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Nursing Process, key things to remember for each:
- Assess-first time nurse is looking at subjective and objective data.
- Plan-"Patient will...."
- Implement-"Nurse will....."
- Evaluate-Did pt. respond and meet expected outcomes
- Physiological needs-eat, sleep, sex, air, water
- Safety and Security
- Love and belongingness
- Self Esteem
- Self Actualization
- pressure of urine in overfull bladder overcomes sphincter control.
- Leakage of small amounts throughout the day and night.
- Bladder is distended and palpable
How do you treat overflow incontinence
- urinary catheterization to decompress the bladder
- No warning or stress precedes involuntary urination.
- Moderate in volume
- Brain issue
How do you treat Urge Incontinence?
- bladder retraining
- decrease dietary irritants
- Calcium channel blockers
How do you treat stress incontinence?
How do you treat Reflex Incontinence?
- Intermittent self catheterization
- Anatomical or functional absence of sphincters
- Spina bifida, scoliosis, MS, Lou Gherigs, Pelvic Surgery
Self Management strategies to reduce incontinence
- stop smoking
- lose weight
- reduction of bladder irritants-caffeine
- schedule voiding regimens
Habit training for incontinence
scheduled toileting with adjustments of voiding intervals, longer or shorter, based on the individuals voiding pattern
scheduled toileting that requires prompts to void from a caregiver every 3 hours....with a reward
Causes of UTI
- E Coli
- Urinary stasis
- structural abnormalities
- Females-proximity of urethra to anus
- Low estrogen in post menopausal women
- decrease in vaginal lactobacilli causing an increase in vaginal pH
How do you treat a UTI?
- Prevention is best by...
- Good hygiene
- Frequent voiding
- Staying hydrated
Complication of Cystitis and describe
- usually cuased by E coli, proteus, klebsiella and Enberobacter
- Vesicoureteral Reflux (urine moves from lower to upper urinary tract
What's a sign of pyelonephritis, that isnt present in cystitis?
fevers, chills and flank pain
#1 Cause of UTI
Non sterile catheter insertion
But also, make sure cath connections are tight and NEVER put urine collection on the floor, or raise it above the level of the bladder
Details of TURP
- removal of prostate tissue without an incision
- done under spinal or general anesthesia
First 24 hours after TURP
Lg. three way indwelling cath with a 30 mL balloon is inserted in to the bladder to provide hemeostasis and facilitate urinary drainage. Bladder is irrigated continuously or intermittently to PREVENT obstruction from blood clots or mucus
TURP post op complications
- clot retention,
- dilutional hyponatremia
Traction on the catheter during CBI which provides counter pressure on the bleeding site decreasing bleeding
- blood clots
- WATER INTOXICATION
Pt. teachig for TURP
- no incision
- no lifting, driving strenuous activity 2-3 weeks
- no straining BM
- Avoid bladder irritants
- Acid Ash diet-NO cheese or dairy
Assault vs. Batter
- Assault is verbal....you need to take your med before I give you your lunch
- Batter is an action....doing any procedure without their permission
- unintentional action that doesnt meet the standard of care
- Didnt check the 5 rights of med admin
- Carelesness/taking short cuts
Slander vs. Libel
- Slander is said....stating your teacher is a B
- Libel is written (letter)...writting on FB your teacher is a B
5 elements of malpractice
- Nurse had a duty to the patient
- That duty was breeched
- Forseability of events was evident
- The patient was injured
- The injury was caused by the breach
Who must HIV patients tell of their status?
sexual partners only
What do you chart a red wound as?
Healthy tissue looks like
dark pink to beefy red....it is "revascularized"
Thick leathery, dry and crusted dead tissue that must be debrided for granulation to occur
What do you note about exudates?
color, consistency and odor of drainage
partial or complete separation of upper layers of a wound
total separation of layers and extrusion of internal organs or viscera through the open wound
Autolytic wound healing
Best...pack with appropraite dressing to provide a moist environment. Allows the bodys natural defense to clean the necrotic wound of debris
Foundation of wound healing
When do you give pain med prior to painful wound dressing change?
30-45 min prior
Hydrophillic wound care products
- cotton gauze
- Best used on closed wounds or wounds free of drainage
Hydrophobic wound care products
- non absorbent
- clear, occlusive and transparent. Acts like a second skin
Provides moist environment to assist in healing and debridement with limited absorption of exudates and requires secondary dressing
Good for absorbing moisture and packing
Holds large amounts of exudates and is non adhesive for easy removal
How do you perform sterile gloving?
- hand hygiene
- dominant hand gloved first
- non dominant hand grasps sterile glove at cuff
- stick non dominant hand in as you hold cuff
Increased porosity of the bone from lack of use
Lung infection R/T retained secretions and inactivity
Type of active, resistive ROM
Foot or Hand Press
Stoppage of urine flow
Increased excretion of urine
Release of calcium from bone
Drop in systolic BP of 15 mm or greater when sitting or standing
Permanent flexion or bending of a joint
Inflammation of the vein wall with clot formation
Plantar Flexion contracture of the foot
Decreased level of protein in the blood
Collapse of lung alveoli R/T decreased air flow
Simple substances synthesized
Breakdown of molecules to simple ones
What happens with anabolism and catabolism with immobility?
Anabolism decreases and catabolism increases causing protein depletion
Which leads to negative nigrogen balance...which leads to muscle wasting
Immobile bones release calcium....what happens?
Hypercalcemia...causing bone weakness which means osteoperosis and also renal calculi
TPN being administered....what if it runs out and it is being delivered peripherally? Centrally?
Hang D10 peripherally and D50 Centrally to prevent hypoglycemia
Infiltration....How do you prevent and treat it?
- Change IV catheter every 72 hrs
- secure device, suport limb, assess frequently
- DC IV
- Elevate extremity
- Stop swelling with a warm or cold compress
How do you treat an infected IV site?
- DC IV
- Call Dr
- Monitor VS
- Culture site (if ordered)
- Meds (if ordered)
Signs of Fluid Overload? What causes it?
Crackles in the lungs or more input than output
- Caused by:
- Excessive amounts of saline
- Infusion rate too high
- Infusing too many solutions
- Pt with CHF or renal disease
Signs of localized infection
- heat at site
Signs of systemic infection
- elevated WBC
- FUO is FIRST SIGN!!!
How do you prevent fluid overload?
- Assess frequently
- Monitor infusion rates
- ID high risk pt
- Weigh at risk pt
- Accurately measure I & O
How do you treat fluid overload?
- Slow or D/c IV...but dont take it out
- call Dr.
- High fowlers
- Monitor Vs q15-30
- Prepare to give lasix
How do you treat an air embolism from an IV site?
- Clamp tubing
- Turn on left
- Admin O2
- Call Dr.
How do you prevent extravasation?
- teach high risk pt to report any pain or burning
- use a central line for severly irritating drugs
How do you treat Extravasation
- Stop infusion
- Disconnect tubing but dont remove IV
- Aspirate Drug
- Call Dr.-Antidote?
- Ice therapy
Serious complication from Heparin
HIT Heparin Induced THrombocytopenia
What do you do if CBG is below 65mg/dL?
Dont give insulin, give milk or crackers and recheck in 10-15 min.
What do Narcotics, hypnotics and sedatives cause?
- Depressed respirations
Where do you want your serum K levels to be?
Serum Dig panic level?
- Serum K normal is 3.5-5.5
- Hold Digoxin if Serum Dig is 2.0 or higher
Hold if Apical is below 60 beats/min
What do you monitor with diuretics?
I&O, lytes and BP
It serum potassium is above ?? hold and call Dr.
3 checks for drugs
- Drug to Mar in med room
- Pt room with Mar and patient
When you are teaching a patient....how do you deal with illiteracy?
- Ask how do you like to learn?
- Provide info in simple terms
- Give pt. credit for life experience
Steps to patient teaching
- Identification of learning needs
- Plan goals and objectives
- Implementation of teaching strategies
- Evluation of learners progress and teaching efficacy
How do you evaluate of you taught your patient well?
Can they verbalize understanding of what I presented or demonstrate what was taught?
How can you obtain a sterile urine sample?
Whens best urinalysis sample taken?
- 20 mLs
- Get to lab within 1 of collecting
What do you test stool for?
- Fecal fat
- occult blood
- ova and parasites
When do you take a throat culture?
Prior to eating....or if ate or drank, wait 1 hour
If you need a wound sample...what are the rules?
- Remove old exudate.
- Take anaerobic (inner) sample first
- Take aerobic (outer) sample second
Procedures you need to be NPO for 8 hours prior?
- Angiogram (angiography)
Which end is an endoscopy from? What do you need to watch for?
Lumbar puncture details: (looking at CSF)
Position during procedure
Position post procedure
- During, side lying, knees bent
- Post flat on back 4-8 hrs
- Assess....CSF leaks, headaches, change in neuro condition
Paracentesis does what?
Considerations during procedure?
Post procedure position
- Removal of fluid from peritoneal cavity...tappin the melon
- void before and after procedure
- Put pt in semi to high fowlers
- assess abdomen before and after procedure and watch for hemorrhage
Thoracentesis does what?
- removal of fluid from pleural space (around lung)
- watch for dyspnea, HOB 30 degrees
- Monitor respiratory status before, during and afer procedure
Liver biopsy Special considerations
- Must be able to hold breath for 10 seconds
- remain still
- stay in supin or left later position with knees flexed.
- AFTER procedure pt will be on right side for 1-2 hours (compresses liver)
Most common complication from liver biopsy? What do you monitor?
- clotting studies
- abdominal assessment
- frequent VS
Hematocrit normal range is what?
- 40-54% for men
- 36-46% for women
It is a measure of % of RBCs and is 3x's Hgb
Hgb normal values
- Measures 02 carrying capacity
- Males 13.5-18 g/dL
- Females 12-16
- Is 1/3 of HCT
Why would you see increased Hgb levels?
RBC Normal levels
- 4.6-6 in males
- 4.0-5 in females
- Decrease can be from over hydration (IV fluids)
- Increase can be from Dehydration, COPD and High Altitude
WBC Normal and panic level
- Normal is 4,500-10,000
- Panic if less than 500
- 150,000-400,000 is normal
- Panic is less than 20,000
Normal range for Potassium
Whats the most important part of perioperative nursing?
Pt education....decreases returns to hospital!!
#1 Nanda for Peri-Operative care is....
What's immediate post op
Time from PACU until return to regular or outpatient unit
What's Post Operative Convalescent?
- Time from discharge from recovery until till full recovery. Includes:
- Post Op afternoon, evening or night.
It is Post Op Day 1!!!
Post Operative assessment Priority
Post Op how often do you monitor VS?
- q 15min x 4
- q 30 min x 2
- q 1 hour x 4
- Monitoring VS 10 x's total but for 6 hours all together
What does shock look like?
- Low BP
- Weak and rapid pulse
- Cold and clammy
How many rails up after surgery?
Pre Op labs
- Serum Electrolytes
- Blood type
- Chest X Ray
Nursing assessments and interventions for the inflammatory response
- Erythema (redness)
- reduced function
When is a fever normal and abnormal after surgery?
First 24-48 hours it's an adaptive response to illness and is NORMAL
After 48 hours it could indicate infection so need to monitor temp q 2-4 hr
What can result from a fever?
A condition when immature neutrophils (bands) are released from the bone marrow in response to low neutrophil count. Means bacterial infection is taking over and possible sepsis
Increased Leukocyte count means
Low RBC, WBC and Platelet count
Who gets Degenerative Joint Disease?
How old and why?
- decreased estrogen and calcium
Herberdens and Bouchards Nodes
Herberdens are found in the Distal part of fingers
Bouchards are found in the proximal part of fingers/hands
crackling sound produced by joint bones rubbing together
- Blocks pain
- Liver Failure
NSAIDS Does what
- anti inflammatory
- gastric upset, HTN
Cox 2 Inhibitor drug is called?
what does it do?
- Anti Inflammatory
- Renal Failure
Opiods do what?
- Vicodin, Norco
- Block pain
- *Dont put a heating pad on site....wont feel skin burning
What diagnoses joint problems?
What scrapes and removes degenerated bone by arthroscopy?
Removal of a damaged synovial membrane
Whats it called when a bone is cut and a wedge is removed so a joint can be realigned?
Joint fusion or putting a rod in the joint
Total joint replacement:
knee, hip, shoulder, finger, wrist, ankle
How do you decrease risk for infection pre op?
Prophylactic IV treatment
What are people at risk for when have joint surgery?
PE or Fat embolus
Abductor pillow does what?
Prevents the leg from ADDUCTING!
How do you properly use a walker?
Walker forward...affected foot to walker, good foot to walker
used for knee replacement...it prevents scar tissue and reduces stiffness.
On for 8-12 hrs a day.
20-30 degree angle flexion and 0 extension, two cycles per minute
Before a knee replacement pt can leave what must the new knee be able to do?
Extend the knee fully and flex the knee 90degrees
How long is a knee replacement pt in the hospital?
- Absorbs water in to stool
- Give one full glas of water with each dose
- Docusate Sodium/Surfak/Colace
- Lowers surface tension of feces....makes soft
When do you use Surfak?
Pt with cardiac failure, htn, edema or kidney problems
When should you use Colace cautiously?
When a persons on anticoagulants....cuz it blocks vitamin K and other fat soluble vitamins and makes them more susceptible to bleeding
- Mineral Oil
- Makes stool slippery
Administer on an empty stomacy, only to pt who dont have a swallowing problems and same anticoagulant problem
- MOM and Go Lytely
- Increase fluid bulk in feces by pulling H20 thru intestinal walls by osmosis
Can cause gas and cramping
Stimulant (chemical irritants)
- Dulcolax and Ex Lax
- Increases peristalsis by chemical irritation to bowl nerve endings
Problems with Dulcolax and stimulants
Abused the most
dont crush or chew them....and dont give within 1 hour of milk or antacids
Dont use if person has obstipation or fecal impaction
- Bowel obstruction with no known cause
- Rigid Stomach
Labs to be done with a pt who has diarrhea
- Stool for occult blood, ova and parasites
- Fecal Fat
Upper GI Diagnostics:
- Pt. will do a barium swallow
- NPO 8-12 hours prior (midnight)
Drink lots of water after....or get constipated
Lower GI Diagnostics
Enemas or Laxatives usually ordered pre care
Post care may have need more laxatives (contrast medium causes impaction)
may be tired and need a ride home
CT Scan WITH CONTRAST ONLY.....pt will
drink 1 litre of water prior to procedure
Must check Bun and Creatinine
NPO 8 hours prior to exam and after NPO till gag reflex returns
Looks at bleeding inflammation, masses, tumors and polyps
Pre and Post Care
Looks at Stomach and Duodenum
NPO 8 hours before exam and NPO after till gag reflex returns
Pre and Post care
Views GB, liver, pancrease using DYE to see organs
NPO 8 hours before exam and post until gag reflex returns
Sigmoidoscopy, Colonoscopy and Proctoscopy
Which procedure has conscious sedation only?
Enemas and laxatives
Watch for fluid and electrolyte abnormalities
Colonoscopy is the only one with conscious sedation
Auscultating the abdomen and bowel sounds
When can I say NO BS?
Normal 5-35 per min
Hyper is more than 35
Hypo is less than 5
Listen in each quadrant for 2 min...then nothing say NO BS
Where are bowel sounds loudest?
Where will I feel fecal mass?
RLQ is loudest
Fecal mass is LLQ
Presbyopia and Presbycusis
Aging of the eyes and ears
Spices assessment in an older adult
- Sleep disorders
- Problems with eating or feeding
- Evidence of falls
- Skin breakdown
Why are elderly more susceptible to temps?
Decreased touch receptors....so use heat/cold therapies with caution
Bath water should be btwn 100-105
Changes in sleep for elderly...what are they and is it normal?
- It is NORMAL
- cant fall asleep
- decreased REM
- increased awakenings
Why are elderly more at risk for UTI's?
Decreased renal function: decreased number of nephrons, decreased GFR
Decreased bladder capacity and muscle tone
Decreased urinary sphincter control
Is incontinence normal in the elderly?
Since urination is difficult in older men due to prostate enlargement what do I encourage when peeing?
Stand and tip forward
4 common health problems in elderly
- Impaired Immobility
- Sensory perceptual deficit
- impaired thought process
- Impaired nutrition
a bised or negative attitude based on age which leads to discimination in the care of the older adult
Eriksons Developmental theor for Elderly
- 65 to death
- Integrity vs. Despair
Feels a sense of fulfillment and contentment and has no desire to make major changes.
Integrity is achieved with successful completion of previous stages, self acceptance and doesnt fear death
Despair has regret, bitterness and anger, focused on past failures, fears death and may consider suicide
Cascade disease pattern in older adults?
- Symptoms will cascade
- Have incontinence, get a folw, get a UTI
Suggestions to promote health and prevent health problems in elderly
- Maintain sufficient intake of protein, calcium and vitamins
- 400 IU of vitamin D daily for calcium
- Be active physically ...but rest too
- Encourage canes, walker if needed
Advantages of physical activity in elderly
- Muscle atrophy
- CARTILAGE DEGENERATION
- Joint Stiffness and decreased flexibility
- Hunch back
50% of physcal decline of elderly is caused by...
disuse...rather than aging process or illness
How can you help an elder learn?
- Give time to complete tasks and process questions
- Keep teaching sessions short and allow time to practice
- Write instructions simply
What can cause short term and reversible acute delirium, and confusion in the elderly?
Elderly are at HIGH risk for injury, especially Falls, how can you prevent in the hospital?
- orient client to environment
- adequate lighting
- consistent caregiver
- bed in low position
- clear path to bathroom
- call light in reach
- use glasses and walkers
Why are psychoactive meds given in lower than normal doses in elderly?
brain receptors are more sensitive so they are more potent
What makes elderly at risk for med intoxication due to absorption issues
Generally not a problem
What makes elderly at risk for med intoxication due to Distribution in the blood issues?
- Decreased cardiac ouput
- decreased lean muscle mass and increased adipose tissue
- Decreased total body water
- REDUCED concentration of SERUM ALBUMIN
- Less affective blood brain barrier
What does albumin do with meds?
It is what the drug binds to...so if less then it just floats around and accumulates
What makes elderly at risk for med intoxication due to metabolism problems
Drugs half life is increase causing prolonged drug effects
Deconed ability to transform active drugs to inactive metabolites
What makes elderly at risk for med intoxication due to excretion problems?
50% decline in kidney and function causing:
- Longer biological half life
- Prolonged and elevated plasma level of bdrugs
- Accumulation of drugs leading to toxicity
the use of multiple meds to one patient who has more than one health problem
What the % of elder hospitalized related to drug reaction?
How can I make sure elderly administer meds safely?
- Reduce meds that arent essential
- Assess alcohol use
- Encourage written reminders
- Encourage use of one pharmacy
Prevelance of pain is how much HIGER in elderly?
What makes elderly suicidal?
- Low SES
- poor social support
- Recent unexpected event
Normal oral temp in elderly 85 and older is
Ideal method for taking a temp in a thing frail old person
A Temp of 101 in a 97 yr old man whose normal temp is 96 would be equivelant to what temp in a younger adult whose normal temp is 98.6?
Respirations in those over 85 are usually:
Faster and more shallow....watch abdomen rise and fall, not chest
When is it more indicative or possible problems for a fever?
Morning or night
What affects pulse rate?
More than just aging
Normal pulse pressure in the old old?