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38 Cards in this Set
- Front
- Back
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Restraints
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human, mechanical/physical device used to restrict client’s freedom of movement/normal access to person’s body
-not usual pt of treatment -Goal for all clients=resistance free environment; but clients at risk for injury from falls, wandering & disruptive/agitated behavior may need temporarily -Complications: pressure ulcers, constipation, pneumonia, urinary/fecal incontinence, urinary retention -Hazards: contracture, nerve damage, circulatory impairment; loss of self-esteem, humiliation, fear, anger |
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Dysphagia
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Assess gag reflex& risk for aspiration:
- normally patients with decreased level of alertness, decreased gag and cough reflex, and clients who have difficulty managing saliva are at risk for aspiration |
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Enteral Feedings
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- Used when patient is unable to ingest food but is able to digest and absorb nutrients
- Types: Inserted through nose (nasogastric/nasointestinal), surgical (gastrostomy/jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy) - Benefits: reduces sepsis, minimizes hypermetabolic response to trauma, maintains intestinal structure and function - Main complication: Aspiration aspiration into lungs causes irritation of bronchial mucosa resulting in decreased blood supply to affected pulmonary tissue necrotizing infection, pneumonia, potential abscess formation. Coughing, nasotracheal suctioning, artificial airway, decreased LOC, and lying flat increase risk of aspirations |
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Gastric/Jejunal tubes
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- Gastric tubes are used if clients have a low risk of gastric reflux
- Gastric reflux leads to aspiration - If there is a risk for gastric reflux, jejunal feeding is preferred - Nasointestinal/jejunal tubes allow for postpyloric feeding; formula placed directly into small intestine, jejunum, or beyond pyloric sphincter of stomach. Good for patients who have gastroparesis, esophageal reflux, or history of aspiration pneumonia. |
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Types of Therapeutic Diets
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Clear Liquid - Broth, bouillon, coffee, tea, carbonated beverages popsicles, gelatin.
Full liquid - Smooth-textured dairy products like custards, refined cooked cereals, vegetable juice, pureed vegetables, ice cream, smoothies, fruit juices Pureed - Scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy Mechanical Soft - finely diced or ground meat, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, etc. Soft/ Low Residue: low-fiber, easily digest food like pasta, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts, cakes, cookies High fiber- uncooked fruits, steamed vegetables, oatmeal Low sodium- 4g no added salt, 2g, 1g, or 500 mg sodium diets. Low cholesterol- 300 mg/day Diabetic- Around 1800 calories and diet must include balanced intake of carbs, fats, and proteins |
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Body Mechanics
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ability to move freely; coordinated efforts of musculoskeletal & nervous systems
- Immobility risk factors: developmental considerations - Physical health - Musculoskeletal problems- affecting joint mobility - Problems affecting the CNS |
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Physiologic Hazards of Immobility:
Cardiovascular System |
Problems:
(1)Orthostatic Hypotension- drop in BP w/ position change; causes decreased circulating volume, pooling in extremities & decreased autonomic response; Increased cardiac workload= increased hart O2 consumption (2) - Thrombus formation- accumulation attached to anterior wall of vain or artery that can occlude vessel; Contribute to thrombus: VIRCHOW’s triad- damage to vessel wall during procedures; blood flow alterations (slowed in calf veins); alterations in clotting factors themselves Interventions: - maintain fluid balance (key in preventing hypertension) - reduce cardiac workload: avoid valsalva maneuver (pushing), breathe out during movement, monitor for orthostatic changes To prevent DVT: - leg, ankle & foot exercises while awake, anticoagulants,SCD -mimic walking, TED hose- reduce swelling & decrease pain, avoid leg crossing (increased risk of blood pooling in extremities), ROM- reduce contracture risk & aid in preventing thrombi, proper positioning- minimize compression of leg veins |
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Physiologic Hazards of Immobility:
Respiratory System |
Problems:
(1) Atelectasis- airless alveoli- alveolar collapse, particularly around periphery (2) Pneumonia (Hypostatic)- (inflammation of lung from stasis/pooling of secretions) lung inflammation from shallow breathing from bedrest - both decrease oxygenation, prolong recovery & add to pt discomfort Interventions: cough and deep breathe: ever 1-2hrs, incentive spirometry, chest physiotherapy, remove binders, adequate fluids |
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Physiologic Hazards of Immobility:
GI |
Problem: Slows peristalsis- decreased appetite, constipation/impaction, trans location of gut bacteria to blood stream
Interventions: feeding @ first moment of B sounds: adequate fluids, protein & calories |
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Physiologic Hazards of Immobility:
Metabolic System |
Problem:slowed wound healing, muscle atrophy, decreased subcutaneous fat, generalized edema
Intervention:high-protein, high calorie diet to repair injured tissue & rebuild muscle |
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Physiologic Hazards Of Immobility:
Urinary System |
Problem: Supine positioning=urinary stasis, infection, renal calculi (calcium stones (hypercalcemia)
Intervention: to maintain optimal urinary fxn & w/o causing bladder distention - adequate fluids, put pt upright to toilet |
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Physiologic Hazards Of Immobility:
Musculoskeletal System |
Problems:
(1) decreased lean body mass (muscle decomditioning)- weakness, atrophy, decreased endurance, joint instability (2) impaired Ca+ metabolism & joint abnormalities- bone resorption (disuse osteoporosis), joint contracture (fixation) Intervention:positioning, ROM- prevent muscle atrophy & joint contractures |
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Physiologic Hazards Of Immobility:
Integumentary System |
Problem: pressure ulcer risk (skin breakdown)
Interventions: positioning, position changes q2h, skin care |
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Positioning:
Principles & steps |
* Alignment & posture key
-avoidance of “contractures” -All patient positioning requires: (1) inform client/asses (2) enlist help (3) elevate & flatten bed (working height=just below hip level) (4) placement of turn sheet -All Positioning ends with: (1) patient comfort check (2) side rails up (3) call bell w/in reach & sight (4) bed back down in lowest position |
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ROM:
Principles, Assessment |
-General Principles:
(1) verify Dr’s orders (2) Make pt as active participant as possible (3) Don’t exceed pain threshold (4) Put joints through full RON - Assessment: for stiffness, swelling, pain, limited & unequal movement - assess baseline to determine if loss has occurred |
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Hygiene:
Bathing, Perianal, Oral |
Bathing & Skin Care:
-consider client’s normal grooming routines; individualize care based on client’s preferences -Physically/Cognitively impaired client- increase skin assessment & provide skin care to reduce breakdown -Complete bed bath: measure HR before, during & after - Partial bed bath: pt unable to reach all body pts - Provide privacy, #1maintain safety, maintain warmth, promote independence, anticipate needs Perianal Care: - pt of complete bed bath - most in need: at greatest risk for acquiring infection, circumcised men, w/ indwelling urinary catheters & recovering from rectal/genital surgery/childbirth - encourage independence Oral Hygiene: - maintain health state of mouth, teeth, gums & lips - poor oral care reduces ability of oral environment to help fight effect of pathogens - enhances well-being & comfort & stimulate appetite - tooth brushing @ least 4x/day after means & bedtime basic to effective oral hygiene |
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I&O Monitoring
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-Ordered by MD but can be nurse-initiated
-fluid intake or urine output is less than normal -intravenous therapy is being administered -medical problems that affect fluid status -after surgery or trauma -Record all intake and output- total at least each shift or per unit norms -use facility-based references for cups, soup bowls, etc. -check 24 hour totals-compare to weight and labs -determine if pt is euvolemic, hypovolemic, hypervolemic |
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I&O Sources and Total Gains/Losses
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-Fluid gains:
--- Oral fluids 1200 mL (Drinking water and other beverages) ---Solid foods 1000 mL (Contained in other foods) -- -Metabolism 300 mL (Through food oxidation) -Fluid Losses: Kidneys 1500 (Urine) -GI 200 (Feces) -Insensible loss: Skin 300 (perspiration) -Lungs 500 (respiration) 24hr Totals: **Total Gains 2500 mL **Total Losses: 2500 mL |
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FVE (Fluid volume excess)
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-Historical Information: Heart failure, liver failure, renal failure, excess sodium intake
-Physical findings: Weight gain, Edema, Ascites(excessive fluid in the abdominal cavity), Anasarca(generalized edema), Neck vein (>2cm), crackles in lungs, confusion -Increased H2O and lowered Na (Na <135)= hyponatremic/overhydration |
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FVD (Fluid volume deficit)
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-Physical findings: Skin turgor, dry tongue and mucous membranes in the mouth, edema, weight loss, flat neck veins, lethargy, oliguria (less than 30 mL per hour), weak pulse, confusion, thirst
-Subjective findings: c/o thirst -Decreased H20 and increased Na (>145)=dehydration (brain affected most) |
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Constipation
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- syx, not disease
- decrease in frequency, harder, drier stool, difficulty evacuating (straining to defecate) Causes: - improper diet (low in fiber) - irregular bowel habits (postponing defecation) - anxiety, depression, cognitive impairment - bed rest - hypocalcemia, hypokalemia - reduced fluid intake - lack of exercise - hypothyroidism - certain medications (narcotics, etc) Complications: - straining = valsalva maneuver - contraindicated due to increases in pressure - glaucoma (increased ICP) - cardiac disease (bradycardia) - post surgical patients (risk of dehiscence) - increased intracranial pressure Assessment: when last BM, description, straining, pain, diet change & lifestyle change Interventions: fluid, fiber, balance b/t activity & exercise (abdominal muscle tone), medication (stool softeners, laxatives), enema |
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Impaction
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-unrelieved constipation; worst case scenario of constipation: hard dry stools, less frequent, unable to pass
Assessment: S&S=decreased stools/continual oozing of liquid stool, loss of appetite, abdominal distention, fecal mass palpated in rectum, x-ray confirmation Interventions: - suppository- stimulates peristalsis - Enema- adds H2O to stool; instillation of a solution into the rectum and sigmoid colon to promote defecation |
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Diarrhea
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-increase in number of stools
-passage of liquid, unformed feces -intestinal contents pass through small and large intestines too quickly too allow absorption of fluids and nutrients Causes: - stress - intestinal infection (Clostridium difficile) - food intolerance - medications (iron, antibiotics) - laxatives - surgical alterations (gastrectomy, colon resect) - smoking - alcohol Interventions: - antidiarrheal agents - clear liquid diet - NPO (worst case scenario) |
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Fecal Incontinence
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Causes: dysfunction of anal sphincter, stool delivery disorder, rectal storage disorders (capacity)
Interventions: - Bowel Training- promote regularity; choose & maintain bowel time, hot drinks, positioning, privacy & exercise - Macedo-Malone Antegrade-Continence Enema- scheduled enemas through surgically created bowel flap to simulate defecation |
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Collection of Stool Samples
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uses clean, not sterile technique
- checks for ova and parasites -stools for occult blood: blood present, test turns blue; could be frequent enough to drop blood count -guaiac & hemoccult |
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Dysuria
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painful voiding, burning sensation during urination
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Polyuria
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formation & excretion of excessive ammt of urine w/o increase fluid intake more than 3000 cc/24 hrs
Causes: DM, diuretic meds, caffeine, alcohol |
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Oliguria
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formation & excretion of decreased ammt of urine (<400 cc/24hrs)
Causes: severe decrease in fluid intake/severe loss of body fluid, renal failure |
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Anuria
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urine output >100 in 24/hrs; renal failure
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Urgency
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subj feelings of being unable leads to delay urge to void leads to incontinence
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Frequency
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void more often than normal pattern w/o increased fluid intake (<250 cc/each time)
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Hematuria
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blood in urine
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Pyuria
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pus in urine
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Urinary retention (NANDA)
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unable to empty bladder of urine
(1) unable to perceive growing fullness (2) unable to relax bladder neck & external urethral sphincter |
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Urinary Incontinence (NANDA)
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loss of urine from bladder involuntarily
Types: - Stress Incontinence- usually weakened bladder muscle floor problem - Urge Incontinence- urgency leads to incontinence - Functional Incontinence- not problem with bladder; mobility issue - Overflow Incontinence- retention status post-surgery |
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Collecting Urine Samples
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Principles: labeled, sealed cover, to lab ASAP; may sometimes be refrigerated
Types: - Clean catch/Midstream specimen: free of microorganisms (use sterile bedpan/cup) - 24-hr Urine Collection/Timed urine collection: measure accurately kidney excretion of certain substances; save all urine in 24-hr period - large collection container; refrigerated during 24-hr period - Specimen from catheter: maintain strict asepsis; specimen from collection port |
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Types of Catheters
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- Indwelling (retention) catheterization; Foley- two lumen
- In-&-Out catheterization- straight tip w/ one lumen - Continuous irrigation Catheter Complications: infection, trauma to urethral tissues, bladder decompression, submucossal hemorrhage |
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Indications for Catheters
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- difficulty w/ urination, incontinence/retention, spinal cord injury pt
- accurate assessment of urinary output: pts with trauma, burns/surgery - bladder irrigation/instill bladder meds - urine specimen/check urine residual |
