Exam 2

Week 4 Key Takeaways

Hygiene

  • Definition: Hygiene refers to practices that help to maintain health and prevent the spread of diseases, specifically concerning cleanliness and bodily care.

Factors Influencing Hygiene

  • Social Practices: Include collective norms and behaviors that influence one’s approach to hygiene.

  • Personal Preferences: Individual choices regarding hygiene products (brands, types), frequency of practices (time allocated for hygiene), and mode of hygiene (bath vs. shower).

  • Body Image: Perception of one’s physical appearance can motivate or demotivate hygiene practices.

  • Ability to Self-Perform Hygiene: Functional ability impacts whether individuals can maintain personal hygiene independently.

    • Socioeconomic Status: Availability of resources can affect access to hygiene products (affordability), availability of utilities (electricity), and concerns regarding safety during hygiene practices.

  • Health Beliefs and Motivation: Individual beliefs regarding health influence motivation for maintaining hygiene standards.

  • Cultural Variables: Different cultures may have varied definitions of cleanliness and utilize different hygiene products, reflecting pride in family practices.

  • Developmental Factors: Age and maturity level can influence one’s ability and willingness to engage in hygiene practices (e.g., children may require help).

Activities of Daily Living (ADLs) Hygiene

  • Who Can Assist in Bathing/Performing ADLs?

    • Unlicensed Assistive Personnel (UAP), Licensed Practical Nurse (LPN), Registered Nurse (RN).

    • Performing ADLs is not below any professional's scope, advocating for teamwork.

    • Specifically for Unstable Patients: Only RNs should assist in ADLs for patients classified as unstable; others must refrain from this practice.

    • Post-Surgery Patient Care: UAPs, LPNs, and RNs may perform ADLs on patients over 24 hours postoperative as long as the patient is stable.

Patient Education

  • Initial Education on Care: This task is primarily performed by RNs as part of evaluating, assessing, and teaching.

  • Subsequent Education: After the initial teaching, it may also be conducted by UAPs, LPNs, and RNs.

Identifying Cues and Symptoms in Patients

  • Functional Ability Considerations: Assess mobility, pain, fatigue, energy levels, muscle strength, balance, flexibility, sensation loss, and breathing patterns.

  • Presence of Tubes/Drains: Monitor and care for tubes or drains during hygiene practices.

  • Environmental Factors: Take into account the patient’s surrounding when conducting hygiene-related tasks.

  • Timing of Hygiene Practices: Perform hygiene before treatments/procedures to maintain patient comfort.

  • Adaptive Equipment: Assess need for additional medical equipment to promote patient independence in hygiene practices.

Types of Baths

  • Complete Bed Bath: For patients who are completely dependent and unable to bathe independently.

  • Partial Bed Bath: Includes bathing only specific areas that may cause discomfort if left unwashed.

  • Sponge Bath at Sink: Patient sits in a chair for washing using a bath basin or sink.

  • Tub Bath: Immersion in a tub for thorough cleaning.

  • Shower: Patient bathes under a continuous flow of water, beneficial for infection reduction.

  • Bath in a Bag: A time-efficient alternative for patients needing comfort during bathing.

  • CHG Bath (Chlorhexidine Gluconate): An antimicrobial bath method aimed at reducing hospital-acquired infections; should never be applied to the face, eyes, ears, or genital areas.

Additional Considerations in Hygiene

  • Patients with Tubes/Drains: Bandages around tubes should be changed 1-2 times daily.

  • Feet and Nail Care: Initial assessments must include evaluating circulation, gait, and skin conditions.

  • Male Perineal Care: Consider circumcision when providing care for male patients.

  • Female Perineal Care: Always performed from front to back to prevent infections.

  • Positioning for Care: Use Trendelenburg or reverse Trendelenburg positions appropriately for blood pressure regulation or spinal injury concerns.

  • Documentation: Required to include assistance needed, any abnormal findings, tolerance to treatment, skin treatments, and need for occupational or physical therapy (OT/PT).

Week 5 Key Takeaways

Mobility

Systematic Effects of Immobility

  • Metabolic Changes:

    • Decreased metabolic rate and appetite.

    • Slower gut movement leading to constipation.

    • Increased fatigue and reduced stamina, leading to fluid and electrolyte imbalances.

    • Result: Constipation, loss of bone density.

  • Respiratory Changes:

    • Increased risk for lung collapse and pneumonia.

    • Higher workload on the heart and increased oxygen consumption.

    • Result: Blood clots, decreased cardiac output.

  • Musculoskeletal Changes:

    • Reduction in lean mass and muscle loss, risk of joint contractures.

    • Lower calcium metabolism leading to osteoporosis and loss of range of motion (ROM).

  • Urinary Changes:

    • Urinary stasis and risk of renal calculi (kidney stones) due to decreased fluid intake.

    • Skin integument changes leading to breakdown and pressure injuries, infections (e.g., UTIs).

Developmental Effects of Immobility

  • Infants, Toddlers, and Preschoolers: May cause posture issues, growth delays, and gross motor skill development delays leading to dependency, with potential effects on intellectual development.

  • Adolescents: Possible experiences of social isolation due to restricted mobility.

  • Adults: Changes in family and social dynamics, as well as self-concept disruptions.

  • Older Adults: Reduced physical activity can lead to bone loss, loss of independence, increased fall risks, and coordination issues.

Mobility Aids

  • Gait Belt: Mandatory for use unless the patient is fully independent. Belt should be snug (allowing space for 2 fingers) and grip positioned upwards for control.

  • Crutches: Must not bear weight on the crutches to avoid nerve damage. Weight should be distributed through hands and elbows at a 30-degree angle.

    • Climbing Stairs: Good leg first, followed by crutches, then bad leg.

    • Descending Stairs: Bad leg first, opposite crutch, then good leg.

  • Walkers: Must ensure all four tips are on the ground while walking; the walking pattern should be walker first, followed by the weak leg, then the strong leg.

  • Canes: Should be held on the strong side with weight placed on the cane; walking pattern is cane with weak leg, followed by the strong leg.

Health Promotion

  • Adults: Encourage 150-300 minutes per week of moderate exercise; 75-120 minutes of intense aerobic activity.

    • Emphasize warm-up and cool-down sessions in exercise routines.

  • Women: Recommend increasing calcium and Vitamin D intake. Vitamin D aids in the absorption of calcium within the body.

Exemplar: Venous Thromboembolism (VTE) or Deep Vein Thrombosis (DVT)

  • Pathophysiology: Formation of a clot in deep veins where platelets adhere to valve structures, leading to accumulation.

    • Clots may later dislodge and travel to major organs (heart, lungs, brain).

  • Signs and Symptoms: Swelling, heat sensation, itching, aches, tenderness, or soreness.

  • Complications: Clots can break off and travel, leading to symptoms such as shortness of breath (S.O.B.), which may be indicative of a clot's dislodgment.

  • VTE Prediction Tool:

    • Scores 0 or below indicate low probability.

    • Scores 1-2 indicate moderate probability.

    • Scores 3-8 indicate high probability.

Nursing Interventions for Immobility

Musculoskeletal System

  • Remove stockings and compression devices every 8 hours (Q8H).

  • Assess abilities to perform ADLs daily (QD).

  • Conduct Range of Motion (ROM) exercises every 1-2 hours (Q1-2H).

  • Assess for pain and comfort every 4 hours (Q4H) and as needed (PRN).

  • Measure vitals every 4 hours (Q4H) or assess for orthostatic hypotension every 1-2 hours (Q1-2H).

  • Assess for peripheral edema every 1-4 hours (Q1-4H).

  • Monitor laboratory results, intake/outputs (I&O), and weights daily (QD).

Respiratory System

  • Assess respiratory status and lung sounds every 2-4 hours (Q2-4H).

  • Conduct cough and breathing exercises every hour (Q1H).

  • Ensure fluid intake of 1.5-2.5 liters of non-caffeinated fluids daily (QD).

Integumentary System

  • Turn and assess for skin breakdown every 2 hours (Q2H).

  • Apply skin protectors and conduct regular skincare.

  • Restrict sitting in a chair for more than an hour, encouraging movement every 15 minutes (Q15M).

  • Update Braden scale for skin assessment daily (QD).

Eliminatory Processes

  • Assess color of urine and patterns of voiding every 4-8 hours (Q4-8H) or as needed (PRN).

  • Provide dietary options high in fiber and maintain adequate fluid intake.

Week 6 Key Takeaways

Oxygenation and Respiration

Factors Affecting Oxygenation

  • Respiratory Issues:

    • Abnormal respiratory rates (hyperventilation and hypoventilation).

    • Lung function, compliance, ability to expand and collapse.

    • Presence of acute and chronic lung infections.

    • Pulmonary embolism risks due to dead tissue.

    • Musculoskeletal weaknesses and neurological conditions.

  • Cardiac and Hematologic Issues:

    • Anemia and associated blood loss.

    • Impaired valve functions leading to dysrhythmias.

    • Factors like pregnancy, obesity, and chest trauma affecting diaphragm function.

  • Developmental and Age Factors:

    • Infants and Toddlers: Higher susceptibility to upper respiratory infections due to smaller airways.

    • School-Aged Children: Increased germ transmission due to communal settings, along with risks from smoking, vaping, and obesity.

    • Young and Middle Adults: Lifestyle diseases due to unhealthy habits, stress, and medication usage.

    • Older Adults: Thickened vascular systems, abnormal heart rhythms, lung calcification, and decreased cilia leading to ineffective clearance.

Noticing and Assessing

  • Diagnostic Labs:

    • Hemoglobin and Hematocrit: Low values indicate anemia.

    • White Blood Cells: High values suggest infection or increased metabolic demands.

    • Serum Electrolytes: Essential for maintaining homeostasis.

    • Cholesterol Levels: Differentiated into low density (bad) and high density (good).

    • Troponin Levels: Increased levels heighten risk for heart attack.

    • Myoglobin: Indicates muscle damage.

    • C-Reactive Proteins: Signify general inflammation in the body.

Diagnostic Tests

  • Pulmonary Function Tests: Measure gas exchange efficiency.

  • Peak Expiratory Flow Rate: Measure lung resistance.

  • Bronchoscopy: Visual examination of lungs for blockages or secretions.

  • Lung Scan: Imaging procedure using radiation to identify abnormalities.

  • Thoracentesis: Procedure to remove fluid from the lungs to aid reinflation.

Nursing Responses

Dyspnea Management

  • Primary Goal: Treat the underlying cause like obstruction or allergic reactions.

  • Medications: Utilize bronchodilators and inhaled steroids to reduce and liquefy secretions.

  • Oxygen Therapy: Administer with humidification for comfort.

  • Breathing Techniques: Implement cough and deep breathing exercises as well as relaxation techniques to ease dyspnea.

Maintaining Airway

  • Hydration: Ensure adequate hydration to maintain respiratory health.

  • Coughing Techniques: Teach proper techniques for effective clearance.

  • Suctioning: Perform oral and deep suctioning as necessary.

  • Chest Physiotherapy: Promote lung expansion through physiotherapy and nebulization.

Lung Expansion

  • Ambulation: Encourage moving about to promote secretion clearance.

  • Positioning: Utilize semi-Fowler's position for optimal respiratory function.

  • Incentive Spirometer: Recommend hourly use and reps to facilitate lung expansion.

Exemplars

  • Hyperventilation:

    • Causes: Anxiety, stress, trauma, pain.

    • Signs and Symptoms: High heart rate, high respiratory rate, shallow breathing, tingling in extremities, dizziness.

    • Nursing Interventions: Stay calm, use a paper bag for rebreathing.

  • Hypoventilation:

    • Causes: Lung collapse, COPD, muscle relaxants, narcotics.

    • Signs and Symptoms: High heart rate, abnormal rhythms, confusion, decreased alertness.

    • Nursing Interventions: Monitor vitals, provide oxygen, and stimulate the patient as needed.

  • Hypoxia:

    • Causes: CO2 buildup, high altitudes, pneumonia, shock/trauma.

    • Signs and Symptoms: High heart rate, high respiratory rate, deep breathing, dizziness, cyanosis.

    • Nursing Interventions: Administer oxygen, monitor vitals, employ cardiac monitoring; if severe, call for rapid response.

  • Atelectasis:

    • Causes: Decreased lung volume due to blockage or alveolar collapse, often from immobility or surgery.

    • Signs and Symptoms: Dyspnea, abnormal lung sounds.

    • Nursing Interventions: Implement breathing exercises, facilitate patient movement.

  • Influenza:

    • Causes: Viral infection of the respiratory tract.

    • Signs and Symptoms: Hypoventilation, headache, dryness of cough, fatigue, weakness.

    • Nursing Interventions: Encourage breathing exercises, allow activities as tolerated, manage symptoms appropriately.