurfacing of new epithelial cells - Maturation or Remodeling Stage: occurs around day 21 o Effects on the wound ▪ Involves strengthening of the collagen scar ▪ Restoration of a more normal appearance o Can take more than a year to complete ▪ Depends on the extent ____________________________________________________________________________________ Healing Processes - Primary Intention: o Little or no tissue loss o Edges approximated, as with a surgical incision o Heals rapidly o Low risk of infection o No or minimal scarring o Example ▪ Closed surgical incisions with staples, sutures, or liquid glue to seal laceration - Secondary Intention: o Loss of tissue  o Wound edges widely separated, unapproximated (pressure injury, open burn areas) o Longer healing time o Increase for risk of infection o Scarring o Heals by granulation o Example ▪ Pressure injury left open to heal - Tertiary Stage: o Widely separated o Deep o Spontaneous opening of a previously closed wound o Closure of wounds occurs when they are free of infection and edema o Risk of infection o Extensive drainage and tissue debris o Closed later o Long healing time o Example ▪ Abdominal wound initially left open until infection is resolved and then closed ____________________________________________________________________________________ Laboratory results for wound healing ____________________________________________________________________________________ Fall risk assessment Falls - Fall is an event where an individual rests inadvertently on the ground, floor, other lower level o Not by a push - Second leading cause of accidental or unintentional injury deaths worldwide - Older adults have the highest risk of death or serious injury following a fall o Decreased bone density, chronic health conditions, slower reaction times - Risk factors o Does not seek assistance in toileting o Did not know, forgot, chose not to use call light o Altered cognition: dementia, sedation, delirium ▪ Sedation – pain medication or antihistamine alter ▪ Delirium – some form of acute confusion that can lead to uncoordinated movements and falls o Awareness and acknowledgement of own risk for falls ▪ Patients might not recognize their own risk of falling o Altered mobility: lower extremity weakness, abnormal gait, shuffling and stumbling ▪ May need assistive device ▪ Sensory deficit ▪ Floor is wet, electrical cords near walkway, intravenous pole, IV pumps impeding movement Fall Prevention - Complete a fall-risk assessment for each client at admission and at regular intervals o Initial and regular assessment o When coming into shift, regularly assessing patient from falling - Educating client o Teaching them how to use call light o Perform a return demonstration ▪ After you teach, “can you please show me how you would use the call light”  ▪ “What situations would you use the call light?” o Place call light within reach - Proximity and monitoring o Come to patient promptly o Offer frequent bathroom assistance before leaving room ▪ “Would you like to go to the bathroom before I leave the room?” - Strategic room placement o Adequate lighting to allow patients to navigate room o Showing them how to turn night light on o Having them familiarize environment - Accessibility and safety o Place assistive device in a place that can be easily reached o Keep bed at the lowest position with the brakes locked o Per CMS ▪ We are not allowed to put 4 side rails up ▪ That's considered a form of restraint ▪ Can only place a max of 3 side rails up - Equipment and footwear o Non-skid footwear, socks to reduce slipping o Important for walking or doing physical therapy - Assistive device - Reporting and documentation o Whole staff hourly rounding - Having family member visiting patients 2 to 3 hours o Showing family members how they can take care of patient once they return home - If patient has fallen o You are going to document in an incident report o Identify any patterns and prevention policies ____________________________________________________________________________________ Crutch walking Types of Gait - 4 point o Client moves left crutch forward o Opposite right leg forward o Other right crutch forward o Other left leg forward o Bears weight on both legs, alternates each leg with the opposite crutch so three points of support are always on the floor - 3 point o Crutches forward together, swing good leg in front of crutches o Bears all weight on one foot while using both crutches o Affected leg should never bear weight or touch the ground - 2 point o More fluid and resemble a natural walking pattern o Client moves one crunch and opposite leg forward at the same time o Means they have a crutch and have a crutch type of walking - Swing through gate o Involves swinging both legs past the crutches o Needs significant upper body and arm strength to maintain balance ____________________________________________________________________________________ Mobility device cane Different types of mobility assistance Gait belt ____________________________________________________________________________________ Dosage calculation Oral dosage calculations Parenteral dosage calculations Injectable dosage calculations Medication management Administering nasal decongestants Medication transcription ____________________________________________________________________________________ Ppd test (purified protein derivative or Mantoux test) Tuberculin Test Procedure - Use for tuberculin testing or checking for medication or allergy sensitivities. - Use small amounts of solution (0.01 to 0.1 mL) in a tuberculin syringe with a fine- gauge needle (25- to 27-gauge) in lightly pigmented, thin-skinned, hairless sites (the inner surface of the mid-forearm or scapular area of the back) at a 5° to 15° angle. - Insert the needle with the bevel up. A small bleb should appear. - Do not massage the site after injection.