NUR2115- Fundamentals of Professional Nursing Final Exam- Summer Latest updated 2022,100% CORRECT

NUR2115- Fundamentals of Professional Nursing Final Exam- Summer Latest updated 2022 *The final exam will cover your required readings from the following chapters: 1, 2, 3, 4, 5, 6, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 31, 32, 33, 34, 36, 37, 38, 40 and 41. All Modules Review various nursing diagnoses related to specific patient problems • Oxygenation • Ineffective Airway Clearance: fatigue, COPD. Thick, yellow secretions • Impaired Gas Exchange: smokers, asbestos workers. Cyanosis altered blood gases • Ineffective Breathing Pattern: anxiety. Hyperventilating, tachypneic. • Infection • Risk for Infection: chronic illness (diabetes), alteration in skin integrity. S/S of infectious process, drainage or secretions. • Thermoregulation • Ineffective Thermoregulation: Trauma, illness environmental temp. Fluctuations in body temp above or below normal. Hyperthermia and Hypothermia. • Tissue Integrity • Impaired Tissue Integrity and Risk for Impaired Tissue Integrity: Alteration in metabolism, ex- tremes of age. Damaged or destroyed tissue. Module 1-3 Concepts: • P- Population/Problem • I- Intervention(s) • C-Comparison (optional) • O-Outcome • “What interventions reduce the incidence and severity of bed sores in residents of long-term care facili- ties?” • P- Elderly • I- Bedsores or pressure ulcers • C- None • O- Reduction in incidence and severity of bed sores • International Council of Nurses- Promotion of health, prevention of illness, and the care of ill, disabled, and dying people • American Nurse Association-Nursing is the protection, promotion, and optimization of health and abili- ties, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communi- ties, and populations. • Main concepts central to nursing: person, health, environment, nursing • Patient is “central focus” of all definitions – Includes physical, emotional, social, and spiritual dimensions of the patient • Review importance of documentation of patient assessments Identify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient’s responses to treatment Formats for Nursing Documentation o Initial nursing assessment: obtained from nursing history and physical assessment o Care plan: patient’s dx, related goals, outcomes, interventions, resolutions to problems o Patient care summary: overview of valuable patient information such as documentation, lab and test results, orders, medications o Critical collaborative pathways: standardized plan of care developed for a specific patient popu- lation with a designated dx (can include list of interventions) o Progress notes: pt’s progress towards achieving expected outcomes… description of the status of the problem, related nursing interventions, pt responses, and needed revisions to the POC. o Communication: primary purpose of patient record!! Helps health care professionals from differ- ent disciplines (who interact with patient at different times) communicate with one another o Diagnostic and therapeutic orders: The chart contains any diagnoses, new and old, and MD or- ders and results of diagnostic tests o Care planning: Modify care plan based on patient’s baseline and ongoing data o Quality process and performance improvement: Accrediting agencies, such as TJC, can review patient records to determine if the hospital or facility is meeting it’s standards. They can review nurse’s charting to ensure patients are receiving quality and competent care o Research; decision analysis: Uses patient record to identify needs to promote EBP o Education: Students and health care professionals will learn from patient’s chart o Credentialing, regulation, and legislation: reviewers can monitor health care compliance within the facility o Reimbursement: Insurance (payers) need to use patient records to reimburse for health care re- ceived o Legal and historical documentation: Legal document in court!!! Historical document for patient to have if needed later on Characteristics of effective documentation o Consistent with professional and agency standards o Complete o Accurate o Concise o Factual o Organized and timely o Legally prudent o Confidential*** - See 16-1 Documentation Guidelines p. 342 Review types of nonverbal behavior which could promote improved communication -Also known as body language Touch- tactile sense, personal behavior that means different things to different people -factors like age and sex play a key role -most effective nonverbal ways to express feelings of comfort, love, affection. security, anger, frustration, aggression, excitement, and others Eye contact- communication begins here -some cultures suggest respect and willingness to listen and to keep communication open -absence often indicates anxiety or defenselessness or avoidance of communication -Asian and Native American = view eye contact as invasion of persons privacy -other cultures people are tough to avoid eye contact out of respect, or to not make eye contact with a superior -the eyes carry other nonverbal messages like : -in a stare during anger -tend to narrow in disgust -ordinarily open wide in fear -people who cant speak send message of anxiety with eyes -blank stare indicates daydreaming or inattentiveness Facial Expression- face is most expressive part of body -can convey anger, joy, suspicion, sadness, fear, and contempt -some people have extremely expressive face -some mask it (makes it difficult for us to know what they’re thinking -as a nurse you need to control your facial expressions Posture- the way a person holds the body carries nonverbal messages -people in good health and positive attitude usually hold their bodies in good alignment -depressed people likely to slouch -provides nonverbal cues for pain and physical limitations: rigid, stiff appearance might me indictor of tension and pain Gait- bouncy purposeful walk carries message of wellbeing -less purposeful shuffling gait can mean person is sad or discouraged -certain gaits can indicate illness -ex: people recovering from abdominal surgery walk eighty bent over and slowly Gestures- using various parts of the body can carry numerous messages -example thumbs up = victory -kicking an object= anger -wringing hands or tapping foot = anxiety or anger -waving hands (towards ) = come on -wave other way (away)= leave -usually used when two people in different languages attempt to communicate General Physical Appearance- mot illnesses cause at least some alterations in general physical appearance -nurses observe and evaluate -example: person w insufficient intake of fluids has dry skin that wrinkles easy, sunken eyes, dull in appearance, poor muscle tone Mode of Dress and Grooming- persons clothing and grooming carry nonverbal message -healthy people: tend to pay attention to details of dress and grooming -ill people: demonstrate little interest in personal appearance -often a sigh of returning health when interests in their physical appearance and mode of dress returns Sounds- crying, moaning, gasping, sighing are oral but nonverbals -person crying: sadness or joy -gasping: fear or pain or surprise -sigh: sign of reluctant agreement to do something or of relief Silence- periods of silence are important nonverbal -between two people: indicates an understanding, both are thinking or angry with each other LMAO Review the importance of QSEN in nursing education o Overall concept is to prepare future nurses to have knowledge, skills, and attitudes necessary to continuously improve quality and safety of health care systems. - Patient centered care - Teamwork and collaboration - Quality improvement - Evidence-based practice - Informatics Review what a sentinel event is o A sentinel event is a Patient Safety Event that reaches a patient and results in any of the follow- ing: - Death - Permanent harm - Severe temporary harm and intervention required to sustain life o Such events are called "sentinel" because they signal the need for immediate investigation and response. Review examples of health promotion activities for primary, secondary and tertiary o Primary: directed toward promoting health and preventing the development of disease processes or injury. o Examples are immunization clinics, family planning services, poison-control information, and accident-prevention education. o Secondary: focus on screening for early detection of disease with prompt diagnosis and treatment of any found o Examples are assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations. o Tertiary: begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning o Examples include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord in- jury, and referring a woman to a support group after removal of a breast because of cancer. - See Table 3-2 Examples of Nursing Activities by Level of Health Promotion and Preven- tative Care. Pg. 50. Review use of ISBARR model of communication • I - Introduction: People involved in the handoff identify themselves, their roles, and their jobs • S - Situation: Complaint, diagnosis, treatment plan, and patient’s wants and needs • B - Background: Vital signs, mental and code status, list of medications, and lab results • A - Assessment: Current provider’s assessment of the situation • R - Recommendation: Identify pending lab results and what needs to be done over the next few hours and other recommendations for care • Other R is read back for orders • Q - Question and answer: An opportunity for questions and answers Review teaching for a patient on anticoagulant therapy- safety considerations -Electric shavers are usually recommended when the patient is receiving anticoagulant therapy or has a bleeding disorder and are especially convenient for ill and bedridden patients. -A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery post-poned due to an increased risk for excessive bleeding, because each of these sub- stances have anticoagulant properties. Age related safety concerns Falls, Motor Vehicle accidents, elder abuse, sensorimotor changes, fires Developmental theories: focus on Erickson’s (I added Maslow’s too) The role of a UAP - Unlicensed assistive personnel are people who are trained to function in an assistive role to the licensed registered nurse (RN) in the provision of patient activities as delegated by and under the supervision of the registered professional nurse. Appropriate delegation- Before the RN delegates any nursing intervention, a number of additional fac- tors, including the qualifications and capabilities of the UAP, should be considered: (1) the stability of the patient’s condition, (2) the complexity of the activity to be delegated, (3) the potential for harm, (4) the predictability of the out- come, and (5) the overall context of other patient needs. The RN re- mains accountable for any delegated nursing care or outcomes and is responsible for the supervision of the UAP to whom tasks are delegated. Inappropriate delegation decisions can jeopardize the safety of patients and endanger a nurse’s professional practice. Communication techniques: when to use open vs. closed ended questions, types of questions (clarifying, validating…). -Open- ended question- when obtaining a nursing history, use the open-ended question tech- nique to allow the patient a wide range of possible responses. It allows patients to express what they un- derstand to be true, yet is specific enough to prevent digressing from the issue at hand. It encourages free verbalization. -Closed question- provides the receiver with limited choices of possible responses and might of- ten be answered by one or two words, “yes” or “no.” Closed questions are used to gather specific infor- mation from a patient and to allow the nurse and patient to focus on a particular area. Closed questions are often a barrier to effective communication. -Validating Question or Comment - This type of question or comment serves to validate what the nurse believes he or she has heard or observed. -Clarifying question or comment allows the nurse to gain an understanding of a patient’s comment. Musculoskeletal: Review education on crutch walking o Crutches: 3 fingers below axilla, 6-12 in out and forward, elbows bent. • Review safety precautions when repositioning patient in bed When pulling a patient up in bed, the bed should be flat or in a Trendelenburg position (when tolerated) to aid in gravity, with the side rail down. For patients with Stage III or IV pressure ulcers, care should be taken to avoid shearing force. The height of the bed should be appropriate for staff safety (at the elbows). If the patient can assist when repositioning "up in bed," ask the patient to flex the knees and push on the count of three. During any patient handling task, if the caregiver is required to lift more than 35 lbs of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used. Review nursing interventions which would be included in caring for a patient with contractures Handle the elders with care, and do not forcefully pull their limbs. Otherwise, it may lead to pain and frac- tures. Review the difference between active and passive range of motion o Active: Completed by client - Maintain or increase muscle strength - Prevent deterioration of joints, and contractures o Passive: completed by another person. No client contraction - No value in maintaining strength, only joint flexibility - Done when client cant do on their own - Completed only to point of slight resistance, never to point of discomfort Vital Signs: Review the assessment of obtaining all vital signs including BP, HR, respirations, temperature and pulse ox I hope we know how to obtain them at this point Review normal values for VS: BP, HR, respirations, temperature and pulse ox BP- 120/80 HR- 60 to 100bpm average =80 Respirations- 12-20 Temperature- 98.6 Puse ox- 95-100% The appropriate situation to use specific types of thermometers • tympanic membrane thermometer- 1 to 3 seconds, core temp, inserted into ear canal tightly enough to seal, 99.5 normal adult average • disposable single use thermometer- non-breakable, within seconds, elimination of cross infection, sometimes requires for transmission-based precautions, taped on abdomen or forehead • temporal artery thermometers- oral and temporal more accurate and precise than axillary and tympanic • rectal- core temp, considered to be most accurate, contraindicated in heart, neutropenic, neurologic dis- order pt., 1 degree higher than oral • electric and digital thermometers- oral, rectal, axillary, 1 to 60 seconds, disposable probe covers = de- crease risk of infection • oral- 98.6 • rectal- 99.5 • axillary- 97.7 Module 4-7: Review definitions of the nursing process including assessment, nursing diagnoses, planning/outcomes, interventions and evaluation. • ASSESSMENT- systematic and continuous collection, analysis, validation, and communication of pt. data • preparing for data collection • collecting and validating data • identifying cues and making inferences • clustering related data and identifying patterns • report and record • 4 types- • initial- shortly after admission, database, assess spiritual and cultural needs here • focused- one system • emergency- physiological and psychological crisis • time lapsed- compare pt. status to baseline from earlier • DIAGNOSIS - begins after the nurse has collected and recorded the patient data PURPOSES : (1) identify how a person, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems. • creating list of suspected problems/ diagnosis • ruling out similar problems • naming actual and potential problems and clarifying contributing cause • determine risk factors that must be managed • identifying resources, strengths, areas for health promotion • OUTCOME IDENTIFICATION/PLANNING - • establish priorities • identify and write expected pt. outcomes • ebp intervention selection • communicate plan of care • IMPLEMENTATION- nursing actions planned in the previous step are carried out. The purposes of imple- mentation are to help the patient achieve valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. • act in partnership w pt. and family • before implementing reassess pt. to determine if action is still needed • modify interventions to pt. psychosocial background and ability and willingness • response to previous nursing measures and process toward goal and outcome • EVALUATING- The nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. The purpose of evaluation is to allow the patient’s achievement of expected out- comes to direct future nurse–patient interactions. • allows achievement of outcomes • directs nurse patient interactions • measures pt. outcomes • identify factors to achieve outcomes • modify the plan of care if necessary Respiratory/Cardiac: Review various lab data and normal values: BUN, electrolytes, CBC, blood glucose, HbgA1C BUN- 7-20 mg/dl Electrolytes- Sodium- 135-145 meq/L Potassium-3.5-5.0 meq/L Calcium- 4.5-5.1 mg/dl Magnesium- 1.3-2.3 meq/L Chloride-97-107 meq/L Bicarbonate- 25-29 meq/L Phosphate- 2.5-4.5 mg/dl CBC- Complete Blood Count RBC- MALE- 4.5-5.5 FEMALE- 4.0-4.9 WBC- 4,500-10,000 Neutrophils- 40-60 Eosinophils- 1-4 Basophils- 0.5-1 Lymphocytes- 20-40 Monocytes- 2-8 Platelets- 100,000-450,000 Hemoglobin- MALE- 41-50 FEMALE- 36-44 Fasting blood glucose- 70-100 for male and female HBGA1C-<6.5% Review the common adventitious lungs sounds (wheezes, pleural friction rub, rhonchi, crackles and stridor) and what specific conditions you would auscultate them (COPD, pneumonia, asthma, CHF) • crackles- heard on inspiration • soft, high pitched intermittent popping sounds when air moves through airways with fluid • classified as fine course medium • bronchial- high pitched, longer, heard over trachea • bronco vesicular- medium pitch and sounds during expiration, heard over the upper anterior chest and inter- costal area • rhonchi- continuous low-pitched rattling lung sounds that often resemble snoring • wheezing- continuous sound heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions for tumors • classified as sibilant hissing or sonorous deep snore Review respiratory terminology: dyspnea, cyanosis, tachypnea, bradypnea, apnea, orthopnea • apnea- periods of which there is no breathing • cyanosis- (always a late sign) bluish discoloration of nail bed and mucous membranes, late indicator of hypoxia, causes include: severe anemia, respiratory obstruction, heart disease, cold environment. • dyspnea- difficulty or labored breathing • tachypnea- > 24 breaths/ min, rapid breathing, usually shallow, caused by metabolic rate change- hy- poxemia or increased demand for oxygen • bradypnea- <10 breaths/min, slow breathing, occurs in some pathologic condition, decreased respira- tory rate • orthopnea- breathing more easily in a upright position > Review the effects of chronic hypoxia on the respiratory system hypoxia- inadequate amounts of oxygen available to the cells. Chronic hypoxia is a common cause of pulmonary hypertension • hypo/hyper ventilation- decrease and increase rate and depth of air into lungs • hypoxemia- abnormally low levels of oxygen in the blood • PEDS= FINES • F- feeding difficulty • I- inspiratory stridor • N- nares flare • E- expiratory grunting • S- sternal retractions • ADULTS= RAT (EARLY) BED (LATE) • R- restlessness • A- anxiety • T- tachycardia/ tachypnea • B- bradycardia • E- extreme restlessness • D- dyspnea (severe) Review the anatomical locations for auscultation of cardiac and respiratory systems (aortic, pulmonic, tricuspid and mitral) > Review how to determine types of pitting edema: 1+, 2+, 3+ and 4+ Review interventions to decrease risks for pulmonary embolism Preventing pulmonary embolism begins with preventing deep vein thrombosis. Exercise lower leg muscles if sitting for a long time while traveling. Get out of bed and move around as soon as pt. is able after having surgery or being ill. The sooner they move around, the better the chance of avoiding a blood clot. Take medicines to prevent clots after some types of surgery Review grading of pulses: bounding, normal, diminished, faint • Absent, unable to palpate • +1 Diminished, weaker than expected • +2 Brisk, expected normal • +3 Bounding > Oxygenation-labs, signs and symptoms, and nursing interventions for both hyper and hypo • normal respirations- 12-20 • normal O2 level- 95-100% • mild hypoxia- 91-94% • moderate hypoxia- 86-90% • severe hypoxia- <85% Integumentary/Infection/Inflammation/Thermoregulation: Review the stages of pressure ulcers including I, II, II and IV as well as unstageable ulcers • stage 1- skin intact, erythema noted but does not blanch, client may report tingling or burning, darker clients may have skin discoloration-warmth-edema-indurations • stage 2- superficial partial thickness skin loss that involves epidermis and possibly dermis, appears like blister, abrasion or crater • stage 3- full thickness loss with necrotic tissue seen in subcutaneous layer, down to but not through fascia, in- jury appears deeper as crater with or without undermining • stage 4- full thickness with tissue necrosis or damage down to muscle, bone and other tissues like tendons or joint capsules, undermining • unstageable- base of ulcer covered by slough and/or eschar in wound bed; slough must be removed to deter- mine true depth which will determine the stage Review integumentary changes in various developmental ages • In children younger than 2 years, the skin is thinner and weaker than it is in adults. • An infant’s skin and mucous membranes are injured easily and are subject to infection. Careful han- dling of infants is required to prevent injury to and infection of the skin and mucous membranes. • A child’s skin becomes increasingly resistant to injury and infection. Expected integumentary system changes with aging- -skin thin and translucent, cry, flaky, tears easily, loss of elasticity and wrinkling -thining of hair -slow growth of nails with thickening -decline in glandular structure and function (less oil, moisture, sweat) -uneven pigmentation -slow wound healing -little sub cutaneous tissue over bony prominences 65+ changes -decreased skin turgor, sub q fat, connective tissue (dermis), which leads to wrinkles and dry transparent skin -loss of sub q fat which makes it more difficult for older adults to adjust to cold temperatures -thinning and graying of hard as well as more sparse distribution -thickening of toenails and fingernails Review the following precautions: protective, droplet, airborne, contact, standard, isolation, airborne PRECAUTIONS Protective- environment to protect clients who are immunocompromised such s those who have had a allogenic hematopoietic stem cell transplant requires: private room, positive airflow 12 or more air exchange/hr, HEPA filtration for incoming air, mask for client when out of room • standard precautions- used for all pt., applied to body fluids, secretions, excretions except sweat, non-intact skin, mucous membranes • contact- pathogen spread by direct contact, sources= draining wounds, secretions, supplies contaminated, pos- sible private room, clean gloves and gown, double bag linens • droplet- pathogen spread via droplet, sources= coughing, sneezing, touching contaminated objects, same PPE for contact in addition to mask and eye protection, private room or w someone of same disease • airborne- pathogen spread via air currents, sources= ventilation systems, shaking sheets, sweeping, PPE same for contact, special room for pt. (negative pressure), special mask (95 respirator), mask when being trans- ported, if splashing possible wear full face protection Review the importance of nutrition and wound healing age- increased age delays healing -loss of turgor -skin fragility -decrease in peripheral circulation and oxygenation -slower tissue regeneration -decreased in absorption of nutrients -decreased in collagen -impaired immune system function -dehydration due to decreased thirst sensation overall wellness- a wound in a young healthy client will heal faster than a wound in an older adult who has a chronic illness decreased leukocyte count- delays wound healing because the immune system function is to fight infection by destroying invading pathogens some medications- (anti-inflammatory and antineoplastics) interfere with the boys ability to respond to and prevent infection malnourished clients- nutrition provides energy and elements for wound healing tissue perfusion- provides circulation that delivers nutrients for tissue repair and infection control low hgb levels- hgb is essential for oxygen delivery to healing tissues obesity- fatty tissue lack blood supply chronic disease- such as diabetes and cardio disorders place additional stress on the bodys healing mechanisms smoking- impairs oxygenation and clotting wound stress- such as from vomiting or coughing puts pressure on the suture line and disrupts the wound heal- ing process Review the difference between a wound evisceration and dehiscence • evisceration- wound completely separates w protrusion of viscera through incisional area • dehiscence- separation of wound layer Review the use and advantages of negative pressure wound therapy (wound vac) Negative pressure wound therapy is a medical procedure in which a vacuum dressing is used to enhance and promote wound healing in acute, chronic and burn wounds. The therapy involves using a sealed wound dressing attached to a pump to create a negative pressure environment in the wound. Applying continued vacuum helps to increase blood flow to the area and draw out excess fluid from the wound. Advantage is that it has improved wound healing. -speed tissue generation -decrease swelling -enhance healing in a moist protected environment Review process of healing: primary, secondary, tertiary primary- little or no tissue loss -edges approximated as with a surgical incision -heals rapidly -low risk of infection -minimal to no scarring -example: closed surgical incision with staples or sutures or liquid glue to seal laceration secondary- loss of tissue -wound edges widely separated, unnaproximated (THINK PRESSURE ULCERS, OPEN BURNS) -longer healing time -increase for risk of infection -scarring -heals by granulation -example: PRESSURE ULCER LEFT OPEN TO HEAL tertiary- widely separated -deep -spontaneous opening off a previously closed wound -closure of wound occurs when free of infection -risk of infection -extensive drainage and tissue debris -closed later -long healing time -example: abdominal wound initially left open until infection is resolved then closed Review the difference between inflammation and infection -infection almost always causes inflammation so it’s a response manifestations include: redness, heat swelling, pain, loss of function -infection manifestations (related to wounds) include: 3-11 days after injury or surgery, purulent drainage, pain, redness edema (in and around the wound), fever chills odor, increased pulse and respiratory rate, increase in WBC count Review the effects of excessive or ineffective inflammatory response which could occur in a patient The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair. In addition to infection, the inflammatory response also occurs in response to injury. It is either an acute or chronic process. Excessive= body is on constant state of emergency causing damage to heart, brain and other organs. Review the purpose of the inflammatory process The inflammatory response is a defense mechanism that evolved in higher organisms to protect them from in­ fection and injury. Its purpose is to localize and eliminate the injurious agent and to remove damaged tissue components so that the body can begin to heal. Review the use and rationale of Braden scale • for predicting pressure ulcer risk • Assess: • sensory perception- ability to respond to pressure related discomfort • moisture - degree to which skin is exposed • activity- degree of physical activity • mobility- ability to change and control body position • nutrition- usual food intake pattern • friction and shearing 16 or less- at risk for pressure ulcer 15 16= low risk 13 14= moderate risk 12 or less= high risk!!!!!!!!!!!!! Review the difference between acute and chronic wounds Acute wounds, such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. Chronic wounds do not progress through the normal sequence of repair. The healing process is im- peded. The wound edges are often not approximated, the risk of infection is increased, and the nor- mal healing time is delayed. Chronic wounds include any wound that does not heal along the expected con- tinuum, such as wounds related to arterial or venous insufficiency, and pressure ulcers. Review the effect or shearing force and friction on skin integrity Friction- two surfaces rub against each other. The skin over the elbows and heels often is injured due to fric- tion when patients lift and help move themselves up in bed with the use of their arms and feet. Shear- separates the skin from underlying tissues. Patients who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from shearing forces. A patient who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. Review infection terms: opportunistic, virulence, phagocytosis Opportunist: bacteria that may potentially be harmful Virulence: ability to produce disease Phagocytosis: engulfing of microorganisms, foreign particles, or other cells by phagocytes Review the chain of infection: reservoir, infectious agent, portal of exit, portal of entry, susceptible host o Infectious agent: bacteria, viruses, fungi, normal flora that becomes pathogenic o Reservoir: natural habitat of the organism; may be living: humans, animals, insects or may be nonliving: food, floors, equipment, contaminated water, soiled dressings (sick person or the host) o Portal of exit: point of escape for the organism- Bodily fluids, coughing, sneezing, diarrhea, seeping wounds, tubes, IV lines. Respiratory, gastrointestinal, genitourinary tracts breaks in skin, blood and tissue o Means of transmission: direct contact (touching, kissing, sexual contact), indirect contact (con- tact with a fomite), droplet (cough, sneeze), airborne (via air conditioning, sweeping), vector: through a bite or sting - Pathogens need nutrients, moisture, temperature, oxygen, ph (5-8, cannot live in a highly acidic environment) and electrolytes and dark to grow and thrive o Portal of entry: point at which organisms enter a new host- Eye, nares, mouth, vagina, cuts, scrapes, wounds, surgical sites, IV or drainage tube sites, bite from a vector - (Portal of Entry could be the same as a Portal of Exit) o Susceptible host: must overcome resistance mounted by host’s defenses - (Person with inadequate defense; Impairment to the skin or mucous membrane, or com- promised immune system) Review stages of infection: incubation period, prodromal stage, full stage of illness, convalescent period o Incubation period: organisms growing and multiplying; from time of infection until manifesta- tion of symptoms; can infect others o Prodromal stage: person is most infectious, vague and nonspecific signs of disease; appearance of vague general symptoms to more specific symptoms; during this time the pathogen is multi- plying; not all diseases have this stage o Full stage of illness: presence of specific s/s of disease o Convalescent period: recovery from the infection; interval where acute symptoms subside; tissue repair, return to health could take days to months Review types of nosocomial and hospital acquired infections (HAI’s) o An infection acquired as a result of healthcare. Theres 4 categories responsible for majority of HAI’s: - Urinary tract infections (Catheter Associated Urinary Tract Infections or CAUTI’s) - Surgical site infections - Bloodstream infections (Central Line Associated Blood Stream Infections or CLABSI) - Pneumonia (If on mechanical ventilation-> Ventilator Acquired Pneumonia or VAP) o Measures to reduce HAI’s or nosocomial infections - Constant surveillance by infection-control committees and nurse epidemiologists - Written infection-prevention practices for all agency personnel - Hand hygiene recommendations - Infection control precaution techniques - Keeping patient in best possible physical condition Review rationale of proper hand hygiene Voids spreading disease…. I mean common sense to all at this point Review terminology: bacteremia Bacteremia- presence of bacteria in the blood Review signs and symptoms of infection -systemic- spread via lymph or blood, cardinal sign =malaise -local- limited, cardinal sign= redness, warmth, edema, loss of function, pain Review the difference between endogenous nosocomial and exogenous nosocomial infection Endogenous nosocomial- an infection caused by an infectious agent that is already present in the body, but has previously been inapparent or dormant. Exogenous nosocomial- are the result of pathogens being spread by patients as they are shed from various portals of exit while the patients are in the health care facility. Glucose Regulation and Tissue Integrity: Review risk factors and complications of diabetes RISK FACTORS Older age (>45 years old) Obesity Family history of diabetes History of gestational diabetes Impaired glucose metabolism Physical inactivity Race/ethnicity African Americans, Hispanics/Latinos, American Indians, some Asians, and Native Hawaiians or other Pa- cific Islanders are at particularly high risk of diabetes COMPLICATIONS Skin infections *Nerve Damage (neuropathy) *Foot Amputation *Kidney disease *Coma Gum disease *Retinopathy *Depression *Stroke *Blindness Diabetes- types, signs and symptoms, normal and abnormal lab values for fasting blood glucose and A1C, nursing interventions, and patient education (Read lesson content in module 7 and the NIH Guide- lines for care of people with or at Risk of Diabetes in Mod 7 required readings) SIGNS AND SYMPTOMS Increased thirst or hunger Frequent urination Weakness Fatigue Blurry vision Tingling in the hands or feet Sores that are slow to heal LAB VALUES The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 per- cent indicates prediabetes. Below 5.7 is considered normal. Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have di- abetes Review treatment modalities for diabetes TYPE ONE Treatment: Requires insulin as part of treatment Blood sugar monitoring Healthy eating Regular exercise TYPE TWO Treatment: Oral anti-diabetic meds or insulin therapy Blood sugar monitoring Healthy eating Regular exercise Review treatment for hypoglycemia Early symptoms can usually be treated by consuming 15 to 20 grams of a fast-acting carbohydrate. Fast-acting carbohydrates are foods that are easily converted to sugar in the body, such as glucose tablets or gel, fruit juice, regular — not diet — soft drinks, and sugary candy such as licorice. If pt is unconscious administer glucagon, SQ, IM, or IV Review education and teaching on foot care of a diabetic patient Inspect your feet daily. Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Bathe feet in lukewarm, never hot, water. Be gentle when bathing your feet. your toes. Cut nails carefully. Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toenails. Never treat corns or calluses yourself. Wear clean, dry socks. Consider socks made specifically for patients living with diabetes. Shake out your shoes and feel the inside before wearing. Keep your feet warm and dry. Consider using an antiperspirant on the soles of your feet. Never walk barefoot. Take care of your diabetes. Keep your blood sugar levels under control. Do not smoke. Smoking restricts blood flow in your feet. Get periodic foot exams. Module 8-Gastrointestinal: Review the complete assessment of the GI system including inspection, auscultation, palpation and per- cussion Inspection: observe contour, any masses, scars, or distention Auscultation: listen for bowel sounds in all quadrants Note frequency and character, audible clicks, and flatus. Describe bowel sounds as hypoactive, hyperactive, absent or infrequent. Hypoactive= constipation; normal during sleep Hyperactive= diarrhea Percussion and palpations: performed by advanced practice professionals Review conditions of diarrhea and constipation and precipitating factors of each Diarrhea Factors: Adverse effects of pharmaceutical agents Abuse of laxatives Emotional stress Intestinal infection Colon disease and other diseases Radiation At least three loose liquid stools per day, increased frequency • Urgency • Reports of abdominal pain Constipation Factors: Decreased fiber in diet Decreased fluid intake Inactivity Delaying defecation when urge is present Abuse of laxatives Use of constipating medications (antacids, opioid analgesics, anticholinergics) Change in routine Pain associated with defecation Decreased frequency of bowel sounds. Passes small “marbles” of hard, hard stool. Review risks and treatments for constipation AT RISK -Patients on bedrest taking constipating medicines -Patients with reduced fluids or bulk in their diet -Patients who are depressed -Patients with central nervous system disease or local lesions that cause pain while defecating TREATMENTS Laxatives Review effects of the GI system on immobility • Risk for heartburn, indigestion, and aspiration due to positioning and inability to sit upright during meal and for one hour after meals. • Loss of appetite from reduced activity, depression, boredom, and illness. • May have impaired taste and smell due to aging changes or drugs. This further reduces pleasure of eating, in- creases loss of appetite, and reduces intake of fluids. • Weight loss and malnutrition from inadequate intake of nutrients. • Decreased peristalsis, decreased intake of fluids, and unnatural positioning for having a bowel movement us- ing a bedpan promotes and contributes to constipation, impaction, nausea, vomiting, and ileus. • Difficulty pushing to eliminate stool when lying on back. • Digestive enzymes break down food. They will cause skin breakdown with prolonged contact with feces. Review the risk factors which increase irritable bowel syndrome (IBS) Being a women Age Family History Emotional trouble - stress Review diagnostic colon cancer screening Stool-based tests: These tests check the stool (feces) for signs of cancer. These tests are less invasive and easier to have done, but they need to be done more often. Visual (structural) exams: These tests look at the structure of the colon and rectum for any abnormal areas. This is done either with a scope (a tube-like instrument with a light and tiny video camera on the end) put into the rectum, or with special imaging (x-ray) tests. Review education and teaching regarding ostomy care NURSING CONSIDERATIONS Keep the patient as free of odors as possible; empty the appliance frequently. Inspect the patient’s stoma regularly. Note the size, which should stabilize within 6 to 8 weeks. Keep the skin around the stoma site clean and dry. Measure the patient’s fluid intake and output. Explain each aspect of care to the patient and self-care role. TEACHINGS Explain the reason for bowel diversion and the rationale for treatment. Demonstrate self-care behaviors that effectively manage the ostomy. Describe follow-up care and existing support resources. Report where supplies may be obtained in the community. Verbalize related fears and concerns. Demonstrate a positive body image. Encourage patient to care for and look at ostomy. Review side effects of diarrhea nausea. -abdominal pain -cramping -bloating -dehydration -fever -bloody stools -frequent urge to evacuate your bowels > Review teaching regarding a patient undergoing a colonoscopy A colonoscopy is an exam of the colon (large intestine). Doctor will use a colonoscope (flexible tube with a camera on the end) to see the inside of the colon on a video monitor. During the procedure, the doctor can: Remove a small sample of tissue (biopsy) for testing Remove a polyp (growth of tissue) Take photos of the inside of the colon It is important that colon is empty for procedure. Doctor will specify on diet to follow days before proce- dure. If taking anticoagulants note when the doctor specifies to stop taking them for the procedure. If on insulin dose may need to be changed. Take Genitourinary: Review the components of performing a GU assess • Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment. • Urinary bladder: Palpate and percuss the bladder or use a bedside scanner… bladder scanner to as- sess PVR • Urethral orifice: Inspect for signs of infection, discharge, or odor. • Skin: Assess for color, texture, turgor, and excretion of wastes. • Urine: Assess for color, odor, clarity, and sediment. Review s/s of UTI, risks for developing UTI and treatments, prevention of UTI SIGNS AND SYMPTOMS A strong, persistent urge to urinate A burning sensation when urinating Passing frequent, small amounts of urine Urine that appears cloudy Urine that appears red, bright pink or cola-colored — a sign of blood in the urine Strong-smelling urine Pelvic pain, in women — especially in the center of the pelvis and around the area of the pubic bone RISK FOR UTIs • Sexually active women • Women who use diaphragms for contraception • Postmenopausal women • Individuals with indwelling urinary catheter • Individuals with diabetes mellitus • Older adults (urospesis) PREVENTION • Push fluids, Showers over baths, cotton Underwear, cranberry or blueberry juice, clean front to back for females, void immediately following intercourse Review the effects of immobility on the GU system *Calcium drains from long bones, causing kidney stones and osteoporosis. *Position may cause difficulty voiding and inability to empty bladder completely. *Fre- quency of urination or overflow incontinence may occur. *Urine pools in bladder, increasing the risk of infection. *Skin con- tact with urine increases the risk of pressure ulcers Review causes of urinary incontinence -Temporary urinary incontinence Certain drinks, foods and medications may act as diuretics, stimulating bladder and Increasing volume of urine -Urinary incontinence may also be caused by an easily treatable medical condi- tion: Urinary tract infection. Infections can irritate your bladder, causing you to have strong urges to urinate, and sometimes incontinence. Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and increase urinary frequency. -Persistent urinary incontinence Urinary incontinence can also be a persistent condition caused by underlying physical problems or changes: • Pregnancy. Hormonal changes and the increased weight of the fetus can lead to stress incontinence. • Childbirth. Vaginal delivery can weaken muscles needed for bladder control and also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum or small intestine can get pushed down from the usual position and protrude into the vagina. Such protrusions can be associated with incontinence. • Changes with age. Aging of the bladder muscle can decrease the bladder's capacity to store urine. Also, involuntary bladder contractions become more frequent as you get older. • Menopause. After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence. • Hysterectomy. In women, the bladder and uterus are supported by many of the same muscles and liga- ments. Any surgery that involves a woman's reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence. • Enlarged prostate. Especially in older men, incontinence often stems from enlargement of the prostate gland, a condition known as benign prostatic hyperplasia. • Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. But more often, incontinence is a side effect of treatments for prostate cancer. • Obstruction. A tumor anywhere along your urinary tract can block the normal flow of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses that form in the bladder — sometimes cause urine leakage. • Neurological disorders. Multiple sclerosis, Parkinson's disease, a stroke, a brain tumor or a spinal in- jury can interfere with nerve signals involved in bladder control, causing urinary incontinence. Review the GU terminology: micturition, oliguria, dysuria, retention, urgency AT THE END micturition-urination Review nursing care for urinary incontinence Place an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device Assist the person to change their clothing to maximize toileting access. Use absorbent products Review the process of obtaining a 24 hour urine collection Initiate a collection at a specific time (which is recorded) by asking the patient to empty the bladder. Discard this urine and then collect all urine voided for the next 24 hours. At the end of the 24 hours, ask the patient to void. Add this urine to the previously collected urine, and then send the entire specimen to the laboratory Review the collection of a midstream urine specimen Clean-Catch or midstream Specimen means that the patient voids and discards a small amount of urine; con- tinues voiding in a sterile specimen container to collect the urine; stops voiding into container; removes con- tainer and continues voiding. So basically… pee a little… pee in cup… pee till done. Types of urinary incontinence include: • Stress incontinence. Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. • Urge incontinence. You have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night. Urge incontinence may be caused by a mi- nor condition, such as infection, or a more-severe condition such as a neurologic disorder or diabetes. • Overflow incontinence. You experience frequent or constant dribbling of urine due to a bladder that doesn't empty completely. • Functional incontinence. A physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough. • Mixed incontinence. You experience more than one type of urinary incontinence. Module 9-Sleep: Review the physiological effects of lacking sleep • Not getting enough sleep prevents the body from strengthening the immune system and producing more cytokines to fight infection • Sleep deprivation can also result in an increased risk of new and advanced respiratory diseases. • A lack of sleep can affect body weight. • Sleep helps the heart vessels to heal and rebuild as well as affecting processes that maintain blood pres- sure and sugar levels as well as inflammation control. Not sleeping enough increases the risk of cardio- vascular disease. • Insufficient sleep can affect hormone production, including growth hormones and testosterone in men. Review benefits of sleep • Increases mental performance • Improves learning • Helps the storage of long-term memory • Restores energy • Improves ability to cope • Strengthens the immune system ADDITIONAL ITEMS TO KNOW ▪ Circadian rhythm • Internal clock (greatest effect on sleep quality) • 24-hour day-night sleep/wake pattern • Affects overall level of functioning ▪ Stages of sleep (Cycles typically every 90 -120 minutes with 4 to 5 cycles per night ) • NREM: slow wave sleep (delta waves). Muscles relax, temperature lowers, HR, RR, BP decrease • REM: highly active; mimics being awake • Lack of REM sleep causes a rebound REM to keep the total amount of REM sleep equal over time Pain: Review the effects that severe/uncontrolled pain has on VS Increased blood pressure Increased pulse and respiratory rates Pupil dilation Muscle tension and rigidity Pallor (peripheral vasoconstriction) Increased adrenalin output Increased blood glucose Review the types of pain: chronic, acute, intractable, neuropathic, radiating, phantom, referred psy- chogenic • acute pain starts suddenly and is short-term • chronic pain lasts for a longer period of time • soft tissue pain happens when organs, muscles or tissues are damaged or inflamed • nerve pain (NEUROPATHIC) happens when a nerve is damaged • referred pain is when pain from one part of your body is felt in another • phantom pain is when there is pain in a part of the body that has been removed • total pain includes the emotional, social and spiritual factors that affect a person’s pain experience. Review which pain management tasks can be delegated to nursing assistant -Nonpharmacological interventions -Hot/ Cold Packs -Taking Vital Signs -Repositioning Patients -Examine patients for bruises, sores any physical findings Review alternative techniques of pain management: hypnosis, distraction, guided imagery, massage, reiki, music, aromatherapy, TENS, healing touch Distraction requires the patient to focus attention on some- thing other than the pain. It is not entirely clear whether distraction raises the threshold of pain or increases pain tolerance Imagery (an example of mind–body interaction) to decrease pain sensation imagine some- thing that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain. Relaxation techniques reduce skeletal muscle tension and lessen anxiety. Massage skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. Hypnosis, a technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain. The person’s state of consciousness is altered by suggestions so that pain is not perceived as it normally would be. TENS is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to in- hibit transmission of painful impulses carried over small-diameter fibers. The TENS unit consists of a battery- powered portable unit, lead wires, and cutaneous electrode pads that are applied to the painful area Healing Touch is an energy therapy. It requires no equipment, uses light touch, and is appropriate for every level of care Reiki is a technique that aids the body in releasing stress and tension by creating deep relaxation. Review risks of inadequate pain management -Acute pain can turn into chronic pain -Opioids are underused because of their negative connotation, this included addition. Miscellaneous Review: Nurse’s responsibilities involved in post-mortem care Post-mortem care *Disconnect any tubes attached to pt.* *Preparing the patient for viewing by the family. *Ensuring proper identification of the patient prior to transport to the morgue or funeral home* *Providing appropriate disposition of the patient's belongings.* Critical thinking to determine which other team members would be beneficial for patient care: PT for gross motor movement and strengthening, OT for task-oriented skill re-training, Speech Lan- guage Pathologist (SLP) for swallowing difficulties (dysphagia) and speech Focused assessments on Pain, skin infection, cardio-pulmonary. PAIN Patient’s verbalization and description of pain Duration of pain Location of pain Quantity and intensity of pain ( can assess the amount of pain experienced by using a pain scale) Quality of pain Chronology of pain Aggravating and alleviating factors Physiologic indicators of pain Behavioral responses Effect of pain on activities and lifestyle Terms in the beginning of each chapter including but not limited to: Orthostatic- decrease in systolic pressure of 20mmhg or decrease in diastolic by 10mmhg within 3 min of standing Oliguria- Scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400 ml Anuria- 24-hour urine output is less than 50 mL; synonyms are complete kidney shutdown or renal fail- ure Polyuria-Excessive output of urine (diuresis) Dysuria- Painful or difficult urination Pyuria-Pus in the urine; urine appears cloudy Nocturia- Awakening at night to urinate Urgency- Strong desire to void Retention- the action of absorbing and continuing to hold a substance Stress incontinence- Involuntary loss of urine Neurologic incontinence- experience of incontinence due to nerve damage Overflow incontinence - experience frequent or constant dribbling of urine due to a bladder that doesn't empty completely. Mixed incontinence- experience more than one type of urinary incontinence. Enuresis- involuntary urination, especially by children at night Calculi- a concretion of minerals formed within the body, especially in the kidney or gallbladder Dyspnea- difficult or labored breathing Tachypnea- increased respiratory rate may occur in response to increased metabolic rate Apnea- refers to periods during which there is no breathing Bradypnea- a decrease in respiratory rate occurs in pathological conditions Acute- Acute illness: rapidly occurring illness that runs its course, allowing a person to return to one’s previous level of functioning Acute pain: episode of pain that lasts from seconds to less than 6 months Chronic- (of an illness) persisting for a long time or constantly recurring Intractable- hard to control or deal with Referred- pain felt in a part of the body other than its actual source Visceral- pain from internal organs Cyanosis- bluish grayish discoloration of the skin, response to inadequate discoloration Atelectasis- partial or complete collapse of the lung Purpura-a rash of purple spots on the skin caused by internal bleeding from small blood vessels Ecchymosis- a discoloration of the skin resulting from bleeding underneath, typically caused by bruis- ing CDI- (clean, dry, intact) Approximated- come close or be similar to something in quality, nature, or quantity