NSG 212 - Final Exam

Continuity of Care

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care.

Stages of Nursing Process

ADPIE
-Assessment
-Diagnosis
-Planning
-Implementation
-Evaluation

Nurses Role in admission

-room assignment (fall risk, infection control)-ID of patient and any risks on wristband (fall, allergies, etc)-Thorough assessment-Review advanced directives-Diagnostic testing-obtain necessary consents-Implementation of providers orders-PATIENT TEACHING IS ONE OF YOUR TOP PRIORITIES

nurses role in discharge

-type of discharge (ordered by physician, AMA)-actual date and time of discharge, who accompanied client, and how client transported-where was the client discharged (home, facility)-a summary of clients condition at discharge-any unresolved difficulties and plans for follow up-dispositions of valuables, meds from home-copy of clients discharge instructions

Nurses role in transfer process

-continuity of care
-info sharing
-SBAR report

Concepts of AMA

-against medical advice
-legally free to leave
-choice carries a risk for increased illness and complications
-Pt must sign release form
-pt is informed of risks prior to signing
-pt signature must be witnessed
-form become part of medical record

Factors that affect Urination

age, environmental factors, medication hx, psychological factors, muscle tone, fluid balance, current surgical or diagnostic procedures, presence of disease conditions
-caffein and alcohol = increase
-high sodium = decreases

Med affects on urination

-diuretics prevent reabsorption of water
-antihistamines and anticholinergics = urinary retention
-chemo= toxic for kidneys
-phenazopyridine = orange, red
-amitriptyline = green-blue
-levodopa = dark
- riboflavin =bright yellow
-roughly 30 mL/hr = 720 mL/day

Alterations in Urinary Function

-polyuria (diuresis) = abnorm large amount 2500 mL/day
-oliguria - less than 500 mL/day
-anuria - less than 100 mL/day
-nocturia = freq at night
-urgency = immediate
-dysuria = painful/difficult
-maturational enuresis = involuntary urinations after 4-5 yrs old.
-urinary retention = inability to fully empty

Assessment of fluid balance

I&O
-output cannot equal input because of absoprtion
-roughly 2400 mL/day
-measureable
DW
-most accurate assessment of fluid balance
-same time
-gain or loss greater than 1lb = mostly fluid

indwelling cath

- double lumen (foley)
-indwelling cath cannot = urinary retention

indwelling foley

-catheter remains in place (within client) for period of time

coude cath

-has a bend
Used for males with prostate complications BPH- benign prostatic hypertrophy(enlarged prostate)

nursing interventions for GI functioning/elim

-promote reg pattern
-meds
cathartics, suppositories
se of conservative methods 1st like mobility food, fluids
anti diarrheals
enemas
-digital removal of impact
-bowel training program
-food and fiber
fiber = 25+30g/day

surgical asepsis

techniques used to destroy all pathogenic organisms, also called sterile technique
-above waist
-dont turn back
-no cough sneeze
- 1 in border
-6 inches above
-dont reach across

what may indicate infection?

-increased WBC
normal is 5,000=10,000
-increased ESR
presence of pathogen in urine, blood, sputum, or draining cultures

Stages of infection

Incubation period
Prodromal stage
Full stage of illness
Convalescent period

incubation period

interval between initial infection and first signs and symptoms

prodromal stage

person is most infectious, vague and nonspecific signs of disease

full stage of illness

specific signs and symptoms

convalescent

recovering from illness

potential treatments for infection

antipyretics
-fever + discomfort
antimicrobial therapy
-kills/stops growth of micro org
anthelminthics
-worm infestations

how to prevent HAIs

freq and proper hand hygiene practice
-avoid electronic equipment
disinfect all equip
-barrier contact precautions
-private rooms

native immunity

Restricts entry or immediately responds to a foreign organism through the activation of phagocytic cells, complement, and inflammation

passive immunity

the short-term immunity that results from the introduction of antibodies from another person or animal.
-breast milk, placenta

active immunity

A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens.

Primary prevention

directed towards promoting health and preventing the development of disease processes or injury

-ex immunization clinics

Secondary prevention

focus on screening for earl detection of disease with prompt diagnosis and treatment of anything found

Tertiary prevention

begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate pts to a maximum level of function

mental impairment in older adults

-Dementia

-Alzheimer's Disease

-Sundowning Syndrome

-Cascade Iatrogenesis

-delirium

-depression

-UTI

principles of pt education

influencing pt behavior to effect change in knowledge, attitude, and skills with the goal of improved health-ongoing and interactive-compliance and adherence

principles of learning domains

• Cognitive: storing and recalling of new knowledge in the brain (KNOWLEDGE)• Psychomotor: learning a physical skill (SKILL)• Affective: changing attitudes, values, and feelings (ATTITUDE)

factors influencing diffusion of gases (O2-CO2)

Factors Influencing Diffusion(Diffusion is gas exchange)
Change in surface area
-Removal of the lung
-Atelectasis
-Collapse of the alveoli... Prevents the exchange of gas by diffusion in the lungs...
Thickening of the membrane
-Pneumonia (lung infection)
-Pulmonary edema
Partial pressure change
-Decrease in environmental oxygen...high altitudes, lack of 02
Solubility and molecular weight of the gas

physiological factors that may increase or decrease respiration

Rate and depth of respirations

-Increase rate/depth in the presence of low 02 or high C02

-Respiratory center; in the medulla of the brain; stimulated by an increase of CO2 and by decreased 02 ( lesser degrees)

Chemoreceptors in the aortic arch and the carotid arteries are sensitive to change in blood gas levels and blood pressure and can activate the medulla to increase the rate/ depth of respirations.

chemoreceptors

sensitive to oxygen saturation
-aortic arch
-carotid arteries
-in response to low oxygen they will increae respirations

medulla (CNS)

triggered to control respirations

rate and depth of respirations

increase rate/depth in the presence of low O2 or high CO2

contributing factors for alterations in the Cardiovascular system

Dysrhythmia or arrhythmia

-Something other than “lub-dub”…Problem with electrical signals; SA node

Myocardial ischemia

-Decreased oxygen supply to the heart…MAIN cause of a heart attack (MI)

Angina

-Coronary Artery Vasoconstriction; decreased oxygen= muscle pain=chest pain

Myocardial Infarction (MI)

-Heart Attack…Caused by lack of oxygen to a part of the heart (blockage)

Heart Failure (Congestive Heart Failure [CHF])

-Failure of the Left Ventricle to pump…Back up of blood into the lungs…Heart AND Lung problem

Dysrhythmia or arrhythmia

disturbance of heart rhythm
-something other than "lub-dub"
-problem with electrical signals;SA node

myocardial ischemia

Lack of oxygen to the heart muscle

-decreased oxygen supply to the heart

=Main cause of a heart attack (MI)

angina

muscle pain=chest pain

-coronary artery vasoconstriction; decreased oxygen

myocardial infarction (MI)

heart attack

-caused by lack of oxygen to part of the heart(blockage)

heart failure

Congestive Heart Failure (CHF)

-failure of the left ventricle to pump

-back up of blood into the lungs

-heart and lung problem

factors affecting cardiopulmonary function and oxygenation

Level of health
-Other chronic illnesses
Developmental considerations
-Lifespan
Medication considerations
-Opioids decrease respiratory drive
Lifestyle considerations
-Occupation, smoking
Environmental considerations
-Pollution
Psychological health considerations
-Stress, hyperventilation

how is oxygen carried?

via plasma and red blood cells

hypoxia

-Low oxygen saturation of the body, not enough oxygen in the blood
-can be caused by hypovolemia, hypoventilation, and interruption of arterial flow

early hypoxia s/s

S/S of Early:
-Tachypnea
-Tachycardia
-Restlessness (ENGAGE)
-Pallor
-Increased BP
-Use of accessory muscles
-Nasal flaring
-Tracheal tugging
-Adventitious lung sounds
-Dyspnea

late hypoxia s/s

S/S of LATE:
-Bradypnea
-Bradycardia
-Confusion and stupor,
-Cyanosis
-Hypotension
-Cardiac arrhythmias
-Metabolic acidosis

decreased rate or depth of air movement into the lungs
-acute disease
-can cause hypercarbia(high CO2)
s/s
-restlessness
-HT
-headache

chronic hypoxia

-live in a state of low oxygen due to disease process
s/s
-Headaches
-Chest pain
-Enlarged heart
-Clubbing the of fingers/toes
-Anorexia
-Constipation
-Decreased urine output
-Weakness
-Muscle pain
-Right sided heart failure
-Respiratory acidosis

safe oxygen administration

Delivered via nasal cannula:
-1 liter 24 %
-2 liters 25 %
-3 liters 32 %
-4 liters 36 %
-5 liters 40 %
-6 liters 44 %
-Humidification 3-4 Liters

Oximizer

high flow nasal cannula

simple mask

40-60% of oxy, 5-8 liters/min-never less than 5 L or CO2 build up can occur

partial rebreather

60-75% at a flow of 6-11 liters/min
-1/3 of expired air from exhaled breath
-bag should stay 2/3 full, complete deflation of the bag during inspiration can cause CO2 build up

non rebreather

80-95% except for intubation; flow of 10-15 liters/min
-Non-rebreather means they are NOT REBREATHING any of their CO2.
-That means that what they ARE breathing in is almost 100% oxygen.

venturi mask

delivers precise amount of O2
-used to prevent oxygen toxicity in pts with COPD

aerosol mask/face tents

fits loosely around the face and neck

oxygen is

combustible

no high levels for

COPD pts
-drive to breath is LOW oxy

diagnostic testing for cardiopulmonary and respiratory diseases

-cardiac coronary cath
-cardiac exercise stress testing
-echocardiogram
-holter monitor
-arterial blood gases
-cardia biomarkers
-CBC
-cytologic sputum
-thoracentesis

cardiac coronary cath

can view and open up blocked coronary arteries

cardiac exercise stress testing

can detect blocks in the arteries (STRESS the heart)

echocardiogram

measures heart conduction

holter monitor

continuous monitor, can pick up changes in conduction

arterial blood gases

-drawn directly from a artery
-direct measurement of O2 and CO2

cardiac biomarkers

--creatinine kinase (CK-BM)

-troponin

-both elevate in the blood due to cardiac damage

complete blood count (CBC)

the body's response to illness

cytologic sputum

may detect cancerous cells

thoracentesis

-Procedure of puncturing the chest wall and aspirating pleural fluid or air from the chest
-At the bedside or under fluoroscopy if they want to really visualize
-Sterile procedure
-Patient sits on side of bed or in a chair
-Monitor VS, ABC's
-Max amount removed is 1000 ml

complications to thoracentesis

-Pneumothorax...Collapsed lung
-Pulling off too much volume
-Tracheal deviation
-Dyspnea/ Very labored breathing
-Assess for respiratory distress, blood tinged sputum, severe coughing
-Notify MD immediately.

good Samaritan laws

-laws to protect individuals providing aid

-need to provide aid within training and scope of practice

-do not leave until assistance arrives or becomes dangerous or going to get assistance

safety is the

first priority

ABCs

airway, breathing, circulation

CABs

chest compressions, airway, breathing
-apply AED as soon as its available

external bleeding

find source and apply direct pressure and elevate area above heart

nosebleed

-pinch soft part of nose
-tip head forward
-after 10 mins go to ED

internal bleeding

harder to tell-monitor ABCs, and LOC

shock

-insufficient O2/nutrients to meet the body's needs=lack of circulation

-SX: First rapid pulse and cold clammy skin; then cyanosis, weakness, N/V, thready pulse; finally lost peripheral pulses, restlessness, yawning/gasping, unconsciousness

shock treatment

-Try to maintain blood flow: Lay down and raise legs (TRENDELENBURG POSITION)

-cover with blanket.

-Check ABC’s—maintain patent airway.

-Stop bleeding; treat underlying cause.

-Call EMS immediately if unconscious.

-If anaphylaxis, use epinephrine-pen—inject through clothes; need to hold in place for 10 sec prior to withdrawing.

wounds/injury

-do not removed embedded objects, stabilize and get help
-direct pressure

thermal burn

burn caused by heat-cool with lots of cold water for 15-30min-cover with non-adhesive dressing-if large area call for EMS

dont use --- directly on burns

Ice or use ointment or break blisters
-blisters are protective

electrical burns

-be sure no lice electricity
-cover entry and exit wounds
-monitor ABCs

musculoskeletal inujries

rest, ice, compression, elevation=RICE

concussion

Very short period of unconsciousness, confusion, vomiting, anxiety, amnesia, visual disturbances

compression injury

Above symptoms to a higher degree, with symptoms worsening over time

objects or chemicals in the eye

-Do not remove embedded objects; rinse with copious sterile water/saline; pull down upper or lower lid.
-Go to ED for chemical spill in eye.

heat exhaustion

mild
-sweating, pale, muscle cramps, weakness, H/A, N/V, faintness
-treatment= loosen clothing, cool moist cloths, move to cool location, cold drinks

heat stroke

emergency
-altered LOC, flushed, hot, dry skin, hyperventilation, 105>
-call EMS, douse in cold water, cover in cold towels, ice packs to groin, neck, and armpits

Stroke

-SX: Facial, arm, or unilateral weakness; speech problems; blurred or dec. vision (especially in 1 eye); sudden severe H/A
-Call EMS.
-Help to comfortable position, observe ABC's.
-If unconscious, place in recovery position on unaffected side.

MI or angina

-SX: Chest pain/tightness, possibly radiating to shoulders, jaw or L arm; nausea/indigestion (especially in women); pale, clammy or gray skin; anxiety; denial
-Call EMS.
-Loosen tight clothing and put in "W position (lying back a bit with knees bent).
-If alert and not on anticoagulants, give 1 adult aspirin.
-If have angina, give nitro; if unrelieved after 2 nitro, call EMS.
-Monitor ABC's and VS.

seizures

-Protect from injury.

-Do not put anything in mouth during seizure.

-After seizure, place in recovery position; monitor respirations.

-Try to monitor time in seizure.

-More to come on this!

Skin cancer S/S

-developed new moles or lesions?
-moles or lesions changed in any way(color, borders, size)?

pressure ulcers

-NOT "bed sores"
-Caused by pressure
-Tissue injury/ischemia caused by external forces
-Results in unrelieved pressure resulting in ischemia and damage to the underlying tissues
-Time + pressure = ulceration
-Braden Risk Assessment
Factors:
-Age
-IMMOBILITY
-Incontinence/ moisture
-Skin friction and shearing
-Vascular disorders
-Obesity
-Mental Status
-Impaired skin integrity
-Poor nutrition/ hydration
-Fever
-Edema
-Chronic disease ( DM, CKD, CHF, COPD)
-Sedation

wounds

injuries in which the skin is broken
-intentional
-unintentional
-open
-closed
-acute
-chronic
-contusion
-abrasion
-laceration
-penetrating
-puncture

intentional wound

a wound that is the result of a planned surgical or medical intervention

unintentional wound

A wound resulting from trauma

open wound

the skin or mucous membrane is broken

closed wound

an internal injury with no open pathway from the outside

acute wound

usually heal within days to weeks