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23 Cards in this Set
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Skin Disorders 1: Discuss the pathophysiology of minor skin irritations. |
Dryness (Xerosis) : use a humidifier take a complete bath every other day, use tepid water, use nonalkaline soap, rinse thoroughly, pat dry, avoid clothing that continuously rubs your skin, maintain daily fluid intake of 3000 mls unless contraindicated, avoid caffeine and alcohol Pruritus: means itching. Caused by stimulation of itch-specific nerve fibers. Subjective condition, conditions that make it worse are dry skin, increased temperature, perspiration, and emotional stress. Priority interventions focus on increasing comfort and preventing skin injury. We treat the underlying skin disorder with topical or systemic drugs. Systemic diseases such as liver and venous disorders can also cause itching ( in liver disease bilirubin builds up in the skin stimulating itch receptors) Urticaria: means hives. Its caused by drugs temperature extremes, foods, infection, diseases, cancer, and insect bites. Interventions include removing the triggering substance, antihistamines, teaching to avoid overexertion, avoiding alcohol, and avoiding warm environments (further dilating blood vessels making urticaria worse). Alcohol increases sedating effects of antihistamines increasing risk of falls. Sunburn: |
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Skin Disorders 2: 1st 2nd and 3rd Intention (Healing) |
1st: a clean incision like a surgical incision with edges will approximated. 2nd: Pressure ulcer or venous stasis ulcer. 3rd: delayed primary closure |
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Skin Disorders 3: Evaluation of wound for size depth presence of infection and indications of healing |
Three Processes for repair of tissue integrity: 1) Re-epithelialization: the production of new skin cells by undamaged epidermal cells in the basal later of the dermis 2) Granulation: in deep partial-thickness wounds and full-thickness wounds the wound cannot heal by re-epithilialization alone. Removal of the damaged tissue results in scar tissue (granulation). During the second phase of healing, new blood vessels form at the base of the wound and fibroblast cells begin moving into the space to deposit collagen. 3) Wound Contraction: Fibroblasts also begin to pull the wound edge inwards along the path of least resistance (contraction).This causes the wound to decrease in size at a rate of about 0.6-0.75 mm/day. |
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Skin Disorders 3: Primary Prevention Interventions for Pressure Ulcers |
1: early identification of high-risk patients 2: implementing aggressive interventions for prevention with the use of pressure-relief or pressure-reduction devices. Pressure mapping with a computerized tool as well as patient and caregiver education are also important. Continuing evaluation and risk assessment are critical especially when the patient's condition changes |
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Skin Disorders 4: Braden Scale |
Mnemonic: MS FAMN Moisture 1-4 Sensory Perception 1-4 Friction/Shear 1-3 Activity Level 1-4 Mobility 1-4 Nutrition 1-4 6-12 = high risk 13-14 = moderate risk 15-18 = at risk 19-23 = no risk |
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Skin Disorders 7: Prioritize nursing care management for a patient with pressure ulcers |
pad contact surfaces do not elevate bed above 30 degrees use a lift sheet do not position directly on the trochanter reposition every 2 hrs or 1 hr in chair do not put a rubber ring or donut under sacral area use a slide board place pillows between bony surfaces keep the pt skin off plastic surfaces keep the pt heels off the bed using bed pillow under ankles ensure fluid intake between 2000 and 3000 mls help the pt maintain an adequate intake of protein and calories perform a daily inspection of the patients entire skin use moisturizers daily on dry skin and apply when skin is damp keep moisture from prolonged contact with skin dry underarms and under breasts use moisture barriers on skin areas where wound drainage or incontinence occurs DO NOT MASSAGE BONY PROMINENCES Humidy the room clean skin whenever soiled use a mild heavily fatted soap or gentle commercial cleanser for incontinence use tepid water dont scrub gently pat dont use powders or talc on the perineum after cleansing apply a skin barrier to areas in contact with urine and feces |
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Inflammation and Immune Response 1: Differences between inflammation and immunity in terms of cells functions and features |
IMMUNITY: is an adaptive internal protection that results in long-term resistance to the effects of invading microorganisms. The responses are not automatic, the body has to learn to generate specific immune responses when it is infected by or exposed to specific organisms. lymphocytes develop actions and products that provide the protection of true immunity. these cells develop specific actions in response to specific invasion. a) Antibody-mediated Immunity : also known as HUMORAL immunity involves B-cells which produce the antibodies. The B-cells identify the intruder and make antibodies specifically for that intruder and then the antibody destroys its target. b) Cell-mediated Immunity: this involves WBC's. Specifically: T-cells and NK-cells. The t-cells recognize the foreign antibodies and punch a hole in them and release deadly enzymes. The NK cells have direct effects without first being "sensitized". They are always on "seek and destroy" missions. INFLAMMATION: occurs in predictable three-stage sequence. The sequence is the same regardless of the triggering event. STAGE ONE: Vascular dilation. This causes redness and warmth of the tissues as there is increased blood flow and nutrition to the area. STAGE TWO: the cellular exudate part of the response. In this stage, an increased number of neutrophils occurs. Pus is formed as the neutrophils attack and destroy. STAGE THREE: Tissue repair and replacement. CELL TYPES INVOLVED IN INFLAMMATION: -Neutrophils (pacman) -Macrophages -Basophils (histamine and heparin releasing) -Eosinophils: associated with an allergic reaction -Monocyte: baby macrophage INFLAMMATION CANNOT PROVIDE IMMUNITY. Long lasting immune actions develop through AMI and CMI FIVE CARDINAL SIGNS OF INFLAMMATION -Warmth -Swelling -Redness -Pain -Decreased function |
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Inflammation and Immune Response 2: recognize the different stages of the inflammation sequence |
INFLAMMATION: occurs in predictable three-stage sequence. The sequence is the same regardless of the triggering event.STAGE ONE: Vascular dilation. This causes redness and warmth of the tissues as there is increased blood flow and nutrition to the area. STAGE TWO: the cellular exudate part of the response. In this stage, an increased number of neutrophils occurs. Pus is formed as the neutrophils attack and destroy. STAGE THREE: Tissue repair and replacement. |
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Inflammation and Immune response 3: Identify the influences of the aging process on Inflammation and Immunity |
Inflammation: -reduced neutrophil function -Leukocytosis does not occur during acute infection -They may not have a fever during inflammatory or infectious episodes AMI: -The total number of colony forming b-cells and the ability of these cells to mature into antibody-secreting cells are diminished. -There is a decline in natural antibodies, decreased response to antigens, and reduction in the amount of time the antibody response is maintained CMI: - The number of circulating T-cells decreases Implications: neutrophil counts may be normal but activity is reduced increasing the risk for infection. Pts may have an infection but not show expected changes in WBC counts. Not only is there potential loss of protection through inflammation but also minor infections may be overlooked until the pt becomes severely infected or septic. Older adults are less able to make new antibodies in response to the presence of new antigens. Thus they should receive immunizations, such as "flu shots" the pneumococcal vaccination, and the shingles vaccination. Older adults may not have sufficient antibodies present to provide protection when they are re-exposed to microorganisms against which they have already generated antibodies. Thus older pts need to avoid people with viral infections and need to receive booster shots for old vaccinations and immunizations especially tetanus and pertussis. Skin tests for tuberculosis may be falsely negative. Older pts are more at risk for bacterial and fungal infection, especially on the skin and mucous membranes in the respiratory tract and in the genitourinary tract. |
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Pain Assessment and Pt. Care: 2: discuss the attitudes knowledge and roles of nurses and clients regarding pain assessment and management. |
Attitudes: BELIEVE THE PT. Pain is subjective. The Nurse's roles are: Comprehensive Pain Assessment Pharmacologic Pain Management Nursing Safety Priority: Action Alert! Teach Pts how to use the PCA device and to report side effects. Monitor sedation level and respiratory status at least ever 2 hrs. Promptly decrease dose if increased sedation is detected. Ensures Pt is able to understand relationship between pain, accepting an analgesic dose, and pain relief. Ensures Pt is cognitively and physically able to use equipment. Nonpharmacologic Pain Management Psychosocial Assessment: Teach Pt to verbalize concerns and personal attitudes about pain, respect the pt verbal and nonverbal expressions of pain and explore support systems and coping strategies Self-management Education |
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Pain Assessment and Pt Care 3: Differentiate between addiction, tolerance, and physical dependance |
Addiction: is not normal and is a disease that is both neurologic and biologic. Tolerance: is a normal response as well and may be treated by an increased dose or a different opioid. Physical Dependance: is a normal response that occurs with repeated administration of an opioid for several days. It is manifested by the occurence of withdrawal symptoms. This can be prevented by tapering the drug instead of immediately stopping it. |
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Pain Assessment and Pt Care 6: Describe the use of non-opioid and opioid analgesics in pain management and nursing management considerations. |
3 groups: non-opioid, opioid, and co-analgesics antidepressives are often used for breakthrough pain. |
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Pain Assessment and Pt Care 7: acute vs chronic |
acute: <3mos chronic: >3-6 mos chronic pain in an exacerbated state is acute pain. If the pt has vital signs related to their pain then it is acute. This is because of how the sympathetic nervous system adapts acute pain has a biologic basis: it serves a purpose. |
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Pain Assessment and Pt Care 8: discuss the importance of pain assessment and three tools to assess pain in older adults |
components of a pain assessment: 1: location 2: Intensity 3: Quality 4: Onset and duration 5: Aggravating and relieving factors 6: Effect of pain on function and Quality of life 7: Comfort-function Outcomes 8: Other considerations such as comorbid conditions (Dementia may mean you need to use the face scale) (faces pain scale revised is perferred in older adults instead of wong baker) CNPI : checklist nonverbal pain indicators PAINAD: groups behavioral indicators into 5 categories: breathing, neg vocalization, facial expression, body language, and consolability |
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Surgical (Preop and Postop) 1: Identify important preop considerations in preparing a client for surgery to include priority nursing interventions |
DONT interrupt medications if the pt is NPO they still need to have their meds. Especially Beta blockers. Education on incentive spirometer. Postop pain may inhibit desire to breathe also VTE!! These are all SCIP points outlined in our text pg 217 (med-surge) |
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Surgical (Preop and Postop) 2: Factors that may increase a client's surgical risk |
pg 219 med surge -65 years or older -meds: antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDS -decreased immunity, diabetes, pulmonary disease, cardiac disease, hemodynamic instability, multi-system disease, coagulation defect or disorder, anemia, dehydration, infection, hypertension, hypotension, any chronic disease - Prior Surgical Experiences: less than optimal emotional reaction, anesthesia reactions or complications, postop complications - Health History: malnutrition or obesity, drug, tobacco, alcohol, or illicit substance abuse, altered coping ability - Family History: malignant hyperthermia, cancer, bleeding disorder -Type of procedure planned: neck oral or facial procedures (airway) chest or high abdominal procedures (pulmonary) or abdominal surgery (paralytic illeus or VTE) |
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Surgical (Preop and Postop) 3: describe legal implications and proper procedures for obtaining informed consent |
The nurse verifies that the consent form is signed, and serves as a witness to the signature, not to the fact that the patient is informed. The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse’s role is to clarify facts that have been presented by the surgeon and dispel myths that the patient or family may have about the surgical experience. |
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Surgical (Preop and Postop) 4: Recognize client conditions or issues that need to be communicated to the surgical and post op teams |
report special needs or concerns and instructions including advance directives. For example, if the patient is a jehovas witness and cannot accept blood products or if the pt is hard of hearing and does not have a hearing aid. |
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Surgical (Preop and Postop) 6: prioritize nursing interventions for the client recovering from surgery and anesthesia during the first 24 hrs |
General anesthetics may cause respiratory depression, where the respiratory rate may slow to less than 10 breaths per minute. The patient may snore and may have high-pitched crowing sounds due to tracheal or laryngeal spasms and edema, mucus in the airway, and tongue relaxation. The color of the wound drainage is not altered by the use of general anesthesia. Skin texture and turgor are assessed in the patient in a medical surgical unit to assess the level of drainage. Redness and warmth of the legs and feet are assessed in the patient with deep vein thrombosis. |
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Surgical (Preop and Postop) 9: Identify important considerations in home care management for a postop client |
assess info about the home environment for safety patient accessibility cleanliness and availability of care-givers. Use the data obtained on admission before surgery to determine the pt needs. For example if the patient is unable or not allowed to climb stairs and lives in a two-story house with only one bathroom advise the pt to rent a bedside commode. Collab wit hthe social worker or discharge planner to identify needs related to care after surgery including meal prep dressing changes drain management drug administration equipment rental physical therapy and personal hygiene. A referral to a home care nursing agency may be indicated. |
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Adults (Age related mental health disorders) 3: Describe evidence-based treatments for the care of the person with serious mental illness |
1: Programs of Assertive Community Treatment (PACT) : use a treatment team approach. The consumer works solely with an established team of professionals who provide comprehensive services and 24/7 access to a team member 2: Cognitive Behavioral Therapy : which helps persons to recognize and reduce unrealistic expectations and distorted thinking has been effective in reducing auditory hallucinations. CBT helps consumers perceive circumstances more accurately and positively by guiding them to reconsider their perceptions. This uses natural consequences and rewards to shape behavior. 3: Social Skills Training: taught in a concrete stepwise fashion 4: Vocational Rehab and Supported Employment: initial employment in a sheltered setting building to a competitive employment in the business world. 5: Promotion of family support and partnerships with providers: based on the premise that having sound support systems is one of the strongest predictors of recovery. An example is NAMI's family to family program a psychoeducational program focusing on the skills families need to cope with their loved one's mental illness |
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Adults 2: describe how a neurotransmitter functions as a chemical messenger |
pg 42 mental health : Monoamines: a) Dopamine: > = schiz and mania, < = parkinsons disease and depression b)NE : > = mania anxiety and schiz, <= depression c)Serotonin > = anxiety < = depression d)Histamine if it's decreased then sedation and weight gain Amino Acids: a) GABA b) Glutamate Cholinergics: a) ACh Peptides (Neuromodulators): a) Substance P b) Somatostatin c) Neurotensin |
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Adults 3: ID the main neurotransmitters that are affected by the following psychotropic drugs and their subgroups as well as important aspects to include in a pt teaching plan |
Antidepressants: (Serotonin) : MAO Adverse: serotonin toxicity and erectile dysfunction. Also tyramine is important with MAO, it takes 2 weeks to get out of the body. Mood stabilizers: NE: adverse reactions: related to lowered BP/orthostatic hypotension/sexual problems (inability to ejaculate) Main one is Lithium. sodium balance is very important with lithium, it takes a while to develop a therapeutic level (5-14 days or as long as 3 wks). this drug has a toxic level, anything higher than 1.5 meq/L Antipsychotic agents/Atypical antipsychotic drugs: Dopamine adverse: blurred vision dry eyes and constipation and EPS |
