NURSE-UN 240 A_E I Study guides Week 1 – Older Adult/Critical Thinking and Nursing Practice,100% CORRECT

NURSE-UN 240 A_E I Study guides Week 1 – Older Adult/Critical Thinking and Nursing Practice Lecture Outcomes: 1. Discuss demographic and health-related data pertaining to older adults 2. Discuss common physiologic changes related to aging and its implications 3. Describe and discuss common health care issues among community dwelling and hospitalized older adults 4. Describe the concept of frailty and its implications in the care of older adults 5. Describe the importance of critical thinking and its relationship it the nursing process Lecture: ● Older adults = 65+ ● Very few older adults live in nursing homes (3.5%) ● Why aging matters o World’s population is getting older o Increasing life expectancy o Chronic diseases have replaced infectious diseases as major causes of death ● More older adult patients and more comorbid conditions as they age so there is a need for more caregivers → we will need more resources and better quality care ● Common issues among community-dwelling older adults: o Decreased nutrition and hydration o Decreased mobility o Stress and loss o Accidents- falls, driving o Drug use and misuse o Mental health/cognition problems (including substance abuse) o Dementia o Delirium o Alcohol use and abuse ● Common issues among hospitalized older adults: o Sleep disorders o Nutrition o Continence o Acute and chronic confusion o Falls o Skin breakdowns ● Ageism – discriminating against older adults o Don’t stereotype o Avoid “elder speak” o Optimize opportunities to engage older adults to participate in their care and health care decision-making including those who have impaired cognition ● Select physiologic changes in aging to pay attention to: o Neurologic/sensory ▪ Loss of axons and neurons (reflex slower) ▪ Slowing of coordinated movements ▪ Decreased sensations (vibrations and proprioception – sense of body position) → implications for safety o Vision ▪ Decreased ability to focus and deal with glare and nighttime vision ▪ Can be an issue of safety when navigating o Hearing ▪ High frequency hearing loss (presbycusis) – may need to communicate in a very clear manner ▪ Thickening of tympanic membrane ▪ Sclerosis of inner ear ▪ Build up of earwax o Taste ▪ Diminished o Integumentary system ▪ More prone to injury, don’t heal as quickly ▪ Loss of collagen fibers and decrease in glandular functions ▪ Decreased moisture and thinning of the dermis ▪ Increased in skin lesions and ‘age spots’ o Thorax and Lungs ▪ Decrease in respiratory muscle strength ▪ Anteroposterior diameter increases ▪ Increase incidence of kyphosis (hunchback – limits thoracic space so lungs can’t expand fully) ▪ Drier mucous membranes – patient could have injury in mucous membrane; if giving oxygen, oxygen can be drying o Heart and Cardiovascular System ▪ Decreased cardiac contractile strength ▪ Baroreceptor sensitivity decreases (responds to changes in pressure) ▪ Decreased arterial compliance – can become hypertensive ▪ Can develop lightheadedness o Gastrointestinal System and Abdomen ▪ Increased amount of fatty tissues in the trunk ▪ Slowing of peristalsis ▪ Altered gastric and intestinal secretions ▪ Decreased liver functions → risk for liver disorders and difficulty metabolizing medications o Urinary System ▪ Decrease in the number of nephrons ▪ Hypertrophy of the prostate ▪ Increased incidence of stress incontinence in older women (dehydration, sleep disruption) o Musculoskeletal System ▪ Muscle mass is lost, declines rapidly if not used ▪ Increased incidence of bone tissues related to aging and osteoporosis ● Most frequently diagnosed conditions: arthritis, hypertension, heart disease, cancer ● Chronic diseases: o Reduce quality of life o Limit activity o Require assistance o Increase healthcare costs o Increase hospitalizations o Impact emotional health ● Common health issues among community-dwelling older adults o Poor nutrition o Impaired mobility – makes it difficult to eat o Stress and loss – precursor to dementia o The 3 D’s – depression, dementia, delirium o THESE ARE ALL RELATED ● Multiple comorbid conditions can lead to polypharmacy (the use of many medications) in older adults – are all of these medications appropriate for this patient? Are all of them necessary? ● Hospitalization with older adults is associated with: o Increased use of medications (polypharmacy) ▪ Adverse drug events o Iatrogenesis (complications that arise from invasive procedures) ▪ Invasive procedures (catheters) ▪ Increased length of stay ▪ Nosocomial infections o Psychological decompensation (20% of hospitalized older adults develop delirium) o Poor outcomes – functional decline, fall-related injury, nutritional and skin problems ● Fulmer’s SPICES o Sleep disorders o Problems with eating or feeding o Incontinence o Confusion o Evidence of falls o Skin breakdown ● Katz index of independence in activities of daily living (ADL) o Assesses older adult’s performance in the following six functions: ▪ Bathing ▪ Dressing ▪ Toileting ▪ Transferring ▪ Continence ▪ Feeding ● Frailty syndrome – a geriatric syndrome with unintentional weight loss, weakness, exhaustion, slowed physical activity ● Nursing process: o Assessment o Nursing diagnosis o Planning o Implementation o Evaluation o The whole time thinking about knowledge, standards, attitudes, experiences ● Different types of implementation o Independent ▪ Nurse-initiated o Dependent ▪ Physician-initiated (giving medications) o Interdependent ▪ Collaborative (rehab, PT, OT) ● Outcomes are more measurable than goals Katz Index of Independence in Activities of Daily Living: ● For each of the six categories (bathing, dressing, toileting, transferring, continence, and feeding) get one point for being able to do it independently and 0 points for needing assistance in that activity ● Scoring - 6 = highest score = patient independent; 0 = lowest score = patient very dependent Fulmer’s SPICES: An Overall Assessment Tool for Older Adults ● Addresses prevalent problems experienced by Older Adults, these problems can lead to longer hospital stays, medical costs and death ● SPICES if an acronym for the common syndromes of the elderly requiring nursing intervention: o Sleep disorders o Problems with eating or feeding o Incontinence o Confusion o Evidence of falls o Skin breakdown Dementia vs. Delirium Week 2 – Safety and Fall Prevention & Mobility and Immobility Lecture: ● Quality of life concerns among older adults: o Falls o Mobility and immobility o Independence o Mortality and morbidity o Recovery from falls o Nursing home placement ● You can fall at any age and not every falls → NOT a normal part of aging ● Falls are the leading indicator of quality and safety in the hospital ● In the last decade, the mortality rate from falls increased maybe because the population of older people increased ● The leading cause of death from injury for adults older than 65 is falls ● Falls are considered a “geriatric syndrome” o Syndromes are a combination of signs and symptoms that trigger other problems like a cascade of events ● A fall is more than just a fall → there are events that predispose it, risk factors, and sequelae (what follows) ● Multiple risk factors for falls (multifactorial) o Intrinsic factors – what’s going on with the patient ▪ Older age, history of falls, depression, muscle weakness o Extrinsic factors/environmental ▪ Polypharmacy, loose carpets, canes/wheelchairs, inadequate lighting ● How do falls come to the attention of the healthcare team? o Medical history o Physical assessment o Mental status o Labs and diagnostic results o Home safety assessment – minimal clutter and adequate lighting ● Mental health status can add risk for falls (delirium – risk for falls increases suddenly) ● Dementia vs. Delirium (up above) ● Common causes of Delirium o Drugs o Elimination o Liver and other organs o Infection (UTI) o Respiratory infections (not enough O2) o Injury o Unfamiliar environment o Metabolic ● Diagnosis of delirium: the diagnosis requires the presence of features 1, 2 and either 3 or 4 o Acute onset and fluctuating course ▪ Is there evidence of an acute change in mental status from the patient’s baseline? o Inattention ▪ Does the patient have difficulty focusing attention or keeping track of what is being said? o Disorganized thinking ▪ Is the patient’s thinking and conversation disorganized or incoherent? o Altered level of consciousness ▪ Is the patient lethargic, hyperalert, or difficult to arouse? ● Screening for fall/injury risk → Hendrich II Fall Risk Model ● Some strategies to promote safety and prevent falls among older adults: o Encourage ambulation and walking plan o Institute general safety precautions according to facility protocol o Improve chair safety and comfort o Improve ability to get out of bed safely o Promote continence and comfort – hourly rounding reduces falls by 25-35% o Provide reminders o Multifactorial interventions o Make sure they have everything they need close to them so they don’t need to get out of bed ● Fall interventions: o Keep the bed in the lowest position o Bed alarms (increase surveillance) o Chair alarms ● Restraints can ONLY be used when ALL others alternatives fail, including: o Close monitoring o Changes in physical space o Evaluation of treatment or medication o Use of therapeutic communication/psychosocial interventions o Use of diversion ● We RARELY use restraints ● Restraints immobilize so they promote muscle breakdowns and do not prevent falls ● Type of physical restraints: o Mittens o Vest and waist restraints o Wrist and ankle restraints o Entrapment modes – associated with falls because patient is confused and immobile so tries to get out of bed ● When deciding whether to use restraints, MUST use the decision algorithm for restraint use – have to be very clear on why you’re using restraints, must exhaust all other options first ● In case restraints are used, you must: o Follow agency policies o Use appropriate-size restraint o Assess patient circulation and ROM o Document ● ADLs – activities of daily living – bathing, eating, toileting, walking, dressing ● IADLs – instrumental activities of daily living – banking, shopping ● Types of mobilization: o Turning o Bed to chair o Ambulation o Migration (sliding down bed, moving to the side) ● To support bed mobility perform ROM ● Mobilization of patients depends on: o Patient characteristics (mental status, age, physical strength) o Patient readiness o Progression toward goal o Activity tolerance o Strategies used o Assessment o Caregiver engagement, training, knowledge, skills Systemic Effects of Immobility Intervention Metabolic Negative nitrogen balance Altered GI function Fluid and electrolyte imbalance (sodium levels) Provide high-protein, high- caloric diet with vitamin B and C supplements Cardiovascular Orthostatic hypotension Thrombus formation Progress from bed to chair to ambulation, Sequential Compression Devices (SCDs) Thrombo-embolic device (TED) hose Leg exercises Anticoagulation therapy (Heparin) Urinary elimination Urinary stasis Renal calculi Adequate hydration Diet rich in fluids, fruit, vegetables, fiber Respiratory Atelectasis Hypostatic pneumonia Cough and deep breathe every 1 to 2 hours Chest physiotherapy Muscular changes Loss of endurance and muscle mass Decreased stability and balance Muscle atrophy Passive ROM vs. active ROM Isotonic vs. isometric exercises Skeletal effects Impaired calcium absorption Joint abnormalities Integumentary Pressure ulcer Ischemia Reposition every 1 to 2 hours Skin care ● Immobility leads to increased risk of falls (immobility→negative nitrogen balance→further loss of mass→increased weakness→immobility…) ● Sequential compression device (SCDs) o Preventing thrombosis – alters the pressure to the extremities o Replicates what happens when you get up and move ● Incentive spirometer o Exercises your lung o Exercise is breathing in, not out Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model: ● Used in an acute care setting to see risk of falls ● Takes certain risk factors and gives them a point system o Confusion/disorientation/impulsivity – 4 o Symptomatic depression – 2 o Altered elimination – 1 o Dizziness/vertigo – 1 o Gender (male) – 1 o Any administered epileptics – 2 o Any administered benzodiazepines – 1 o Get-Up-and-Go Test: “Rising from a chair” ▪ Ability to rise in single movement – no loss of balance with steps – 0 ▪ Pushes up, successful in one attempt – 1 ▪ Multiple attempts but successful – 3 ▪ Unable to risk without assistance during test – 4 ● Scoring – score of 5 or higher is HIGH RISK Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders ● Valid quality indicators of falls: o Ask your patient about recent falls o Ask about or examine presence of balance or gait disturbances o If a patient reported two or more falls in the past year, or a single fall with injury requiring treatment, then there should be documentation that a basic fall evaluation was performed o If a vulnerable elder reports or is found having new or worsening difficulty with ambulation, balance, or mobility, then document that a basic gait, mobility, and balance evaluation as performed within 6 months o If there is decreased balance or proprioception then an appropriate exercise program should be offered and an evaluation for an assistive device should be performed o If there are problems with gait or strength or endurance, an exercise program should be offered Safe Patient Handling and Movement Algorithms: ● First check if patient can assist ● Then check is patient is cooperative Are Nurses Recognizing Delirium?: ● Delirium has four components: o Disturbance of consciousness with reduced ability to focus, sustain, or shift attention o Change in cognition or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia o The disturbance develops over a short period of time and tends to fluctuate during the course of the day o Evidence that the disturbance is directly caused by the effects of a medical condition ● Unrecognized delirium in older adults results in complications during hospitalization, increased length of stay, nursing home placement, death ● Nurses need to assess patient thoroughly in order to be able to identify cognitive problems ● Nurses see the symptoms but sometimes don’t know its delirium ● It is hard to translate nurse recognition of delirium into practice ● For nurses to recognize delirium they need: o Time with the patients o Knowledge of the key features of delirium o An objective instrument to guide their assessment and documentation of delirium o Support of leadership within the organization ● Key points: o These studies suggest nurses are missing key symptoms of delirium and appear to be performing only superficial mental status assessments o Although related, the concepts of nurse knowledge of delirium, nurse recognition of delirium, and nurses’ assessment and documentation of delirium in older adults are all different o If nurses have not been explicitly taught the nuances of how delirium is manifested in older adults, they cannot be expected to readily recognize it at the bedside o For nurses to recognize delirium, they need time with patients, knowledge of the key features of delirium, an objective instrument to guide assessment and documentation, and the support of leadership within the organization Lecture on How to Use the Nursing Diagnosis Handbook: ● Step one: Assess o Assess and collect data ▪ Client’s signs and symptoms, objective and subjective data, clinical state, known medical or psychiatric diagnoses o Cluster or group data and identify priority problems/concerns/situations/conditions ● Step two: Formulate nursing diagnoses ● Step three: determining if the nursing diagnoses identified are appropriate ● Step four: determining outcomes o Have one long term and one short term o Outcomes must be: ▪ Specific ▪ Measurable ▪ Attainable ▪ Reasonable/realistic ▪ Timed (within a time frame) ● Step five: determining interventions ● Step six: evaluating nursing care o Determine if you have met your short or long terms outcomes o If your nursing interventions were not effective reassess the client Week 3 – Skin and Wound Care and Quality and Safe Care Lecture on Quality and Safe Nursing Care: ● IOM – Institute of Medicine – advisory to policy makers on healthcare policy and safety – said healthcare isn’t as safe as it could be ● About 48,000 to 98,000 people are killed by medical errors (more than motor vehicular accidents, breast cancer, and AIDS put together) ● IOM and safe and quality care is: o Safe – avoid injury and harm to patient o Timely – reducing waits o Effective – care based on evidence and educated providers o Efficient – avoiding waste ($) o Equitable – quality does not vary because of gender, ethnicity, socioeconomic status → available to everyone o Patient-centered – respectful and responsive care based on patient values ● Different types of errors that can occur in the healthcare system: o Latent failure ▪ Arising from decisions that affect organizational policies, procedures, and allocation of resources ▪ Involve decisions made by board or management that can have serious implications ▪ This is sometimes called the “blunt” end – they are invisible factors (we don’t see them) o Active failure ▪ Direct contact with the patient ▪ What we see and consider most of the time when we think of healthcare errors ▪ There are factors that affect how and why that person committed these errors ▪ Sometimes referred to as the “sharp” end o Organizational system failure ▪ Indirect failures related to management, organizational culture, protocols/processes, transfer of knowledge, and external forces o Technical failure ▪ Indirect failure of facilities or external resources ● Swiss Cheese Model o A theory that explains why healthcare errors occur o When the holes align (like holes in Swiss cheese) errors occur, so if you fix one hole it will help o This study looked at why interns in Australia are committing prescribing errors o Factors of Swiss cheese model: ▪ Latent factors ● Organizational processes – workload, handwritten prescriptions ● Management decisions – staffing levels, lack of support for interns ▪ Error-producing factors ● Environmental – busy ward, interruptions ● Team – lack of supervision ● Individual – limited knowledge ● Task – repetitious, poor medication chart design ● Patient – complex, communication difficulties ▪ Active failures ● Error – slip, lapse ● Violation ▪ Defenses ● Missing – no pharmacist ● No one double checked ● Josie video – she died because of an error, when family member say something LISTEN ● Common errors in healthcare: o Medication errors o Surgical errors – wrong site o Diagnostic/laboratory inaccuracies – wrong lab results o Equipment failure o Blood transfusion error – wrong blood type for patient o Systems failure ● The Joint Commission o Holds all healthcare places responsible for the National Patient Safety Goals (NPSG) to promote specific improvements in patient safety o They aim to protect errors from happening o They accredit certain healthcare organizations that their care is safe and efficient ● The 2015 NPSG includes: o Identify patients correctly ▪ Use two ways ▪ Make sure correct patients get correct blood during transfusion o Improve staff communication ▪ Get important test results to the right staff person on time o Use medicine safely ▪ Before a procedure label medicines in the area where medicines are set up ▪ Take extra care with patients who take blood thinners ▪ Record and pass along correct information about patient’s medications – make sure patient knows which medicines to take at home o Use alarms safely ▪ Make improvements to ensure that alarms on medical equipment are heard and responded to on time o Prevent infection ▪ Use hand cleaning guidelines from CDC and WHO ▪ Use proven guidelines to prevent these infections: ● That are difficult to treat ● Of the blood from central lines ● After surgery ● Of the urinary tract that are caused by catheters o Identify patient safety risks ▪ Find out which patients are most likely to try to commit suicide o Prevent mistakes in surgery ▪ Make sure correct surgery is done on correct patient in correct place ▪ Mark the correct place where surgery is to be done ▪ Pause before surgery to make sure mistakes aren’t being made ● How to improve patient safety? o Use-centered design ▪ Equipment needs to be user friendly o Avoid reliance on memory ▪ Make a checklist o Attend to work safety ▪ If you see its unsafe, report it o Avoid reliance on vigilance ▪ Prepare medication only when you’re ready to give it o Training concepts for teams o Involve patients in their care o Anticipate the unexpected ▪ Always need alternate plans; what is electronic healthcare system shuts off? o Improve access to accurate, timely information ● Quality and Safety Education in Nursing (QSEN) o Prepares nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously deliver quality and safe patient care o Addresses these six competencies: ▪ Patient-centered care ▪ Evidence-based practice ▪ Quality improvement ▪ Informatics ▪ Safety ▪ Teamwork and collaboration o All of these competencies are related and are very important ● An error is usually not just one person, it is the system ● Majority or errors are system failures, not human failures ● We are human, errors will occur Article “To Err is Human”: ● IOM ● Types of errors: o Diagnostic – error or delay in diagnosis; failure to employ indicated tests; use of outdated tests or therapy o Treatment – error in operation, procedure, test; error in administering treatment; error in dose or method of drug o Preventative – failure to provide prophylactic treatment; inadequate monitoring or follow-up treatment o Other – failure of communication, equipment failure, other system failure ● Mistakes can be prevented by designing the health system at all levels to make it safer and to make it harder for people to do something wrong and easier for them to do it right ● Strategy for improvement: o Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety – congress should create a center for patient safety to set national safety goals and track progress o Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging healthcare organizations and practitioners to develop and participate in voluntary reporting systems o Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of healthcare o Implementing safety systems in health care organizations to ensure safe practices at the delivery level’ ● Many of these have already been implemented by Clinton – Agency for Healthcare Research and Quality (AHRQ) Lecture on Skin Integrity and Wound Care: ● Pressure ulcers may be associated with severe pain – premedicate the patient before treating ● Pressure ulcer used to be called bed sores, pressure wounds ● Pressure ulcer definition – a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear ● Pressure is THE major element in the cause of pressure ulcers and these factors matter: o Pressure intensity o Pressure duration o Tissue tolerance – elasticity, what the tissue can handle (depends on if patient is malnourished or old) ● Shear force – happens if patient is sitting in an upright position for a while and their body begins to slide down but some patients need to sit upright such as those with a compromised respiratory system ● Wrinkles you get fro sleeping are the start of a small pressure ulcer ● Risk factors contributing to skin breakdown: o Impaired sensory perception o Impaired mobility o Alteration in level of consciousness o Shear and friction o Moisture/maceration (skin is wet because it was exposed to fluid – urine, feces, food → increases skin breakdown) o Decreased general health o History of healed ulcers o Uses of braces, collars, oxygen tubes, or other pressure-forming devices o Falling asleep sitting up o Food under the patient ● Vulnerable areas for pressure ulcers – BONY PROMINENCES o Back o Sacrum o Elbows o Knees o Nose o Heels o Ankles ● You MUST turn the patient to check for pressure ulcers everywhere ● Ear doesn’t have a bone so it can never be stage 4 ● Stage One vs. red skin – stage one isn’t blanchable ● Stages of pressure ulcers: o Stage one – redness and doesn’t blanch o Stage two – skin is broken o Stage three – full thickness, into fat layer o Stage four – see muscle and bone o Unstageable – covered in slough o Suspected deep tissue injury – purplish bruising ● If you see a stage one developing you can put some protective barriers but don’t use a barrier cream on skin that is already broken ● Incontinence associated dermatitis vs. pressure ulcer o Incontinence associated dermatitis (IAD) ▪ Kind of like a diaper rash ▪ Get it from being in a pool of urine – exposure to urine or stool ▪ Diffuse, in skin folds ▪ Not necrotic ▪ Pain and itch ▪ Between the thighs o Pressure ulcer ▪ Over bony prominence ▪ Partial thickness to full thickness loss ▪ Necrosis may be present ▪ Pain and itching may be present ● Stages 3 and 4 can take 6 months to 2 years to heal ● Pressure ulcer terminology: o Granulation tissue ▪ Wound is trying to get better – this is an intermediate step in healing process of full thickness wounds ▪ Want this for healing but it is also fragile and prone to easy injury ▪ Want it to be beefy and red (when there is inadequate blood flow, may be pale in color) ▪ Composed of extracellular matrix of fibrin, fibronectin, proliferating endothelial cells, new capillaries, mixed with macrophages and lymphocytes ▪ The process of granulation provides the early scaffolding necessary to promote healing from the edges of the wound ▪ Granulation tissue doesn’t mature into epithelium, it is eventually covered by a layer of epidermal tissue o Slough ▪ A stringy mass that may or may not be firmly attached to surrounding tissue ▪ If it is covering the wound, may have to say unstageable but generally a stage 3 or 4 ▪ Need to remove slough because granulation tissue cant grow over it ▪ Can remove either enzymatically or surgically ▪ Can turn into eschar ▪ Can range in color from: ● White – scant bacterial colonization ● Yellow/green – larger bacterial counts ● Brown – hemoglobin is present ▪ May become thicker and harder to debride the longer its present ▪ Can be smelly o Eschar ▪ Never debride, might get better and might not ▪ Scab or dry crust o Exudates ▪ Amount, color, consistency and odor of wound ▪ Serous ● Clear, watery plasma ▪ Purulent ● Thick, yellow, green, tan, or brown ● Can smell a lot ▪ Sero-sanguienous ● Pale, red, watery ▪ Sanguineous ● Bright red ● Measuring pressure ulcers in centimeters: o Length – longest or 12 o’clock o Width - widest or 3 o’clock o Depth – use a cotton tipped applicatory o Undermining o Tunneling ● When documenting pressure ulcer be sure to include: o Accurate pressure ulcer stage classification o Location or pressure ulcer o Size of pressure ulcer (L x W x D) o Tunneling/undermining o Exudates – color, odor, consistency o Pain/tenderness ● Are pressure ulcers avoidable or unavoidable? o Avoidable but sometimes cant help it o Unavoidable in patients who are hemodynamically unstable, terminally ill, have certain medical devices in place, nonadherent with artificial nutrition or repositioning ● Assessment of wound: o Include a comprehensive assessment such as: ▪ Nutritional status – how much patient ate/drank – I&O ▪ Pain ▪ Presence of co-morbidities ▪ Psychological health ▪ Use of pressure relieving devices ▪ Patient and family knowledge ▪ Duration of treatment o Use reliable and valid instruments such as Braden Scale ▪ Bad = 9 ▪ Best = 23 o Reassess each shift and each dressing change ● Management of wound: o Use of support surfaces that provide better pressure redistribution, shear reduction, and micro climate control o Positioning: ▪ Turn and position regardless of support response ▪ Do not use ring or donut shaped devices ▪ When in a chair, use pressure distribution cushion ▪ Turn and position every 2 hours – make a turning schedule o Some beds can even turn you o Silly putty pillows ● Pressure ulcer wound care: o Use non-toxic cleansers such as normal saline or sterile water for clean ulcers and those with anti-microbials for pressure ulcers that have debris, infected or suspected high levels of bacterial colonization o Debridement: ▪ For wounds that seem stable: ● Mechanical such as Wet-to-Dry Dressing ● Enzymatic ▪ For those with cellulitis (tissue infection, don’t mess around because things will get worse) or signs of deterioration: ● Sharp/surgical ● Do not debride stable and dry eschar in ischemic limbs such as the heal o Might not want to cover DTI because it develops real quick o Use of dressings: ▪ Type of dressing/wound care is based on stage of the ulcer, objective of the dressing, and kind of exudate ▪ There are more than 200 available types of dressings ▪ Types of wound dressings: ● Hydrocolloids o For clean stage II or shallow stage III ● Transparent film dressing o Could be used for autolytic debridement ● Hydrogel o For shallow minimally exudating pressure ulcer that are not infected and are granulating ● Alginate dressing o For moderate to heavily exudating ulcers ● Silver-impregrated dressings (Silver Sulfadiazine) o For infected wound ● Honey-impregrated dressing o Use of medical grade honey for stage II and III ● Gauze dressing o Do not use for clean granulating wounds o Other wound care management motalities: ▪ Negative Pressure Wound Therapy (use of wound vac machine) ● Assists in wound closure ● Draws the edges of the wound together ● Evacuates exudates ● Maintain moist environment ● Addressing nutrition: o Assess nutritional status within 24 hours of admission: ▪ Serum Albumin an Pre-albumin level ▪ Assess for significant weight loss o Need for high-protein and vitamin-rich diet ▪ Consult a dietician, speech therapist, and occupational therapist as needed ▪ Monitor intake and output (I&O) every shift ● A nurse who focuses on wounds – wound and ostomy nurse ● Article on VAC therapy o VAC therapy unit – provides intermittent and continuous therapy with integrated patient safety features o SensaT.R.A.C. Technology – regulates the pressure at the wound site to provide accurate delivery of prescribed therapy settings o V.A.C. GranuFoam dressings – help provide the necessary mechanisms to promote granulation tissue formation o Under negative pressure, VAC therapy and proprietary VAC granufoam dressings applies mechanical forces to the wound to create and environment that promotes wound healing ▪ Macrostrain – visible stretch that occurs when negative pressure contracts the form ● Draws wound edges together ● Provides direct and complete wound bed contact ● Evenly distributes negative pressure ● Removes exudate and infectious materials ▪ Microstrain – the micro deformation at the cellular level which leads to cell stretch ● Reduces edema ● Promotes perfusion ● Promotes granulation tissue formation by facilitating cell migration and proliferation o Using VAC therapy with VAC GranuFoam Dressing results in both macrostrain and microstrain for advanced wound healing o What is SensaT.R.A.C technology? ▪ Monitors and maintains target pressure at the wound site for consistent therapy delivery ▪ Helps reduce tubing blocks and false alarms through enhanced fluid dynamics ▪ Provides alarms for enhanced patient safety Wound Healing Barrier V.A.C Therapy Mechanism Excess bacterial burden Removes infectious materials Inadequate protection against infection Provides protected wound healing environment Excess exudate Removes exudate Excess edema Reduces edema Absence of moisture Provides a moist wound healing environment Lack of adequate blood flow Promotes perfusion Lack of granulation tissue formation Removes barriers to cell migration and proliferation ▪ Enhances patient comfort Braden Scale for Predicting Pressure Sore Risk: ● Assess level of risk for development of pressure ulcer ● Based on six indicators: o Sensory perception – ability to respond to pressure-related discomfort o Moisture – degree to which skin is exposed to moisture o Activity – degree of physical activity o Mobility – ability to change and control body position o Nutrition – usual food intake pattern o Friction or shear ● Scores range from 6 to 23, lower score indicates higher level of risk, score of 19 or above is no risk – get more points for being healthy Week 4 – Introduction to Pharmacology and Safe Medication Administration Lecture: ● To safely and accurately administer medications you need knowledge related to: o Pharmacology o Pharmacokinetics – movement of drugs throughout the body o Life science o Human anatomy o Mathematics ● Federal regulation of drugs – FDA o Labels drugs and can pull drugs off the market ● Who can prescribe medications? o Advanced practice registered nurses o But it is different in every state ● Guidelines for safe narcotic administration: o Store all narcotics in locked secure cabinets (like an omnicell) o Count narcotics with every opening of the narcotic drawers or at change of shift o Document use of narcotics and follow facility protocol to dispose of unused narcotics ● Basic pharmacological concepts: o Drug names: ▪ Brand name: Tylenol ▪ Generic name: acetaminophen (always lowercase) ▪ Chemical name o Classification ▪ Effect of the drug on a body system, symptoms the medication relives, or the medication’s desired action ▪ Example: analgesic – relieves pain o Medication forms: ▪ Solid ● Capsule, tablet ▪ Liquid ● Elixir, suspension ▪ Topical ● Ointment, transdermal patch ▪ Parenteral ● Injectable (solution, powder) ▪ Suppository ▪ Intravenous ● Intravenous Tylenol = omniferv ● Pharmacokinetics describe how medications move through the body and go by the acronym ADME o Absorption ▪ The passage of medication molecules into the blood from the site of administration ▪ Can be absorbed through skin, mucous membrane, stomach, duodenum, bucally (side of cheek) ▪ Factors that influence absorption: ● Route of administration ● Ability to dissolve ● Blood flow to site of administration ● Lipid solubility of medication because cell membranes have a lipid layer, it is easier to absorb o Distribution ▪ After absorption, distribution occurs within the body to tissues, organs, and to specific sites of action ▪ Depends on: ● Circulation ● Membrane permeability ● Protein binding o Inactive are drugs bound to protein ▪ Two protein bound drugs sitting in system, good chance it’ll be toxic o Active are not bound to protein o Metabolized ▪ Medications are metabolized into a less potent or an inactive form ▪ Biotransformation occurs under the influence of enzymes that detoxify, degrade, and remove active chemicals ▪ Biotransformation occurs in the liver – enzymes to break down the medications are stored in the liver too ▪ Some medications immediately get excreted through the feces but some go to the liver and are metabolized ▪ Bioavailability is the % of what’s left after it is metabolized and detoxified ▪ Some medications immediately get excreted through feces and the rest go through the liver and go through biotransformation where it detoxifies any chemicals that are added into the medication o Excreted ▪ Medications are excreted through: ● Kidney (primarily) o Good indication of good kidney functioning is creatinine excretion o Drugs that are protein bound cannot be excreted through the kidney so it increases the risk of toxicity ● Liver ● Bowel ● Lungs ● Exocrine glands o Sweat glands o Salivary glands o Mammary glands (breast milk) ● Effects of aging on medication metabolism – everything slows down o Drug-receptor interaction: ▪ Brain receptors become more sensitive making psychoactive drugs very potent o Circulation ▪ Vascular nerve control is less stable ● Antihypertensives may overshoot and drop blood pressure too low ● Digoxin may slow heart rate too much o Absorption ▪ Gastric emptying rate and gastrointestinal motility slow ▪ Absorption capacity of cells and active transport mechanism decline ▪ Peristalsis slows o Distribution ▪ Lean body mass falls ▪ Adipose stores increase ▪ Total body water declines, raising the concentration of water-soluble drugs, such as digoxin, which can cause heart dysfunction ▪ Plasma protein diminishes, reducing sites available for protein-bound drugs and raising blood levels of free drug o Metabolism ▪ Liver mass shrinks ▪ Hepatic blood flow and enzyme activity declines ▪ Metabolism drops to ½ to 2/3 the rate of young adults ▪ Enzymes lose ability to process some drugs, prolonging drug half-life o Excretion ▪ In kidneys, renal blood flow, glomerular filtration rate, renal tubular secretion and reabsorption, and number of functional nephrons decline ▪ Blood flow and waste removal slow ▪ Age-related changes lengthen half-life for renally excreted drugs ▪ Antidiuretic drugs, among others, stay in the body longer ● Biotransformation = degradation of medication, it detoxifies ● Process of pharmacokinetics example – pathway of a tablet: o Drug is swallowed – lost in feces, not dissolved o Drug dissolved in GI fluid – lost in acid o Dissolved drug reaches intestine – lost in food, acid, digestion o Drug absorbed portal system o Drug in liver – biotransformed to noneffective state, bound to plasma proteins o Drug in circulation – broken down in tissues, bound to plasma proteins o Drug distributed throughout body – reaches reactive tissues, excreted by kidneys and lungs and skin etc., bound to fat tissues o Drug does its thing ● Actions of medicine: o Therapeutic effect: ▪ Expected or predictable: ● If it doesn’t what it is supposed to do, evaluating the effects of its intended purpose, also when does the medication peak and how long does it work for without intolerable side effects ▪ Side effect: ● Unintended, secondary effect ● Side effect is expected o Adverse effect: ▪ Severe response to medications: ● Unexpected or unintended and can cause injury ● Doesn’t occur right away, can be hours days or months after especially for chemotherapeutic medications ▪ Allergic reaction: ● Unpredictable (or patient forgot they had an allergy) response to medication ● Can sometimes be prevented but sometimes cant ● Anaphylaxis o Idiosyncratic reaction: ▪ Over- or under-reaction to a medication: ● Example – Benadryl can cause agitation in children which is the opposite of normal ▪ Toxic effect ● Medication accumulates in the blood stream ● Can draw a drug level for some medication like vancomyocin or cumadin ● Medication dose responses: o Onset ▪ Time it takes for medication to produce a response (to have an effect) ● Acetaminophen PO – an hour ● Omniferv (IV) – ½ an hour o Trough ▪ Minimum blood serum concentration before next scheduled dose ▪ Want to draw blood again before you administer so that you can get the minimum drug level o Duration ▪ Time medication takes to produce greatest result o Serum half-life ▪ Time for serum medication concentration to be halved ● To know how much drug is still in the blood ● Relates to a frequency of medication o Peak ▪ Time at which a medication reaches its highest effective concentration o Plateau ▪ Blood serum concentration is reached and maintained after repeated fixed doses ● Therapeutic range: o Narrow range between minimum effective concentration and toxic concentration o Drug reaches top efficacy at therapeutic range ● What constitutes a complete medication order? o Route of administration o Dose o How often ● Routes of administration: o Oral ▪ Sublingual, buccal o Parenteral (needles) ▪ Intradermal ▪ Subcutaneous ▪ Intramuscular (flu shot) ▪ Intravenous ▪ Epidural ▪ Intrathecal ▪ Intraosseous ▪ Intraperitoneal ▪ Intrapleural ▪ Intraarterial o Inhalation ▪ Nebulizer ▪ Albuterol o Topical ▪ Cream, shampoos, patch, gel ▪ Corticosteroids o Intraocular ▪ Eye drops o Vaginal o Rectal ● Types of medication orders: o Standing or routine: ▪ Administered until the dosage is changed or another medication is prescribed ▪ Example – daily o Single one-time: ▪ Given one time only for a specific reason ▪ Example – give glucagon to raise blood sugar o PRN (Pro Re Nata): ▪ Given when the client requires it ▪ Example – pain level of 5-10, give Percocet o STAT: ▪ Given immediately in an emergency ● Prescriber’s role: o Must document the diagnosis, condition, or need for each medication o Can be physician, NP, or PA o Orders can be written, verbal, or by telephone o Verbal orders: ▪ Only in urgent situations when a written order isn’t feasible ▪ There needs to be clear institutional policies and guidelines regarding verbal or telephone orders ● COW – computer on wheels ● WOW – work station on wheels ● Article from Theresa Brown: o Katherine Hyatt gave a medication called calcium chloride to an 8-year-old patient and calculated the dose wrong and the patient died five days later, nurse ended up committing suicide ● What is a medication error? o Wrong medication o Wrong dosage o Wrong route o Wrong time o Wrong patient o Wrong rate o Wrong preparation of a medication ● Errors of omission o Drugs not prescribed, dispensed, administered, or taken ● Errors of commission o Communication failure o Incomplete prescribing order o Failure to follow policies o Overuse of a drug without therapeutic benefit o Incorrect drug administration o Drug calculation error o Poor medication administration practices ● Preventing medication errors: o Right drug ▪ Know trade and generic name ▪ Don’t administer drug if you don’t know what its for ▪ Always check medication orders o Right dose ▪ Double check therapeutic ranges ▪ Do not substitute different form ▪ Double check calculation ▪ Use only accepted abbreviations o Right route ▪ Double check order o Right time ▪ Know facility’s policy ▪ Be timely o Right client ▪ Never assume patient identity ▪ Two forms of identification ▪ Never are you “Mr. John Doe” ▪ Be alert when there are two patients with the same name o Right documentation ▪ Document in a timely fashion ▪ Note responses especially PRN medications ▪ Note site of injection o Right to refuse ▪ Clients have right but need to clarify reason and notify prescriber ● If error has been committed: o Notify prescriber o Fill out incident report ● Medication errors occur due to: o Human factors o System factors (work overload) o Complex process if prescribing, dispensing, administration Chasing Zero: Winning the War on Healthcare Harm ● Dennis Quaid – his twins were almost killed by a medication error with Heparin ● He initiated a call to action for healthcare leaders to invest in patient safety ● Documentary that shows how caregivers can overcome such challengers ● Highlights medication errors When Nurses Make Mistakes by Theresa Brown ● Story of Kimberly Hyatt ● Nurses make mistakes – we are human Facts about the Official “Do Not Use” List by the Joint Commission ● U for unit (mistaken for 0 or 4) ● IU for international unit (mistaken for IV or number 10) ● Q.D., QD, q.d., qd (for daily) – write daily ● Trailing zero or lack of leading zeros ● MS, MSO4, MgSO4 ● Greater than or less than sign ● Abbreviations for drug names ● @ ● cc Medication Errors ● Medication errors have economic consequences and increase hospital stays ● These errors can occur at any point in the process: ordering, transcribing, dispensing, administering, or monitoring medications ● Some errors result from an unsafe act – an action that violates policy or procedure by may be done to save time ● Elderly o Patients taking multiple drugs, having depressive symptoms or poor health status, being female, or making several outpatients visits in the past year are at greater risk for medication errors o Patient does not understand and follow the prescribed regimen o Elderly are more sensitive to effects of medication, and adjustments in dose may be necessary o The true number of medication errors is difficult to assess because: ▪ Only a small percentage of medication errors and ADEs are detected and even less are reported ▪ There are inconsistencies in the way that errors are reported and counted ▪ Most studies have looked at medication errors only in an inpatient hospital setting o Many aren’t reported because of embarrassment or fear of punishment o Because of this nothing is learned from the errors and actions cannot be instituted to prevent similar mistakes o Majority of errors reflect systems failures, not individuals Week 5 – Oxygenation, Circulation, Tissue Perfusion Lecture: ● Oxygenation is a function of a well functioning respiratory and cardiovascular systems – these systems should not be separated – they are interrelated ● Need to have a well functioning respiratory system for your cardiovascular system to work ● Blood comes from systemic circulation and enters right side of heart and that deoxygenated blood goes through pulmonary respiratory system to be oxygenated and once that is completed it goes out again to left side of heart and delivered to systemic circulation ● OXYGENATION IS A COMBINATION OF RESPIRATORY AND CARDIOVASCULAR SYSTEMS ● Respiratory system: o Ventilation ▪ Process of moving gases in and out of the lungs, which is dependent on: ● Involves respiratory muscles which are responsible for maintain pressure with respiratory system and facilitates ventilation o Example – lung compliance elasticity – fully expand and collapse back to get rid of gas back out to environment o Work of breathing – inspiration and expiration need to be well coordinated and complimentary ● Involves lung volumes – variations in these lung volumes are very important diagnostic parameters for people with respiratory issues o Tidal volume – amount of air exhaled after normal inspiration o Residual volume – amount of air left in alveoli after full expiration o Forced vital capacity – max amount of air that can be removed from lungs during forced expiration ● Pulmonary circulation o Air exchange between alveoli and blood o Gas exchange between alveoli and blood is oxygen and carbon dioxide transport o REVIEW HOW AIR EXCHANGE HAPPENS – how carbon dioxide can be eliminated and oxygen can be absorbed ● Cardiovascular physiology: o Perfusion ▪ Ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs ▪ Process is influenced by: ● Well functioning cardiac chambers, how blood flows through myocardium ● Conduction system – how stimuli travels throughout heart ● Blood flow through muscles of heart ● Blood ejected from heart to be delivered into systemic circulation o Cardiac conduction system ▪ Disturbances in conduction ● Cardiac arrhythmias (dysrhythmias) – irregular heart beat or rhythm ● Stimulus for conduction of heart comes from SA node and then through intermodal pathways to AV node and from AV node to bundle branches and separates to left and right and then ends at the purkinje fibers which stimulate ventricles at the lower part of the heart ● Any problems with this system would impair rhythm of the heart and cause cardiac arrhythmias ● Could come from electrolyte imbalance or trauma from the heart ▪ Altered cardiac output ● Problem with ability of heart to eject blood to rest of the body or other chambers ● Heart failure – inability of heart to eject blood to systemic or other chambers ● Left sided heart failures – left side cant deliver blood to systemic circulation ● Right sided heart failure – problem delivering blood to pulmonary system ● Can be bi-ventricular – both side of the heart have issues with contraction ▪ Impaired valvular function ● Valves not competent – valvular stenosis – hardening of valve – valve cant fully open or close during contraction and can impair ability of blood to deliver blood to next chamber ▪ Myocardial ischemia ● Impaired blood flow to heart (but still flowing) ● Coronary arteries not well perfused – obstruction or narrowing of coronary arteries – decreased blood flow to specific part of heart ● Angina – chest pain ● Myocardial infarction – total blockage of blood to heart leading to death of specific part of heart (necrosis) ● Factors that affect oxygenation o Physiological factors ▪ Decreased oxygen carrying capacity ▪ Body isn’t able to carry oxygen fully – anemia ▪ Decreased inspired oxygen concentration ▪ Hypovolemia – dehydration, hemorrhage – your blood delivers oxygen to different parts of body so a decreased blood flow can lead to decreased oxygenation ▪ Increased metabolic rate o Conditions affecting chest wall movement and full lung expansion ▪ Pregnancy ▪ Obesity ▪ Musculoskeletal abnormalities – decreased space in thoracic cage (kyphosis) ▪ Trauma – gun shot wound can interfere with pressure in thoracic cavity ▪ CNS/Neuromuscular diseases – can interfere with how lungs expand or the major muscles that expand diaphragm, some issues can weaken diaphragm ● Altered respiratory functioning manifestations: o Hyperventilation ▪ Lungs remove carbon dioxide faster than its produce → acid base imbalance ▪ Severe anxiety, aspirin poisoning o Hypoventilation ▪ Alveolar ventilation is inadequate to meet oxygen demand of body or eliminate CO2, obtaining too much CO2 ▪ Atelectasis – collapse of alveoli – prevents normal exchange of CO2 and O2 – as more collapse it gets worse o Hypoxia ▪ Inadequate tissue oxygenation at cellular level ▪ Results from deficiency of oxygen delivery ▪ Decreased hemoglobin level, lower oxygen carrying level of blood, high altitude, inability of tissues to attract oxygen from blood, pneumonia, poor tissue perfusion (shock), impaired ventilation can cause hypoxia ▪ Early signs – a decrease in mental status or change in mental status; brain cells very sensitive to level of oxygen in body and will tell body that there is a problem ▪ Late signs – cyanosis – bluish tint – body has already reacted to hypoxia ▪ Want to intervene in early stage ● Assessment: o Nursing history focus: ▪ Explore factors or conditions associated with impaired oxygenation ▪ What can be causing the impaired oxygenation status? o Physical Assessment: ▪ Assess level of consciousness (fully alert? Lethargy? Confusion?), general appearance (pale (anemia)? Blue (cyanosis)?), breathing pattern (look at rate and depth, is it within 12 to 20 BPM? Labor exerted during breathing; SOB? Is patient comfortable?), etc. ▪ Auscultate for lung and heart sounds (normal vs. adventitious breath sounds) ▪ Assess capillary refill (should flow back in less than 3 seconds), edema (means some volume is staying in lower extremities), etc. ● Common ventilation and oxygenation diagnostic studies (836-837) o X-rays ▪ Chest x-ray – see what’s going on – outline of chest ● Could identify masses ● How big cavity in chest that houses heart is ● See outline of lungs o Common blood tests ▪ CBC/Hemogram ● Trying to figure out number and type of RBC and WBC ● Normal values for a complete blood count (CBC) vary with gender ● A CBC determines the number and type of RBC and WBC per cubic millimeter of blood ● CBC measures RBC cell count; volume of RBC and WBC, concentration of hemoglobin which reflects patients capacity to carry O2 ● Normal values: o Hemoglobin ▪ Males – 14-18 ▪ Females – 12-16 o Hematocrit ▪ Males – 42-52% ▪ Females – 37-47% o RBC count ▪ Males – 4.7 to 6.1 ▪ Female – 4.2 to 5.4 o WBC count ▪ 5,000-10,000 ▪ Cardiac enzymes – to rule out myocardial infarction ● Cardiac troponins o Most accurate and sensitive for patients who may be having myocardial infarction o Plasma cardiac Troponin I ▪ Value elevates as early as 3 hours after myocardial injury ▪ Value often remains elevated for 7-10 days o Plasma cardiac Troponin T ▪ Value often remains elevated for 10-14 days ● Creatine Kinase (CK) o A serial CK with 50% increase between 2 samples 3-6 hours apart, peaking 12-24 hours after chest pain or a single CK elevation twofold is diagnostic for an acute myocardial infarction o Male normal – 55-170 o Female normal – 30-135 ● Myoglobin o Early index of damage to myocardium in myocardial infarction or reinfarction o Increases within 3 hours ▪ Serum electrolytes ● Potassium (3.5-5) o Patients on diuretic therapy are at risk for hypokalemia because potassium is released o Patients receiving antihypertensive medications called Angiotensin-Converting Enzyme (ACE) inhibitors are at risk for hyperkalemia because potassium is retained in patients ▪ Cholesterol ● Normal values: o Fasting cholesterol less than 200 mg o LDL normal greater than 130 mg o VLDLs 7-32 mg o HDL ▪ Male greater than 45 ▪ Female greater than 55 o Triglycerides ▪ Male 40-160 mg ▪ Female 35-135 o Bronchoscopy ▪ To pass a flexible tube into patients respiratory tract to have a visual of respiratory tract ▪ Can be diagnostic ▪ Can obtain fluid, sputum, biopsy samples to test for cancer in respiratory tract ▪ Patient will be sedated ▪ Requires consent to take place ▪ Nursing responsibilities for bronchoscopy: ● Patient preparation: o Explain procedure to patient o Advocate for patient o Verify that informed consent have been obtained by physician o Check NPO status 4-8 hours before procedure – could aspirate if patient ate before o Administer sedatives/anti-anxiety medications as ordered o Check blood work results: CBC, electrolytes, etc. ● During procedure: o Monitor vital signs and maintain IV access o Alert physician of abnormalities ● Follow up care: o Monitor vital signs and for potential complications: bleeding, hypoxemia, etc. o Tube nicking arteries or veins can lead to bleeding o Lung computerized tomography (CT) Scan ▪ Shows you more than an x-ray– more specific o Oxygen saturation ▪ Assess ability of heart to oxygenate ▪ Normal is between 95-100% ▪ Amount of hemoglobin bound to oxygen o Thoracentesis ▪ Involves surgical perforation of chest wall usually with a large needle into patients pleural space to aspirate fluid or remove specimen for biopsy ▪ Performed with anesthetic ▪ Patient sits upright supported by a pillow and table ▪ Nursing responsibilities: ● Making sure patient is properly positioned before procedure ● Verify if physician obtained consent ● Advocate for patient ● Monitory vital signs and for potential complications during and after procedure: o Chest x-ray after the procedure o Auscultate breath sounds o Check puncture site for bleeding or leakage o Document procedure o TB Testing ▪ Or PPD testing ▪ Assess for induration/swelling NOT redness 2 to 3 days after injecting ▪ Positive if: ● 15 mm or more: no known risk factors ● 10 mm or more: recent immigrants; injection drug users; residents and employees of high-risk settings; children less than 4 years of age, infants, and adolescents exposed to high risk adults ● 5 mm or more: patients who have HIV/AIDS, have had organ transplants or have depressed immune systems ▪ Persons vaccinated with BCG vaccine will come out positive no matter what o Sputum tests ▪ To rule out some organisms that cause pneumonia or lung infection o Cardiac-related: ▪ Electrocardiogram (ECG) ● Ruling out a cardiac related condition ● Gives you an idea of how the heart is working – contraction of the heart ● Will be assisting, taking ECG and will learn what each indication means as part of normal conduction rhythm READ THE TEXTBOOK chapter 40 page 825-828; 830-835; 840-855 A&E Medsurge Review Sheet Lecture 1 – COPD (9-15 questions) Lecture Outcomes: ● Explain the risk factors, pathophysiology, clinical manifestations, and complications associated with COPD ● Describe spirometry and its indices used in the diagnosis of COPD ● Discuss priority nursing diagnoses and evidence-based interventions for patients who have COPD Notes (**WATCH PODCAST): ● COPD refers to chronic lung disorders that result in blocked air flow in the lungs ● Two main COPD disorders are: o Emphysema ▪ Loss of lung elasticity and abnormal permanent enlargement of the air space distal to the terminal bronchioles ▪ With loss of elasticity, alveoli are not able to fully expand and relax, alveoli are flabby and loss of surface area of alveoli causes decrease in CO2 and O2 exchange – not able to fully compress alveoli back to original shape causing retention of CO2 in the system → leads to obstruction o Chronic bronchitis ▪ Chronic inflammation of the bronchi and the bronchioles causing vasodilation, congestion, mucosal edema ▪ Causes increased inflammation and production of mucous leading to obstruction ▪ Smoking is #1 cause ● Damage from COPD is usually permanent and non reversible ● What makes COPD chronic? What makes it obstructive? What is the outcome of the obstructive disease? o Obstruction of airway → maintaining CO2 – not getting in oxygen and also retaining the gas that you should be eliminating o If you retain CO2, you will get acidosis ● Chronic bronchitis and emphysema may appear to be different because they follow a different route but both lead to obstruction (retention of CO2); they both lead to obstruction causing retention of CO2 ● Relationship between chronic bronchitis and emphysema: o May see a combo of chronic bronchitis plus/and emphysema ● COPD is a multisystem issue ● Why cigarette smoking leads to COPD: o When you smoke, you are increasing the action of proteases (watcher of your lungs, these are the things that protect your lungs); cigarette smoking increases the number of protease in the lungs which causes increased injury to lungs because proteases are eating up your lung tissues because there are too many of them o Consequences of smoking due to increase in proteases: ▪ Decreased ciliary activity ▪ Possible loss of ciliated cells ▪ Cellular hyperplasia – increase # of cells in your lungs ▪ Production of mucus ▪ Reduction in airway diameter ▪ Increased difficulty in clearing secretions o Nicotine (most potent chemical in cigarette smoking) acts as a stimulant to the sympathetic nervous system, resulting in: ▪ Increased heart rate ▪ Peripheral vasoconstriction ▪ Increase blood pressure and cardiac workload ● Focused assessment on respiratory system: o History: ▪ Risk factors: ● Age – as one gets older, risk increases ● Gender – men do not outnumber women in pulmonary disease anymore ● Occupational history – what does this person do, was he exposed to second hand smoke? ● Family history o Physical assessment: ▪ Abnormal breath sounds ● May hear: o Wheezes ▪ Narrowing of the airway o Crackles ▪ Can be fine or coarse ▪ Mean there is fluid in the lungs ▪ Barrel chest ● Normally anterior posterior diameter is smaller than transverse diameter (1:2) ● In COPD, anterior and posterior diameters equals that of the transverse (1:1) ▪ Clubbing ● Can be unknown cause or due to chronic hypoxia ● In COPD it is a result of chronic hypoxia ● Your fingers enlarge because of vasodilation; it is a compensatory action in order to increase the oxygen supply ● Not every with COPD will have this ▪ Cyanosis – late sign – discoloration in mouth area (hypoxia) ▪ Dyspnea – difficulty breathing (SOB) ● Use of Visual Analog Dyspnea Scale (VADS) o Says indicate the about of SOB you are having at this time by marking the line o Ask the patient to place a mark to indicate his perceived breathing difficulty o Ranges from no SOB to SOB as bad as can be ● Use of accessory muscles ▪ Usually assume tripod or orthopneic position ● Enlarges the thoracic cavity to facilitate breathing – compensatory ● Optimizes oxygenation ▪ Unplanned weight loss from nutrition or energy expenditure – increased rate of breathing uses more energy ● Blue Bloater vs. Pink Puffer o Blue Bloater – Chronic Bronchitis ▪ Clinical Diagnosis: daily productive cough for three months or more, in at least two consecutive years ▪ Clinical Manifestations: ● Overweight and cyanotic ● Elevated hemoglobin ● Peripheral edema ● Rhonchi and wheezing o Pink Puffer – Emphysema ▪ Clinical Diagnosis: pathologic diagnosis, permanent enlargement and destruction of airspaces distal to the terminal bronchiole ▪ Clinical Manifestations: ● Older and thin ● Severe dyspnea ● Quiet chest ● X-Ray shows hyperinflation with flattened diaphragms ● Common Diagnostic Tests for COPD o Arterial Blood Gas (ABGs) ▪ Normal ABG levels: ● pH = 7.35-7.45 o Less than 7.35 = acidosis o Greater than 7.45 = alkalosis ● CO2 = 35-45 o Less than 35 = alkalosis o More than 45 = acidosis ● HCO3 = 22-26 o Less than 22 = acidosis o More than 26 = alkalosis ▪ There is evidence of chronic respiratory acidosis related to hypercapnia or hypercapnia o CBC ▪ Polycythemia (increased level of RBC) may be present because body is trying to compensate for loss of oxygen ▪ Risk for blood clots because of increased viscosity which leads to increased workload o Alpha-1 Antitrypsin Serum Level ▪ Will test if person has genetics to develop COPD ▪ If this enzyme is increased, they have the genetics o Sputum analysis ▪ To assess for infection in hospitalized patients with acute respiratory infections o Decreased O2 sat ▪ You have to know the patient’ baseline ▪ When you check this also need to check level of hemoglobin and hematocrit because if you have 99% O2 sat but very low hemoglobin or hematocrit levels, the O2 sat doesn’t really matter o Chest X-Ray ▪ To rule out other disorders ▪ Not useful in early or moderate disease ▪ Used to rule out other pulmonary conditions o Pulmonary Function Test ▪ Test of lung volumes using a spirometer ▪ See video link under week 5 folder ▪ Spirometry is a method of assessing lung function by measuring the total volume of air the patient can hold and expel from the lungs after a maximal inhalation – want to measure if patient can retain gas or has a problem exhaling air ▪ Test determines your vital