MDC 1 Final

Therapeutic vs. Non-Therapeutic Communication

DO:

• Active listening

• Eye contact

• Open-ended questions

• Empathy

DON’T:

• Give advice

• Ask “why”

• Use clichés

• Change subject

Communication Barriers

• Language

• Pain

• Anxiety

• Cultural Differences

• Cognitive Impairment

Home Safety

• Carbon Monoxide Poisoning

• Toxins from Work Environments

• Burns (scald injuries, warming food/formula, sunburn, contact burns, chemical agents)

• Fires

• Suffocation (drowning, choking, smoke/gas inhalation)

• Firearms

• Falls

Phases of Nurse-Client Relationship

1. Pre-Interaction

• Before meeting client

• Reviewing the chart

• Getting report

2. Orientation

• Introduction of yourself + role

• Establish trust + rapport

• Set goals + expectations for care

• Assess the client’s needs

3. Working

• Implement plan of care

• Patient will express feelings + concerns to nurse

• Provide education + interventions

4. Termination

• Patient will participate in identifying the goals accomplished/progress

• Patient will verbalize feelings about termination of relationship

• Discuss follow-up care + resources

Systemic Complications of Immobility

1. Integumentary System

• Pressure injuries (pressure ulcers)

• Skin breakdown

2. Musculoskeletal System

• Muscle atrophy

• Contractures

• Decreased bone density

• Weakness

• Impaired balance + stability

3. Cardiovascular System

• Venous stasis

• Orthostatic hypotension

• DVT

• Increased cardiac workload

• Decreased cardiac output

4. Respiratory System

• Decreased lung expansion

• Increases secretion (Aspiration Pneumonia)

• Shallow breathing

• Collapsed lung

5. Gastrointestinal System

• Slows peristalsis

• Constipation

• Appetite loss

• Paralytic Illeus

6. Urinary System

• Urinary retention

• Increase UTIs

• Kidney stones

7. Psychosocial Effects

• Isolation

• Mood change

• Depression

• Anxiety

Nursing Interventions - Immobility

1. Integumentary System

• Reposition every 2 hours

• Assess client for pressure ulcer risk

• Teach client to shift weight every 15 mins if possible

• Use positioning devices

• Assess skin and provide skin + perineal care

2. Musculoskeletal System

• Perform passive ROM exercises

• Reposition every 2 hours

• Encourage independent activity if possible

• Provide assistance devices

3. Cardiovascular System

• Increase client’s activity

• Assess for peripheral, sacral + pedal edema

• Assess calves for signs + symptoms of thrombus formation (redness, warmth + tenderness)

• Measure calf circumference

• Use TED hose or Sequential Compression devices

• Administer low-dose heparin

4. Respiratory System

• Turn, Cough, + Deep Breath every 2 hours

• Incentive Spirometer every 2 hours

• Encourage client to sit in Fowler’s position

• Use chest physiotherapy

• Encourage fluid intake

• Assess lungs, cough, and sputum production

5. Gastrointestinal System

• Maintain hydration

• Include fresh fruit + vegetables in diet

• Promote normal positioning for elimination

6. Urinary System

• Encourage fluid intake

• Bladder training

• Assess for urinary retention using Bladder Scanner

• Promote urination by pouring warm water over the perineum area

7. Psychosocial Effects

• Involve clients in daily care

• Provide stimuli (newspapers, TV, magazines)

• Assist with grooming + hygiene (shaving, makeup)

Physiological Changes Related to Aging

1. Sensory Changes

• Decreased vision

• Decreased hearing

• Reduced depth perception

2. Musculoskeletal Changes

• Decreased muscle strength

• Loss of muscle mass

• Reduced flexibility

• Decreased bone density

3. Neurological Changes

• Slower reflexes

• Delayed reaction time

• Reduced coordination

4. Cardiovascular Changes

• Orthostatic hypotension

• Decreased cardiovascular reserve

5. Cognitive Changes

• Slower processing of information

• Possible confusion or memory changes

Osteoarthritis - Pathophysiology

Non-inflammatory “wear and tear” disorder of the joints

Osteoarthritis - Clinical Manifestations

• Pain with activity

• Stiffness

• Crepitus

• Reduced ROM

• Joint enlargement

• Difficulty with mobility/ADLs

Osteoarthritis - Diagnostics

1. X-Ray

• Joint space narrowing

• Bone spurs

• Cartilage loss

2. Physical Assessment

• Pain with movement/activity

• Decreased ROM

• Crepitus

Osteoarthritis - Medical Management

• NSAIDs

• Steroid injections

• Exercise

• Heat/ice therapy

• Weight loss

• Arthroplasty

Osteoarthritis - Nursing Interventions

• Pain management

• Encourage mobility

• Heat therapy

• Joint protection

• Fall prevention

Osteoporosis - Pathophysiology

Bone loss (osteoclasts) > bone formation (osteoblasts)

Osteoporosis - Risk Factors

• Aging

• Female

• Smoking

• Corticosteroids

• Menopause

• Decreased calcium + vitamin D

Osteoporosis - Clinical Manifestations

• Fractures

• Kyphosis

• Height loss

• Back Pain

Osteoporosis - Diagnostics

• DEXA Scan

• FRAX Tool

Osteoporosis - Medical Management

• Biphosphonates

• Calcium

• Vitamin D

Osteoporosis - Nursing Interventions

• Fall prevention

• Weight bearing exercises

• Mobility promotion

• Nutrition teaching (calcium, vitamin D)

Osteomyelitis - Pathophysiology

Bone Infection

Osteomyelitis - Risk Factors

• Open fractures

• Surgery

• Diabetes

• Poor circulation

Osteomyelitis - Clinical Manifestations

• Fever

• Bone pain

• Swelling

• Elevated ESR/CRP

Osteomyelitis - Medical Management

• IV antibiotics

• Surgical debridement

Osteomyelitis - Nursing Interventions

• Sterile wound care

• Administer antibiotics

• Teach completion of antibiotics

• Monitor infection

• Pain management

Nursing Care for Client with Recent Arthroplasty

• Monitor neuro-vascular status (capillary refill, skin turgor, etc.)

• Monitor for bleeding, swelling, infection or pain

• Ice

• Elevation (keep operated limb above the heart)

• Pain medications

• Early ROM

• Early mobility

Nursing Care for Clients with recent Hip Arthroplasty

• No crossing legs

• No bending > 90 degrees

• No twisting

• Use abduction pillow

• Prevent DVT (SCDs, TED hose, Lovenox, early ambulation)

• Monitor neuro-vascular status, drainage, infection, pain

• Fall prevention + home safety

Diagnostics Tests for Musculoskeletal Disorders

1. X-Ray

• Fractures

• Bone alignment

• Arthritis

• Bone deformities

2. MRI

• Muscles

• Ligaments

• Tendons

• Cartilage

• Disc problems

3. CT Scan

• Complex fractures

• Bone tumors

4. Bone Scan

• Bone infection (osteomyelitis)

• Stress fractures

• Bone cancer/metastasis

• Bone inflammation

5. Blood Tests

• WBC —> infection

• ESR —> inflammation

• CRP —> inflammation

• CK (Creatinine Kinase) —> muscle injury

• Calcium/Vitamin D —> bone health

Bone Tumors - Pathophysiology

Abnormal growth of bone tissue that can be benign or malignant

Bone Tumors - Risk Factors

• Family history/genetics

• Previous radiation exposure

• Metastatic cancer

• Certain bone disorders (Paget disease)

Bone Tumors - Clinical Manifestations

• Persistent bone pain (often worse at night)

• Swelling or palpable mass

• Tenderness

• Decreased ROM

• Pathologic fractures

• Limping or mobility problems

Bone Tumors - Assessment + Diagnostics

Assessment:

• Bone pain unrelieved by rest

• Swelling

• Weakness of affected extremity

• Difficulty ambulating

• Possible fracture without significant trauma

Diagnostics:

• X-Ray —> bone destruction, abnormal bone growth

• CT Scan —> detailed bone involvement

• MRI —> soft tissue involvement, tumor size/location

• Bone Scan —> detects tumor spread, identifies metastatic lesions

• Biopsy —> definitive diagnosis, determines benign vs. malignant

Bone Tumors - Nursing Interventions

• Assess pain frequently

• Administer analgesics as prescribed

• Assist with ambulation

• Prevent falls

• Protected affected extremity

• Neuro-vascular changes

• Address anxiety/fear

• Monitor for infection (post-op)

Types of Fractures

• Complete —> fully broken

• Open (compound) —> bone through skin

• Closed (simple) —> skin intact

• Spiral —> twisting injury

• Oblique —> diagonal

• Comminuted —> 3+ fragments

• Transverse —> across

• Incomplete —> not fully broken through

• Greenstick —> bends/cracks

Complications of Fractures

Hemorrhage

• Hypovolemic shock risk

Fat Embolism Syndrome

• Fat globules enter bloodstream

• 12-48 hours after fracture

Compartment Syndrome

• Pressure restricts circulation

Osteomyelitis

Avascular Necrosis

Delayed Union (slow healing)

Nonunion (no healing)

Malunion (misaligned healing)

Nursing Interventions for Cast Care

Neurovascular Assessment (assess the 6 Ps):

• Pain

• Pallor

• Paresthesia

• Pulse

• Paralysis

• Poikilothermia

Monitor the Cast:

• Check for cracks or soft spots

• Assess for drainge/foul odor

• Monitor for tightness

Patient Education:

• Keep cast clean + dry

• Do NOT insert objects inside cast

• Do NOT scratch under cast

Types of Musculoskeletal Traumas

1. Contusion

• Soft tissue injury (bruise)

2. Strain

• Injury to a muscle or tendon

3. Sprain

• Injury to a ligament

• RICE (Rest, Ice, Compression, Elevation)

4. Dislocation

• Bone completely displaced from a joint

5. Subluxation

• Partial dislocation

6. Fracture

• Break in the bone

Types of Traction

Skeletal:

• Pin, wire, or screw in the fractured bone

Skin:

• Applying splints, bandages, or adhesive tapes

Nursing Care for Traction

• Maintain proper body alignment

• Free-hanging weights ONLY

• Assess skin/pin care

Cataracts - Pathophysiology

Clouding of the eye lens causing blurry vision

Cataracts - Causes

• Aging

• Diabetes

• Smoking

• UV exposure

• Corticosteroids

Cataracts - Clinical Manifestations

• Blurred/cloudy vision

• Glare sensitivity

• Poor night vision

• Halos around lights

• Yellowed vision

Cataracts - Nursing Interventions

• Fall prevention

• Assist with ADLs as needed

• Monitor post-op complications

• Eye protection/shield

Cataracts - Treatment

Surgical lens replacement

Glaucoma - Pathophysiology

Increased intraocular pressure (IOP) damaging the optic nerve

Glaucoma - Causes

• Increased IOP

• Family history

• Diabetes

• Aging

Glaucoma - Clinical Manifestations

• Peripheral vision loss

• Eye pain

• Halos around lights

• Blurred vision

• Headache

• Nausea/vomiting

Glaucoma - Nursing Interventions

• Administer eye drops correctly

• Monitor vision changes

• Reduce fall risk

• Encourage lifelong treatment adherence

* DO NOT stop Glaucoma medications abruptly

Glaucoma - Treatment

• Eye drops

• Laser therapy

• Surgery

Macular Degeneration - Pathophysiology

Degeneration of the macula causing central vision loss

Macular Degeneration - Causes

• Aging

• Smoking

• Family history

• Hypertension

• UV exposure

Macular Degeneration - Clinical Manifestations

• Central vision loss

• Blurred/distorted vision

• Difficulty reading/driving

• Straight lines appear wavy

Macular Degeneration - Nursing Interventions

• Stop smoking

• Use magnifying devices

• Monitor vision changes

• Wear sunglasses

Macular Degeneration - Treatment

• Vitamins (AREDS)

• Anti-VEGF injections

• Laser therapy

Retinal Detachment - Pathophysiology

Separation of retina from underlying tissue

Retinal Detachment - Causes

• Aging

• Eye trauma

• Severe myopia

• Diabetes

• Previous eye surgery

Retinal Detachment - Clinical Manifestations

• “Curtain over vision”

• Floaters

• Flashes of light

• Sudden vision loss

Retinal Detachment - Nursing Interventions

• Position as prescribed

• Protect affected eye

• Monitor vision changes

• Fall prevention

Retinal Detachment - Treatment

• Emergency surgery

• Laser repair

Appropriate Ways to Communicate with Someone Who is Blind or Has Low Vision

• Introduce yourself when entering the room

• Tell the patient who is present

• Use a normal tone and volume

• Describe what you are going to do

• Tell them before touching them

• Explain room layout

• Never leave without telling the patient

• Let the patient hold your arm + walk slightly ahead

• Leave personal items in same location

• Use the “Clock Method” for meals

Ear Infection - Otitis Externa

• Pain with tragus movement

• Itching/discharge

Ear Infection - Otitis Media

• Ear pain

• Fever

• Fluid/pressure

Vertigo - Pathophysiology

Sensation of spinning/dizziness caused by balance disturbance

Vertigo - Clinical Manifestations

• Dizziness

• Nystagmus (rapid/repetitive eye movements)

• Nausea/vomiting

• Unsteady gait

• Balance problems

Vertigo - Risk Factors

• Inner ear disordesr

• Infection

• Meniere disease

• BPPV

Vertigo - Nursing Interventions

• Fall precautions

• Assist with ambulation

• Slow position changes

• Reduce sudden head movement

• Safety precautions

Vertigo - Treatment

• Meclizine

• Antiemetics

• Treat underlying cause

Meniere Disease - Pathophysiology

Inner ear disorder causing episodes of vertigo + hearing problems

Meniere Disease - Clinical Manifestations

• Vertigo

• Tinnitus

• Fluctuating hearing loss

• Ear fullness

Meniere Disease - Nursing Interventions

• Fall precautions

• Quiet/dark environment during attacks

• Monitor hearing changes

• Assist with ambulation

• Educate on low sodium diet

Meniere Disease - Treatment

• Low-sodium diet

• Diuretics

• Meclizine

Appropriate Ways to Communicate with Someone Hard of Hearing

• Face patient directly

• Speak clearly + slowly

• Use normal tone of voice

• Enunciate words

• Maintain eye contact

• Reduce background noise

• Use visual cues (gestures, facial expressions, demonstrations)

Stages of Pressure Injuries

Stage 1:

• Non-blanchable redness

• Over bony prominence

Stage 2:

• Partial-thickness

• Blister/shallow crater

• Epidermis + dermis involved

Stage 3:

• Full-thickness loss

• Fat visible

• Tunneling/undermining possible

Stage 4:

• Bone/tendon/muscle exposred

• Slough/eschar common

• Deep wound

Pressure Injury Causes

• Pressure (prolonged pressure over bony prominences)

• Friction (client dragged across bed sheets)

• Shear (client sliding down in bed)

• Moisture (incontinence, sweat, wound drainage)

Pressure Injury Risk Factors

• Immobility

• Impaired sensation (quadriplegia, spinal cord injury)

• Poor nutrition

• Dehydration

• Advanced age

• Edema

• Fever/infection

• Incontinence

• Diabetes

• Poor circulation

Pressure Injury Complications

Infection:

• Redness

• Warmth

• Swelling

• Fever

• Purulent drainage

• Increased pain

Cellulitis:

• Redness

• Swelling

• Warmth

• Tenderness

Osteomyelitis:

• Fever

• Bone pain

• Delayed wound healing

Sepsis:

• Fever

• Tachycardia

• Hypotension

• Altered mental status

Delayed Wound Healing:

Tissue Necrosis:

• Black eschar

• Nonviable tissue

Pressure Injury Prevention

Repositioning:

• Reposition every 2 hours

• Avoid prolonged pressure on bony prominence

• Float heels off bed

Skin Care + Moisture Control:

• Keep skin clean + dry

• Change incontinence briefs promptly

• Use barrier creams

• Assess skin daily

Nutrition + Hydration:

• Adequate protein intake

• Encourage fluids

• Monitor nutritional status

• Consider dietician

Mobility:

• Encourage ambulation

• ROM exercises

• Avoid prolonged bedrest

Pressure Redistribution:

• Therapeutic massages

• Pressure-reducing cushions

• Heel protectors

Risk Assessment:

• Use Braden Scale

• Identify high-risk clients early

• Implement prevention measures immediately

Age Related Skin Changes

• Thin, fragile skin

• Decreased collagen + elasticity

• Slower healing

• Increases risk for tears/pressure injuries

Complications of Burns

Infection:

• Most common cause of death in burn patients

• Loss of skin barrier increases infection risk

• Signs/Symptoms: fever, purulent drainage, redness, delayed healing

Fluid Volume Deficit (Hypovolemia):

• Massive fluid loss from damaged skin

• Can lead to burn shock

• Signs/Symptoms: hypotension, tachycardia, decreased urine output

Electrolyte Imbalances:

• Hyperkalemia (early) - damaged cells release potassium

• Hypokalemia (later) - occurs during healing phase

Hypothermia:

• Loss of skin barrier causes heat loss

Respiratory Complications:

• Hoarseness

• Singed nasal hairs

• Wheezing

• Difficulty breathing

Contractures:

• Tightening of skin during healing

• Causes decreased mobility

• Common in severe burns + joints

Scarring:

• Hypertrophic scars

• Keloids

Nursing Interventions for Burns

• Assess airway immediately

• Monitor respiratory status

• Administer oxygen if possible

• Monitor IV fluids

• Strict I&O

• Monitor urine output

• Administer prescribed analgesics

• Assess pain frequently

• Prevent infection

• Wound care

• Nutritional support (high protein + high calorie diet)

Skin Assessment

Assess

• Color

• Temperature

• Moisture

• Texture

• Turgor

• Lesions

• Breakdown

Braden Scale (prediction of developing pressure ulcers)

• Assess sensory perception, moisture, activity, mobility

• < 18 = at risk

Norton Scale

• Assess physical condition, mental state, activity, mobility, incontinence

Diagnostic Procedures for Skin

Blood Studies

• CBC

• CRP

• WBC count (4,000-11,000 normal range)

• Purpose: to detect infection/inflammation

Skin Biopsy

• Diagnose infection, cancer, or skin disorders

Wound Cultures

• Identify bacteria/fungi causing infection

Swabbing

• Collect surface bacteria

Needle Aspiration

• Collect fluid from deeper wound areas

Psoriasis - Pathophysiology

• Chronic autoimmune disorder

• Rapid skin cell turnover

• Plaques form on skin

Psoriasis - Causes

• Stress

• Infection

• Skin injury

• Certain medications

Psoriasis - Clinical Manifestations

• Scaly plaques

• Itching

• Bleeding

• Pain

Psoriasis - Nursing Interventions

• Emotional support

• Skin assessment

• Encourage medication adherence

Psoriasis - Treatment

• Topical therapy (corticosteroids)

• Light therapy (UV phototherapy)

Eczema - Pathophysiology

• Chronic inflammatory skin disorder

• Dry itchy skin/rash

Eczema - Types

• Atopic dermatitis

• Contact dermatitis

• Dyshidrotic eczema

• Stasis dermatitis

Eczema - Clinical Manifestations

• Dryness

• Itching

• Redness

• Blisters

Eczema - Nursing Interventions

• Avoid triggers

• Skin hydration

• Prevent scratching

Eczema - Treatment

• Moisturizers

• Steroids

• Antihistamines

• Phototherapy

Furuncle (Boils) - Pathophysiology

• Infected hair follicle

• Boil filled with pus

Furuncle (Boils) - Causes

• Staph infection

• Poor hygiene

• Ingrown hairs

Furuncle (Boils) - Clinical Manifestations

• Red tender lump

• Pain

• Pus drainage

Furuncle (Boils) - Nursing Interventions

• Warm compresses

• DO NOT squeeze

Furuncle (Boils) - Treatment

• Antibiotics if severe

• Incision/drainage if needed

Cellulitis - Pathophysiology

Bacterial skin infection affecting deeper tissue

Cellulitis - Clinical Manifestations

• Redness

• Warmth

• Swelling

• Tenderness

• Fever/chills

Cellulitis - Nursing Interventions

• Monitor spread of redness

• Elevate affected area

• Assess pain

Cellulitis - Treatment

• Antibiotics

• Rest/elevation

• Pain control

Community MRSA - Pathophysiology

Antibiotic-resistant staph infection