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Stroke –common effects
Loss of face, hand, arm, leg, or body control
Hemiplegia
Changing emotions
Difficulty swallowing (dysphagia)
Aphasia or slowed slurred speech
Changes in sight, touch, movement, and thought
Impaired memory
Urinary Issues, loss of bowel control, constipation
Depression and frustration
Hypertension
a long-term condition where blood pressure in the arteries is consistently high. Blood pressure is usually diagnosed when it's 130/80 mm Hg or higher
Fractures-cast care/traction
Closed Fracture- Bone is broken, skin is intact
Open fracture- Broken bone has come through the skin
Movement of the bone ends is prevented with a cast, traction, etc.
Cast Care- Keep the cast dry, clean, avoiding putting weight on it. Elevate the cast.
HIV/How are they spread/precautions
Spread through body fluids
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Angina & Myocardial Infarction – what occurs
Angina is chest discomfort caused by insufficient blood flow to the heart muscle.
Myocardial infarction- blood clot stops blood flow to the heart.
Heart Failure (CHF) – what is it; nursing interventions
Occurs when a heart is weakened and cannot pump normally
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Diabetes – what is it/interventions/treatments
Type 1- Mostly in children, teens, young adults
Type 2- Any age
Risk factors are being over 45, being over weight, lack of activity, hypertension.
Treatment:
Type 1- Daily insulin therapy, healthy eating, and activity
Type 2- Healthy eating and activity, oral drugs, some need insulin, loss of weight.
Tuberculosis (TB) - how is it spread/precaution level
Bacterial infection in the lungs
Spread by airborne droplets with coughing, sneezing, speaking, singing, or laughing.
Risk factors:
Close, frequent contact
being close, crowded areas
age
poor nutrition
HIV
Standard precautions and isolation precautions (airborne)
Mouth and nose should be covered when sneezing, coughing, or producing sputum
Tissues are flushed down the toilet, placed in a biohazard bag, or placed in a paper bag and burned
Stroke- Care
A stroke is caused by a blocked artery in the brain
Therapy and help with day to day life.
The goal is to help them regain independence.
Hepatitis B/How are they spread/precautions
Inflammation of the liver
Follow standard precautions and the Bloodborne Pathogen Standard
Isolation precautions ordered as necessary
Hepatitis B
Is present in the blood and body fluids of infected persons
It is spread by:
IV drug use and sharing needles
Accidental needle sticks
Sex without a condom
Contaminated tools used for tattoos or body piercings
Sharing a toothbrush, razor, and nail clippers.
Care for persons with hearing aids and hearing loss
Take off and turn off before sleep
Keep away from heat, cold, and moisture
Make sure they are off before showers
Keep hearing aids clean
Speak slowly and clearly
Care for persons with vision loss
Provide adequate lighting
Provide access to their glasses
Keep the environment uncluttered, arrange things consistently
Communicate giving clear directions and using their preferred method
Nurse should be one step ahead in stairs and steep areas
Blindness- Key points for caregivers
Identify Oneself
Position items: Use an imaginary clock face to help position items
Provide verbal cues
Maintain safety
Keep the room well-lit
Communicate directly: Use the patient's preferred method
Support independence
Use the clock method: For example, describe meat as 12 o'clock, peas as 6 o'clock, and potatoes as 9 o'clock
Cut food into small portions: This can be useful for children
Avoid overfilling cups
Indicate liquid level
Cataract surgery post-surgery points
no bending
no carrying too much weight or participating in demanding activity
no swimming or getting wet
Shield your eyes
Don’t rub eyes
Avoid possibly infectious substances (such as makeup)
Restorative Nursing Care – what does it do
Helps persons regain health, strength, and independence
Helps maintain the highest level of function
Prevents decline in function
Restorative Nursing may involve:
Self-care
elimination
positioning
mobility
communication
cognitive function
Key points for caregivers re: Rehabilitation
Promote the person’s independence
Preventing decline
Receptive Aphasia
Difficulty understanding spoken language
Expressive Aphasia
Difficulty speaking language
Stroke patients
Physical, occupational, and speech therapy. The goal of stroke rehabilitation is to help patients regain lost abilities
Some general components of stroke rehabilitation programs include:
Treating the disease:
Improving function
Providing adaptive tools
Characteristics of normal respirations
12-20 per minute
Hypoxia- Definition and signs of
Cells do not have enough oxygen
Early signs include restlessness, dizziness, and disorientation
Deep breathing and coughing
purpose of- Remove mucus and bring air into most parts of the lungs
How it is done-Breathe in through their nose, hold for 2-3 seconds, release until ribs fall.
How often- 4 times or as requested every 1-2 hours.
Orthopneic position
Sitting position, head over a bedside table.
Oxygen sources and devices
Wall Outlet
Oxygen Tank
Oxygen Concentrator
Liquid Oxygen system
Pulse oximetry- normal range
Measures the amount of oxygen in your blood
95%-100%
Repositioning
Usually easier in Fowler’s and Semi-Flowler’s position
Persons often prefer orthopneic position
Positioning changes at least every 2 hours
O2 therapy
Oxygen therapy is used for persons with lung failure, problems, or difficulty breathing.
Flow rate
Flow rate is set by the nurse or respiratory therapist
Monitor the flow rate to make sure it is what it’s supposed to be.
If the flow rate is too high or too low, report to the nurse at once.
Cause of pressure sores
Unrelieved pressure that results in damage to the underlying tissues
Prevention of pressure sores
-Changing positions (q 2 hours)
-Using pillows
-Padding
-Keep skin clean and dry
-Promote hydration
Treatment
-Wound care products
-Drugs
-Treatments
-Special equipment to promote healing
Positioning techniques
Complications
-Infection
-Osteomyelitis (Inflamation of bone)
Persons at risk
-Bedfast or chair fast
-Need some or total help moving
-Have loss of bowel or bladder control
-Are exposed to moisture
-Lowered mental awareness
-Problem sensing pain or pleasure
-Circulatory problems
-Older, obese, or very thin
Osteomyelitis
Inflammation of the bones
Shear
Injury that will not be seen at the skin level because it happens beneath the skin
Bony prominence
Areas where bones are close to the surface
Key points for caregivers in preventing pressure injuries
-Inspect daily for signs of pressure injuries and report if spotted.
-Promote proper nutrition
-Change a persons position q 2 hours
-Keep the skin clean and dry
-Promote movement
Skin Tears
A break or rip in the skin
Circulatory Ulcers
Caused by decreased blood flow through the arteries or veins
Venous Ulcers
-Open sores on the lower legs or feet
-Caused by poor blood flow through the veins
-Are commonly found on heels and inner aspect of ankles
Arterial Ulcers
-Are open wounds o legs or feet Caused by poor arterial blood flow
-Are found between toes, on top of toes, an the outer side of the ankle
Diabetic Foot Ulcer
Open wound on the foot caused by complications from diabetes
-Check the persons legs and feet everyday
Purpose of Heat Applications
Increases blood circulation
Purpose of Cold Applications
Reduce pain, prevent swelling, and decrease circulation and bleeding
Types of Heat Applications
-Moist heat has faster and greater effects than dry heat
-Includes hot compresses, hot soaks, sitz baths, and hot packs
Dry heat applications stay at desired temp longer
-Some hot packs and the aquathermia pad are dry heat applications
Types of Cold Applications
Moist cold applications penetrate deeper than dry ones (cold compress)
Dry cold applications include ie bags, ice collars, ice gloves
-Cold packs can be moist d dry
Complications of Heat & Cold Applications
Heat
-High temp can cause burns
-When heat is applied too long, blood vessels constrict (flow of blood decreases)
Cold
-Pain, burns, blisters, and poor circulation
-When cold is longer than 20 minutes, the blood vessels dialate (flow of blood increases)
Length of Treatment for Heat & Cold
15-20 minutes
Binders
Montgomery ties
Montgomery ties are a type of tie that can be used to secure a bandage and change it without having to replace the tape each time. Can be used to facilitate frequent dressing changes and help prevent skin trauma.
Key points for caregivers
Friction and shearing
Friction occurs when two surfaces rub against each other, causing resistance. Shearing happens when layers of skin slide over each other. For bedbound individuals, friction and shearing can lead to pressure ulcers.
Thrombus
Blood clot.
A clump of blood that has changed from a liquid to a gel and forms in blood vessel. They can form in areas of slow blood flow.
Elastic stockings
Improve blood flow in the veins of your legs.
Aquathermia pad
An electrical device that produces dry heat to treat muscle sprains, mild inflammations, and pain.
Active ROM
The ability to move your body parts without the assistance of another person.
Passive ROM
the range of motion that a joint can achieve when an outside force, like a therapist or machine, causes movement.
Orthostatic Hypotension
A condition that causes a sudden drop in blood pressure when standing up from a sitting or lying position.
Dorsiflexion
Movement of the foot towards the body
Plantar Flexion
Movement of the foot away from the body
Ambulation
Act of walking or moving
Purpose of bedrest orders
Bed rest orders are prescribed to reduce physical activity and promote healing in patients with certain medical conditions or injuries.
Types of supportive devices for bedrest
Types of Supportive Devices for Bedrest:
Pillows for elevation and support.
Overbed tables for meals and activities.
Bedside commodes for toileting.
Footboards to prevent foot drop.
Bedpans for toileting needs.
WHy are supportive devices used?
To prevent pressure injuries, promote comfort, and enabling movement.