Nurs509A Exam 2
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Centering Health Care
- Health and illness is on a spetrum
- excellent health to gravely ill
Dunns Health Grid
- Environmental Axis: favorable to not favorable environment
- Health Axis: death to peak wellness
- a balance of input and output
- when energy output exceeds input=illness
- more energy generated than expanded=wellness
- Biological (genetics, gender, developmental stage, age)
- Physical Activity
- Sleep and Rest
- Meaningful work
- Gordons Function Health patters
- Lifestyle choices
- family relationships
- environmental factrs
Growth and Development
- Growth from health, chest, trunk then lower extremeties
- Development: center of body out
Robert Havinghust's Developmental Tasks
Six stages: infants/toddlers, preschool and school age, adolescents, young adults, middle adults, older adults
Sigmund Freud psychoanalytic theory
Jean Piagets Cognitive Developmental Theory
Erik Eriksons psychosocial development theory
- Stage 1 (birth -18 mo.): Trust vs. mistrust
- Stage 2: (18-36 mo.): Autonomy vs. shame and doubt
- Stage 3: (3-5 years): Initiative vs. guilt
- Stage 4 (6-11): Industry vs. inferiority
- Stage 5: (11-21): Identity vs. role confusion
- Stage 6 (21-40): Intimacy vs. isolation
- Stage 7 (40-65): Generativity vs. stagnation
- Stage 8 (over 65): Integrity vs. despair
Cardiovascular Disease (CVD)
- number one and number two cause of death at a global level by year 2020
- >90% risk
- abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits/veg., alcohol, physical activity
- health promotion before primary, secondary, tertiary interventions
- preventing risk factor epidemics
- smoking health line
- smoking is one of the leading preventable causes of death
- by age 5
- By the age of five, a child who lives with at least one person who is a smoker will have inhaled the equivalent of 102 packs of cigarettes
By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calculated for all ages, both sexes.
- Two-thirds of adult Americans are either overweight, obese, or severely obese
- One in three American children born in 2000 will develop diabetes in their lifetime. Among African American and Latino children, that number is one in two.
- Underweight: <18.5
- Healthy Weight: 18.5-24.9
- Overweight: 25.0-29.9
- Obese: 30.0-39.9
- Extremely Obese (Severe Obesity): 40.0 +
Maslows Hierarchy of Needs
Stages of Illness Behavior
- experiencing syptoms
- sickrole behavior
- seeking professional care
- dependence on others
occurs suddenly and lasts for a limited amount of time.
- lasts for a long period of time, usually 6 months or more, often for a lifetime
- life changes
symptoms are minimal to none
- age-realted reduction of muscle mass and/or function
- from decrease protein synthesis and increae protein degradation
pyscho issues reduce physical activity
- deterioration and abrasion of joint cartilage, new bone formation at the joint surfaces.
- 55 yrs, more in women
RA- causing inflammation (synovial fluid hypertrophies_ deformity and crippling. 20-40
- demineralization of the bone, decrease in mass and density
- lack calcium, excessive calcium loss, poor absorption.
excess uric acid accumulated in blood-uric acid deposits around joints causing severe pain.
Medicare Never Events
- serious injury or death
- falls, burns, restrains or bedrails
Safety Nursing interventions
- Falls (put on socks, shoes before walking)Never events
- equipment related accidents
- fires and electrical hazards (RACE-rescue, activate, confine and extinguish)
- back injury
- needle stick injury
- radiation exposure
- workplace violence
- harmful chemical ro waste material discharged into the air, water or soil
- air pollution
- water contamination
Hospital Never Events
- -foreign object lfe in patien during surgery
- air embolism
- administer wrong type of blood
- severe pressure ulcers
- infection from catheter or IV
- symptoms poor sugar control
- DVT or PE following total hip/knee replacement
Morse Fall Scale
- does patient have history of falling
- one or more medical diagnosis
- ambulatory aids
- IV line or heparin lock
- gait normal
- mental status
- four risk factors the chance of falling is over 60%; an example might be a client with
- taking numerous medications
- having moderate weakness in the legs
- bathing without grab bars/bath mat or using a low commode
Hendrich II assessment tool
- fall risk factors
- symptomatic depression
- altered elimination
- administered antiepileptic or benszodiazepine
- get up and go test (ability to rise)
- Metabolism & GI:
- -slows peristalsis leads to constipation, gas and difficulty evacuating stool
- -increase lactic acid and decreases ATP
Respiratory: decrease strength of muscles in chest expansion-effects ventilation, decreased ability to cough and red secretions
Cardio: increase workload of heart
Urinary: kidney stones, stasis means UTI
Integumentary: pressure ulcers
Psych: isolation and mood changes
Metabolic: decrease BMR, fluid/electrolyte imbalance
Nutrition: decreased calorie and protein, GI, nitro balance
collapse of alveoli leading to partial collapse of lung
due to lack of exercise and movement
inflammation of lung tissue from stasis or pooling of secretions
due to lack of exercise and movement.
when patient goes from laying down to sitting to standing and blood pressure drops, cant compensate
duet to lack of exercise and movement
deep vein thrombosis
due to lack of exercise and movement
stasis and clotting leads to DVT.
Lack of movement interventions for Respiratory
- head of bed up
- frequent turning
- cough, deep breathe
- incentive spirometry
- avoid dehydration
Lack of movement interventions for Cardio
- sit up in bed
- isometric exercises
- avoid a Valsalva maneuver (bearing down)
- can cause arrhythmia
- decrease BP
- TED hose
- Pneumatic compression devices
- Early Ambulation
Lack of movement interventions for Musculoskeletal
- early mobilization
- body alignment
- frequent turning (every 2 hours)
Lack of movement interventions for Skin and Urinary
- Urinary: hydration, commode, limit catheterization
- Skin: position change, skin care, skin assessment (Braden Scale)
Increase Mobility: exercises
- Quads: push down with knees and flexi feet.
- Gluteal muscles: pinch her buttocks together.
- Arm Exercises Biceps: install a trapeze bar, or encourage lifting of objects like water bottle
- Triceps: lift upper body off the mattress by pressing with palms.
- Dangling - a seated position at the side of the bed. Helps avoid orthostatic hypotension when first getting up.
- Allows patient to experience being upright with limited risk of falling.
Wound Healing Process
- Inflammatory Phase: clean wound, stimulate fibroblasts (vascular phase, cellular phase)
- Proliferation Phase: fibroblasts synthesize collagen, secrete it, granulation occurs
- -granulation fibroblasts collagen formation
- -contraction edges come together
- epithelialization new later
- Maturation or remodeling: remodeling of collagen, increase tensile strength
- edges close together or wound brought together with sutures
- less chance of infection
- wound not closed
- tissue loss
- wound can become infected
- slower healing
- Skin surrounding wound
- Patient Response
Risk Factors Pressure Ulcers
- poor nutrition
- impaired cognition
- impaired circulation
- fever, rash, itching
- impaired sensation
Extrinsic: pressure, friction (damage outer layer), shearing (epidermal layer slides over dermis case damage to vascular bed), moisture
Pressure Ulcer Staging
- STAGE I. Nonblanchable erythema of intact skin: heralding of lesion of skin ulceration. The reactive hyperemia lasts 30 minutes beyond removal of pressure.
- STAGE II. Epidermis is broken, superficial lesion, non-measurable depth. Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
- STAGE III. Full thickness skin loss involving damage or necrosis down through dermis and may include subcutaneous tissue that may extend down to, but not through, underlying fascia.
- STAGE IV. Full thickness skin loss with extensive destruction extending into supportive structure such as muscle, tendon, bone and have various sinus tracts.
Note: the lost muscle, fat and dermis can’t be replaced, but only granulated - fills defect. So chart “healing stage 4 ulcer occurring”.
- at each dressing change
- clean with saline water
Donning Sterile Gloves
- Wash hands
- Place glove wrapper on a dry surface
- Touch only the outside of the glove packaging
- Remove one glove without touching the inside of the wrapper
- Hold the glove by the folded-back cuff
- Slip the dominant hand into the glove Slip fingers of the gloved hand under the cuff of the sterile glove
- Slip the non-dominant hand into the glove
- Adjust gloves as necessary protecting gloved fingers with the sterile fold of the cuff
Client With One Sided Weakness
- Stand on client weak side
- Use gait belt
- One hand around client waist
- One hand around client arm and supporting axilla
- Get help if needed to ambulate
- Use cane on strong side
- For maximum support: move cane, weak leg, strong leg
- Need two points on ground at all times
- Measure client height, angle of elbow flexion, distance between crutch pad and axilla
- Length of crutch is 3-4 finger widths below axilla to a point 6” lateral to heel
- Client must not bear weight on axilla but on hand grips with elbows flexed
- Belief: something that is accepted as true with emotion or spiritual sense of certainty.
- value: accepted principle or standard of individual or group
- Spirituality: way of living come from values, meanings, and beliefs that are important to the person.
- Morality: practice of behavior that furthers the common good and is based on philo and theological principles. good conduct
- Religion: the belief in a supernatural power that has created the universe and has involvement in human life.
- Faith: inner knowing about ideas, people, events.
Self Perception Self Concept Pattern Definition:
- Self-Identity: body boundary that defines the person, distingushing the self from nonself.
- Self-Esteeem: these are the thoughts and feeling that comprise self evaluation
- Self-competency: self evaluation of capabilities: cognitive, social, and physcial
- Body Image: mental picture of one body related to apperacne and function.
Sizing walking aids
- canes: inches from side of foot. 30 degree flexion of elbow
- Walkers: at hip joint, hold with 30 degree flexion of elbow
- Crutches: measure distance between heel and anterior fold of axilla and add one inch. 4-6 inches from side, 3 fingerbreaths below axilla
- outer 1 inch is contaminated
- first glove: slide dominant hand into gloves keeping hand and fingers above waist and away from body.
- 2nd glove: slide your gloved fingers under the cuff of the glove for the nondominant hand, keeping gloved the well away from you ungloved hand. lift up and away from table.
Setting up sterile field
- only sterile items should enter a sterile field. any compromise in packaging means that the items is assumed not to be sterile.
- open flap away from you first
- 1 inch form the table edge is considered unsterile.
- check for iodine, latex allergies
- iodine: front to back
- Women: far labium majora, near labium majora, inside far labium, inside near labium and directly down the center
- insert until see urine flow, then 2 inches after that
- Men: uncircumcised pull back foreskin. clean glands in circular motion. hold penis at 90 degree angel. insert until bifurcation.
Prevent UTI: keep everything connected, empty at least every 8 hours, keep back below bladder. if soiled clean with soap and water.
Maintain free flow of urine: bag below bladder, clamp catheter if above bladder
- drink plenty of fluids
- maintain skin integrety
- look for signs of UTI
- pelvic flood muscle exercise.
- hold 5-10 seconds
- 40-60 reps
44% of victims are under under 18, 80% are under 30
one of every six women in US have survived rape or attempted rape.
- IPV (intimate partner violence): one in four women in US experience some form of domestic violence in her lifetime.
- unwanted pregnancies put women at higher risk for IPV: 4 times greater
- 10-30% of adolescents have experienced IPV
- S&S: forced to dress a certain way, strict gender roles, sexual insults, forced into having sex, insist on sec when ill, tired, harm, involve other ppl, controls birth control, disregards your feelings during sex.
- Tier 1: sterilization, IUD, implant
- Tier 2: pill, patch, ring, shot, LAM
- Tier 3: diaphragm, condom, withdrawal, sponge, cap
PLISSIT model of sex therapy
- Permission (required)
- limited information
- specific suggestions
- intensive therapy
Types of Injuries
Partial thickness injury: limited to epidermis and superficial dermis with no damage to dermal layer. Healing occurs by regeneration of epithelial tissue. Examples: Scrapes, burns (formerly termed 1st degree), very early stages of pressure and of venous and arterial ulcers.
Full thickness injury: Involving loss of dermis and extends to deeper tissue layers, disrupts dermal blood vessels. Healing involves synthesis of several types of tissue and scar formation. Examples: Stage 2-4 pressure ulcers, stasis ulcers
dead cells appearing pale, white that is adherent to viable tissue or black
- dry gangrene: dry shriveled, darkened area
- wet gangrene: liquefied underlying necrotic tissue
creamy white, stringy tissue adheres to wound
- fluid, cells that slowly discharged from cells or blood vessels.
- important for moist healing-provides environment for healing.
- need for moist dressings
Pressure ulcer causes
ischemia for prolonged period of time. bony prominence.
- autolytic: occlusive dressing for several days, own body does work (WBC and enzymes). watch for immunocompromised
- Enzymatic: use enzymes to dissolve nonviable tissue. Elase, granule. careful with good tissue
- -wet-dry dressing: most dressing allow to dry, mesh adheres to necrotic tissue. Painful.
- -Hydrotherapy: use syringe use 35 ml with 19 gauge
- -Surgical: use surgical tools
- most environment leads to epithelialization.
- stage 2-3: semipermeable or occlusive dressing
- stage 3-4:
- wet gauze (sodium chloride) then cover with dry
- alginates: fibers from seaweed form ropes form gel like covering keeps moist.
- Foam: nonadherent wafers that absorb, semipermeable.
- Hydrocolloid: gel.
- introduce solution into rectum to softe feces, distend the colon and stimulate peristalsis and evacuation of feces.
- cleansing enemas: sever constipation/impaction
- retention enemas: oil
- no more than 12 inches above
- hypotonic is more common
- law on side, warm solution, hold for up to 15 minutes.
Caring for Stoma
- pay attention to skin around the stoma
- mointor drainage
- immediately report if: pale, dusky, black in color, dry, slough
Testing stool for occult blood
- don't contaminate with toilet paper
- obtain sample
- if turn blue= positive for blood
- drain when 1/3-1/2 full
- 1/16 to 1/8 larger than the stoma circumference.
- place gauze on stoma when measuring to abrob
- womens first awareness of fetal movement
- 18 weeks
conception to onset of labor
- father. symptoms
- loss of appetite, N & V, headache, fatigue, and weight gain
Barriers to prenatal care
- inadequate care
- systemic (miss work for appts, limited childcare, transportation)
- attitudinal: unsympathetic health care workers
At risk for miscarriage criteria
3 sequential SAB (spontaneous abortions)
Presumptive signs of pregnancy
- N & V
- breast changes (2-3 wks)
- fatigue (1st trimester
- urination frequency increase
Probable signs of pregnancy
- Chadwicks sign: bluish/purpose color of vagina, cervix.
- Goodells: softening of cervix
- Hegar's softening of lower uterine segment
- skin: miasma (choasma)-pregnancy mask linea nigra, nipples and areola become darker.
- tests: hCG *(human chorionic gonadotropin
- 1st: LMP through12 weeks
- 2nd: 13 weeks-27
- 3rd: 28-40
- LMP April 27
- -3 months
- January 27
- +7 days
- EDD Feb 3
- produce image
- done for: gestational age, fetal growth, fetal anatomy, placental abnomalies and location
- fetal activity, amount of amniotic fluid
- gestational sac at 5 weeks
- fetal cardiac activity at 6-7 weeks
Nuchal translucency testing
- 11-14 weeks
- maternal blood test (P-APPA and hCG)
- nuchal translucency screen
- increase in both may be down syndrome
- maternal blood four markers:
- AFP, Estriol, hCG, InhibinA
- down syndrome
- then do amniocentesis if positive (needle and get amniotic fluid)
- Fetal lung maturity ratio
- fluid reduction
- chromosomal abnomalities
Chroionic villus sampling (CVS)
- chromosomal abnormalities, metabolic disorders, DNA testing
- aspiration of placental tissue
Cell Free Fetal DNA testing
- fetal dna testing
Fetal Kick Counts
- fetal well being
- identify if potential for hypoxic
- duration 2 hours=10
- duration 1 hour=4
- at 28 weeks
- fetal well being
- increase heart rate
- FHR increases 15 beats above baseline for 15 seconds twice in 20 minute
- less that 32 weeks gestation two peek at 10X10 in 20 minutes
Contraction Stress Test
- fetal oxygenation
- mimic contraction
- monitor FHR for 20 minutes
- no decelerations of FHR=negative (normal)
Amniotic Fluid Index
- volume of amniotic fluid
- 8-24cm normal
- <5cm: oligohydramnios
- >24cm: polhydramnios
biophysical Profile (BPP)
- fetal breathing, gross fetal development, fetal tome, AFI
- with NST
Uterine massage for preventing postpartum haemorrhage
uterine massage given every 10-60 minutes reduced blood loss
Pregnancy Nutritional needs
- additional 300 calories
- weight gain 3.5 during first trimester, and just under 1 pound per week during the rest of the pregnancy
- folic: neural tube defect
- decreased nutrition/protein: spontaneous abortions, dec. brain dev., dec. blood volume, anemia
Stages of fetal develpment
- zygote: fertilization until implantation
- embryo: implantation until 8 weeks
- fetus: 8 weeks to term
bluish/purpose color of vagina, cervix.
Goodells: softening of cervix
softening of uterine isthmus segment
Positive Signs and Symptoms of pregnancy
- auscultate heart rate
- observe fetal movement by HCP
number of pregnancies. regardless of length
number of pregnancies lasted more than 20 weeks, regardless of deliver
- T: number of term births
- P: number of preterm births (born prior 37 weeks)
- A: number of pregnancies under 20 weeks
- L: number of living children
- if mom is Rh neg, dad Rh+ =antibody is produced, need rhogam.
- 2nd child at risk
5 factors affecting the process of labor
- passenger: fetus and placenta
- Passageway: birth canal (most common gynecoid pelvis)
- Powers: contraction, maternal push
- Position: of mother
- Psychological Response: environment
- relation of the presenting part of the fetus
- 0-at ischial spines
- above: negative
- below: positive
largest transverse diameter of the presenting part has passed through he maternal pelvis brim into the true pelvis.
Signs and Symptoms that Precede labor
- back,sacroiliac pain
- B-H contractions
- increased vaginal discharge
- weight loss
- burst of energy
- ROM (rupture of membrane)
- GI signs and smptoms
Hormonal changes labor onset
- increase in estrogen and prostaglandins
- decrease in progesterone
- fetal firbronectin protein: positive go into labor in 2 wks
- aging placenta
- uterine distension
Stages of labor
- 1st: onset of contraction (latent: <3cm, active 4-7cm 6-24 hrs, transition 8cm to complete 3-6 hrs)
- 2nd: dilation of cervix to birth of fetus (latent rest, labor down; active is pushing)
- 3rd: birth of fetus to delivery of placenta
- 4th: last about 2 hrs, bonding of baby.
open circulator path between placenta and fetus through umbilical vessels
with contractions compress arteries-temporarily stops blood flow
- well being: normal baseline, accelerations, absence of decelerations with or without contractions
- compromise due to: hypoxemia, reduced blood flow, reduced oxygen if mom anemia or hemorrhage, alter fetal circulation (cord)
Types of fetal Monitoring
- External fetal monitor: no impact on mobidity/motality
- Fetal Scalp Electrode (FSE): internal heart monitor
- Intrauterine pressure catheter (IUPC) internal contraction monitor
Fetal Heart Rate ranges
- 110-160 BPM
- between contractions
- tachycardia above 160
- bradycardia below 110
- schultze (shinny)-against uterine wall
- Duncan (dirty)
- bleeding after detachment of placente
- shouldn't cover more than a full pad in an hr.
- determine fetus location in the fundus
- determine location of fetal back
- presenting part
- location of cephalic prominence.
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