Exam 3 Fundamentals 32,36,37,40,44 Chapter 32: Skin Integrity and Wound Care https://www.youtube.com/watch?v=k6g_Wv6VFQ8 - Video Lecture on Skin Integrity and Wound Care https://quizlet.com/202708385/fundamentals-of-nursing-chapter-48-skin-integrity-and-wound-ca re-practice-questions-flash-cards/ - Quizlet Cards Structures of the Skin - Epidermis: Stratified epithelial cells, waterproof barrier, no blood vessels. Dermis: Elastic, connective tissue, Nerves, hair follicles, glands and blood vessels Subcutaneous tissue: Anchors the skin to body tissue, Fat storage/insulation, Blood/lymph vessels, nerves. - Functions of the skin: - Protection Temperature regulation Psychosocial Sensation Vitamin D Production Immunologic Absorption Elimination Mucous Membranes - Basic Principles - Unbroken and healthy skin and mucus membranes serve as 1st line of defense against harmful agents - Resistance to injury varies among people (example: age, underlying illness) - Adequately nourished and hydrated body cells resistant to injury - Adequate circulation necessary to maintain cell life. - Factors Affecting Skin Integrity - Age - Lifestyle Variables - Nutrition - Hydration - Illness (neuropathy, decrease sensation, decreased circulation increase risk for skin breakdown) - Level of Activity/Therapeutic Measures - Diagnostic Measures - Exposure (sun, occupational/environmental exposure) Construction worker under the sun. - Developmental Considerations - Infants: Under 2 years old have thinner/weaker skin - Older Individuals: have decreased elasticity, increasing risk for skin breakdown Chart about older adults’ skin. - State of Health - Very thin and very obese patients are more susceptible to skin irritation and injury. - Fluid loss through fever, vomiting, and diarrhea reduces fluid volume - Excessive perspiration predisposes skin to breakdown - Patients with jaundice may be more likely to scratch and cause and open lesion - Disease of the skin (eczema and psoriasis) may cause lesions to require special care Wounds - Any interruption in normal skin/tissue integrity Examples of wounds - Types of Wounds - Incision: Cutting or sharp instruments - Contusion: Blunt instrument, possible bruising or hematoma. - Abrasion: Friction, rubbing, or scrapping epidermal skin layers - Laceration: Tearing of skin and tissue with blunt or irregular instrument - Puncture: Blunt or sharp puncturing skin - Chemical: Toxic agents such as drugs, acid, alcohols, metals, and substances that result from tissue necrosis. - More types - Thermal: High or low temperatures - Irradiation: Ultraviolet light or radiation exposure - Pressure ulcers: Compromised circulation secondary to pressure or pressure with friction. - Venous ulcers: Injury and poor venous return, resulting from underlying condition such as an incompetent valve or obstruction. - Arterial ulcers: Injury and underlying ischemia, resulting from underlying conditions such as atherosclerosis or thrombosis. - Diabetic ulcers: Injury and underlying diabetic neuropathy, peripheral arterial disease, foot structure. Top is an extreme pressure ulcer, and the bottom is a diabetic ulcer. - Wound Classification - Intentional versus unintentional - Intentional: planned intensive therapy or treatment. Low risk of infection. - Unintentional: Accidental and occurs from unexpected trauma. Higher risk of infection. - Open vs closed - Open: Secondary to trauma whether intentional or unintentional - - - Closed: Secondary to blunt trauma. Acute vs Chronic - Acute: Heals within days to weeks, follows expected healing pathway (Ex. surgery) - Chronic: Healing delayed, usually gets stuck at the inflammatory stage of healing. (Ex. pressure ulcer) Partial thickness vs full thickness vs complex - Partial: All or a portion of dermis is intact - Full: Entire dermis and sweat glands and hair follicles are severed - Complex: Dermis and underlying subcutaneous fat tissue are damaged or destroyed. Wound Healing - Primary: Edges well approximated, require little tissue replacement. Secondary intention: Loss of tissue, Longer healing time, Wound open, more scar tissue. Tertiary: wound left intentionally open, Delay closure to allow for edema or infection to resolve or fluid to drain and then are closed, large amount of tissue replacement needed. Phases of Wound Healing - - - - Homeostasis - Occurs immediately after initial injury (2 or more days) - Vessels constrict/platelets cluster/clotting - Vessels then dilate and blood components leak into the area forming exudate - Exudate dries causing scab formation (scab helps protect) - Platelets then stimulate other cells to come join in healing beginning the next phase of healing Inflammation - Follows homeostasis (2 to 3 days) - The primary function is to starve off infection during wound healing process - WBCs move to the area and begin cleaning the wound of foreign material Proliferation - Last for several weeks or years depending on wound size - New tissue formation - Capillaries grow across the bed - Epithelial tissue forms over the wound - Granulation tissue forms - WBCs have largely migrated away from the wound around week 2 Maturation - Begins 3 weeks after injury, possibly continuing for months or years - Collagen now remodeled and new collagen continues to be deposited, forming a scar - Scars do not sweat, grow hair, or tan - Scars can limit mobility Factors Affecting Wound Healing More Factors Wound Complications Infection - Symptoms occur 2 to 7 days after injury or surgery - Symptoms = purulent drainage, increased drainage, pain, redness, swelling in and around wound, increased body temperature, and increased white blood cell count. - Can lead to other complications like bone infection and sepsis. Hemorrhage - Check dressing and wound under dressing frequently during first 48 hours after injury and no less than every 8 hours afterwards - Fluid replacement may be necessary and surgical intervention may be required. - Internal hemorrhage can cause hematoma formation - Tissue ischemia may occur. Dehiscence and Evisceration - Dehiscence: partial or total separation of wound layers as result of excessive stress on wounds that are not healed. - Evisceration: Most serious complication of dehiscence; wound completely separates with protrusion of viscera through incisional area. - Emergency treatment: Cover wound and any protruding organs with sterile towels or dressing soaked in sterile normal saline. Do not reinsert organs. Place patient supine with hip and knees bent. Observe for signs of shock. Fistula formation - Definition: abnormal passage from an internal organ to the outside of the body or from one internal organ to another. Presence increases risk for delayed healing, additional infection, fluid and electrolytes imbalances, and skin breakdown. Pressure Ulcer - Definition: Wound with a localized area of tissue necrosis Factors in Pressure Ulcer development - External pressure - Usually occur over bony prominences such as sacrum, followed by trochanter and heel. - May form in as little as 1 to 2 hours if patient has not moved or has not been repositioned. - Friction and shear - Shear happens when one layer of tissue slides over another layer. Risks for Pressure Ulcer Development - - - - Immobility - Those who are unconscious and paralyzed, those with cognitive impairment, or have other physical limitations, surgeries, recent use of tranquilizers or sedative Nutrition and hydration - With malnutrition, cells are damaged easily. Moisture - Primary sources = perspiration, urine, feces, and wound drainage - More alkaline pH promotes premature shedding of skin cells and decreases the skin’s defense against bacteria Mental status - Apathy, confusion, and comatose state can diminish self-care activities and increase likelihood of skin breakdown Age - Aging skin more susceptible to injury Common Areas for Pressure Ulcers Pressure Ulcer Staging - First Indication: Blanching (becoming pale and white) of the skin over area under pressure Pressure relieved and reactive hyperemia (area red and feels warm, but blanches when slight pressure applied) occurs. Pressure ulcer occurs if pressure continues after ischemia and circulation is further impaired Appropriate intervention depends on early recognition of the stage of development of the pressure ulcer. 6 stage classification: Suspected deep tissue injury, Stage 1, Stage 2, Stage 3, Stage 4, and unstageable. - Suspected deep tissue injury - Purple or maroon discolored, but intact skin caused by damage to underlying tissue. May present as painful, firm, mushy, boggy, warmer, or cooler area as compared to adjacent tissue. - Stage 1: Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Tissue swollen and congested, with possible discomfort at site. Darker skin tones may not have visible blanching, but color may differ from surrounding skin. example of Stage 1 pressure ulcer - Stage 2: Partial thickness skin loss involving the epidermis and dermis. Ulcer visible, superficial and may appear as abrasion, blister , or shallow crater. Edema persist and ulcer may become infected, possibly with pain and drainage. example of Stage 2 pressure ulcer. - Stage 3: Full thickness tissue loss with damage to or necrosis of subcutaneous tissue. Ulcer may extend down to fascia. Ulcer appears as a deep crater. Slough may be present but does no obscure depth of tissue loss. No exposure of muscle or bone. Drainage and infection is common. THIS SHOULD NOT BE COMMON(RARELY SEEN) example of a stage 3 pressure ulcer. - Stage 4: Full thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. May have tunneling, eschar (black scab-like material), slough, undermining (extension of wound edges underneath). example of a stage 4 pressure ulcer. - Unstageable: Base of ulcer covered by slough and/or eschar example of an unstageable pressure ulcer. Wound Assessment - Inspection, Palpation, Drainage, odor, pain Determines status of the wound Identifies barriers to the healing process Identifies signs of complications Early recognition and intervention is key to minimizing complications and healing time. Appearance - Location - Described in relation to nearest landmark - Size - Taken in millimeters - Length X Width X Depth - Wound Edges - Approximated - Dehisced - S/S infection - Odor - - Wound Bed - Epithelial (pink), Granulation (beefy red), Slough (Yellow), Eschar (Black) Drainage - Amount, Color, Consistency - Type: - Serous: Clear, contains serum of blood that is watery clear, and slightly yellow - Serosanguineous: Light Pink, contains serum and red blood cells - Sanguineous: Red color contains serum and red blood cells - Purulent: yellow/green/brown/tan - Often thick/opaque - Foul odor - Contains white blood cells, tissue debris and bacteria Example of drainages - - Psychological Effects: Wounds and Pressure Ulcers - Pain - Anxiety and Fear - Activities of Daily Living - Changes in Body Image Pain Assessment - Assess at each dressing change; before, during, and after - Surgical pain most severe 1st 2-3 days Pain + increased/purulent drainage = delayed healing/infection Pain scale image Drains: Open Drainage - Penrose Drain - Drains into absorbent dressing - Passive drainage - From area of greater pressure to lesser pressure - Large safety pin placed on outer portion to keep drain from slipping into wound image of a penrose drain Closed Drainage - Example: Jackson-Pratt and Hemovacs - Connected to electrical suction device to have portable built-in reservoir to maintain continuous low suction - Sutured in place - Allows for accurate measurement of drainage Sutures and Staples - Used to hold tissue and skin together Sutures may be dissolvable or may need to be removed - Maintain Nutritional Status - Laboratory criteria can indicate a patient is nutritionally at risk for a pressure ulcer - Albumin level <3.2 mg/dL Prealbumin <19 mg/dL Body weight decrease of 5-10% Total lymphocyte <1800 mm Hemoglobin A1C >8% Glucose >120 mg/dL Pressure Ulcer Assessment Tool - 19-23 = No risk 15-18 = mild risk 13-14 = moderate risk 10-12 = high risk 9 or less = very high risk Wound Care/Wound Management - - Goal: Promote tissue repair and regeneration Treatment: Open to air or closed wound care Open to air: Wound heal more slowly as a scab/dried eschar forms. If scab removed accidentally before healing completes, reinjury occures and new cells are exposed. More prone to environmental factors and potential injury. Closed wound care: Uses dressings to keep wound moist (best for wound healing), promoting healing. Wound surface moist, then epidermal cells migrate more rapidly. Changing The Dressing - Administer pain analgesic 30 to 45 minutes before changing the dressing - Change in between meals Use appropriate aseptic technique Surgical wound that have dehisced = sterile Pressure ulcers = nonsterile Wound Care: Dressing Change - - Check MD order Have all needed materials gathered and at the beside before procedure Explain to client what you are about to do and answer any questions Provide privacy Remove old dressing carefully - Pull up small portion of tape, hold tape, push the skin away from the tape - Use adhesive remover for those with frail skin or for tape with high adhesion Note drainage: amount, color, type, odor Discard dressing Hand hygiene Wound Care: Packing - Moisten the packing material as ordered - Place in tunnels and undermined areas first - Pack loosely - Cover entire wound bed Use one piece of packing Keep packing off of intact skin Cover with ordered top dressing Secure as ordered Chapter 36 Nutrition absorption: process by which drugs are transferred from the site of entry into the body to the bloodstream anorexia: lack or loss of appetite for food anthropometric: measurements of the body and body parts aspiration: misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract basal metabolism: amount of energy required to carry out involuntary activities of the body at rest body mass index (BMI): ratio of height to weight digestion: gastrointestinal system’s breakdown process of food into particles small enough to pass into the cells and be used by the cells dysphagia: difficulty in swallowing or inability to swallow enteral nutrition: alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula gastric residual: feeding remaining in the stomach gastrostomy: opening created into the stomach nasogastric (NG) tube: tube inserted through the nose and into the stomach nasointestinal (NI) tube: tube inserted through the nose and into the upper portion of the small intestine NPO: nothing by mouth (Latin: nil per os) nutrients: specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury nutrition: study of the nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment obesity: weight greater than 20% above ideal body weight parenteral nutrition (PN): nourishment provided via IV therapy percutaneous endoscopic gastrostomy (PEG): surgically (open or laparoscopically) placed gastrostomy tube peripheral parenteral nutrition (PPN): prescribed for patients who require nutrient supplementation through a peripheral vein because they have an inadequate intake of oral feedings recommended dietary allowance (RDA): recommendations for average daily amounts of essential nutrients that healthy population groups should consume over time waist circumference: a numerical measurement of the waist, used to assess an individual’s abdominal fat and establish ideal body weight 1. List the six classes of nutrients, explaining the significance of each. 2. 3. 4. 5. 6. 7. 8. 9. Identify risk factors for poor nutritional status. Describe how nutrition influences growth and development throughout the life cycle. Discuss the components of a nutritional assessment. Develop nursing diagnoses that correctly identify nutritional problems that may be treated by independent nursing interventions. Describe nursing interventions to help patients achieve their nutritional goals. Plan, implement, and evaluate nursing care related to select nursing diagnoses that involve nutritional problems. Identify nursing interventions to safely deliver enteral nutrition. Identify nursing interventions to safely deliver parenteral nutrition. Chapter 37: Urinary Elimination https://quizlet.com/569680277/fundamentals-chapter-37-urinary-elimination-flash-cards/ – Quizlet cards https://quizlet.com/549561582/chapter-37-urinary-elimination-flash-cards/ - Quizlet cards https://www.youtube.com/watch?v=I2yhxrqjmmA&t=1585s - Video Lecture Kidneys - Located behind the peritoneum in the upper abdominal cavity Help maintain the composition/volume of body fluids About once every 30 min total blood volume of the body passes through the kidneys for waste removal Nephrons - Basic structural/functional unit of kidney - Removes urea, creatinine, and uric acid - Maintain and regulate fluid balance Ureters - Tube that drains urine produced by the kidney into the bladder - This fluid moves via peristalsis A membrane in the bladder folds over the ureter to keep urine from backing up into the ureters - Urethra - - Transports urine from the bladder to the outside of the body Male urethra - Longer - Part of excretory and reproductive systems - Consists of the prostatic, membranous, and cavernous portions - Located beyond the prostatic portion Female Urethra - Shorter Urination - - - Also called micturition or voiding Reflexive, though control can be learned - Autonomic bladder - Bladder not controlled by the brain due to injury or disease Act of urination - Detrusor muscle contracts, internal sphincter relaxes, and urine moves into posterior urethra - Mucles of perineum and the external sphincter relax, abdominal wall muscle contracts, diaphragm lowers - Micturition occurs Urinary incontinence - Any involuntary loss of urine Dysuria - Painful/Difficult urination Frequency of Urination - - - - Depends upon the amount of urine produced First void of the day usually more concentrated - Sometimes used for urine testing Infrequent Voiding - Normally secondary to low fluid intake, inaccessible toileting facilities, work circumstances (nursing), illness, limited mobility - Higher incidence of UTI - May also indicate renal/circulatory disorder Urinary retention - Normal amount of urine produced; However, not fully excreted from the body - Secondary to medication (antihistamines, anticholinergics, Tricyclic antidepressants), enlarged prostates, vaginal prolapse, tumors, bladder nerve damage, kidney stones. Developmental Considerations: - We are born with involuntary control of bladder - Voluntary control normally occurs between 2 and 5 years - Before toilet training should begin child should - Hold urine 2 hrs, recognize feeling of bladder fullness, communicate the need to void, control urination until at the toilet. Factors Affecting Urination - Normal aging may effect urination in older adults - Nocturia- The diminished ability of the kidneys to concentrate urine may result in night time urination. - - Decreased muscle tone and capacity to hold urine results in increase in frequency Decreased bladder contractility may lead to urine retention and stasis which increases likelihood of UTI Neuromuscular problems, degeneratinve joint problems, alterations in though processes and weakness may interfere with voluntary control and ability to reach toilet Medications for other health problems may interfere with bladder function (diuretics) Food and Fluid Intake - - Intake and output should be about equal If dehydrated the kidneys reabsorb fluid - Urine is more concentrated - Decrease in amount of urine Kidneys excrete large amounts of fluid in fluid overload Activity and Muscle Tone - Exercise increases metabolism and urine production helping urinary system maintain optimal function Immobility decreases bladder tone and sphincter control Indwelling catheters decrease bladder tone because the bladder is not being stretched by the bladder filling with urine. Other causes of decreased bladder tone. - Child birth, muscle atrophy, trauma to muscle. Pathologic Conditions: - Failure of Kidneys to remove waste Acute-Sudden decline in function - Secondary to dehydration, anaphylactic shock, pyelonephritis, ureter obstruction Chronic-Develops slowly - Can be caused by diabetes, HTN(Hypertensions), Glomerulonephritis. Medications - - Nephrotoxic - NSAIDS, GENTAMYCIN, VANCOMYCIN, LITHIUM, DIPHENHYDRAMINE, FLUOXETINE Certain drugs cause urine to change color Anticoagulants- can cause hematuria Diuretics - Lighten the color of urine (dilute) Phenazopyridine (pyridum)- Causes orange/red urine Amitriptyline (elavil) and B vitamins - can cause blue/green urine Levodopa and iron- Can cause black or brown urine Nursing History - Usual Pattern - How often, nocturia, describe Recent Changes - Leak urine, any changes in frequency/amount/color/ability/comfort Use of aids (anything that helps patient to eliminate) History of urinary problems Presence of artificial orifices - Urinary diversion-Surgical creation of alternative urinary route Physical Assessment - Positioned below the symphysis Can only be palpated when full Bladder scanner - Ultrasound - - Sometimes creates image of bladder - Estimates urine volume - Noninvasive/Painless Urethral Orifice - Inspect for inflammation, Discharge, Odor - Place females in dorsal recumbent position - Retract Foreskin of uncircumcised men - Always place the foreskin back in normal position following assessment. Urinary Characteristics - Color - Normal color varies from pale yellow/Clear, to Amber; However, Dark urine should be noted as may indicate dehydration - Odor - Sweet odor indicates glucose - - - - Fetid odor indicates possible infection - Musty odor may indicate asparagus Turbidity - Cloudiness may indicate infection pH - Normal approximately 5-6 - Range: 4.6-8 Specific Gravity - Measure of concentration of solutes - High can indicate dehydration or kidney disease - Normal range is 1.015-1.025 Constituents - Abnormal constituents- Pus, glucose, ketones, casts, bacteria, bile Measuring Output - - - Continent Individuals - Have client void into container - Bedpan, hat, urinal - Pour urine into graduated measuring device - Place on flat surface and note amount - Discard the urine appropriately Incontinent Individuals - Note the amount of times client voids - Note odor/color - If strict I/O needed consider temporary catheter Measuring output of catheter bag - Wash hands and don gloves - Place graduated device under collection bag - Place spout above device and open clamp - Allow all urine to drain - Clamp device and wipe end with alcohol oab - Place clamp back into holder Look this over to be familiar with the terms POC testing - Point of care urine testing Always follow company protocol and make sure you have been properly trained/educated - Before every test make certain that prior quality control tests have been run according to protocol. Look this over to be familiar with the terms ● A cystoscopy ○ is a procedure to look inside the bladder using a thin camera called a cystoscope. Maintaning Normal Voiding Habits - Schedule-support client’s normal urinary pattern Urge to void-assist client to void when they first feel the urge Privacy- provide as much privacy as is safe for the client Position- help client assume the most natural position as tolerated for the client Hygiene- assist client to cleanse perineal/genital area and wash hands Promote Fluid Intake - Encourage 2000ml-2400 ml daily in normal adult with no reason for restriction - 8-10 oz glasses Water is best Avoid too much coffee, tea, soda, sugary drinks Kegel Exercise - Strenghthen muscle tone Help with stress incontinence Contract pelvic muscle - Instruct client to contract for 10sex then relax for 10 sec - Encourage the client to incorporate into daily routine - Can be done anywhere Assisting with toileting - Safety first Always use gait belt when assisting a client with ambulation Encourage client to perform as much of the process as capable Bedpan - Standard and fracture - Always maintain privacy gait belt Urinary Tract Infections - - - UTI’s Second most common type of infection Women at higher risk Risk factors: - Sexual activity especially in women, contraceptive diaphrams, post-menopause, indwelling catheters, diabetes mellitus, elderly. Urinalyis/Culture & Sensitivity - Positive C&S shows at least 100000 organisms/ml - Presence of bacteria along with SX (Dysuria, increased frequency/urgency, cloudy urine) indicates UTI - RBC’s/Nitrates may be present in urine Treatment - Short course ATB - Educate client on ways to prevent UTI’s - Drink 8-10 8OZ of water cups daily - Wipe front to back - Drink water before and after Sexual intercourse - Void immediately after sex - Cotton crotch underwear. Incontinence - Any involuntary leakage of urine - More common in women and elderly Absorbent products available to help contain the urine review these terms Post-Void Residual - Amount of urine remaining in the bladder following urination A PVR of less than 50 Ml indicates adequate bladder emptying Greater than 100 ml means inadequate emptying! Treatment - Kegal exercises Biofeedback Electrical stimulation Timed voiding/bladder training Medications Pessiaries Incontinent-Associated Dermatitis - Prolongued contact of the skin with urine or feces leads to a form of moisture-associated skin damage. Condom Catheters - Placed over penis just like the contraceptive. Make sure penis is cleansed thoroughly and fully dried before placing. Catheterization - Catheter associated UTIs are most common nosocomial infection - Therefore catheterization should be AVOIDED when possible Intermittent Catheter - Lower risk of URI than indwelling catheter In hospital this is sterile technique - Indwelling catheter - Foley Catheter Ballon is inflated with sterile water/saline inside the bladder securing the catheter and blocking the urethral passage - - Indwelling caths are at least double lumen - One lumen for the ballon, one for urine - Some are triple lumen to allow for irrigation Normal size for adults is 14-16 FR Suprapubic Catheter - Used for Long-tem continuous drainage Inserted surgically - Incision above pubis Diverts urine from urethra when injury, stricture, prostrte obstruction Associated with decreased risk of UTI Hazards fo Catheterization - - Urosepsis - UTI moves into blood stream - Can be life threatening Trauma Insertion of Catheter - Most common position is Dorsal recumbent - Sims is sometimes used in female clients Surgical sepsis needs to be observed Insert Indwelling catheters in male patients all the way to the bifucation (Yport) to avoid inflating ballon in the urethra. Insert tip lubricant syringe into meatus and gently release the lubricant intor urethra Secure the catheter to the thigh or abdomen to prevent excessive force on urethra. Drainage system - Keep client off of tubing Keep tubing patent and unkinked - Keep catheter drainage bag below the level of the bladder at all times Keep drainage bag of the floor Check for leakage. Care for indwelling catheter - - Wash hands before and after caring for catheter Clean perineal area in around meatus after each bowel movement - Use mild soap and water - Rinse well Clean catheter tubing/system Record volume/character of urine every shift Teach personal hygiene Only change catheter when needed. Removing Indwelling catheter - Wash hands, don gloves Deflate ballon, aspirate all the liquid used to insert ballon Have client take several deep breaths while gently removing the catheter Clean perineal area after removal Encourage fluid intake after in client able Educate that voluntary control may take a little bit of time to reestablish May have some burning with first couple urinations Observe and record any abnormalities Continuous Bladder Irrigation - Ordered when a blood clot threatens to block the catheter Closed-system recommended to prevent the introduction of pathogens Look and review terms Dialysis - - Remove waste from blood of client’s who suffer severe renal impairment (failure) Hemodialysis - Machine does the work of the kidneys - Filters blood of harmful wastes - Vascular access needed - Vascular access (Arteriovenous fistula-surgically created connection between an artery and a vein) AV fistula Peritoneal Dialysis - Blood vessels of the pritoneum serve as kidneys to remove waste - Dialysate washes in and out of the peritoneal space What is a normal amount to urinate? The normal range for 24-hour urine volume is 800 to 2,000 milliliters per day (with a normal fluid intake of about 2 liters per day) - 0.8-2 L Chapter 38 Bowel Elimination Chapter 40 Fluid electrolyte and acid base balance https://quizlet.com/301045194/fundamentals-chapter-42-fluid-electrolyte-and-acid-basebalance-flash-cards/ - Quizlet questions Chapter 44 Sensory Functioning Sensory reception is the process of receiving data about the external or internal environment through the 6 senses; -Visual (sight) -Auditory (hearing) -Olfactory (smell) -Gustatory (taste) -Tactile (touch) -Sterognosis (size and shape of object) Kinesthesia- awareness of positioning of body parts and body movement; To receive data about the world, 4 conditions must be met; -A stimulus- an agent, act, or other influence capable of initiating a response by the nervous system—must be present. - A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. -The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. -A particular area in the brain must receive and translate the impulse into a sensation. An impaired ability to communicate with others or maintain good balance can lead many people to: -Feel socially isolated, have unmet health needs,have limited success in school or on the job. -An impaired sense of smell or taste can lead to poor nutrition or the inability to detect smoke, gas leaks, or foods that are unsafe to eat. Arousal Mechanism To receive stimuli and respond appropriately, the brain must be alert or aroused. The reticular activating system (RAS), a poorly defined network that extends from the hypothalamus to the medulla, mediates arousal/sensoristasis. -Renin-angiotensin system (RAS) is one of the major control systems for blood pressure and fluid balance. Sensory Adaptation- Body’s ability to quickly adapt to constant stimuli. States of Arousal/Awareness; Conscious States; Delirium: Disorientation, restlessness, confusion, hallucinations, agitation, alternating with other conscious states Dementia: Difficulties with spatial orientation, memory, language; changes in personality Confusion: Reduced awareness, easily distracted, easily startled by sensory stimuli, alternates between drowsiness and excitability; resembles minor form of delirium state Normal consciousness: Aware of self and external environment, well oriented, responsive Somnolence: Extreme drowsiness, but will respond normally to stimuli Minimally conscious states: Part consciousness; sleep–wake cycles present; some motor function, including automatic movements; inconsistently follows commands Locked-in syndrome: Full consciousness; sleep–wake cycles present; quadriplegic, auditory and visual function preserved; emotion preserved Unconscious States Asleep: Can be aroused by normal stimuli (light touch, sound) Stupor: Can be aroused by extreme and/or repeated stimuli Coma: Cannot be aroused and does not respond to stimuli Vegetative state: Cannot be aroused. Sleep–wake cycles, postures or withdraws to noxious stimuli, occasional nonpurposeful movement, random smiling or grimacing. Sensory deprivation VS Sensory overload Sensory deprivation occurs when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. ○ RAS is no longer able to project a normal level of activation to the brain. Risk for sensory deprivation; -Patients in the environment with a decreases stimuli (private bed-rest, home isolation) -Patients with impaired vision, hearing loss -Patients with spinal cord injuries or brain damage Nursing Interventions; Teach patient about self-stimulating methods; signing, reading; a pet may provide great stimuli Visual; colorful sheets, pijamas,face-face human contact, flowers, clocks, calendars, family pictures Auditory; calling someone by name, reading to the patient, radio, TV Gustatory; seasoning the food Tactile; Back rubs, foot soak, hugs, touching arms/shoulders ● Sensory Overload ○ Sensory overload is excessive stimuli over which a person feels little control; the brain is unable to meaningfully respond to or ignore stimuli. Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload. Contributing factors; Pain, discomfort, IV lines, light, noises, sounds, odors, treatment equipment (mammogram), caffeine Nursing Interventions; Offer a simple explanation of the procedures Speak calmly, move slowly, communicate confidence Offer earplugs, pain medications Sensory perception ● Sensory perception involves detecting, recognizing, characterizing and responding to stimuli. ○ There are 5 different kinds of stimulus; - mechanical, chemical, electrical, light and temperature Reasons to be at risk for sensory disturbances; Aging, neuropathies (loss of sensation), drugs, exposure to chemicals, flying objects, loud sounds, bed-rest, isolation. Factors affecting sensory stimulation; -Developmental Consideration, Culture, Personality & Lifestyle, Stress and Illness, Medication ● Developmental (newborns); ○ Different types of sensory stimulation are needed for growth as sensory receptors, organs, and the nervous system mature. Appropriate stimulation includes; soothing, holding, rocking, and changes of position (tactile and kinesthetic sensations), singing and being talked to (auditory sensations), and changing patterns of light and shade, such as through the use of mobiles and bright objects (visual sensations) -Medically fragile infants are recommended to have limited light and visual and vestibular stimulation to simulate being in the womb. ● Cultural; ○ certain cultures view touching as a natural and welcome custom, whereas other cultures may view it as insulting or offensive. Sensory Changes Related to Aging; Vision changes; Presbyopia; A loss of elasticity in the lens of eye Macular Degeneration; Most common cause of blindness in older adults Cataract; Progressive loss of vision Glaucoma; Serious eye disease Nursing Interventions; Provide adequate lighting and clear pathways/declutter, ensure contact lenses/glasses, encourage ophthalmologist visits Teach patients; 1. Know that regular exercise maintains blood flow to the eyes. 2. Plentiful sleep keeps eyes lubricated and helps remove irritants. 3. Do not rub the eyes. 4. Avoid eyestrain, e.g., reading in poor light or viewing television or smart devices when tired. 5. Avoid damage from ultraviolet rays. 6. Protect eyes from foreign bodies. Hearing changes; Presbycusis; Loss of high frequency tones. Background noise aggravates it. Tinnitus; Ringing in the ears Meniere's disease; hearing loss, dizzines, tinnutis Nursing Interventions; (1) Orient the person to the nurse's presence before initiating conversation. This may be done by moving so the nurse can be seen or by gently touching the person; (2) Decrease background noises (television, radio) if possible before speaking; (3) Make sure that hearing aids (if applicable) are working optimally; (4) Nurse should position herself so that the light is on her face and the person can see the nurse's lips and expressions; (5) Talk directly to the person while facing him, or angle the chair so that the nurse's voice reaches the ear that hears best. If the person is able to lip-read, use simple sentences and speak in a quiet, natural manner and pace; (6) Be aware of nonverbal communication; (7) Do not chew gum, cover mouth, or turn away when talking with the person; (8) Determine ideas to be expressed, as appropriate (9) Avoid verbal conversation, because it will heighten the client's feeling of isolation. Changes in smell and taste; Burning mouth syndrome; tongue is burning or tingling Control.factors; Vitamin B deficiency, GERD, allergies, diabetes Peripheral Sensations Altercations; Peripheral Neuropathy; Nerve pain/ nerve damage -circulatory problems, vitamin deficiency (B6. B12. Folate) Phantom Limb Pain; pain where the amputated limb was The North American Nursing Diagnosis Association International (NANDA-I, 2018) recognizes the following diagnostic labels for sensory/perceptual problems: Acute Confusion; alteration of consciousness with reduced ability to focus, sustain, or shift attention. Risk for Acute Confusion; underlying brain disease such as dementia, stroke, or Parkinson's disease Chronic Confusion; An irreversible, long-standing, or progressive deterioration of intellect and personality Impaired Memory; state in which an individual experiences the inability to remember or recall bits of information or behavioral skills PROMOTING HEALTH LITERACY ; Risk factors for inadequate health literacy include; advanced age, low educational level, poverty, inability to read, learning disabilities, and lack of English proficiency. Patients may also be at risk for inadequate health literacy because of hearing or visual impairments or confusion and inability to process or remember what is heard. Please see in the BOOK, Chapter 44; - Focused Assessment Guide 44-1 (PAGE 1730) -Examples of Nursing Diagnosis ( PAGE 1733) -Teaching Tips 44-1 Sensory Function (PAGE 1736) *PrepU extra informations; *The nursing diagnosis is not a "risk for" diagnosis, it must have a "related to" and "as evidenced by" statement. *When the RAS is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action. *Sensory overload? Focus on client safety first. *How should the nurse best respond to this client's disorientation? Reorient the client to place and time. *Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation. *Question to assess sensory stimulation? Do you feel bored? *Impaired memory; state in which an individual experiences the inability to remember or recall bits of information or behavioral skills *Proprioception (or kinesthesia) is the sense though which we perceive the position and movement of our body, including our sense of equilibrium and balance, senses that depend on the notion of force *Adaptation: The body quickly adapts to constant stimuli. The repeated stimulus of a continuing noise, such as a low-level cardiac alarm, eventually goes unnoticed. *A client who hallucinates simply to maintain an optimal level of arousal is experiencing; Sensory Deprivation *Somnolence: Extreme drowsiness, but will respond normally to stimulus *Dementia; (Using lots of detail with demented patients may cause additional confusion and hinder communication) *Sensory alteration; a change in the pattern of sensory stimuli followed by an abnormal response to such stimuli *-Medically fragile infants are recommended to have limited light and visual and vestibular stimulation to simulate being in the womb *Be aware of a patient’s need for sensory aids and prostheses, such as eyeglasses, contact lenses, hearing aids, dentures, canes, and artificial limbs, ensuring that they are available as needed. *COMMUNICATING WITH A PATIENT WHO IS UNCONSCIOUS; Be careful of what you say in the person’s presence. Hearing is believed to be the last sense lost… Assume the person can hear you. Speak to the person befpre touching them. Keep noise as low as possible.
