Exam 2

NUR 240

Traditional Knowledge

Passed down from generation to generation

Authoritative Knowledge

Comes from an expert, accepted as truth based on person’s perceived expertise

Secientific knowledge

Obtained through the scientific method (research)

Nightingale influences

• Demonstrating efficient and knowledgeable care

• Defining nursing practice as separate and distinct

• Differentiating between health and illness nursing

Societal Influences

• Shift to planned educational curriculum

• Women entering the workforce due to war

• Shift of nursing to a science

Theory

group of concepts that describe a pattern of reality

• can be tested, changed, or used to uide research

Concepts

Abstract impressions organized into symbols of reality; describe objectives, properties, and events and relationships among them

• conceptual framework or model a group of concepts that follow an understandable pattern

Nursing theory

developed to describe nursing and differentiates it fro other disciplines and activities

Deductive reasonsing

examines general ideas and considers specific actions or ideas

Inductive reasoning

Builds from specific ideas or actions to conclusions about general ideas

Goals of theoretical frameworks

• Holistic patient care

• Individualized care to meet needs of patients

• Promotion of health

• Prevention or treatment of illness

Scientific inquiry

process that. uses observable and verifiable information (data), collected in a systemmic manner, to describe, explain, or predict events

Reasearch

conducted to validate and refine current knowledge or to develop new knowlege

Goals of research

• Develop explanations (in theories)

• Find solutions to problems

Qualities of a Community-based Nurse

• Knowledgeable and skilled

• Independent in making decisions

Roles of a Community-Based Nurse

• Patient advocate

• Coordinator of services

• Patient and family educator

Continuity of Care

Ensures smooth transition between ambulatory or acute care and home health care or other types of health care in community settings

Care transitions

a continuous process in which a patient’s care shifts from being provided in one setting of care to another

Aim of Care coorination

• link patients when resources in the community to enhance their well-being

• improve information exchange

• Reduced fragmentation and duplication of services

Nurse navigator

• Identified and removed barriers to treatment

• Clinically trained nurse

• Central point of contact for patient care

Patient navigator

• nurse, social worker, or lay person

• Focuses on the support aspects of care

Vulnerable Populations

people with disabilities or multiple chronic conditions

Leaving AMA

• Patient is legally free to leave

• Choice carries a risk for increased illness or complications

• Patient must sign a release form

• Patient is informed of risks prior to signing form

• Patient’s signature must be witness

• Form becomes part of medical record

Critical thinking

Knowing how to focus your thinking to get the results you need (includes applying logic, intuition, standards, and evidence-based practice)

Critical reasoning

Throught processes that allow healthcare providers to arrive at a conclusion

Clinical judgement

• The result of critical thinking

• the skill of recognizing cues regarding a clinical situation, generating and weighting hypotheses, taking action, and evaluating outcomes for the purpose of arriving at the satisfactory clinical outcome

Situational awareness

the perception of the elements in the environment in a volume of time and space, the comprehension of their meaning and the projection of their status in the near future

Nursing Process

Mental Model - Assessment - Diagnosing/Identifying actual or potential problems - Planning - Identifying interventions and rationales - Evaluation

Reticular activating system (RAS)

• Facilitates reflex and voluntary

• Controls cortical activities relate to state of alertness

Hypothalamus

control center for sleeping and waking

Non-rapid eye movment (NREM) Stages I and II

5% to 50% of sleep, light sleep

Non-rapid eye movement (NREM)

10% of sleep, deep-sleep states (delta sleep)

Rapid eye movement (REM)

20% to 25% of a person’s nightly sleep time; pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase; skeletal muscle tone and deep tendon reflexes are depressed

insomnia

difficulty falling asleep, intermittent sleep, or difficulty maintaining sleep

Central disorders of hypersomnolence

constant or recurrent episodes of extreme sleepiness, particularly during the day

Circadian rhythm sleep-wake disorders

disruptions in the natural sleep-wake cycle, often resulting in insomnia or excessive sleepiness, due to misalignment between the internal clock and external environment, i.e. working night shift, jet lag

Parasomnias

Nightmares, sleep-walking

Idiopathic hypersomnia

characterized by excessive sleep, particularly during the day

Narcolepsy

Characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep

• up to 70% of people with narcolepsy also experience cataplexy, the sudden, involuntary loss of skeletal muscle tone lasting from seconds to one or two minutes

Restess leg syndrome (RLS) or Willis-Ekbom disease (WED)

sleep-related movement disorder that affects up to 15% of the population, most often middle-aged and older adults

Pharmacologic Therapy for Dyssomnias

Sedatives or Hypnotics

Nonpharmacologic Therapy for Dyssomnias

Cognitive behavioral therapy (CBT)

Cognitive Behavioral Therapy (CBT)

• Progressive muscle relaxation measures

• Stimulus control

• Sleep restriction; sleep hygiene measures

• Biofeedback and relaxation therapy

Epidermis

• Protective waterproof layer of keratin

• Cells have no blood vessels of their own

• Regenerates easily and quickly

Dermis

• Elastic tissue made primarily of collagen

• Nerves, hair follicles, gland, immune cells, and blood vessels

Subcutaneous

• Anchors the skin layers to underlying tissues

Functions of the Skin

Protection, Body temperature regulation, Psychosocial, Sensations, Vitamin D production, Immunologic, Absorption, Elimination

Causes of Skin Alterations

• Fluid loss

• Jaundice

• Diseases of the skin

• Very thin and very obese people are more susceptible

Types of Wounds

• Intentional (Surgical) or unintentional (traumatic)

• Neuropathic or vascular

• Pressure related

• Open or closed

• Acute or cronic

• Partial thickness, full thickness, complex

Avulsion

Amputation

Crush Injury

Puncture

Laceration

Hemostasis

• Occurs immediately after initial injury

• Involved blood vessels constrict and blood clotting begins

• Exudate is formed, causing swelling and pain

• Increased perfusion results in heat and redness

• Platelets stimulate other cells to migrate to the injury to participate in other phases of healing

Inflammatory stage

• lasts 2 to 3 days

• White blood cells, predominantly leukocytes and macrophages, move to the wound

• Macrophages enter the wound area and remain for an extended period

• Exudate is formed

• the patient has a generalized body response

What do exudates cause to the body during the inflammatory phase?

cause pain, redness, and swelling at the site of injury

What do macrophages do during the inflammatory phase?

They ingest debris and release growth factors that attract fibroblasts to fill the wound

Proliferation Phase

• Lasts for several weeks

• New tissue is built to fill the wound space through the action of fibroblasts

• Capillaries grow across the wound

• A thin layer of epithelial cells forms across the wound

• Granulation tissue forms a foundation for scar tissue development

Maturation Phase

• Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years

• Collagen is remodeled

• New collagen tissue is deposited, which compresses the blood vessels in the wound, causing a scar

Scar

flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

Local Factors Affecting Wound Healing

• Pressure

• Desiccation (dehydration)

• Maceration (overhydration)

• Trauma

• Edema

• Infection

• Excessive bleeding

• Necrosis (death of tissue)

• Presence of biofilm (thick grouping of microorganisms)

Age

children and health adults heal more rapidly

Circulation and oxygenation

adequate blood flow is essential

Nutritional status

healing requires adequate nutrition

Wound etiology

Specific condition of the wound affects healing

Health status

corticosteroid drugs and postoperative radiation therapy delay healing

Systemic Factors Affecting Wound Healing

Age, Circulation and oxygenation, Nutritional status, Wound etiology, Health status, Immunosuppression, Medication use, and Adherence to treatment plan

Wound Complications

infection, Hemorrhage, Dehiscence and evisceration, and Fistula formation

Factors Affecting Pressure Injury Development

Aging skin, Chronic illness, Immobility, Malnutrition, Fecal and urinary incontinence, Altered level of consciousness, spinal cord and brain injuries, and Neuromuscular disorders

Microclimate

Temperature and moisture of the skin

Mechanisms in Pressure Injury Development

External pressure compressing blood vessels, friction or shearing forces tearing or injuring blood vessels, microclimate

Risks for pressure injury development

nutrition and hydration, immobility, mental status, and age

Psychological Effects of Wounds

Pain, Anxiety, Fear, Impact on activities of daily living, change in body image

When do you do a skin assessment on a patient in an acute care setting?

Every shift

When do you do a skin assessment on a patient in a long-term setting?

weekly for 4 weeks then quarterly

When do you do a skin assessment on a patient in a home health care setting?

every visit

Wound assessment

Assess for appearance and drainageas well as size, depth, and surrounding skin condition.

Serous

Yellow

Sanguineous

Bloody

Serosanguineous

yellow and bloody

Purulent

pus (foul oder)

Venous Ulcers

Brownish discoloration, Pulses present, swollen, warm; frequently have significant drainage

Arterial Ulcers

Dry, minimal drainage; may have black eschar; cool and pale

Types of wound dressings

• those that maintain moisture

• those that absorb moisture

• those that add moisture

How often should a pressure injury/wound be cleaned?

With each dressing change

Bandages

• Roller

• Circular turn

• Spinal turn

• Figure-of-eight turn

Open Systems

Penrose drain

Closed systems

• Jackson-Pratt drain

• Hemovac drain

Binders

• Slings

• Abdominal

• Chest

• T

Red tissue

Protect

Yellow tissue

Cleanse

Black tissue

Debride

Mixed wound

contains components of Red, yellow, and black wounds

Factors Affecting the Response to Hot and Cold treatments

• Method and duration of application

• Degree of heat and cold applied

• Patient’s age and physical condition

• Amount of body surface covered by application

Applying Heat

• Dilates peripheral blood vessels

• Increases tissue metabolism

• Reduced blood viscosity and increases capillary permeability

• Reduces muscle tension

• Helps relieve pain

Applying Cold

• Constructs peripheral blood vessels

• Reduces muscle spasms

• Promotes comfort

Macro nutrients

Supply energy and build tissue: i.e., carbohydrates, fats, and protiens

Essential nutrients

not synthesized in the body or are made in insufficient amounts; must be provided in the diet or though supplements