Assessment – establishing a database- Complete total health history and full examination. Describes the current and past health state and forms a baseline against which all future changes can be measured. A database includes all the pertinent patient information collected by the nurse and other healthcare professionals. Demographics, social determinants of health, health disparities, and physical, functional and psychosocial, environmental, spiritual, transpersonal and economic assessments. Assessed needs, values, preferences, knowledge of the healthcare situation, Prioritizes collection of data based on consumers’ immediate condition. Honoring a person’s healthcare preferences. KnowSubjective- patients own perspective of their feelings and perceptions Objective- observed characteristics (measurable and observed by the nurse) and patient history SUBJECTIVE- data that can be seen, heard, felt, smelled 1. Location-be specific 2.Character or Quality-specific descriptive terms 3. Quantity or Severity -pain scale 1-10 4.Timing-(onset, duration, frequency) 5.Setting-What where you doing or where where you when it started 6.Aggravating or Relieving Factors- what makes it worse? what makes it better? 7.Associated Factors-primary symptom associated with any others? 8.Patients Perception-How does it affect daily actives? Initial- Definition/Introduction. Data collected shortly after the patient is admitted. The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. USUALLY FIRST VISIT Focused- problem centered, for a limited or short-term problem that has already been identified. May be done with the initial assessment if the patient problem surfaces. Question include (when did it start, what are your signs and symptoms. What makes it better or worse?) -Collect a "mini" database, more targeted than the complete database. Usually incorporates one problem or system and the history surrounding that problem. Emergency- an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Dx- Two-part statement vs 3-part statement and prioritize PES (problem, etiology, signs) problem etiology and defining characteristics. Something/ problem, related to / cause, Problem Related to, Etiology……AEB As Evidence by Defining characteristics or risk factors. Use Maslow’s hierarchy of needs1 Physiological need comes first- ABCs Airway, Breathing, Circulation food, water clothing, sex, sleep, homeostasis, excretion 2 Safety and Security 3 Love and Belonging 4 Self Esteem 5 Self- Actualization Validate dx with support- mal adaptive coping related to positive test result of lymphoma. as evidenced by patient crying uncontrollably. Nursing diagnosis is problem focused concerning the undesirable human response to a health condition. A risk diagnosis, is a clinical judgement concerning the motivation and desire to increase wellbeing and to actualize human health potential. Identify outcomes- The outcome statement is a direct resolution of the problem statement. Such as the nurse works in partnership with the patient and family to identify priorities and write patient expected outcomes. The goal or aim in the event of a wellness diagnosis. Using measurable timely SMART goals to determine that the outcome has been met. Implement the plan of care- determine the patients new or continuing need for care. Promote self-care and assist the patient to achieve valued health outcomes. Delegation- the five right so delegation Right task Right circumstance Right person Right direction and communication Right supervision and evaluation Reassess the patient and review the plan of care Evaluation- the patient and the nurse together measure how well the patient has achieved the goals and outcomes specified in the plan of care. Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. Documentation guidelines- all information needs to be complete and accurate and relevant in nonjudgmental matter of fact language. All documentation needs to be done in a timely manner Indicate each entry both date and time Never document something before it has been carried out. If you make a mistake, write mistaken entry. Something that is ineffective does not attribute to the health and wellbeing of the patient. Resource called Up to Date that includes interventions Use the ABCs to prioritize DX Documentation- SBAR Situation, background, Assessment, Recommendation, Readback Bedside report- elements include, incoming and outgoing nurse seeing the patient together and assessing the goals for the shift. Reviewing the medications and nursing orders. Nurse informatics- definition of nursing informatics- the specialty that integrates nursing the science and data information and technology. IN- informatics nurse specialist involved it the implementation of the EHR and is considered a superuser with additional training but who does not have an additional degree. and specialist- responsible for strategy development and implementation and maintenance and evaluation of systems. has a graduate degree in nursing informatics and could have a masters degree. Telehealth is the use of electronics and telecommunications to support and promote clinical health care long distance. The cycle of infection includes six componentsInfectious agent Reservoir- the natural habitat of the organism. People animals, soil food water milk and inanimate object Portal of entry and exit can be the same- the point of escape of the organism from the reservoir Direct contact, indirect contact, vector, fomite Antimicrobial agent- Stages of infectionIncubation- no symptoms Prodromal- early signs and symptoms are present, vague and nonspecific fatigue, malice and low-grade fever. The most infectious Full or acute stage of the illness- demonstrate all of the symptoms of the disease. Convalescent period- recovery from the infection Means of transmition- droplet or contact or airborne transmition Portals of entry Susceptible host Know the difference bx medical and surgical asepsis- the difference between medical asepsis and surgical asepsis Medical asepsis or clean technique involve procedures and techniques that reduce the number and transfer of pathogens. Surgical asepsis or sterile technique includes practices to render and keep objects and areas free from microorganisms. Inserting anything into the body, ie cath or iv. Asepsis and infection control – deficit of fluid volume- decrease in bp, pulse pressure and pulse volume. Risk for infection etc. Meds and injection Know the different precautions and their diseases Rights of medication administration (11) Right medication Right patient Right dose Right reason Right assessment data Right documentation Right response Right education Right to refuse Meds and injection Investigate the right needles for right meds and person????? Intramuscular injection Reducing discomfort with injections- select correct needle length Vastus lateralus- 5/8 to 1 in Deltiod 5/8 to 1in Deltoid adult 5/8 to 1.5 in Ventro gluteal 1 to 1.5 in 1-5 ml range – needle needs to be perpendicular to the persons body Make sure needle is clean Use the z track meth with im injections to prevent leakage of medication Inject medication into relaxed muscles Do not inject into places that feel hard on palpation Insert with dart-like motion Only inject the prescribed amount of solution Inject slowly, 10 seconds per 1 mL Gently apply pressure unless contraindicated Allow patient to talk about their fears of injections Rotate sites if patient is to receive multiple injections Provide age appropriate support to children including participation of the parents Focus on older people- decreased gastric motility Decreased lean bod mass decreased total body water Decreased number of protein binding sites Decreased liver function and hepatic perfusion Decreased kidney function Altered peripheral Venus tone Decreased nervous system function Decreased production of oral secretions Decreased blood supply to the skin Decreased renal and kidney function can lead to increased drug toxicity The auditory canal changes as you age know how Adult ear drop instillation- pull pna up and back School aged child-pull straight back Child under 3- pull pina down and back Factors effecting urinationAdults don’t pee at night because their kidneys are concentrating urine Developmental age has to do with sphincter control- at age 18 to 24 months Toilet training begins at 2-3 years Continued incontinence of urine past toilet training is termed enuresis The inability of the kidneys to concentrate urine at night is termen nocturia Urge incontinence is the involuntary loss of urine after feeling an urgent need to void The normal ph of urine should be between 5 and 6 can be from 4.5 -8 Specific gravity should be between 1.015 to 1.025 Urine should be pale yellow and have an aromatic smell Urine is measured by ultrasound Some possible nursing dx related to urinary elimination Impaired skin integrity – Disturbed body image Toileting self-care deficit Adults should dink 2000 to 2400mL of fluid per day 8 to 10 glasses UTIs drink 8-10 glasses of water and monitor for color and consistency of urine Void immediately after intercourse, drink 2 glasses of water before and after take showers rather than baths wear cotton underwear types of urinary incontinence Transient- appears suddenly Stress- when there is an increase of intraabdominal pressure Mixed= 2 or more types Overflow- associated with bladder distention Function caused by inability to reach the toilet Reflex incontinence- happens without sensation (spinal cord injuries) Total – surgery or malformation Prevention and treatment of constipation and bowel issuesPrevention and treatment of diarrhea- the passage of three or more loose stools in a day- teach patients to avoid sweets, cold fluids and rich foods. Avoid antidiarrheals until the bacterial cause has been ruled out. Keep clean and provide moisture barrier cream Watch for bp drop in digital fecal removal because of vagal nerve stimulation. Stoma goal and care- keep the patient free from odors and inspect regularly- should be moist and beefy red looking. Note the size, which usually stabilizes within 6-8 weeks (stoma may be flush with the skin) Dressing is usually removed after 24 hours. Record intake and output every 4 hours for the first 3 days. Colon ostomy irrigation may be indicated in patients who have a left sided end in the descending or sigmoid colon. Eggs may cause gas and odor Skin integrity and wound care Vitamins ABCK + Protein and water needed for wound healing Process of wound healing Hemostasis-immediately after injury, blood vessels constrict and blood clotting begins Inflammatory- lasts about 2-3 days leukocytes and macrophages move to the wound Proliferation- fibroblastic or connective tissue phase capillaries grow across wound and granulation tissue is formed which leads to scaring. Maturation- remodeling happens 3 weeks after injury. Scar tissue is formed. Factors that affect wound healing are desiccation (dryness), maceration (too moist) need to promote epithelialization by keeping wound moist but not wet. Necrosis (death of tissue and presence of biofilm), trauma, edema, infection, excessive bleeding, age circulation and oxygenation. Pressure injuries staging 1-partial thickness whare all of the tissue is intact- no blanchable erythema 2-full thickness where all of the dermis sweat glands and hair follicles and severed exposing sub q or muscle bone or tendon. 3- full thickness 4-unstageable Types of woundsIncision where wound edges are in close approximation Contusion- skin in tact blunt instrument possible bruising or hematoma Abrasion-friction rubbing epidermal layers Laceration- tearing of tissue with blunt or irregular instrument tissue not aligned loose flaps PuncturePenetratingAvulsion- tearing a structure from its original location Pressure ulcers/ injuries combined with friction- loss of circulation usually due to a bony prominence and an external source cutting off circulation Venus or arterial ulcers- lack of adequate perfusion due to inadequate venous return, atherosclerosis or thrombosis. Diabetic ulcer- diabetic foot loss or neuropathy For older people maintain adequate fluid intake and measure I&O People on corticosteroids are at risk for decreased wound healing Dehiscence is the separation of a wound and evisceration is when the abdominal organs come through the wound Fistula is the unnatural passage between to viscous organs. Infection can become present between 2-7 days after injury Use caution when removing tape (older people have a slower inflammatory response) Monitor serum albumin levels, total protein Maintain aseptic dressing changes Administer supplements and oxygen as prescribed Know concentration vs dilute urine Iv sites and solutions Psychological effects of the stoma Wound healing protein/ nutrition know the care and staging of wounds Stage 4- muscle and bone 3- sub q tissue Unstageable has eschar covering it Hygiene activity nutritionPatients with diabetes should file toenails don’t cut them with clippers, encourage them to see a professional in order to have foot care. All peri car should be done matter of factly and with respect. Wash from the cleanest to the dirties areas Transfers of patients should be done safely and use proper equipment (gait belts and lifts) Employ the help of another care giver. Use smooth steady rocking motion. Side roll or push/pull rathe than lift if possible us in body weight. Avoid friction on patient’s skin When transferring the patient from bed to chair, position the char at a right angle to the bed on the persons strong side and have them pivot on the strong foot Nutritional consideration for older adults Use of powder on toes Don’t cut off corns or bunions Patients without diabetes- cut nails straight across Always wash from cleanest to dirtiest Altered ability to chew-chop shred or puree foods, encourage dental care Loss of smell and taste- serve food one at a time, serve foods with different tastes and aromas and textures, attractive. Decreased gastric secretions- chew foods thoroughly, eat meals on a regular schedule, be alert to nutritional deficiencies Decreased peristalsis- eat high fiber diet, remain as active as possible, increase fluid intake, Lowered glucose tolerance- discourage sugar, eat more complex carbohydrates Reduction in appetite and thirst- offer meals at frequent intervals, offer fluids at regular intervals, offer small meals Loss of appetite related to depression and loneliness Inadequate or imbalanced nutrition, less than body requirements related to insufficient dietary intake as evidenced by “foods just don’t taste good anymore” Patient seems fatigued and undernourished. Physical disabilities- assist with opening of containers, arrange home delivery meals, conserve energy when preparing meals. Factor affecting sleep and rest People 65 and older get less sleep and often older adults need more time to fall asleep, wake up early or multiple times during the night. Losing sleep or having a sleep deficit can cause a person to lengthened reaction times NREM sleep-stage 1- 5 % of total sleep only lasts a few minutes and person can be easily aroused. Stage 2- 55 % of total sleep, feeling of falling asleep, person can arouse with relative ease Stage 3-10 % of total sleep, depth of sleep increases and person is not as easily aroused. Stage 4- greatest stage of sleep the delta stage, pulse and respiratory rates decrease, muscles are relaxed, difficulty arousing person. REM sleep- 20 -25 % of sleep, eyes dart back and forth, small muscle twitching, rapid irregular pulse, large muscle immobility, BP fluctuates, increase in gastric secretions. Sleep disorders- Stress, illness and medication, insomnia, breathing disorders, (obstructive sleep apnea), Central disorders of hypersomnolence, Circadian rhythm sleep wake disorders, Parasomnias, Sleep related movement disorders, Sleep deprivation. Narcloepsy. Focus on the older adult’s pain, Let them know that pain is not a normal side effect of aging Observe nonverbal signs of pain, grimacing, wincing or movement, use open ended questions, include family or caregiver, monitor for behavior changes or confusion. Monitor for respiratory depression when giving pain med and caution about alcohol use. Monitor for over sedation Explain side effects to patient Complementary and alternative therapies can be used inn conjunction with pain medication to control pain including meditation, yoga and mindful breathing. Preventing pain is easier than treating it Many cancer patients experience breakthrough cancer pain (incident pain or idiopathic) Adjuvant analgesics can enhance the use of opioids and can reduce side effects, be used for depression and neuropathic pain. PCA pump, fentanyl or hydromorphone Use the pain ladder to determine which pain med to give and in which combination. Know the different types of pain (visceral, somatic, referred) VisceralIdiopathicSomaticReferredTeaching tips for emergency know spiritual distress Safety and emergenciesThe use of restraints, documentation and alternatives legal and moral implications. It is important to see if there are reasons why the person is wandering and address those first before restraints are used. Such as making sure hearing aids and glasses are close by as well as seeing if the persons medication may be a factor etc.. Preventing fires and maintaining fire safety. Use the RACE acronym with the patient being the first priority. Safety event reports are not in the medical record and should include the person and or family members effected by the event. Spiritual distressAsk about a person’s spiritual beliefs- in what ways can I and the other nurses help you meet your spiritual needs? Spiritual distress is the perception of lack of meaning in one’s life Inability to reconcile current life situation. Readiness for enhanced hope Readiness for enhanced spiritual wellbeing Each person has a need for Love, relatedness and forgiveness Oxygenation and perfusionThe respiratory center in the brain is located in the medulla and stimulated by in creased levels of carbon dioxide and to a lesser degree, decreased oxygen levels. Chemoreceptors in the aortic arch are sensitive to ABGs and blood pressure and can activate the medulla. Hypoxia is signaled by dyspnea, elevated blood pressure, low pulse pressure, increased respiratory rate and pulse rate, anxiety, cyanosis, palor, restlessness and confusion. Hypoxia is often caused by Hypovolemia- Abnormally low circulating blood volume Left-sided Heart Failure: - characterized by decreased functioning of the left ventricle (fatigue, breathlessness, dizziness and confusion) Right-sided Heart Failure: characterized by impaired functioning of the right ventricle (weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema) Cheyne-Stokes Respiration- occurs when there is decreased blood flow or injury to the brainstem. Cardiopulmonary Diagnostic Blood Studies: Complete Blood Count (CBC) - Cardiac Enzymes - Cardiac Troponins - Serum Electrolytes - Cholesterol - Additional Tests Breathing is an automatic and rhythmic act produced by networks of neurons in the hindbrain (the pons and medulla). The neural networks direct muscles that form the walls of the thorax and abdomen and produce pressure gradients that move air into and out of the lungs. - Arterial Blood Gases - Pulmonary Function Tests - Peak Expiratory Flow Rate (PEFR) - Bronchoscopy - Lung Scan - Thoracentesis - Sputum Specimens Nursing DX for resp - Activity Intolerance - Decreased Cardiac Output - Fatigue - Impaired Gas Exchange - Impaired Verbal Communication - Ineffective Airway Clearance - Ineffective Breathing Pattern - Risk for Aspiration Tracheostomy- reasons include replacement of endotracheal tube, provide a method for mechanical ventilation, to bypass airway obstruction. Tube inserted through the second or third cartilage . cuffed or uncuffed. Not recommended for a patient with a history of aspiration. Humidified air is administered because the air going in bypasses the nose and mouth. Develop a report through eye contact and gestures with the patient since they are not able to speak. Nurse is responsible for changing the inner tube to keep the airway clear, regularly change dressings. Clean the skin around the trache. Newly inserted tube may require care every 1-2 hours. Tracheal suction using sterile technique Suctioning needs to be limited to 15 seconds and hyperoxygenation the patient before and after. Monitor patient pule often Appropriate pressure should be no more than 150mmhg Oxygen concentrators are low cost, portable and easy to use. CPAP uses positive air pressure. A chest tube is indicated when negative pressure in the pleural space is disrupted. How to provide tracheotomy care what happens if tube comes out STERAL WATER p.1513 Do tic tac toe respiratory alkalosis/ acidosis what does respiratory acidosis look like in the patient? Fluid, electrolyte and acid base balance- Fluid volume deficit is caused by both loss of water and solutes in the same proportion from the ECF. AKA Hypovolemia. Hypervolemia is indicative of fluid excess and can be accompanied by edema. Fluid can be pulled from the cells to equalize the hypertonicity of the excess water and salt. Interstitial fluid and ICF are affected, water move from the ICF to the ECF Hyponatremia can be caused by loss of sodium or increase of water. Causes include vomiting diarrhea, fistulas, sweating, or from the use of diuretics. The decreases in sodium causes fluid to move from the ECF to the ICF. Which leads to swelling of the cells. Other signs of hypervolemia include- high blood pressure, shortness of breath, headache and stomach bloating, crackles in the lower lungs. Hypernatremia- refers to a surplus of sodium in the ECF caused by excess water loss or an increase in salt. Hypokalemia- deficit of potassium, the major intracellular electrolyte. Signs include muscle cramps, weakness, paresthesia and dysrhythmias. 15% fluid loss is considered life threatening Some signs of dehydration include loss of skin turgor, a furrowed tongue and increase in temperature. Tongue turgor is not affected by age so it is a good way to assess. Tachycardia is the earliest sign of fluid volume deficit. Irregular pulse is present in potassium imbalances and magnesium deficit. Pulse quality and amplitude is decreased. Respiratory considerations for acid/base imbalances include Deep rapid respirations may be compensatory for metabolic acidosis, or primary disorder causing respiratory alkalosis. Slow shallow respirations may be compensatory for metabolic alkylosis Moist crackles indicate fluid volume excess A decrease in systolic blood pressure of more than 20 mmhg or decrease in diastolic of more than 10 mmhg can indicate postural hypotension may indicate fluid volume deficit. Whenever a fluid volume deficit is suspected measure BP in both sitting and standing positions to determine presence of orthostatic changes. PH of urine is usually between 4.6 and 8.2 Urine specific gravity ranges from 1.005 to 1.030 Normal blood pH is 7.35-7.45 Low pH indicates acidosis. Higher pH indicates alkalosis. PaCO2 is the lungs while HCO3 is the kidneys if either one of these is high then the acidosis is caused by that system PaCO2 should be 35-45 HCO3 should be 22-26 Central lines- use of ultrasound to install. All require radiographic verification of placement. Taking daily weights can be a good indicator of fluid imbalance Blood tests include complete blood count and hemoglobin as well as increased hematocrit Factors affecting self-concept- developmental considerations, culture, internal and external resources, history of success and failure, stressors, illness and trauma. Developmental- the growing child needs freedom to explore and develop the ability to meet increasing personal needs. Culture- a child’s culture can influence the expectations of the child on society and vs versa. Internal and external- ones coping mechanisms with internal and external value systems such as the use of humor. People who have a good sense of self-esteem often have the ability to recognize available support systems and resources, feel a connection to community A person who has had multiple past failures may subconsciously encourage more failures in their life through destructive relationships. Three things affect how someone deals with a crisis Perception of the crisis Available coping mechanisms and the persons resources Society values youth and vitality and they deny the eventuality of the signs of aging Helping the at risk patientA patient sense of self can be largely dependent on how other people and the staff treat them- be conscientious, respectful, acknowledge the patient’s status and roles, speak non-patronizingly, respect privacy. GAS- general adaptation syndrome (alarm reaction, stage of resistance, stage of exhaustion) Effects of stress on basic needscan affect physiologic including sleep patterns, eating and elimination, Safety and security including the feeling of being threatened (ineffective coping) Love and belonging-withdrawn, isolating, blaming others, aggression Self-esteem- becomes a work-acholic, exhibits attention seeking Self-actualization- refuses to accept reality, centers on own problems, demonstrates lack of control. Death and Dying- 5 stages of grief Denial, Anger, Bargaining, Depression, Acceptance Signs of impending death- difficulty talking or swallowing, nausea flautas, abdominal distention, urinary or bowel incontinence, loss of movement, sensation or reflexes, Decreasing body temperature, weak, slow or irregular pulse, decreasing blood pressure, noisy Cheyne Stokes breathing pattern, restlessness or agitation, cooling and modeling of extremities, cyanosis Stages of consciousness/ arousal Delirium, Dementia, Confusion, normal Consciousness Somnolence, Minimally Conscious state, Locked in state Stupor Coma Vegetative Know all of the dosage calc questions.
