foundations theory exam 2

how much urine should the kidneys produce per hour

30 mL per hour (if less something is wrong)

gastric residual volume must be below ___ before tube feeding

500mL

how much should the bladder fill for a strong sense of urgency

400-600 mL

urinary retention

• inability to empty the bladder partially or completely

• acute or chronic

functional incontinence

loss of continence due to causes outside urinary tract

• cognitive impairment (dementia, delirium)

• manual dexterity (arthritis, fracture)

• altered mobility

• environmental barriers

ureterostomy

urinary diversion

• permanent incontinent urinary diversion created by transplanting ureters into a closed off part of the intestinal ileum and bring the other out to abdominal wall forming a stoma

• anterior

nephrostomy

urinary diversion

• small tubes that are tunneled through the skin into the renal pelvis. tubes placed to drain the renal pelvis when ureters are obstructed

• posterior

• pt education needed

• reversable

types of catheterization

• intermittent/ straight- no balloon

• double- lumen- used in lab; y shape port

• triple lumen- used for continuous bladder irrigation

• suprapubic- inserted surgically into bladder through the abdominal wall above the pubic symphysis

bowl diversions require what

lots of patient education and body image help;

irrigation and cleaning; nutritional considerations; psychological considerations;

meticulous skin care

empty pouches when 1/3 to 1/2 full to avoid leakage

colostomy

hard stool; external bag

ileostomy

liquid stool

cleansing enemas

tap water, normal saline, hypertonic solutions, soapsuds

if patient has a cardiac disease or takes cardiac/ hypertensive medications

obtain a pulse rate

• manipulation of rectal tissue stimulates the vagus nerve and can cause sudden decline in pulse

The Joint Commission

promote patient education in learning through speak up initiatives (police of hospitals)

• process: sender » message → receiver → feedback

  
  

three purposes of patient education

• health promotion

• restoration of health

• coping with impaired function

what to assess for willingness to learn

• physical readiness (strength/ condition and pain)

• emotional readiness (no negative feedback, be supportive and do not relate to yourself)

• cognitive readiness (assess intellectual development before beginning teaching plan)

nursing process v. teaching process

nursing process

• reveals the patient’s health needs, objective/ subjective/ observation/ assessment

teaching process

• begins when education becomes a part of the care plan; consists of a deliberate set of action,

• learning represents a change in behavior

learning needs

• assess level of understanding

• assess past medical experiences

• assess patient and family emotions

• assess patient and family sense of responsibility for their health

learning principles

• motivation to learn (direction of behavior, perception, preferences)

• readiness to learn (willingness to engage)

• ability to learn (cognitive ability)

• learning environment (room comfortable, clean, and free of distractions, 15-30 min)

factors that influence adult’s readiness to learn

motivation, relevance to their life experiences, perceived usefulness, self-directed learning, sense of control, prior knowledge and experience, personal goals, positive self concept

preschool developmental age: 3-5

children need to begin asserting control and power over the environment

middle school developmental age: 6-11

children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills

teen developmental age: 12-18

developing a sense of personal identity which will continue to influence behavior and development for the rest of a person’s life

adult developmental age

4 assumptions

self concept (dependence v. independence), previous experiences, readiness to learn, material usefulness

self efficacy

verbal persuasion, vicarious experience, enactive mastery experience, psychological and affective states; how and when

health promotion

a strong predictor of healthy behaviors and improves self efficacy, resulting in improved lifestyle choices; education

assume adult reading level is

6th to 8th grade level

• work simple to complex, utilize visual aids appropriate to what you are teaching

health literacy

repetition and clarification; teach back; visual aids; patient centered care; non judgmental environment

3 domains of patient instruction

cognitive (understanding), affective (attitude), and psychomotor (motor skills)

*cognitive domain

6 mental skills to develop ability to recall data and information

1. knowledge/ remembering

2. comprehension/ understanding

3. application

4. analysis

5. synthesis

6. evaluation

affective domain

receiving, responding, valuing, organizing, internalize values

psychomotor domain

guided responses (immediate positive feedback), mechanism (higher order), adaptation

cultural barriers

social behavior, laws, customs, beliefs

how people express themselves, language differences, resource availability

do not go against culture → help them find resources

short term v. long term outcomes

both- time oriented, realistic, measurable, written as patient behaviors

short term- withing 24 hours

long term- by discharge

how to prioritize outcomes

1. assess the patient’s individual needs and literacy level

2. identify the most critical information related to their condition and treatment plan

3. tailor educational materials and delivery methods to ensure understanding and engagement

4. regularly evaluate comprehension to ensure desired outcomes

5. if not achieved, document and modify

nursing diagnosis domains

1. cognitive domain- knowledge deficit r/t newly diagnosed or newly prescribed therapy

2. affective domain- knowledge deficit r/t misunderstanding of prognosis

3. psychomotor domain- knowledge deficit r/t inexperience with skill

intervention criteria

apply to the nursing diagnosis

outcomes

comprehensive

specific

pertain to the objectives

rationale

scientifically accurate- an explanation that rationalizes the need to do something

pharmacologic based- moa of the drug, nursing indications, S and S of the drug

physiologic based- the infection and inflammation are causing the lung tissue to have overproduction of mucus

support- the patient’s medical problem

teach back

evaluates the success of a teaching plan; reinforces health behavior; affirms level of success

zones of personal space

intimate- 0-18 inches

personal- 18-40 inches

social- 4-12 feet

public- 12 feet or more

phases of nurse-patient relationship

preinteraction

orientation

working

termination

barriers to effective communication

sociocultural, cultural, and language factors

to correct errors properly…

draw a single line through the error, initial, and date

erickson develompmental stage of older adults

integrity v. despair

older adults reflect on life, meaning, accomplishment, losses, changing roles, living arrangements, and maintaining purpose

*tool for geriatric assessment

SPICES

sleep disorders

problems with eating or feeding

incontinence

confusion

evidence of falls

skin breatdown

age related cardio changes

• arterial stiffness (higher systolic BP)

• reduced baroreceptor response (orthostasis)

• reduced cardiac reserve (less tolerance for stress/ fluid shifts)

age related respiratory changes

• stiffer chest wall and reduced elastic recoil

• weaker cough/ respiratory muscles

• lower reserve (greater impact of infection, sedation, immobility)

age related renal/ urinary changes

• lower renal blood flow/ filtration

• reduced concentrating ability (dehydration risk)

• drug clearance may decline (new incontinence/ retention requires assessment)

age related skin changes

• thinner, drier, more fragile, less elastic skin

• less subcutaneous tissue

• greater risk for tears, bruising, pressure injury, temperature intolerance (wet skin breaks down more easily)

age related musculoskeletal changes

• sarcopenia and decreased strength

• reduced bone density and joint flexibility

• balance changes (fall/ fracture risk: avoid unnecessary bed rest)

  • bed rest causes muscles to atrophy quickly

age related GI/ nutrition changes

• slower motility (constipation risk)

• dentition, dry mouth, dysphagia, meds may reduce intake

• unintended weight loss is concerning (not normal aging)

age related vision changes

• presbyopia and slower dark adaptation (slight decrease normal)

• glare sensitivity/ reduced contrast

• provide lighting and access to glasses

  • all sudden changes need to be addressed right away

age related hearing changes

• presbycusis: high frequency loss

• background noise worsens comprehension

• face patient: speak clearly/ do not shout

age related neuro/ sleep changes

• processing/ reaction time may slow

• major cognitive loss is NOT expected

• sleep may be lighter; sudden mental status change requires assessment

the 3 Ds

• delirium- medical urgency- acute onset; fluctuating course, impaired attention/ awareness; find and treat cause immediately

• dementia- gradual, progressive cognitive decline; interferes with function; calm, simple communication; routines; support remaining abilities

• depression- not normal aging; mood/interest, sleep/apatite, fatigue, withdrawal may change; screen, follow up and take hopelessness/ self-harm statements seriously

kubler-ross theory of grief

• denial

• anger

• bargaining

• depression

• acceptance

factors that influence loss and grief

human development, personal relationships, nature of the loss, coping strategies, socioeconomic status, culture, spiritual beliefs

palliative care

• holistic method to prevent and reduce symptoms

• promote quality of life

• achieve the best possible quality of life

• used for patients still seeking a cure AND for those with terminal illness

hospice care

end of life care

• a more specialized form of palliative care for the dying

• focuses on care, comfort, and quality of life of a person who is dying

• priority is pain and symptom management, comfort, and quality of life

• patient criteria- less than 6 months to live

physical changes before death

• increased periods of sleeplessness/ unresponsiveness

• coolness, pallor, mottling of extremities

• bowl/ bladder incontinence

• decreased urine output/ dark colored urine

• restlessness, confusion, disorientation

• decreased food intake/ dysphasia

• congestion, increased pulmonary secretions, noisy respiration (death rattle)

• altered breathing pattern

• decreased muscle tone, relaxed jaw, sagging mouth

• weakness and fatigue

care after death

• organ and tissue donation

• autopsy

• legal requirements

• postmortem care

• respect and dignity

dying person’s bill of rights

• be treated as a human being till death

• maintain sense of hopefulness

• be cared for by those who can maintain sense of hopefulness

• express feelings and emotions in own way

• participate in decisions about care

• continuing medical and nursing goals (“comfort goals”)

• not to die alone

• to be free of pain

• have questions answered honestly

• retain individuality without judgement

• expect sanctity of the body will be respected after death

• be cared for by caring, sensitive, knowledgeable people

importance of nutrition

supports healing and tissue repair

high nutrient dense food

influences cognitive functions

macronutrients

needed by the body in high amounts

• carbohydrates- primary energy source

• protein- builds/ repairs tissue; wound healing

• fat- absorption of vitamins

• water- essential for life

micronutrients

• vitamins

• minerals

• required in small amounts

• support metabolic and immune processes

important vitamins

• *vitamin C- wound healing and immunity

• vitamin B- metabolism and energy

• vitamin A- vision and immune support

• *vitamin D- bone health

• vitamin E- immune function

• *vitamin K- increases blood clotting

important minerals

• *calcium- bones and teeth; muscle contraction

• *iron- oxygen transport

• *potassium- muscle and nerve function (should be between 3.5-5) too little can be fatal; heart function

• sodium- fluid balance

factors affecting nutrition

developmental differences, physical activity level, health conditions and medications, cultural influences

grapefruit and vitamin K can decrease function of medications

nutritional assessment

• diet history - allergies, preferences, intolerance

• anthropometric measurements- BMI (<19 underweight and >30 obese) Waist circumference (better indicator) and weight trends

• lab values- prealbumin (indicates protein status) and hemoglobin (detects iron deficiency

• physical assessment - signs of malnutrition (weight loss, muscle wasting, fatigue, poor wound healing, dry skin, brittle hair and nails)

fluid shift

rapid loss or gain in weight within 24 hours

strategies for age related diet changes

• modify food texture for dental issues

• enhance flavor to address taste loss

• ensure smaller, nutrient dense meals

• promote hydration

• environmental enhancements

enteral nutrition

tube feeding for swallowing impairments; GI tract needs to be functional

nasogastric- short term (<4 weeks)

gastric- long term (>4 weeks)

parenteral nutrition

IV nutrition for non-functioning GI tracts

diabetic diet

• ½ green vegetables, ¼ lean protein, and ¼ high nutrient carbs

• choose beans, whole grains, fruit, plain yogurt, and water

• avoid sugar and simple carbs

low Na diet (heart healthy)

• aim for <2000 mg Na/day

• choose fresh/ frozen vegetables without sauce or salt, whole grains, fruits, beans, nuts, fish, and unsaturated oils

• avoid canned soup, deli meat, bacon, instant noodles, salty snacks, and sauces

internal pH check (nasogastric tube)

• <5- stomach- grassy green with particles

• greater than or equal to 6- intestine- clear or straw to deep golden yellow

• greater than or equal to 6- respiratory tract- off white to tan with mucus

biggest risk of enteral tube feeding

aspiration

• elevate head of bed to 30-45 degrees

enteral tube medication administration

• crush one at a time and mix each with 15-30 mL of room temp water

• flush with 15-30 mL water before and after med admin

• turn off suction and feeding prior to admin and for 30 min after

meds you cannot crush

enteric coated, gel capsule, and long acting or extended release