NRS 204 Exam 2 #2

gastrointestinal assessment

- history

- physical assessment

- stool assessment

gastrointestinal inspection

- skin changes: wounds/scars, color

- contour

- symmetry

- masses

What should you do before palpating the abdomen?

Auscultate the belly

What is the normal range for bowel sounds per minute?

3-5 sounds per minute

What defines hypoactive bowel sounds?

Less than normal, less than 5 sounds per minute

What defines hyperactive bowel sounds?

More than normal, more than 5 sounds per minute, very noisy

what defines borborygmus bowel sounds?

more than 35 per minute

what defines absent bowel sounds?

no sounds after 5 full minutes

absence of bowel sounds after

fluid volume deficit assessment

* more common than fluid volume excess

vital signs:

- tachycardia, postural hypotension

strict intake/output measurements:

- output>intake

decreasing weight:

- taken immediately after waking in AM

symptoms:

- weak peripheral pulses

- cool extremities

- prolonged capillary refill

- skin findings (tenting)

- oliguria

- headache, dizziness, lethargy, fainting

fluid volume excess assessment

vital signs:

- increased HR, bounding pulse

strict intake/output measurements

- intake > output

increasing weight:

- taken immediately after waking in AM

symptoms:

- enlarged jugular veins even when upright

- edema (peripheral, pulmonary)

- dyspnea

- orthopnea (hard to breathe laying down)

- polyuria

- skin findings (swelling)

dehydration symptoms

neurologic:

- mild: restless

- severe: lethargic

BP:

- mild: normal

- severe: low or undetectable

Pulse:

- mild: normal

- severe: rapid or slow

Skin Turgor:

- mild: elastic

- severe: tenting

Mucus membranes:

- mild: moist

- severe: parched/cracked

Urine:

- mild: normal

- severe: oliguria or anuria

Extremities:

- mild: warm, normal CRF

- severe: cool, pale, delayed CRF

Eyes:

- mild: normal

- severe: deeply sunken, no tears

dehydration considerations: elders

BP/postural hypotension is a sensitive measure

unquenchable thirst is concerning

loose skin makes skin turgor assessment less sensitive

dehydration considerations: infants

palpate fontanel; sunken indicates FVD

tachycardia is an early sign

hypotension is a late sign

health promotion

primary prevention

secondary prevention

tertiary prevention

nursing and collaborative interventions for FVD

consider loss of fluids:

- gastric: water, sodium, chloride

- stool: water, potassium, bicarb

- sweat: water, some electrolytes

- blood: water, electrolytes, cells, proteins

replace fluids lost:

- medical-grade replacement solutions

- oral rehydration therapy (slow, non-invasive)

- IV rehydration therapy (fast, invasive)

- blood transfusion if bleeding is causing the loss

fluid maintenance therapy:

- oral, enteral tube, IV

nutrition assessment (history)

- nutritional assessment tools

- difficulty chewing or swallowing

- intake

- nausea, vomiting, diarrhea

- appetite changes

- weight change

- medications

- family/social history

- alcohol use

- abdominal complaints

- constipation or diarrhea

- special dietary needs

weight and healthcare disparity: obesity

experiences w/in healthcare

- unequal treatment

- inappropriate comments about weight

- facilities lack appropriate gowns, chairs, BP cuffs, exam tables

leads to...

- feelings of being judged or stigmatized

- distrust of health care workers

- poor treatment outcomes

- avoidance of health care

weight and healthcare disparity: eating disorders

often diagnosed late, difficult to recognize

can be deadly

energy balance model

a gross oversimplification of weight regulation

body mass index

a gross oversimplification of disease risk

other factors regarding gaps in current models of intake and weight regulation

- endocrine and metabolic differences

- changing body energy needs

- environment: air pollution, light pollution, reduced green space, endocrine-disrupting pollutants

- heredity

- microbiome

- unconscious behaviors

nutrition assessment

popular measurements:

- BMI

- waist-to-height ratio

- waist circumference

- waist-to-hip ratio

- neck circumference

- food diary

assessment tools:

- mini nutritional assessment (MNA)

specific nutrient lab tests

disease-specific testing and treatment

sensory perception concept: scope

optimal function - impaired function

optimal function

senses:

- vision

- hearing

- taste

- smell

- touch

- proprioception

- balance

sensory perception definition

The ability to receive sensory input and, through various physiological processes in the body, translate the stimulus or data into meaningful information.

sensory perception attributes

internal stimulation

external stimulation

internal stimulation

sensory input coming from within the body

external stimulation

sensory input coming from outside the body

sensation definition

The ability to turn energy (light, pressure, sound, heat) or chemistry (smell, taste) or position (proprioception, balance) into nerve impulses.

perception definition

The human experience of sensory input as translated into meaningful information in the brain.

function definition

The individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being

vision: health promotion

protecting eyes

- glasses

- mask against bright light

- ointment

- safety goggles (protection against droplet transmission)

vision: optimization

surgeries/equipment to optimize/restore vision

- lasik surgery

- cataract surgery

- corneal transplant

- glasses, contact lens

vision: secondary prevention

- visual impairments often develop slowly

- individuals sometimes don't notice

- ask other people (family, teachers)

- simple screenings

vision: assessment

- history

- inspection

- visual acuity testing

- eye movement

- pupillary response

- collaborative assessments (assisting eyecare professionals)

- corneal reflex (strabismus)

vision: developmental changes

visual acuity over the lifespan

- preterm infants

- infants

- children (20/20 by 2)

- 40s to 60s - decline

reading and verbal comprehension

full color perception

vision: abnormal findings

- Disconjugate gaze, pupil changes, swelling, eye discharge, discoloration

- Scleral discoloration

- Opacity of the lens

- Lack of "following"

- Acuity change

- from minor distortion to complete blindness

- Emergencies (not limited to): Sudden vision change/ loss, eye injury, retinal hemorrhage, "raccoon eyes," eye pain

- Photophobia

- Report of visual disturbancesfloaters, stars, visual field change

- Sudden loss of vision in any field

consequences of vision impairments

- inability to drive

- difficulty with navigation

- occupational limitations

- inability to read printed words

- ADL deficits

- loss of autonomy

- depression

mitigation of vision impairments

- accessible transit

- safe, clutter-free spaces

- occupational programs

- auditory info or Braille

- organized environment

- targeted assistance

- medication treatment

hearing: health promotion

- avoid prolonged exposure to loud noise

- avoid any exposure to noise extremes

- PPE

- presbycusis (age-related adult hearing loss)

- high frequencies usually lost first

hearing: secondary prevention

- hearing impairments often develop slowly

- the sufferer may not notice

- simple screenings

- diagnostic testing

hearing: assessment

history

- hearing aids

- ototoxic medications

- genetics

- communication trouble

hearing screen/evaluation

inspection of inner and outer ear

hearing: normal findings

- bilaterally equal hearing

- normal bone and air conduction tests (Rinne, Weber)

- whisper can be heard with each ear

- normal external ear structures, same color as face, no lesions

- ear canals are smooth without excessive wax

- eardrums intact, translucent, and not bulged or sunken

hearing: abnormal findings

abnormal hearing test results

- tinnitus

- presbycusis

- external injury

- ear discharge

- foul-smelling, dried, hard, or obstructing cerumen

- bulging, red, or punctured tympanic membrane

- ear pain

- emergencies (not limited to): sudden hearing loss, Battle's sign

consequences of hearing impairments

- social isolation

- suicidality

- impaired communication

- safety risks in the home

- increased demential risk

mitigation of hearing impairments

- external assistive devices

- cochlear implant

- sit directly in front of listener; minimize background noise; talk at a moderate rate with a normal tone of voice

- written communication

- tactile or visual alerts

taste, smell, and touch: health promotion

no current screening recommendations

avoid injury

avoid smoking

COVID-associated loss of taste and smell

- loss of smell could become a diagnostic criterion

- 41-96% of COVID sufferers experience smell loss

- taste loss usually follows

- 3/4 of patients recover these senses

taste, smell, and touch: assessment and normal findings

taste and smell: few established norms

touch: sensation varies depending on the part of the body touched

patients should be able to differentiate several stimuli:

- sharp vs. dull

- light vs. firm touch

- cold vs. warm

touch sensation is equal bilaterally

taste, smell, and touch: abnormal findings

taste/smell:

- anorexia/malnutrition

- complaints

- underexamined

touch:

- lack of sensation

- bilateral asymmetry

- silent injury

- decreased quality of life

balance and proprioception: assessment and normal findings

- Normal gait

- Ability to maintain upright stance despite minor upsets

- Ability to perceive changes in head position and acceleration (aka equilibrium and balance)

- Ability to perceive changes in body/ joint position (aka proprioception)

- Ability to integrate the senses to allow for safe movement

gait and sensory perception

body must combine info of leg joint positioning with visual, tactile, and balance cues to safely walk

balance and proprioception: abnormal findings

- Vertigo

- Falls

- Dizziness without an external cause

- Motion sickness

- Romberg test

consequences of balance and proprioception impairments

- impaired mobility

- impaired ADLs

- social isolation

- safety risks in the home

mitigation of balance and proprioception impairments

- assistive devices

- targeted ADL assistance

- facilitate social connection

- minimize safety risks and trip hazards in the home

functional ability definition

The individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being.

Basic Activities of Daily Living (BADLs or ADLs) definition

Activities of personal care and mobility, including eating as well as hygienic and grooming activities such as bathing, mouth care, dressing, and toileting.

Instrumental Activities of Daily Living (IADLs) definition

More complex skills that are essential to living in the community, such as managing money, grocery shopping, cooking, house cleaning, doing laundry, taking medication, using the telephone, and accessing transportation.

safety definition

minimize risk of/actual harm to patients, families, communities, and systems

scope of safety

keeping everyone/patients safe --> patient injury or death due to error

safety attributes

knowledge

skills

attitudes

physical environment

five ways Hight Reliability Teams (HRTs) promote organizational safety

1. sensitivity to operations

2. comittment to resilience

3. deference to expertise

4. reluctance to simplify

5. preoccupation with failure

culture of safety definition

one in which a health care organization's leaders, managers and workers are committed to core values and behaviors that emphasize safety over competing goals

a culture of blame invites...

oversimplification

scope of culture of safety

culture of blame --> culture of safety

multifactoral reality of healthcare safety

reason's swiss cheese metaphor

- when holes on cheese slices line up, it increases chances of errors

- by implementing policies and factors to increase safety and get rid of the aligned holes, errors are less likely to occur

culture of blame: error response

error is investigated

nurse is found responsible for the error

nurse is reprimanded

nurse is unlikely to repeat the mistake

diagnostic error

A diagnosis delayed, missed, mistaken, or mismanaged

treatment error

A treatment delayed, omitted, or done incorrectly

preventive error

failure to provide appropriate preventive care or to prevent harm

communication failure

Lack of, inadequate, or erroneous communication

near miss

An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. (IOM)

adverse event

An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient (IOM)

sentinel event

A patient safety event that reaches a patient and results in any of the following: death, permanent harm, severe temporary harm, or intervention required to sustain life.

never event

JCAHO (Joint Commission on the Accreditation of Health Organizations) designates some sentinel events as "never events:" preventable hazard that can result in injury or death - that should NEVER happen

human factors

study of the interrelationships among people, technology, and the work environment

- nurses' work is complex

- multiple distractions

- competing priorities

- self-care

what is one of the most powerful sources of coping and resilience available to us that improves our mental and physical well-being?

self-compassion

self-care as a safety practice

self-neglect and institutional indifference --> nurses leave profession

institutions prioritize and support self-care, nurses practice self-compassion --> nurses stay

all restraints must...

- be medically necessary

- benefit the patient (medical restraint)/ensure safety of others (behavioral restraint)

- be the only effective option

- be specifically ordered by a LIP (Licensed Independent Practitioner)

all patients in restraints must be...

- assessed at least every 2 hours

- at least every 15 mins if restrained to prevent violence towards self or others

- nurses must be trained in appropriate use of restraints

- assessment cannot be delegated

- helped with ADLs

- free of injury

- an injury that is caused by restraints is a sentinel event

what level of error is an injury caused by restraints?

Sentinel event

target germs where they live: outside the body

- eliminate the reservoir

- disinfect the surface

- sterilize the surface

- maintain awareness of dirty, clean, and sterile surfaces around you

target germs where they get out

- dispose of trash appropriately

- normal trash

- biohazard waste

- use standard precautions always

keep germs from getting around

- wash your hands

- read the sign: precaution guidelines

standard precautions

- big germs

- dont last outside body

- not very infectious

- not particularly deadly

- does not aerosolize

-ex: HIV

high level containment

- tiny germs

- hardy germs

- highly infectious

- deadly

- aerosolized

- ex: COVID, Ebola

how to keep germs from getting in

- wash your hands

- practice safe food handling

- scrub the hub

- don't break natural barriers to infection

- if you do, make sure equipment is sterile

avoid making the next person sick

- wash your hands!

- are any of your patients immune compromised?

- get yourself vaccinated

- encourage patients to get vaccinated

- police yourself and your colleagues (633,000 HAIs/yr)

- report diseases as required by law-certain STIs, meningococcemia, measles, many others