NSG 100 FINAL EXAM STUDY GUIDE

NSG100 Final Exam NURSING CONCEPTS Clinical Judgement (Nursing Process) ▪ Differentiate the terms clinical judgment, critical thinking, and clinical reasoning o Clinical judgement: ▪ Refers to the result (outcome) of critical thinking or clinical reasoning-the conclusion, decision, or opinion made. End product of the complex process of clinical decision making ▪ Combines critical thinking abilities, evaluative decision making, nursing experience to determine appropriate responses to patient’s complex situation ▪ Nursing diagnosis is clinical judgment about a person or family’s situation or response to a health concern or life process o Critical thinking: ▪ Definition: The deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factual and belief-based (ACEN) ▪ Necessary for making clinical decisions: process in clinical setting to evaluate and select best actions to meet desired goals ▪ Critical thinking is acquired through experience, commitment, and active curiosity. o WHY? o HOW? ▪ Clinical reasoning and clinical judgment are key components to critical thinking in nursing ▪ Intellect—ability to think, understand, and reason. ▪ Creativity—finding unique solutions to unique problems. ▪ Inquiry—form of research. Defined as search for knowledge or facts. ▪ Reflection-action of retrospectively making sense of occurrences, experiences, situations, or decisions and learning from them ▪ Intuition-use of nursing knowledge, experience, expertise for understanding without conscious use of reasoning ▪ Reasoning • Deductive: “top down” by stating general ideas, observations, or principals and analyzing them to develop specific predictions. • Inductive: “bottom- up”. Nurse observes specific behaviors or symptoms and develops a general conclusion by putting significant, specific cues together. • Clinical • Clinical reasoning-thinking process by which a nurse reaches a clinical judgement · Learned skill that novice nurses must practice · Requires critical thinking · Ability to reflect on previous situations and decisions, evaluate their effectiveness ▪ Tanner Clinical Judgement model ▪ Noticing: o having a sense of what is happening in the patient’s situation o may include recognition of or absence of expected significant clues from the patients response o includes influences of the nurse’s own health beliefs about patient situations and expectations of the work culture ▪ Interpreting: using logical reasoning to gain understanding about a situation and determine appropriate action ▪ Responding: analyzing a situation and choosing the best course of action ▪ Reflecting: ▪ considering appropriateness of the assessment data obtained in the situation, actions taken, and positive and negative outcomes for the patient ▪ learning from actions (done or not done) o What did or didn’t work? o What could have been done differently? o What was done well? o What necessary resources were available? Priority Assessment of Safety Risks and Physiologic Deterioration ( ▪ Frameworks for prioritizing care o Priority setting Frameworks can help the nurse answer basic questions such as: ▪ Which client should I see first? ▪ What is the most important assessment finding? ▪ Which interventions should I do now, which can be done later? ▪ Which situation poses a risk to client safety? o Priority Setting Frameworks: ▪ Nursing Process: • Helpful assessment data before taking action • Observe for cues about pace, emotions of staff already working on unit • After getting information from shift report, make quick safety check of patients • Become aware of any patients at risk • Ask about complexity of patient problems • Ask about special safety concerns for patients • Note routine responsibilities and interventions that have time constraints • Know how many and what level of nursing staff available for task delegation • Note presence/absence of necessary resources on unit • Ask about patient preferences ▪ ABC): Must be able to assess and prioritize threats to airway, breathing, and circulation (ABCs) ▪ Airway: A patent airway so oxygen will have a pathway into the lungs for gas exchange and for carbon dioxide to be expelled from the body ▪ Breathing: An effective breathing pattern and respiratory effort to take in enough oxygen to meet cellular demands for oxygen throughout the body ▪ Circulation: An effective circulatory system to deliver oxygen throughout the body and exchange carbon dioxide and oxygen through the pulmonary circulatory network. ▪ Maslow's Hierarchy of Needs ▪ Low priority o Problems can typically be resolved easily with minimal interventions o Problems that do not cause significant dysfunction ▪ Medium priority o Problems that may have unhealthy physical or emotional consequences o Not life-threatening ▪ High priority o Life-threatening problems o Problems of airway, breathing, circulation o Conditions that have potential to become life threatening in short term ▪ Urgency Factor Model: Urgency factor model helps rank priorities based on: o Time imperatives o Severity of patient needs Urgency Factor Model o Time priority: time constraint is present when completing actions o Deadlines for completion of nursing interventions (administration of scheduled medication) o Essential activities not performed may result in negative consequences for patients o Urgency factor: how much time can safely elapse before patient’s health status is compromised o Urgency of interventions (severity of patient needs): o Changes in patient’s condition o Deterioration of patient’s health status o Complexities of patient’s condition Urgency Factor Model: Urgency Levels ▪ Nonacute o Low urgency factor o Delay would not negatively affect patient outcomes ▪ Acute o Medium priority o Low potential for patient’s condition to become life threatening if interventions not completed in short time o Interventions can be scheduled when time constraints of higher-priority interventions allow ▪ Critical o Medium-high urgency o Urgent need to respond to physical or psychologic problems in short amount of time o Potential for patient’s condition to become life threatening if interventions delayed o Quick recognition, rapid response required to prevent worsening of problem ▪ Imminent death o Highest urgency o Action takes priority over everything else o Nurse must act immediately to prevent further deterioration, threat to life ▪ Triage ▪ Emergent (immediate) o For life-threatening issues that require prompt treatment, care o Stabilization of patient’s condition is critical ▪ Urgent (delayed): For serious conditions in which delay would not result in life- threatening situations ▪ Nonurgent o For patients who have minor issues not requiring prompt care o Often patient can ambulate, is stable o Some emergency departments (EDs) use satellite divisions for patients with nonurgent issues ▪ Phases of nursing process (ADPIE) ▪ Assessment: collecting, validating, and communicating patient data ▪ Diagnosis: analyzing patient data to identify patient strengths and problems ▪ Planning: specifying patient outcomes and related nursing interventions ▪ Implementation: carrying out the plan of care ▪ Evaluation: measuring extent to which patient achieved outcomes NURSING CONCEPTS ▪ Writing client goals/outcomes ▪ Difference between nurse (independent), provider (dependent) and collaborate interventions o Nurse (Independent): Nurse teaches client relaxation techniques and positioning methods to reduce the need for pain medication. Nurses are licensed to do within their scope of practice. Ex. Physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other healthcare professionals o Provider (dependent): Physician orders pain medication. Nurse administers medication safely o Collaborate intervention: Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals Infection Control • Infectious process Infection → invasion of body tissue by microorganisms with the potential to cause illness or disease -human body continually threatened by foreign substances, infectious agents, and abnormal cells. -widespread antibiotic use led to resistant microorganism -methicillin-resistant staphylococcus aureus -multidrug -resistant tuberculosis -irritable bowel syndrome -heartland virus *Infection control is central to delivering high-quality nursing care* Microorganisms exist everywhere (in water, in soil, and on body surfaces such as skin, intestinal tract, and other areas open to the environment- eg. Mouth, upper respiratory tract, vagina, lower urinary tract) • Most are harmless, some are beneficial- essential function in the body • Some are normal flora in one part of the body, produce infection in another o (large intestine, regimen bacteria, on the throat or skin o Lowering ph o Help with digestion o If normal flora escape form normal location can cause disease ▪ E-coli migrate to urinary tract o E-coli is normal inhabitant of the large intestine ▪ But common cause to urinary tract infection • Immunosuppression can allow otherwise harmless bacteria to cause disease. Infectious Process: Infection → Asymptomatic or subclinical infection- No clinical evidence of disease • Disease o When microorganisms produce detectable alteration in normal tissue function and alter bodily function or processes. • Infectious disease: Caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi. o Commonly transmitted from one individual or animal to another or from an animal to an individual o Major cause of death worldwide o -highly transferable to new individual o Caused by toxin- tenus not communicable • Communicable disease: illness that is o Directly: transmitted from one individual or animal to another by contact with body fluids o Indirectly: contact with contaminated objects, airborne particles, or vectors (e.g ticks mosquitoes, other insects • HAI risk factors and prevention strategies HAI Risk Factors • Medical procedures and Antibiotic use – Medical therapies or diagnostic procedures that disrupt the body's natural defences – Antibiotic-resistant microorganisms are increasing at an alarming rate, primarily because of the prolonged and inappropriate use of antibiotic therapy • Improper use of equipments • Infecting organisms develops resistance to treatment or host’s immune system unable to fight off the infections • Infections agent – may be biological treats to communities – cause widespread • Organizational factors – Adoption of best practices: infection control, hand hygiene, attention to safety culture, and antibiotic stewardship • Patient Characteristics : host susceptibility • Nursing assessment (signs & symptoms) of client with infection Assessing patients for infection is vital to o Treating patients o Preventing spread of infection ▪ Individual who have IV line, catheter, surgical wounds • Especially important for patients at risk of infection such as those with o IV lines o Indwelling catheters o Surgical wounds Observation and Patient Interview: Assess degree of patient risk for infection Nurse reviews the patient’s chart and structures the patient interview to collect data regarding the factors that influence the development of infection: • Observations of patient’s current condition o Visually assess skin, scalp, eyes, presence of absence of foul odor, o Assess sign and symptom of elevated temperature, shivering, sweating, complaints of feeling warm, o Respiratory difficulty: elevated respiratory rate, coughing, wheezing , shortness of breath o Sign or Symptoms of pain: facial expression or guarding , indication unable to remain comfortable in the chair or bed • Interview: ask question relative to their health history • Existing disease process • History of recurrent infections • Current medications, therapeutic measures • Current emotional stressors • Nutritional status • History of immunizations (up to date?) Physical examination • Vital signs: increase in HR, RR, temperature, fever • Ear assessment: pain, drainage, redness, pus or fluid • Oral cavity assessment: bright red or Enlarged tonsils, bleeding or discolored gum, cherry red or dry lips, bright red throat , yellow or white exudates on the tonsils • Eye assessment: “crust” on eyelids, tearing, redness , excessive tears, eye pain or itching • Lymph node assessment: Enlarged note, tender nodes, asymmetrical nodes • Respiratory assessment: rapid breathing, abnormal respiratory sounds (wheezing, crackers, strider) • Skin assessment: rash, pallor, itching, burning, swelling, tenderness with palpation or movement palpable heat in the infected area • Urinary assessment: frequency, burning, cloudy, blood in urine, discolored urine , foul smell • Nursing care related to clients with infection: bacterial vs viral; local vs systemic and exemplars (MRSA, C. Diff, UTI) MRSA • Methicillin-resistant Staphylococcus aureus (MRSA) is a cause of staph infection that is difficult to treat because of resistance to some antibiotics. – Child in daycare, sharing equipment • In the healthcare setting, MRSA can cause severe problems such as: – bloodstream infections, – pneumonia, or – surgical site infections. • MRSA colonizes in the nares and skin. It is transmitted primarily by direct physical contact. In the health care setting MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. People who carry MRSA but do not have signs of infection can spread the bacteria to others (i.e., people who are colonized CAUTI • UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter. • The most important risk factor for developing a catheter- associated UTI (CAUTI) is prolonged use of the urinary catheter. • Risk of infection, insertion of central lines and urinary catheters • Conduct sterile procedure • Catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. CDC Guidelines for proper catheter use • Limit catheter use to appropriate situations and only for as long as needed. • Duration of use should be minimal in patients with high risk of mortality from infection • Catheters should not be used for nursing home residents simply to manage incontinence. • Alternatives to indwelling catheters should be utilized when possible • Catheter care should be performed only by individuals with proper training. • Catheters should be changed as clinically indicated (e.g., infection, obstruction, system compromise) Always hand hygiene before and after! C. diff • Clostridioides difficile (also known as C. diff) is a bacterium that causes diarrhea and colitis (an inflammation of the colon). • Most cases of C. diff occur after taking antibiotics or soon after you’ve finished taking antibiotics. Other risk factors include: – Being 65 or older – Recent hospitalizations – A weakened immune system – Previous infection with C. diff or known exposure to the germs – Increase risk with length of hospitals stay, especially in intensive care unit (ICU) CDC Recommendations to Prevent C. difficile infection (CDI) 1. Prescribe antibiotics cautiously. 2. Use contact precautions for patients confirmed or suspected of having CDI. This includes a private room and use of gown and gloves when entering the room and during patient care. 3. Use effective hand hygiene. 4. Have room and nondisposable equipment cleaned with bleach or other appropriate disinfectant. 5.Upon transfer out of the facility, notify the new facility about the C. difficile infection Safety • Science of Safety • Unsafe situations can occur in all settings • Quality: level of performance consistent with current evidence that increases efficiency, effectiveness for desired patient outcomes • Requires everyone in a facility to engage in safe behaviors, be aware of surrounding to protect against unsafe situations, prevent safety hazards • Attributes of safety: qualities or properties of remaining safe • Precautions taken to be safe, prevent adverse occurrences • Safety regulatory agencies and National Patient Safety Goals Safety regulatory angecies: AHRQ, USDHSS - The Agency for Healthcare Research and Quality's • Produce evidence that supports healthcare safety, make it more available, have higher quality, be equitable, and cost-effective while reducing medical errors improving patient safety • CDC - Engages in health research, surveillance, promotion, and response to promote and increase the health security of the United States • Institute of Medicine (IOM) - provides reliable evidence to the govt and the private sector to support informed health decisions about assessment and improvement of healthcare systems and policies • The Joint Commission - promotes quality and safety through accreditation and certification of healthcare facilities representing high quality, safety, and value for patients • National Institute for Occupational Safety and Health (NIOSH) -A federal agency that provides evidence-supported recommendations on the prevention of worker injuries and illnesses to preserve human resources • Occupational Safety and Health Administration (OSHA) - US Department of Labor-a national public health regulatory An agency that protects workers against safety and health hazards in the work environment by enforcing compliance with health and safety standards • Quality and Safety Education for Nursing (QSEN) - designed to Prepare nursing students with knowledge, skills, and attitudes(KSA's) needed to improve the quality of patient care and safety of providing healthcare using systems thinking • World Health Organization (WHO) - international authority to direct and coordinate health within the United Nations' system National patient safety goals: Purpose of National Patient Safety Goals • National Patient Safety Goals (NPSG) program • Goal: to help accredited organizations deal with specific topics on patient safety • Developed and revised by Patient Safety Advisory Group (PSAG) • Panel of nurses, physicians, pharmacists, risk managers, engineers, other professionals with expertise related to patient safety issues • Determine topics for NPSGs by analyzing safety concerns, evaluating which will have maximum impact and usefulness for minimum cost • Input solicited from practitioners, provider organizations, purchasers, consumer groups • Updated annually • Each goal accompanied by elements of performance identified by The Joint Commission as necessary to meet goal • Safety risk based on environment and developmental level Attributes of Safety • Schedule hazard surveys, safety/health inspections in all areas • Implement effective hazard reporting system available to employees • Investigate all safety incidents for root causes • Perform job hazard analysis for all departments • Keep safety, health rules, work practices readily available • Have applicable OSHA-mandated safety programs in place • Make sure personal protective equipment is used effectively • Ensure that appropriate housekeeping is properly maintained • Confirm that facility has disaster plans for internal, external emergencies • Analyze workplace injury/illness data • Promote performance of safety and health responsibilities through policies • Provide safety and health training for all employees at least Annually Role of the Nurse in Client Safety Nurses should encourage patients to: • Actively speak up, ask questions about medications, therapies, tests, procedures • Be knowledgeable about their condition or illness, how to prevent complications • Have support person to assist in these areas, be vigilant about safety of care • Practice safe behaviors • Good hand hygiene • Asking for help when needed • Eating appropriate foods on prescribed list • Reporting any noted mistakes to nurse or another staff member Employees need to: • Be competent in and use a range of safety skills • Be able to identify safety hazards • Take responsibility for correcting them • Interventions to reduce risk for injury (lifespan considerations) Standard precautions: Include universal precautions and body substance isolation • Proper hand hygiene • Protective equipment • Safe injection practices • Effective management of potentially contaminated surfaces, equipment Safety in the Perinatal Period and for Infants Safety • The perinatal period Risk factors • Maternal obesity • Maternal smoking during pregnancy • Maternal severe hypertension or diabetes • Congenital anomalies • Infections • Placental and cord problems • Intrauterine growth retardation o perinatal period ▪ Early and regular prenatal care can result in healthy pregnancy, promoting healthy birth ▪ Genetic counseling ▪ Education about genetic health conditions ▪ Determining chances of having child with gene-related condition • Monitoring of health of mother, development of fetus • Modifying behavior with regard to controllable risks • Obesity • Smoking ▪ Infants ▪ Birth defects: changes in physical structure present at birth • Depending on severity and location, may or may not affect expected lifespan • Birth weight is good predictor of survival, healthy development of newborn • Screening of newborns for birth defects that are not visible • Hearing loss • Heart defects • Hemoglobin disorders • Hormonal insufficiency • Cystic fibrosis • Inability to process certain nutrients • State determines type of screening, how many conditions to look for • Infants Causes of infant mortality • Congenital anomalies, short gestation continue to be common causes as newborn matures into infant • Sudden infant death syndrome (SIDS) • Leading cause of death among infants 1–12 months of age • Unintentional injuries • Suffocation • Falls • Being struck by or against something • Bites, stings • Maltreatment, abuse, neglect Injury prevention • Never leave the infant unattended • Safe sleep practices • Position infant on the abdomen during supervised play only • Monitor setting for objects that are choking hazards • Use car seats properly Disease prevention • Regular well child visit Immunizations Safety for Toddlers and Preschoolers Unintentional injuries are leading cause of death among all ages of children • Risks for specific injuries varies by age Toddlers • Small size, developing bones make them particularly vulnerable during motor vehicle crashes or when hit, pushed, or shaken • Drowning of particular concern • Leading causes of death Accidents with unintentional injuries • At risk for injury or death due to fires, burns, suffocation • Death caused by being left inside parked motor vehicles Safety for Toddlers and Preschoolers • Preschoolers • Fewer injuries, fatalities than among toddlers • Most common causes of injury, fatality same as for preschoolers • Leading cause of death • Accidents with unintentional injuries • Often related to motor vehicle crashes • Other common causes of death • Fires or burns • Suffocation Injury Prevention • Childproof home environment • Prevent poising Use car seat properly • Supervised play • Education about safety • Crossing street, riding bikes • Fire safety • Water safety • Safety around adults Safety for School-Age Children and Adolescents • School-age children • Leading causes of death • Unintentional injuries account for almost one third • Over 40% of those are caused by motor vehicle crashes • Nonfatal injuries • Unintentional falls • Overexertion • Bicycle accidents Injury Prevention • Help to avoid activities that are potentially dangerous • Safety Education: Fire, firearms, eater, what to do in an emergency • Use of proper safety equipment for sports/play • Use of seatbelts • Safety around adults Adolescents • Leading causes of death • Motor vehicle crashes • Poisoning • Drowning • Suicides account for a small percentage • Unintentional nonfatal injuries • Being struck by or against something • Unintentional falls • Overexertion • Being occupant of motor vehicle Injury Prevention • Teach safe driving skills and avoidance of distracted driving • Teach avoidance of tobacco and alcohol • Teach about guns and violence • Discuss dangers associated with the internet Young adults Leading causes of death Poisonings • Mostly by drugs, narcotics, medicines, biological agents • Motor vehicle crashes • Malignant tumors • Heart disease • Suicide • Homicide Sources of nonfatal injuries • Unintentional falls • Overexertion • Being accidentally struck by or striking something • Unintentional cuts or piercing wounds ▪ Middle adults Leading causes of death o Malignant tumors o One third of deaths o Heart disease ▪ Poisoning o From drugs, narcotics, medicines, or biological agents NURSING CONCEPTS o Motor vehicle crashes o Falls ▪ Causes of nonfatal injuries o Unintentional falls o Overexertion o Accidental injury caused by being struck by or against something o Motor vehicle crashes Safety for Older Adults • Culture of Safety o Historically, a culture of blame has existed; identify the clinician at fault, followed by disciplinary measures o Now—the focus is on what went wrong rather than who to blame. o Culture of safety is needed to address errors and to prevent a reoccurrence Just Culture • A health care system’s value is in reporting errors without punishment. • “Just culture” seeks to find a balance between the need to learn from mistakes and the need for disciplinary action against employees. Gas Exchange • Process of blood gas exchange, Oxygen delivery devices The process by which oxygen is transported to cells and carbon dioxide is transported from cells is called gas exchange. Gas exchange is the process of absorbing inhaled atmospheric oxygen molecules into the bloodstream and unloading carbon dioxide from the bloodstream into the atmosphere. This process is completed in the lungs through the diffusion of gases from areas of high concentration to low concentration. • Oxygen delivery devices o Nasal cannula - Most common and comfortable device. Delivers flow rates from 2 to 6 L/min that administer 24-45% fraction of inspired oxygen or FiO2. o Oxymizer - A special nasal cannula that provides a higher luminal diameter in combination with an incorporated oxygen (O2) reservoir. o Simple Face mask - Delivers flow rates from 5 to 8 L/min that administers 40-50% FiO2. o Non-Rebreather mask - FiO2 up to 70-80% can be achieved. o Venturi mask - Delivers a known oxygen concentration to patients on controlled oxygen therapy. • Risk factors for impaired gas exchange • Age • Chronic conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), heart failure (HF) • Air pollution and allergies • Neurological disorders • Prolonged immobility NURSING CONCEPTS • Smoking • Stress and anxiety • Prevention strategies and interventions to promote gas exchange - Smoking and tobacco cessation (nicotine replacement therapy, help patients develop a plan, provide referral), management of environmental air quality may decrease concentration of respiratory irritants. Nursing Interventions : o Deep breathing exercises o Positioning o Encouraging smoking cessation o Monitoring activity tolerance o Promoting secretion clearance o Suctioning o Assisting with activities of daily living o (ADLs) • Nursing process related to gas exchange: Assessment of a patient’s respiratory system includes both subjective and objective data obtained through physical assessment and taking the patient’s health history. The following signs and symptoms signal hypoxia: • Increasing restlessness, irritability or unexplained sudden confusion. • Rapid heart rate accompanied by a rapid respiratory rate. Pharmacology • General principles of pharmacology o Pharmacotherapeutics: is the science of the therapeutic uses and the action of drug on biological systems. o Pharmacokinetics is the study of how a medication enters the body, moves through the body, and ultimately leaves the body. It is described as what the body does to a drug, refers to the movement of drug into, through, and out of the body—the time course of its absorption, bioavailability, distribution, metabolism and excretion. o Pharmacodynamics is the process in which a medication interacts with the body’s cells to produce a biologic response. Pharmacodynamics (sometimes described as what a drug does to the body) is the study of the biochemical, physiologic, and molecular effects of drugs on the body. • Individual variables that influence drug therapy & Nursing process and medication administration Generic Name - an official name given to a drug by a pharmaceutical company. Generic names are not capitalized. • Ex. Acetaminophen Brand/ Trade Name - a drug’s commercial or proprietary name, which is capitalized and varies according to the company that is producing or marketing it. • Ex. Tylenol • Drugs that require prescription are “prescribed drugs” because they are harmful if taken without supervision. Ex. include: o Antibiotics - ceftriaxone (Brand name: Rocephin) ▪ Treat infection o Antihypertensive - captopril (Brand name: Capoten) ▪ Treat high BP o Diuretics - furosemide (Brand name: Lasix) ▪ Promote urination o Narcotic Analgesic - fentanyl (Brand name: Sublimaze & Duragesic) ▪ Opiate-based drugs for pain relief • Other drugs are “nonprescription” and are available over-the-counter because they are safe to take without supervision. Ex. include: o acetaminophen (Brand name: Tylenol) o ibuprofen (Brand name: Advil) o diphenhydramine (Brand name: Benadryl) o loratadine (Brand name: Claritin) o Ranitidine (Brand name: Zantac) Pharmaceutics - addresses how different forms of drug affect the dissolution, absorption rate, and eventually onset of action of a drug. Oral drugs - come in tablet, capsule, liquid, or powder form (drug pt. takes through the mouth but inhales into lungs) • Enteric-coated drugs (EC) dissolve when the drug reaches the intestine. • Extended-release drugs (ER) release over a period of time. They also referred to as: • Extended length (XL) • Sustained release (SR or XR) • Sustained action (SA) • Immediate-release expedites release of drugs. Drug rate of absorption from longest to shortest: Parenteral (Injectable) Drugs - can be administered IV, IM, Sub-Q. Topical/Transdermal Drugs - can be applied on pt.’s skin, eyes, ears, nose, rectum, vagina, or lungs. • Deliver a constant amount of drug over an extended period of time, have a slower onset of action, and a longer duration of action than oral/parenteral administered drugs. Pharmacokinetics - describe the absorption, distribution, metabolism, & excretion of drugs. The liver is responsible for most of the metabolism of drugs that occurs in the body. The kidneys are responsible for excretion. Drug Half-Life - time it takes the drug in the body to decrease in amount by half. • This decrease shows how quickly & efficiently the drug metabolizes & excretes in the body. • Short half-life requires more doses throughout the day. • Longer half-life requires less doses throughout the day. Onset - the amount of time it takes for the drug to show a therapeutic response. Peak - time it takes the drug to demonstrate its full therapeutic effect. Duration - length of time the drug’s therapeutic effect lasts w/o additional doses. Peak Level of Drug - point in time when drug is at its highest level in the body. Trough Level of Drug - point in time when drug is at its lowest level in the body. • These levels are determined by blood samples when the amount of drug is measured in the pt.’s blood. • Strict monitoring of drug level is needed because a certain amount has to stay in the patient’s blood in order to be effective (ex. antibiotic). Pharmacodynamics - biochemical changes that occur in the body as a result of taking a drug. • Therapeutic effects are the intended effects of the drug. Adverse drug reactions are the unintended effects of the drug. The action a drug exerts in the body is a drug’s expected pharmacological action. Many drug’s pharmacological actions have more than one therapeutic use. • For example, Benadryl is a drug that pts. take to treat allergies (antihistaminic effect). • It can also be taken for motion sickness (antiemetic effect) • Hypnotic or sleep aid for insomnia (sedative effect) • Treatment plan for Parkinson’s disease (anticholinergic effect) Adverse Drug Reaction (ADR) - nontherapeutic, unintended effects of a drug that occur at a therapeutic dose. Can either be tolerable or life threatening. • The most severe type of ADR is an allergic reaction. Can either be itching/rash/hives or life- threatening anaphylactic shock. If pt. is allergic the first time, they should not try the drug again since the second time can be more severe of a reaction. • Histamine is released in anaphylactic-shock. • Benadryl is given to block additional release • Symptoms include swelling of eyes, face, mouth, & throat; difficulty breathing; wheezing; rapid heart rate; & extreme low BP, which may all lead to cardiac arrest. Drug Tolerance - the body’s decreased response to a drug it receives over a period of time. For a drug to continue to give its therapeutic effect, the dosage must be increased. • Pharmacodynamics tolerance is the term used to describe tolerance associated with long-term use of opioid analgesics Cumulative effect - when the body is unable to metabolize the previous dose of drug before another dose is given. Nurses should monitor vital signs & lab results that will help reduce ADR in pts. Drug toxicity - occurs when a pt. receives drugs in excessive dosages, resulting in negative physiological effects. • Effects may at times be irreversible. • Ex. vancomycin may cause permanent damage to cranial nerve 8 resulting in decreased hearing or deafness. Acetaminophen may cause temporary damage to liver or permanent damage resulting in liver failure. Contraindications - drugs a provider should not prescribe because they have the potential to cause serious or life-threatening ADR. When it comes to pt. teaching, the purpose of the drug should be given along with generic & brand name, proper method, schedule of administration, ADR, & precautions pt. needs to take while taking it. • Evaluate the pts. knowledge by asking them to specific questions about the drug or teaching Variables that influence drug therapy: diet, comorbidities, age, weight, drug–drug interactions, and genetics 5 Rights of Medications: right patient, right drug, right dose, right route, and right time (Legal, ethical and cultural considerations): NURSING CONCEPTS Mobility • Mobility principles and hazards from immobility across the life span. Principles • Lifespan considerations • Bones and muscles adapt with aging • Some bones fuse during infancy • Bones in children grow as child ages • Growth ability turned off as adults • Bones undergo remodeling • Older adults experience physiologic changes that decrease strength and mobility • Children and adolescent • Fontanels • Space between skulls bones at birth • Close between 1 and 19 months of age • Spine adapts as child develops over the first year of life • Long bones o Epiphyseal plate o Secondary ossification as long bones grow • Rapid growth of bones -> quicker healing of fracture “growing pains” • Skeletal maturity: between 18 and 25 years of age • Muscles almost completely formed at birth • Skeletal muscles increases from 25% of body weight in childhood to weight in adulthood • Boys and girls: equal amounts of muscle mass until age 13-14 • Infants and children • Most likely result from genetic disorders or congenital malformations • Children, adolescents, young adults: o Result of trauma injuries, abuse, motor vehicle crashes • Pregnant women • Decreased ROM • Back pain o Strain on back from postural changes caused by growing fetus o Abdominal weakness from stretched abdominal muscles o Hormonal changes that loosen ligaments in pelvic joints • Managed conservatively: o Postural changes, other adaptations o Acetaminophen o Nonsteroidal anti-inflammatory drugs (NSAIDs) avoided in pregnancy • Older Adults • Normal changes in bones, muscles, joints o Bone density decreases o Spinal discs lose fluid and become thinner o Spinal column compression ▪ Results in short stature, stooped posture • Normal Muscle changes • Muscle fibers atrophy (sarcopenia) • Muscles have less tone and decreased speed and power of contractions • Decreased strength, slower reaction time, more rapid tiring, impaired balance • Hazards of Immobility • Respiratory o Atelectasis and Pneumonia • Metabolic o Decreased energy and negative nitrogen balance • Fluid and Electrolytes o Diuresis and loss of sodium, potassium and o calcium • Gastrointestinal o Decreased peristalsis causes constipation • Cardiovascular o Decreased BP, increased HP, risk for DVT • Musculoskeletal o Decreased strength, endurance, muscle mass, contractures, osteoporosis • Integumentary o Pressure on skin, weight on bony prominences, skin breakdown • Urinary o Urinary stasis, renal calculi • Risk factors that may limit mobility for patient and nurse • Risk factor that may limit mobility for patient: • Non-modifiable aging is primary risk factor o Joint problems decreases mobility o Lower back pain • Modifiable o Obesity ▪ Excess weight strains joints ▪ Increases destruction rate of cartilage and other tissues ▪ Hinders common movements o Maternal nutrition before birth ▪ Folic acid o Well-Balanced diet • Risk factors that may limit mobility for nurse: • Improper body mechanics and bad posture • Patient handling • Uncoordinated lift • Repeated movements • Age • Bad nutrition • Not exercising • Not taking advantage of lift devices • Ergonomics • Evidence based strategies to prevent risks and improve function Strategies to prevent risks and improve function: • Proper body mechanics for lifting o Stand close to the item being lifted and lift straight up o Bend the knees and keep back straight o Distribute weight evenly between both feet o Use feet to pivot rather than twist or turn o If object is too heavy to lift ask for help • Education about proper body mechanics o Good nutrition NURSING CONCEPTS o Exercising o Calcium intake o Lifting weights/weight training to maintain core • Promoting comfort: o If this was a patient then you could also reposition the patient every couple of hours or put a pad under their bone premises to prevent discomfort o Braces and support devices to stabilize musculoskeletal structures • Nursing care for clients with alterations in mobility o Blindness: ▪ service dog ▪ Teaching them to use assistive devices like cane or walker ▪ Texture coding ▪ Clear pathways ▪ Provide instructions in braille o Confusion: ▪ any changes in cognition require assessment. So we need to figure out why they are confused ▪ help orient patient ▪ if possible meet in a surrounding that is familiar to the patient ▪ support and reassure the patient • Roles of PT/OT Role of Physical Therapist • Help patients prevent muscles atrophy if they are unconscious or bedridden for more than a few days Role of Occupational Therapist • Can help the patient regain any motor skills needed to perform ADL’s that may have been compromised. Helps people with an injury, illness or disability learn or re-learn to do everyday activities. • For adults, this could include: o Getting dressed o Cooking o Driving • For children, this could include: o Learning o Playing Functional Ability • Describe the concept of functional ability: Concept • ADL & IADL o “Activities of daily living,” or ADLs, refers to the basic tasks of everyday life, such as: ▪ Eating ▪ Bathing ▪ Dressing ▪ Toileting ▪ Transfering o Activities of daily living are activities related to personal care. They include: ▪ Bathing or showering ▪ Dressing ▪ Getting in and out of bed or a chair ▪ Walking ▪ Using the toilet ▪ Eating o “Instrumental Activities of Daily Living” or IADLs, are actions that are important to being able to live independently, but are not necessarily required activities on a daily basis. The IADLs include: ▪ Basic communication skills - such as using a regular phone, mobile phone, email, or the internet ▪ Transportation - either by driving oneself, arranging rides, or the ability to use public transportation ▪ Meal preparation - meal planning, cooking, clean up, storage, and ability to safely use kitchen equipment and utensils ▪ Shopping - the ability to make appropriate food and clothing purchase decisions ▪ Housework - doing laundry, washing dishes, dusting, vacuuming, and maintaining a hygienic place of residence ▪ Managing medications - taking accurate dosages at the appropriate times, managing refills, and avoiding conflicts ▪ Managing personal finances - operating within a budget, writing checks, paying bills and avoiding scams o Measuring an individual's inability to perform the ADLs and IADLs is important not just in determining the level of assistance required, but as a metric for a variety of services and programs related to caring for the elderly and for those with disabilities. o When people are unable to perform these activities, they need help in order to cope, either from other human beings or mechanical devices or both. o Although persons of all ages may have been performing ADLs. prevalence rates are much higher for the elderly than the nonelderly. Within the elderly population, ADL prevalence rates rise steeply with advancing age and are especially high for persons aged 85 and over. • Changes in environment, lifestyle and technology require some continued development of functional skills across the lifespan • Functional ability in older adults generally refers to the safe, effective performance of ADL’s essential for independent living • Screening for functional deficits in older adults should be a part of routine care just as screening for developmental milestones is for children and adolescents • Risk factors for functional decline /loss of ADLs and their corresponding prevention strategies. (lifespan considerations): Risk Factors • Developmental abnormalities • Age • Cognitive function • Level of depression • Physical or psychological trauma or disease • Social and cultural factors • Physical environment Prevention strategies • Well-balanced nutrition • Physical activity • Routine health checkups • Stress management • Regular participation in meaningful activity • Avoidance of tobacco and other substances associated with abuse Lifespan Considerations • Functional ability changes across the lifespan as a function of development • Identification of problems with functional ability requires careful assessment of developmental milestone at each of the following life stages: o Infant o Toddler o Preschool o School age o Adolescent o Young adult • Nursing assessment of functional ability (Katz/Lawton) • Comprehensive functional assessment is indicated under specific circumstances • Children who are delayed in meeting developmental milestones and accomplishing development tasks • Older adults who have demonstrated a loss of functional ability, experienced a change in mental status, have multiple health problems or are a frail elderly person living in the community • Functional Assessment screening o Vision/Hearing o Mobility o Fall history o Continence NURSING CONCEPTS o Nutrition o Cognition o Affect/Depression o Home environment o Social Participation • The assessment of functional status is critical when caring for older adults. Normal aging changes, acute illness, worsening chronic illness, and hospitalization can contribute to a decline in the ability to perform tasks necessary to live independently in the community. The information from a functional assessment can provide objective data to assist with targeting individualized rehabilitation needs or to plant or specific in home services such as meal preparation, nursing care, homemaker services, personal care, or continuous supervision o Katz Index of Independence in Activities of Daily Living (ADL) o Lawton Instrumental Activities of Daily Living (IADL) Scale • Nursing care related to preservation and restoration of ADLs. o A key factor in quality of life and health is an individual's ability to function. Appropriate screening and early identification of risk factors are key to maintain health. o Management of functional ability impairment is multidisciplinary. Early intervention can include the following services: ▪ Nursing/Medicine ▪ Physical Therapy ▪ Occupational Therapy ▪ Individual/family counseling ▪ Nutritional consulting ▪ Speech and language services ▪ Audiology services ▪ Home health/community services Tissue Integrity • Risk factors for impaired tissue integrity (Braden scale) Risk Factors ▪ Genetic Considerations ▪ Heritable skin disorders ▪ Gender ▪ Men more affected by infectious skin disorders ▪ Women more affected by pigmentary, autoimmune disorders ▪ Age ▪ Changes in skin thickness, surface pH, quality of wound healing ▪ Skin color ▪ Some conditions more prevalent in individuals with darker skin ▪ Others more prevalent in individuals with lighter skin ▪ Many chronic illnesses and their treatments increase the risk for impaired skin integrity ▪ Cardiovascular disorders ▪ Diabetes mellitus ▪ Neurovascular Disorders ▪ Medication Therapies ▪ Thinning of skin (corticosteroids) ▪ Increase sensitivity to light (antibiotic) ▪ Therapeutic measures: Bed rest, casts, radiation therapy, chemotherapy Risk factors for impaired tissue integrity (Braden scale) - Sensory Perception -Moisture -Activity -Mobility - Nutrition -Friction/Shear • Prevention strategies for impaired tissue integrity ▪ Topical skin care and incontinence management ▪ Protect bony prominences, skin barriers for incontinence (with cream /lotion) ▪ Positioning ▪ Turn and reposition at least every 2 hours ▪ Support surfaces ▪ Decrease the amount of pressure exerted over bony prominences ▪ Mattress, cushion, pad ▪ Good hygiene (clean, dry, intact) ▪ Good nutrition (protein supplement, high in calorie) ▪ Adequate hydration ▪ Impeccable nursing care ▪ Avoiding pressure points ▪ Turn 30 degree ▪ Put pillow underneath • Nursing intervention for impaired tissue integrity (exemplars: pressure ulcers, surgical wounds and cellulitis) • Interventions to prevent infection of pressure injuries include: -keeping skin clean, dry, and moisturized -maintaining appropriate nutrition and hydration -recognizing early stages of pressure injuries **Manifestations of pressure injuries include: Stage 1: • Pressure injuries with nonblanchable erythema • Intact skin with localized redness • Does not blanch when pressed Stage 2: • Pressure injuries with partial-thickness loss of dermis • Shallow open wound or blister • No slough Stage 3: • Pressure injuries with full-thickness tissue loss • Deep, open wound bed • Necrosis of subcutaneous tissue • Possible exposure of underlying bone, muscle, and support structure • Slough or eschar present Stage 4: • Suspected deep tissue injury • Intact skin with localized purple discoloration • Possible quick development of a thin blister or eschar Unstageable The patient experiences full-thickness tissue loss with depth completely obscured by slough or eschar in the wound bed. Depth of the wound cannot be determined until slough or eschar is removed; once it is removed, the injury will be classified as stage 3 or 4. Suspected Deep Tissue Injury The patient experiences intact or nonintact skin with localized, nonblanchable maroon, deep red, or purple discoloration or blood-filled blister. These injuries indicate damage of underlying soft tissue from pressure or shear. They may rapidly evolve into thin blisters over dark wound beds or develop thin eschar. They may be difficult to detect in patients with darkly pigmented skin. -reporting to the healthcare provider at the earliest appearance of a change in tissue integrity -maintaining and improving patient activity levels. • Untreated wounds are usually seen shortly after the injury and should be assessed as follows: -Assess the location and extent of tissue damage. -Measure the length, width, and depth of the wound. -Inspect the wound for bleeding. Other pointers include: -The amount varies by type and location. -Penetrating wounds may cause internal bleeding. -Inspect the wound for foreign bodies. -Assess associated injuries such as fractures, internal bleeding, spinal cord injuries, or head trauma. -If the wound is contaminated with foreign material, determine when the patient last had a tetanus toxoid injection. • Assessment of a treated wound involves monitoring: -observation of its appearance, size, and drainage -presence of swelling and pain -status of drains or tubes. The three stages of wound healing are as follows: • Inflammatory phase - Classic signs of the inflammatory phase are redness, heat, pain, and swelling at the site -Hemostasis results from vasoconstriction of the larger blood vessels, the retraction of injured blood vessels, the deposition of fibrin and the formation of blood clots in the area. A scab forms on the surface of the wound. The injured blood vessels leak exudate, causing localized swelling. -During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients, and enzymes create the swelling, heat, pain, and redness that are commonly seen during this stage of wound healing. • Proliferative phase - characterized by the addition of collagen and the formation of granulation tissue. Approximation occurs as collagen forms and strengthens the edges of the wound to begin to close -The wound is rebuilt with new tissue made up of collagen and extracellular matrix. • Maturation phase - occurs when collagen formation becomes more organized and the scar becomes stronger. -Also called the remodeling stage of wound healing, the maturation phase is when collagen is remodeled from type III to type I and the wound fully closes. Nursing interventions related to wound care include: • keeping a sterile dressing technique during wound care • premedicating for dressing changes as necessary • thoroughly wetting the dressings with sterile normal saline solution before removal • monitoring the patient's continence status and minimizing exposure of the skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage • implementing an incontinence management plan if the patient is incontinent • administering antibiotics as ordered • telling the patient to avoid rubbing and scratching • providing gloves or clipping the nails if necessary • encouraging a diet that meets nutritional needs. Several events can interfere with the healing of a wound, thereby leading to complications like: • Hemorrhage severe, abnormal bleeding that can be caused by a dislodged clot, a slipped stitch, or an erosion of a blood vessel. • Infection contamination of a wound surface with a microorganism that multiplies excessively or invades tissues. • Dehiscence partial or total rupture of a sutured wound, usually involving an abdominal wound in which layers below the skin also separate. • Evisceration protrusion of the internal viscera through an incision. Types of wound healing include: • Primary intention healing occurs where the tissue surfaces have been approximated can be with NURSING CONCEPTS stitches, staples, skin glue, or tapes is used when there has been very little tissue loss. • Secondary intention healing is extensive and involves considerable tissue loss such that the edges cannot be brought together to heal in this manner differs from primary intention healing in three ways: 1. repair time is longer 2. scarring is greater 3. chances of infection are far greater. • Tertiary intention healing is also known as "delayed" or "secondary closure” is indicated where there is a reason to delay suturing or closing a wound some other way. Nonpharmacologic therapies for wounds include: -infection-prevention measures -compression bandages or hosiery -vacuum-assisted wound closure if the wound is large and traditional therapies have failed -stem cell therapy to introduce rapidly regenerating cells -skin or tissue grafts -biosurgery for non-healing wounds with necrotic tissue or slough. • Cellulitis is an acute bacterial infection of the dermis. Its chief symptom is inflammation, which includes intense pain, heat, redness, and swelling. • This condition allows cellular debris to accumulate, the result being enlarged areas of involvement. If not treated promptly, it can develop into life-threatening septicemia. • If a wound is present, good wound care is a vital part of cellulitis prevention and includes: -Washing the wound carefully with soap and water. -Applying an antibiotic cream or ointment daily. -Covering the wound with a bandage to maintain adequate moisture. -Monitoring the wound for signs of infection. • Skin protection is also an important part of cellulitis prevention and includes: -Keeping the skin moist with lotion. -Wearing shoes that fit properly. -Having good nail hygiene. -Wearing protective equipment when participating in work or sports. Nutrition • Basic nutrients needed for health • Carbohydrates (4kcal/gram) → main source of energy o Simple = sugar → absorbed quicker/ short-term energy ▪ fruit, milk, vegetables, honey o Complex = starches → break down slower/ long-term energy supply ▪ grains, legumes, & root vegetables NURSING CONCEPTS • Protein (4kcal/gram) → energy; build new tissues; functions as enzymes and antibodies; form hormones o Complete = contain all 9 amino acids ▪ meat, poultry, fish, milk eggs, and cheese o Incomplete = do not contain all essential amino acids ▪ legumes, nuts, grains, cereals, & vegetables • Fats (9kcal/gram) → supply energy (most); protection; insulation + temperature; absorption of vitamins (fat-soluble) o Saturated (contain all the material) = solid at room temperature; animal source ▪ Butter, fat inside or around meat (beef, pork, & chicken) o Unsaturated (not contain all the material) = liquid at room temperature; heart healthy; plant source ▪ Oil, nut, olives, seeds, & fish Micronutrients (regulate body processes; needed in smaller amount) • Vitamins: regulating body functioning o Fat-soluble (A, D, E, & K) o Water-soluble (B complex & C) • Minerals: maintaining fluid & electrolytes balance; maintaining acid-base balance o Most abundant: Calcium Essential nutrient (needed for survival) • Water (60% of body weight in adult; 75% body weight in infants o Transportation; regulations; serve as solvent for other nutrients; lubricant; cushion; body temperature; maintain blood volume & weight • Risk factors for impaired nutrition • Personal food choice (religious, culture practice; appetite) • Financial issues • Portion size • Impaired oral intake (dysphagia; teeth problem; diseases) • Impaired digestion & absorption (lactose, celiac disease, …) • Altered organ function • Medication (alter taste; complications) • Age • Prevention strategies for impaired nutrition (lifespan considerations) • Infants (unique) o Breastfeeding exclusively 1st 6 months o Continue breastfeeding as foods introduced in 1st year • Children o ½ plate is fruits and veggies o Choose healthy source of protein (lean meat, nuts, eggs) o High fiber (whole grain); reduced refined grains o Broil, grill, or steam food o Limit fast & junk food o Offer water or milk instead fruit drink & soda NURSING CONCEPTS • Adolescents o Increase calories intake: protein, calcium, iron, iodine, & vit B o Increase water consumption • Pregnant women o More protein, iron, calcium, & folic acid • Older adults (unique) o Lower caloric needs o More vit D, B6, B12, & calcium • Signs and symptoms of impaired nutrition • Undernutrition (insufficient food intake) o Underweight o Slower bone development + failure to thrive (pediatrics) o Growth failure o Compromised immune status o Poor wound healing o Muscle loss o Physical & functional decline • Overnutrition (exceeds nutrients than body require) o Overweight (BMI 25-30) o Obese (BMI >30) o BMI >25.0 • Prioritize specific nursing care of clients with obesity and nutritional deficits (lifespan considerations) Nursing care for obesity • Encourage patient to identify factors & help patients to eliminate these causes • Establish realistic weight-loss goals & exercise/activity objectives • Assess patient’s nutritional knowledge; provide appropriate diet teaching • Discuss behavior modification strategies: self monitoring & environmental management • Monitor weight loss, BP,and laboratory data (blood glucose and lipid) Nursing care for nutritional deficits • Identify and eliminate the causes • Instruct patient to take 1 multivitamin daily • Refer to dieticians • Set an appropriate short/long term goals • Provide a pleasant environment → promote appetite • Encourage exercise • Nutritional supplements • Provide good oral hygiene Elimination • Risk factors and prevention strategies for alterations in elimination Risk factors affecting urinary elimination: • Developmental considerations (aging) • Fluid and food intake/output o alcohol → inhibit antidiuretic hormone → increase output; o high sodium food → urinary retention • Muscle tone o Poor muscle tone → altered the output of urine • Pathologic conditions o Renal failure o Diseases: diabetes mellitus; neuromuscular diseases; BPH; ... • Psychosocial factors o Privacy, positioning, working time • Surgical and diagnostic procedures o Restriction for fluid intake → decreased urine output o Stress → urinary retention o Direct visualization → trauma & edema → difficulty voiding • Medications o Altered urine input/output (diuretics - increase output; cholinergic - increase output; analgesics & tranquilizer - decrease awareness of the need to void) o Some can alter urine color (anticoagulants - hematuria; diuretics - pale,yellow; iron compound - brownish …) Prevention strategies for alteration in urinary elimination: • Lifestyle modification o Maintaining a healthy weight o Eating high fiber diet → prevent constipation → prevent alterations in urinary elimination o Avoiding bladder irritants: alcohol, caffein, acidic, or spicy food o Adequate fluid intake (2-3L/daily) • Regular exercise • Refraining from tobacco use • Reviewing medications • Reducing physical barriers (for patients with limited functional abilities) Risk factors affecting bowel elimination: • Lifestyle o Personal habits o Nutrition & fluid intake ▪ Fiber & water o Exercise • Developmental (aging; different needs; physical changes) • Physiological o Pregnancy o Motor & sensory disturbances o Intestinal pathologies (bowel obstruction, crohn’s disease, cancer…) o Medications ▪ Indirect (tranquilizers, morphine, codein, iron) ▪ Direct (laxatives, stool softeners, antidiarrheal) ▪ Affect the appearance (antibiotics → gray-green; aspirin → red or black; iron → black stool) o Surgical procedures • Psychosocial o Stress & anxiety → increased peristalsis → diarrhea o Depression → decreased peristalsis → constipation • Pain Preventive strategies for alteration in bowel elimination: • Controlling the causes • Increasing physical activity • Fiber consumption • Fluid intake • Avoid straining • Pelvic floor exercise • Nursing assessment and interventions for urinary and bowel incontinence and retention Compare and contrast constipation, diarrhea, urinary retention (BPH), and bladder incontinence: assessment, treatment, and evaluation. Nursing Assessment (urinary incontinence & retention) • Observational & Interview: o S&S = odor, soiled clothing, use of incontinence product, frequently ask to go to bathroom o A voiding diary: frequency, pattern, volume of intake & output, recent changes o Past history problems o Inquire about methods use to deal with incontinence, use of pelvic floor exercise, medication, any chronic diseases, related surgeries, & effects on daily social activity • Physical examination: o Physical and mental status ▪ Physical limitations & impaired cognition o Skin & mucous membrane ▪ Assess hydration o Kidneys ▪ Flank pain → infection or inflammation o Bladder ▪ Distended bladder rises above symphysis pubis o Urethral meatus ▪ Observe for discharge, inflammation, irritation, and lesions o Pelvic muscle tone • Assess urine: o Intake and output o Characteristics of urine ▪ Color ▪ Clarity ▪ Odor o Urine testing ▪ pH range 4.6 - 8.0 ▪ Specific gravity 1.015 - 1.025 Nursing Interventions (urinary incontinence & retention) • Health promotion: o Patient education o Promoting normal micturition • Stimulating micturition reflex o Maintaining elimination habits o Maintaining adequate fluid intake o Promoting complete bladder emptying o Preventing infection • Acute care: o Maintaining elimination habits ▪ Allow time and provide privacy. o Medications ▪ Parasympathetic stimulation of the detrusor muscle aids emptying. ▪ Cholinergic drugs increase bladder contraction and improve emptying. o Catheterization • Restorative care: o Strengthening pelvic floor muscles o Bladder retraining o Habit training o Self-catheterization o Maintenance of skin integrity o Promotion of comfort o Plan for home care o Prevent social isolation Nursing Assessment (bowel incontinence & retention) • Health history o Usual pattern of bowel elimination ▪ Frequency, time of day o Normal characteristic of stool ▪ Watery or formed; soft or hard; typical color o Specific routine followed to promote normal elimination o Use of medications (laxatives; bowel elimination aids) o Dietary habits: ▪ Normal & changes of dietary intake ▪ Normal & changes of fluid intake ▪ Changes in appetite ▪ Recent weight gain or loss o Physical activity ▪ Any changes in daily activities o Surgery or illnesses (affecting GI tract) o Medication use (may affect bowel pattern) • Physical assessment o Abdomen ▪ Inspection: contour, symmetry, scars, distensions, masses, stomas ▪ Auscultation: note frequency (5-30m/min) & character ▪ Palpate: areas of tenderness, guarding, palpable masses o Anus ▪ Inspect: ulcers, inflammation, rashes, or excoriation (pick or scratch) o Mobility & strength ▪ Independent or needed assis