Nurs 226 MIDTERM

Normal Range

• Temp

Normal Range

• Temp

96.8° - 100.4°F

Normal Range

• pulse

60/100 beat/min

Normal Range

• RR

12-20 breaths/min

Normal Range

• Pulse Ox

95%-100%

Normal Range

• pain

scale from 0-10

Classifications of Pain

• Cutaneous/Superficial

• localized

• short duration (needle stick)

Classifications of Pain

• Deep Somatic/ Visceral

• pain from internal organs

  • can diffuse/radiate

Classifications of Pain

• Radiating

• pain extending from 1-side to another

Classifications of Pain

• Referred

• pain is separate from the source

Classifications of Pain

• Phantom

• pain in a limb is NO longer there

Classifications of Pain

• Psychogenic

• brain causes pain when there is NO source

NONpharmacological interventions for pain

• relaxation/guided imagery

• music/humor

• journaling

• massages

• cold/hot compress

Non-Opiod Analgesics

• NSAIDS

• Acetaminophen

Opioids

• Narcotics

• PCA pump

Adjuvant

• antidepressants/anti-seizure

• muscle relaxants

• steroids

ABCDE

A-ask ab pain regularly

B- believe patient in their pain report

C- choose pain control options appropriate for patient

D- deliver interventions timely, logical fashion

E- empower patient and family

body’s reaction on UNRELIEVED pain

• increased HR, BP and O2

• increased cardiac workload

• shallow breathing

• depression/anxiety

When documenting pain, make sure you document…

• pain assessment

• pain management

• patient response to pain & treatment

• updated pain assessment

__A__DPIE

• A

Assessment

• gather information on patient’s condition

A__D__PIE

• D

Diagnosis

• what is the problem?

AD__P__IE

• P

Plan

• how do we fix the problem?

ADP__I__E

• I

Implementation

• put plan to action!

ADPI__E__

• E

Evaluation

• did the plan work?

PURPOSE of nursing diagnosis

classify health problems within the domain of nursing

What is a Nursing Diagnosis?

a statement of patient’s health status

• NURSES can identify, prevent, and treat independently

Medical diagnosis

From a Doctor

• defines a medical condition/disease/ or injury

TYPES OF NURSING DIAGNOSIS

• Problem-Focused

based on response to existing problem

TYPES OF NURSING DIAGNOSIS

• Risk diagnosis

increased potential for patient to develop a problem

TYPES OF NURSING DIAGNOSIS

• Health Promotion

represents patient’s desire/motivation to improve their health

Formulating an ACTUAL DIAGNOSIS (3pts)

• problem

• related factors

• defining characteristics

Formulating a RISK NURS. DIAGNOSIS (2pts)

• problem

• related factors

Classification of Priority

1. Emergent, Urgent, Non-urgent

2. ABC’s

3. Maslows Hierarchy

4. Chronic vs Acute

“SMART" acronym

• for Goals

Specific

Measurable

Attainable

Realistic

Timely

Selection of Intervention

• DARFCH acronym

• __D__esired patient outcome

• __A__cceptability to the patient (doing good by them)

• __R__esearch-based knowledge (for intervention)

• __F__easibility of intervention

• __C__haracteristics of Nurs. Diagnosis

• __N__urse competency

TYPES OF INTERVENTIONS

• Nurse Initiated

independent

• actions a Nurse initiates

TYPES OF INTERVENTIONS

• Health- Care provider initiated

dependent

• requires DR order

TYPES OF INTERVENTIONS

• Collaborative

INTERdependent

• required combined skill & knowledge

What is Direct Care?

treatments preformed through interaction WITH patient

What is Indirect Care?

treatments preformed away from the patient (but on behalf of the patient)

4 indicators for comprehensive evaluation

• ECRU

1. __E__xamine results

2. __C__ompare achieved effects with goals

3. __R__ecognize errors

4. __U__nderstand patient situation

FACTORS INFLUENCING HYGIENE

• social practices

ex: do you showering everyday?, wake up & brush teeth?, etc..

FACTORS INFLUENCING HYGIENE

• socioeconomic status

can person afford hygiene products?

FACTORS INFLUENCING HYGIENE

• developmental stage

look @ who the patient is

• child/toddler

• cognitive: is patient confused?

FACTORS INFLUENCING HYGIENE

• physical condition

• is patient physically able to clean themself?

partial bed bath

face, pits, ass, perineal area, feet, hands, etc..

CHG bath

antimicrobial bath

sitz bath

usually for women who just gave birth

or

patients with hemorrhoids

tub bath

usually only seen in long term care

What does patient need in order to be cleared for a shower

Need a physician’s orders

• fall risk

what is infection

invasion of a susceptible host by a pathogen

Colonization

WITHIN HOST

• NO tissue damage

• NO active disease

Communical disease

able to MOVE from PERSON TO PERSON DIRECTLY

STAGES OF INFECTION

• incubation

time it takes for infection to develop AFTER EXPOSURE

STAGES OF INFECTION

• prodromal

AFTER INCUBATION → infection agents replicate/multiply

STAGES OF INFECTION

• Illness

presence of specific signs/symptoms of disease

STAGES OF INFECTION

• Convalescence

symptoms resolve, patient begins to return to normal function

TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS

• exogenous

from OUTSIDE source (salmonella, tetanus, etc…)

TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS

• endogenous

flora becomes ALTERED

• OVERGROWTH occurs

• caused by antibodies

TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS

• Iatrogenic

due to invasive procedure

Physical/chemical barriers

skin, tears, mucus, cilia, stomach acid, urine, neutrophils

non-specific innate

barriers that keep harmful materials from entering your body

specific adaptive

antibodies that attack and destroy foreign invaders and are able to prevent disease in the future by remembering what those substances look like

CHAIN OF INFECTION

• infection agent

• pathogens

• normal flora become infected

• Virulence (ability to produce disease)

CHAIN OF INFECTION

• reservior

Source of infection

• location where that pathogens thrive (warm&dark)

• anaerobic VS aerobic (requires O2 for growth)

CHAIN OF INFECTION

• Portal of entry

how infection spread and exits

CHAIN OF INFECTION

• Mode of transmission

  • contact

direct: touching, kissing, sex

indirect: doorknob (inanmiate object)

CHAIN OF INFECTION

• Mode of transmission

  • droplet

water droplets inhaled/entered thru eyes

• ex: cough, sneeze, inhaled sputum

CHAIN OF INFECTION

• Mode of transmission

  • airborne

through particles in the air

• ex: TB, COVID, measles

CHAIN OF INFECTION

• Mode of transmission

  • vector

from a tick/mosquito bite

CHAIN OF INFECTION

• Mode of transmission

  • Vehicle

from dirty instruments or needles & soiled linens

TRANSMISSION BASED PRECAUTIONS:

• Contact precautions

• private room

• clean gown/gloves/face shield

• double-bag linen

TRANSMISSION-BASED PRECAUTIONS:

• Droplet precautions

• same as contact precautions

• clean gown/gloves/face shield/EYE PROTECTION/MASK

TRANSMISSION-BASED PRECAUTIONS:

• Airborne precautions

• same as contact

• special room and mask

Protective Isolation

for ANY immunosuppressed patients

• prevent spread of any microorganism to these patients

Protective Isolation precautions

• room w/ air filters

• avoid standing H2O (humidifier)

• restrict visitors

How do you break the chain of infection

• promote ASEPSIS

• support Host defense

Medical Asepsis

state of being free from disease causing microorgansims

Surgical Asepsis

removing ALL microorganisms (used for sterile procedures)

cardiopulmonary structures

heart, blood vessels, trachea, lungs, and bronchi

cardiopulmonary functions

• responsible for picking up & carrying O2 to cells

• discarding CO2

Ventilation

movement of air IN and OUT the respiratory system

Perfusion

circulation of blood thru vessels or other natural channels

Exchange of Respiratory Gases

O2: bloodstream → lungs

CO2: lungs → blood

FACTORS THAT INFLUENCE OXYGENATION

• physiological

• cardiac disorder

• respiratory alterations

• decreased O2 carrying capacity

• decreased inspired O2

• increased metabolic rate

Hypovolemia

decrease in circulating blood volume results in hypoxia to body tissue

hyperventilation

ventilation in excess of that requires to eliminate CO2 produced by cellular metabolism

hypoventilation

alveolar ventilation inadequate to meet body’s O2 demand of to eliminate

Lifestyle factors

• nutrition

• lack of exercise

• smoking

• substance abuse

• anxiety/stress

Environmental factors

• air quality

• urban VS rural

• occupational hazards

developmental factors

• premature infants (they ”forget to breathe”)

• infants & toddlers (smaller shorter airways)

• children & adolescents (2nd hand smoke, vaping, respiratory infection)

• young/middle age adults (smoking?)

• older adults (decreased muscle mass)

purpose of oxygen therapy

prevent/relieve hypoxia

Methods of O2 delivery

• nasal cannula (NC)

• oxygen mask

what is the % of O2 in room air

21%

Simple Mask

short term supply

• 6-12 L

• 35-50% O2

  • long term may cause skin breakdown

Venturi Mask

delivers precise concentration

• 4-12 L

• 24%-60% O2

Non-rebreather and Partial breather

for higher O2 concentration

• 10-15 L

• 60-90% O2

  • level of O2 will depend on PT’s overall health

• reservoir bag should be filled with O2 @ all times

How do you liquefy secretions?

humidify O2 & offer fluids to patient

what does liquefying secretions do?

thins out secretions → this then allows patient to cough up secretions

Chest PT

helps loosen & move secretions so they can be coughed up

LUNG EXPANSION

• Ambulation

change of position