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392 Cards in this Set
- Front
- Back
Principles of Body Mechanics
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Wide Base Support
Low Center of Gravity Keep Object Lined Through Base Support Face Direction, prevent twisting Keep Objects Close Have pt. help if Possible Draw Sheet to Reduce Friction |
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Trochanter Rolls
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Prevents external rotation of legs when pt. are in the supine position
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Foot Boots
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Maintain feet in dorsiflexion
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Sandbags
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Provide support & shape to body contours.
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Fowlers
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Supine, elevated 40-60
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Semi-fowlers
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30
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Prone
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pt. on abdomen
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Lateral Bed Positions
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Pt. suported on rt. & lft. side
Arms r flexed toward shoulders Hips & knees are slightly flexed |
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Sims
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Semi-PRONE on side w/ thigh, & knee flexed and resting on bed.Underneath arm behind, protect abdomen
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Supine
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Back flat against bed
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Dorsal Recumbent
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Supine position with pillow supports head & upper shoulders; hips & knees slightly flexed w/ supporting pillow
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Trendelenburg
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Prone or Supine; pt. rest on inclined surface w/ head lower than heart, legs, & feet.
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Reverse Trendelenburg
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Entire bed frame tilted downward with foot of bed down; promotes gastric emptying, prevents esophageal reflux
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TB Symptoms
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Cough (poss bleeding)
Spit brownish weight loss fever night sweats loss of appetite chest pain scratching |
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Fire Safety
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Rescue
Alarm Contain Evacuate & Extinguish |
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restraints time period
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skin / 30 minutes
skeletalmuscular / 2 hours remove every 2 for 30 min. |
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electrical fire ( your actions)
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Activate
Evacuate Confine Extinguish |
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Principles - Restraints
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How to apply
use least restrictive restraint possible tie to frame not rails |
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What causes shearing force
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Sitting Fowlers to long
Skin stays in same place Deeper tissue attached to skeletal move downward Deeper tissue & superficial tissue meet causing damaged blood vessels & tissue |
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Calcium loss for Immobility can be noted within
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two weeks
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What is Osteoporosis?
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Porous bone
Decrease in bone mass & structural deterioration Often no signs or symptoms until break |
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DO NOT give to immobile pt (intake)
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Calcium & phosphate
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Negative nitrogen balanced caused by
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poor nutrition
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lab work routinely done prior surgery
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Diagostic screening
Complete blood count (CBC) Blood Chemistry (SMA 7 or CHEM 7) Coagulation studies blood type urinalysis screen for UTI renal disease diabetes mellitus 12-lead electrocardiogram chest x-ray ht. wt. |
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nursing obligation about informed consent
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if pt. is confused or uncertain about procedure; ethical obligation to inform dr. prior to surgery
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postoperative exercises taught postoperative
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daiphragmatic breathing
incentive spirometry controlled coughing turning leg exercises |
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postoperative assessment;
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respirations
circulations infection control gastrointestinal function comfort |
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postoperative assessment; respiration
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respiratory rate, rythym, & depth every 15 minutes for 1hr.
observe for symmetry of chest wall movement, color of skin and mucuos membranes ausculate breath sounds for rales, wheezing, decreased or absent sounds apply pulse oximeter to detec o2 saturations |
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postoperative assessment; circulation
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monitor pulse rate & rhythm as well as bp every 15min. for 1hr. then every 30min twice, & then every hr for 4 hrs.
assess level of consciousness & symptoms of restlessness or altered menatl status obeserve skin, nail beds, & mucous for color & hydration auscualtate lungs for signs of congestion paplate peripheral pulses distal to surgical site, tight dressing, tourniquent, or cast inspect for amt of bleeding on dressing, in drainage system, & underneath pt. monitor ECG if ordered |
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postoperative assessment; infection control
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monitor pt. temp. & white blood cell count as indicated
observe surgical wound for redness, edema, warmth, purulent drainage, & dehiscence inspect any output (urine, wound drainage) for color, consistency, & odor |
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postoperative assessment; gastrointestinal function
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inspect for abdominal distention caused by gas or bleeding
ausculate for bowel sounds in all four quadrants at least every shift until discharge palpate abdomen for firmness caused by gas, fluid, or mass monitor NG tube for patency & NG tube output for color & amount of drainage if present observe pt ability & willingness to tolerate fluids & food advance diet only with return of active bowel sounds |
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postoperative assessment; comfort
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observe for signs & symptoms of discomfort
observe pt for individual manner of dealing with pain & discomfort assess for any side effects of pain medication (altered mental status, depressed respirations, bradycardia, othostatic hypotension, nauses or vomiting, urinary retention, constipation) |
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common problems post op
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airway compromise
cardiac/circulatory compromise neurological compromise gastrointestinal compromise hypothermia pain skin/wound problems |
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ineffective airway post op
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respiratory rate
* CNS depressant drugs slow respirations patency of airway * foreign object * relaxation of tongue * increased secretion patterns of respiratory work * shallow breath common with abdominal surgery * airway spasms breath sounds * aspiration of vomit or secretions * fluid overload |
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Nursing interventions for ineffective airway Post OP
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client's airway will remain patent
o2 saturations WNL 92-100% show no signs of aspiration respiration rate within +5 of baseline can cough & deep breath effectively No s/s of pneumonia - fever, chills, productive cough, chest pain, dyspnea |
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Cardiovascular/circulation compromise Post OP
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bp
heart rate peripheral pulses skin temp & color post op dehydration (blood loss, bleeding) DVT's |
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Cardiovascular Nursing Intervention Post Op
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Maintain tissue perfusion & cellelular o2 within normal parameters
all pulses palpable extremitites warm with normal color no complaints of tingling limbs vital signs normal for client. q 15min x 4, q 30min x 2, qhr x 4 1500-3000 ml output daily hgb, PT(perthrombin) & arterial blood gasses WNL Anti-embolism stockings |
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Gastrointestinal compromise Post Op
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inspect for abdominal distension
observe for nausea/vomiting check for return of bowel function * bowel sounds * advance diet as bowel function returns * flatus |
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neurological functional assessment
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pulilary reflexes
orientation hand grasp movement LOC/sudden change in consciousness |
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gentirourinary compromise
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observe for bladder distension
* restlessness, agitation, increased bp watch for adequate urine output (foley) |
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Pain post op
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behavior symptoms
*restlessness *grimacing *vital signs pain scale review pain medication orders in PACU with anesthesiologist or CRNA PCA pump most often utilized |
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problems with skin or wound Post Op
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rashes
drainage dehiscense evisceration |
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circulating nurse (non-sterile)
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reviews pre-op orders & check sheet
transfers client to OR positions pt on OR table assist anesthesia with induction prep's pt assess urine & blood loss ensures team maintains sterile tech. anticipates surgical team needs counts instruments & laps, needles documents happenings in OR |
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scrub nurse (sterile)
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sets up sterile field
dresses surgical team assist in draping hands instrument and supplies to surgeon anticipates what surgeon needs counts laps, needles & instruments |
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surgical assistant (sterile)
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hold retractors, suction wound, cut tissue, suture & dress wound
can be another surgeon, resident, intern, nurse practioner, PA, RN |
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complication from general aneshesia
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complication of intubation
* broken teeth * injured vocal cords * neck injury malignant hyperthermia * caused by rapid increase in temp, increase in calcium & potassium overdose unrecognized hypoventilation complications related to anesthetic agent |
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complication from regional anesthesia
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respiratory depression (especially morphine)
hypotension (local can cause vasodilation) nausea & vomiting (high concentration of opioid) urine retention (opioids inhibit parasympathetic effects of bladder) pruritus allergic reaction |
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classifications of surgery
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serious
urgency purpose |
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purposes of surgery
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diagnostic
ablative palliative reconstructive procurement for transplant constructive cosmetic |
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included in pre-op teaching
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reasons for test & procedures
why NPO what will happen during & after surgery pain relief measures post-op exercises * deep breathing & coughing, incentive sprometer * leg exercises |
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gate control theory
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when everything works together the gate is open & we experience pain; when one of the modulators or regulators interfere this causes the gate to close & we don't experience or perceive pain.
certain nursing interventions can close the gates by stimulating the release of endorphins |
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Physiology of pain (how it works)
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a pain receptor must be stimulated either by direct damage to the receptor cell or by the release of chemicals such as the amino acid bradykinin
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types of pain stimuli
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mechanical
thermal chemical |
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transmission/perception of pain
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body releases substances (histamine, etc) that combine w/ receptors that initiate the neural tramsmission
these impulses travel through either fast A-delta fibers or C fibers |
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the A or C fiber
continuation of how pain works |
the fibers take the transmission to the dorsal horns of the spinal cord where they synapse (with the help of substance P) from periphery nerves to spinothalamic tract & up to the brain
synapse occurs at the spinal cord with A fiber & motor neurons to cause muscle contraction |
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modulators of pain
continuation of physiology of pain |
modify the transmission by either exciting or inhibiting the pain transmission & perception
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modulators for pain increase or decrease; name 5
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substance P inhances
serotonin inhibit norepineprhrine inhibit endorphins inhibit bradykinin enhance |
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autonomic NS stimulated
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flight or fight for lower intensity & superficial pain
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parasympathetic NS stimulated
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deep, visceral, unrelenting, severe pain
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reactions to pain are either physiological or behavioral
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autonomic NS
parsympathetic NS anticipation of pain aftermath of pain |
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Variables influencing a person's pain (pain assesment)
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physiological
psychological sociocultural environmental |
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pain assessment
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onset
duration location severity quality pattern of pain relief concomitant symptoms physical s/s alterations of ADL expectations |
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quality of pain
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tell me what your pain feels like
burning stabbing aching vice like sharp |
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severity of pain
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Numerical scale
Verbal description Visual scale (helpful w/ children & uncommunitive pt) |
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pain interventions
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reduce reception & perception
cutaneous stimulation * back rub, warmth or ice * TENS (electrical nerve simulation) * distraction * relaxation anticiapatory guidance analgesics |
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non-narc pain meds
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ibuprofren
naproxen (alleve) toradol tolectin |
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narcotic meds
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demerol
morphine codeine |
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types of loss
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external objects
of know environment of significant other of life aspects of self |
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characteristics of normal grieving
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physical
cognitive emotional behavioral |
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physical responses to loss
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tightness in throat
heavy chest fatigue |
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cognitive responses to loss
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inability to concentrate
forgetfulness daydreaming |
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emotional responses to loss
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sadness
isolation anger frequent crying |
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behavioral responses to loss
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inability to sleep
loss interest in sex restlessness use of alcohol or drugs imagine seeing person |
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factors that affect greif
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cause of death
suddenness of the death potential of the deceased role within the family attachemet to deceased personality unfinished business support system socioeconomic factors cultural influences religious influences secondary losses age & sex health status |
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complicated greiving
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difficulty progressing through normal stages of grief
chronic grief - stay depressed delayed grief - stay in denial exaggerated greiving - overwhelmed masked grief - acting out grief whith physical symptoms |
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purpose of hospice
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provide dignified quality comfort care
mulit-disciplinary approach assure the well being of survivors after loss lead & influence health care community by end-of-life issues shape public opinion & policy on issues realted to death enhance the quality of life affected by death |
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kubler-ross stages of dying
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denial (act as if nothing happened; unable to admit dying or death
anger (pain or loss projected on others) bargaining (represents a last effort at overcomming death by earning a longer life) depression (when the full impact of imminent death strikes) acceptance (grieving; coming to grips with death) |
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coping with loss TEAR
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to accept
experience the pain adjust to the new environment reinvest in new reality |
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comfort measures for loss
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pain management
management of symptoms of disease comfortable environment religious rituals prevent isolation |
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what are the non-medicine treatments
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Nurtition
exercise water (internally & externally) sunlight temperance fresh air rest trust in god |
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Heat Therapy Goal
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Vasoldilation
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Vasodilation does
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increases blood flow - brings o2, nutrients, antibodies, leucocytes
accelerates the inflammatory process - increased phagocytic cells & removal of waste products produces skin redness & warmth that can be assessed by touch - increased capillary permeability & increased metabolism |
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Heat therapy
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dry heat
moist heat |
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dry heat is used for heat conduction
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hot water bottles
electric pad aquathermia pad disposable pad |
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moist heat is used for systemic effects (greater risk for burns & maceration, but penetrates deeper)
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sitz bath
tepid baths hot pack/back fomentations fever treatments whirlpools |
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rebound phenomena occurs for both heat & cold
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heat produces vasoldilitation
cold vasconstricts after an hour homeostasis goes into effect to and the opposite will happen |
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prolonged exposure to cold results in
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impaired circulation
cell deprivation damage to tissues from lack of o2 & nutrients |
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signs of symptoms of tissue damage due to cold (similiar to hypothermia)
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bluish-purple appearances
numbness stiffness pallor blisters pain |
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dry cold - administered for local effect
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ice bags 2/3 full to release air
ice collars ice gloves disposable cold pack |
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moist cold - administered for either local or systemic effects
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wet cold sheet wrap
hot/cold shower |
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cold produced maxiumum vasoconstirction when skin temp reaches
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60 degrees
below 60 degrees vasodilation |
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during cold bp can
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blood is shunted from cutaneous circulation to internal vessels
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variables which affect pt tolerance to heat or cold
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impaired mental status
impaired circulation neurosensory impairment open wounds recent injury/surgery |
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in open wound heat/cold can
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heat increases bleeding
cold decreased blood flow to wound, but can inhibit healing |
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decrease in or lack of meaningful stimuli caused by
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reduced sensory input (hearing loss, confusion, bedrest
affective changes (boredom, restlessness, anxiety, etc) cognitive changes (inability to solve problems, poor task performance, disorientation) perceptual changes (reduced attention span, disorganized visual & motor coordination) |
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sensory overload
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occurs when an individual is unable to process or manage the amount of intensity of sensory stimuli
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sensory overload caused by
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increase stimuli in external environment
increase stimuli in internal environment inability to distinguish stimuli selectively |
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people at risk for sensory overload
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pain
accutely ill pt. in accute setting pt. being closed monitored in ICU CNS disturbances |
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cerumen accumulation
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build up of earwax in the external auditory canal
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sensory intergrative disorders
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is a neurological disorder that results from the brain's inability to integrate certain information received from the body's five basic sensory systems. These sensory systems are responsible for detecting sights, sounds, smell, tastes, temperatures, pain, and the position and movements of the body.
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sensory modulation
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is when the senses work together. Each sense works with the others to form a composite picture of who we are physically, where we are and what is going on around us. Sensory modulation is a neurological function that is responsible for producing this composite picture. It is the organization of sensory information for on-going use.
Typically healthy sensory modulation occurs automatically, unconsciously and without effort |
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sensory modulation disorder
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Over, or under responding to sensory stimuli or seeking sensory stimulation. This group may include a fearful and/or anxious pattern, negative and/or stubborn behaviors, self-absorbed behaviors that are difficult to engage or creative or actively seeking sensation.
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Sensory Discrimination Disorder
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have difficulty distinguishing between various sensory inputs, therefore inappropriately responding to stimuli. They have difficulty in their social interactions and functioning in their environment
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normall sensory changes occuring in age
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hearing acuity
speech intelligiblity pitch discrimination reduced visual field increased glare impaired night vision reduced accomodation reduced depth perception reduced color discrimination loss of cells in olfactory bulb decrease sensory cells in nasal lining reduced sensitiving to odors taste buds atrophy can't avoid obstacles as quickly declining sensitivity to pain, pressure & temp. |
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interventions for preventing sensory deprivations
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reorient pt. to reality
assist or encourge pt. to wear glasses, hearing aids, etc arrange environment that offsets deficit |
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interventions for preventing or controlling sensory overload
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adjust lighting
less disruptions respond quickly |
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preoperative assesment
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physical
patient history risk factors |
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preoperative care & teaching
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pre-op checklist
diagnostic screening informed consent pre-op teaching |
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intraoperative team
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surgeon
surgical assistant scrub tech/Nurse Circulating RN Anestheiologist/CRNA |
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anesthesia
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general
regional local conscious sedation |
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complications from general anesthesia
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complications of intubation
malignant hyperthermia overdose unrecognized hypoventilation complications related to anesthetic agent |
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risk for altered body temp
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anesthetic agents interfere w/ the body's temp regulating mech.
hypothermia hyperthermia |
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hypothermia during surgery
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cool environment
decreased metabolic rate medications cold IV fluids |
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hyperthermia during surgery
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malignant hyperthermia
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ineffective airway post op
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respiratory rate
patency of airway patterns of respiratory work breath sounds |
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neuro checks after surgery
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pupilary reflexes
orientation hand grasp movement LOC/Sudden change in consciousness |
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pain after surgery
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behavior symptoms
pain scale review pain meds PCA pump |
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gallblader pain can be felt
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in right shoulder
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heart pain can be felt in
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back
chest area head left shoulder |
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kindney pain can be felt in
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right thigh
back |
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liver pain can be felt
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in right kneck
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lungs & diaphragm pain can be felt
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in left kneck
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pain has two functions
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protective - remove parts from harm
warns against possible tissue damage |
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types of pain stimuli
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mechanical
thermal chemical |
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acute pain
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usually treated more agressively
can threaten pt recovery rapid onset, brief duration pt. expects relief quickly |
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chronic pain
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usually treated less aggressively
varies in intensity, usually last months exacerbations body doesn't adapt to pain |
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variables influencing person's pain
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physiologic
sociocultural psychological environmental |
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legal considerations w/ dying
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end of life decisions
POA cornoner/death examinier post mortem organ donations |
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end of life decisions
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life sustaing procedures
living will DNR death with dignity act |
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Virchows triad
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Impaired venous return to heart
hypercoagulability of the blood injury to vessel wall |
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Symptoms of DVT
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tenderness
pain swelling warmth discoloration of skin |
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Benefits of Mobility
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Maintain body's normal physiological functioning
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Reasons for Immobility
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Severe pain
Impairment of musculoskeletal or nervous system Disorders causing weakness Psychosocial problems Surgery Therapeutic rest |
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Musculoskeletal Changes due to Immobility
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*Decreased muscle mass (muscle astrophy)
- occurs when muscules don't contract *Loss of muscle strength & endurance *Decrease in stability and balance *Muscle & skeletal changes - joint contractures (atrophy) - Ankylosis *Disuse of osteoporosis |
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Musculoskeletal Nursing Interventions due to Immobility
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Body repositoning
Weight bearing activities Independence of ADL;s ROM |
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Cardovascular Changes due to Immobility
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Orthostatic (postural) hypotension
Increased workload on heart Rapid heart rate Edema Thrombus Formation |
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Cardovascular Nursing Interventions due to Immobility
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Movement & Excercise
Regain peripheral vasoconstriction with vertical postures Elastic stocking |
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Respiratory Changes due to Immobility
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Decreased lung expansion
Co2/o2 Imbalance Respiratory muscle weekness stasis of secretions Increased accumalation of secretions |
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Respiratory Nursing Inverventions due to Immobility
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Fluid intake of at least 2000 ml per day
Coughing & deep breathing Diaphragmatic-abdominal breathing Turning, positioning & exercise |
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Gastrointestinal & Metabolic changes due to Immobility
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Anorexia
Negative Nitrogen Balance Dyspepsia Constipation |
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Gastrointestinal & Metabolic Nursing interventions due to Immobility
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Diet
Vitamin & Mineral Suppements Weight-bearing exercises Movement & exercises |
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Urinary & Endocrine Changes due to Immobility
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Urinary stasis
Renal calculi Urinary incontinence Urinary reflux Increased UTI |
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Urinary & Endocrine Nursing Interventions due to Immobility
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Turning, repositiong & exercise
Improving hydration Perineal hygiene Acidifying the Urine Position & relaxation for urination Urinary catherization Preventing urinary incontinence |
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Integumentary Changes due to Immobility
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Decubitus (pressure) Ulcers
Causes - Pressure, friction, and shearing |
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Pressure Ulcer stages
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Pinkish-red; skin doesn't turn normal color when pressure is removed
Cracked, blistered, broken skin, shallow to full-thickness Broken skin with tissue involvement Extensive ulceration w/ penetration to the muscle & bone |
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Preventing Skin Damage
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Wrinkle free bed
Special mattress (egg crate) Special pads on pressure areas Raising HOB no more than 30 degrees Ongoing skin assesment Change position every 15 min. - 2 hr. Good Nutrition |
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Psycho/Social Effects of Immobility
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Decreased motivation to learn & solve problems
Decreased perception of time & space Increases sense of powerless Diminshed ability to make decision, concentrate or cope Inability to sleep |
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Psycho/Social Nursing Interventions due to Immobility
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Room w/ active person w/ similiar interest
Same nurse to care for pt. if possible Maintain positive self-image Set short & long term goals Minimize sleep interuptions Allow client to express feelings Provide for intellectual stimulation |
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Assesment for Body Mech. & Joint Mobility
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Observe pt. gait & ADL
Inspect joints measure ROM Inspect for redness or swelling observe signs of pain signs of fatigue paleness compare VS w/ baseline |
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Pathological influences on alignement, exercises & activity
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Congental defects
Disorders of bones, joints, muscle contractures central nervous system damage musculoskeletal trauma |
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Pressure Ulcer Prevention
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regulary turning
clean & dry skin lift sheets or devices to turn pt mantain head below 30 degr. if poss. avoid massage maintain adequate nutrition |
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Virchow's triad describes
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the three broad categories of factors that are thought to contribute to thrombosis
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Virchow's triad
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Hypercoagulability
Hemodynamic changes (stasis, turbulence) Endothelial injury/dysfunction |
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Thrombosis
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is the formation of a blood clot (thrombus) inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets and fibrin to form a blood clot, because the first step in repairing it (hemostasis) is to prevent loss of blood. If that mechanism causes too much clotting, and the clot breaks free, an embolus is formed.[1][2]
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Hypercoagulability
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tendency for excessive blood clotting: a potentially dangerous condition in which blood coagulates excessively, even within the blood vessels
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Virchow's Triad - Causes of Thrombosis
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1] Changes in the blood vessel wall
2] Changes in the blood flow 3] Changes in the blood composition |
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Name the Immune Responses
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Active & Passive
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Active Immunity is
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• Natural active immunity
– Antibodies are formed in presence of active infection • Artificial active immunity – Antigens (vaccines) administered to stimulate antibody formation – Lasts for many years |
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Passive Immunity is
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Natural passive immunity
– Antibodies transferred naturally from an immune mother to baby • Artificial passive immunity – Occurs when immune serum (antibody) from an animal or another human is injected |
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Symptoms of Localized Infection
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Redness
Swelling Pain Heat Drainage |
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Symptoms of Systemic Infection
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Fever
vomiting diarrehea body aches Increased white blood cell |
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Links of Chain of Infection
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Infections agent (etiologic)
Reservoir Portal of Exit Mode of Transmission Portal of Entry Susceptible Host |
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Standard Precautions apply to
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blood
body fluids secretions excretions (not sweat) non-intact skin mucous membranes |
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Infection Interventions
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hand hygiene
gloves mask gowns cleaning linen bags sharpy containers private room |
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Defense against infection (naturally)
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Normal Flora
Body Systems Defenses Inflammation Immune Response |
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Categoriies for Sterilization, Disinfection, & Cleaning
Critical Items |
Sterilization
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Categoriies for Sterilization, Disinfection, & Cleaning
Semicritical Items |
Disinfection
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Categoriies for Sterilization, Disinfection, & Cleaning
Noncritical Items |
Cleaning
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Health Promotion (concerning Infection control)
Preventions |
Nutrion
Immunization Personal Hygiene Regular Rest & Exercise |
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Normal Flora
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Microorganisms normal on body that usually help
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Infectious Agent
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Any microorganism capable of producing an infecious process
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systemic infection
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infection in which the pathogen is distributed throughout the body rather than concentrated to one location
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Bacteremia
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Infection of the blood
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Nosocomial
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Infection associated with Health Care
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Factors that increase risk of infection
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Age
Heredity Stress Nutrional Status Current Medical therapy Pre-exsisting disease |
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Mode of Transmission
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Contact
- Direct - Indirect - Droplet Air Vehicles Vector |
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Break Chain of Infection
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Medical asepsis
Surgical asepsis Hand Hygiene -Hand washing -Antiseptics -Alcohol based handrub |
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What can massages do for pt.?
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lower Bp
feel more relaxed relieve tension soothe away headaches relax tense muscles increase alterness |
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types of massages
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swedish
deep tissue remedial sports reflexology |
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swedich massage
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relaxes muscles
eases aches & pains long strokes kneading & friction techniques used on superficial layers of muscles superficial strokes keep one hand on person at all times |
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deep tissue massage (drink lots of water before and after)
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released chronic patterns of tension in the body through slow strokes and deep finger pressure on contracted areas
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remedial massage
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helps restore function to injured tissues
may involve the use of various types of massage may be coordinated with physical therapy |
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sports massage (not a specific technique)
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combines different massage techniques to enhance sports performance and recuperation
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reflexology theory
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use thumb and finger pressure on the reflex points of the body to assist in achieving balance within the body
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spefic massage techniques
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effleurage
petrissage tapotement |
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Don't massage over
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reddened area
varacous veins |
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Diabetic Foot Care Do's & Don't
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NO soaking
NO clippers or sciccors keep dryness under control regular visits to the podiatrist prevent impaired ciruculation inspect daily NO barefoot proper fitting shoes & socks exercise to Increase circulation NO hot-water bottles treat cuts promptly; use a mild antiseptic |
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assesment of skin
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turgor & condition
areas of breakdown or potential texture, thickness, temperature tissue perfusion (purple, blue) |
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Nutritional client assessment
Signs of nuritional status |
general appearance; thin overweight
hair; dull sparse eyes; pale conjuntivae, night blindness tongue/lips; glossitis, chelitis teeth; cavities, dentures fit gums; bleeding, swollen skin; scaly, bruising, poor healing, ulcers nails; ridged, brittle muscles; weak, flaccid, atrophied bones; bowlegs neurological; depression, depressed reflexes cardiovascular; tachycardia, hypertension |
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components of diet history
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age
medical diagnosis medical history exercise history mental health status food/drug allergies weight changes Nutritional supplement medications fluid//alcohol intake cultural beliefs special diet |
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more components of diet history
|
appetite
condition of teeth/dentures/mouth chewing, swallowing, chocking problems favorite foods/dislikes personal or religious restrictions location & number of meals who purchases & prepares meals eating & snacking habits |
|
components of nutritional assessment
|
assessment
diet history anthrompometric measurements laboratory values |
|
Indicators of malnutrition
|
listless
weight issues sagging shoulders, sunken chest, humped back impaired ability to walk, poor tone inattentive, irritable, confused anorexia, indigestion, constipation, diarrhea rapid heart rate, enlarged heart, elevated bp easily fatigued, looks tired missing teeth edema in legs & feet |
|
measuring for ng tube
|
tip of nose to ear lobe to xiphoid process will be the length needed.
|
|
managing tubes
|
check formula for right viscosity for size of tubes
irrigating tubes flush 30cc irrigant exert gental pressure (saline, water, etc) |
|
Administering feeding
|
confirm placement
high fowlers warm food to room temp aspirate residual & return contents to stomach to prevent electrolyte imbalances greater than 150ml, hold feeding check tube placement by aspirating contents & measuring pH check bowel sounds. If absent hold feeding notify MD flush tube following feeding remain high fowlers after feeding for 30 minutes |
|
therapeutic diets
|
clear liquid
full liquid pureed mechanical soft soft/low residue high fiber low sodium low cholosterol diabetic regular |
|
clear liquid (ordered for pt. with N/V, diarrhea, GI problems, & after surgery
|
jello
any juice u see through clear soda broth popsicles |
|
full liquids (neck/face surgery, dental work, wired jaw)
|
all clear liquds
cream soup milk products |
|
pureed (stroke, head & neck surgeries)
|
soft, smooth, easily swallowed foods
baby food consistancy scrambled eggs mashed potatoes yogurt |
|
mechanical soft (pt with chewing or swallowing difficulties)
|
addition of ground meat
flaked fish cottage cheese rice peanut butter bananas |
|
soft/low residue (bowel disease)
|
addition of low fiber foods
pasta casseroles canned fruit canned vegetables |
|
low sodium (high bp, heart disease, kidney problems
|
sodium is restricted to
- 2-3 grams (mild) - 1 gram (moderate) - 0.5 grams (strict) - 0.25 grams (severe) |
|
low cholestrol (pt. w/ cornary heart disease)
|
low saturated fats
avoid foods such as - whole milk - egg yolk - shrimp - organ meats - butter |
|
diabetic diet (pt w/ dibetes or wishing to loose weight)
|
ADA is recommending moving away from what used to be standard ADA diets using exchange systems.
|
|
regular diet
|
no restriction
|
|
high fiber (pt w/ high cholestrol remissions of IBS, ulceraive colitis)
|
fresh fruit
steamed vegetables bran oatmeal dried fruit |
|
parental nutrition
|
adiministration of a nutrional solution by route other than gi tract
example vascular system |
|
Parenteral nutrition PN
|
is not appropriate for pt who can absorb adquate nutrition. Only for use when GI tract not functioning.
|
|
PN Parenteral nutrition solution
|
glucose
amino acids lipids minerals, electrolytes, trace elements vitamins |
|
anthropometric measures
|
wrist circumference
skin fold thickness height weight |
|
lab values
|
Hemoglobin & Hct
Albumin Electrolytes Nitrogen |
|
Advantage of source record documentation
|
able to easily locate the proper section of the record
|
|
disadvantage of source record documentation
|
record is fragmented; record not organized by pt. problems so problems appear in multiple areas.
|
|
What are the four problem-oriented record systems
|
database
problem list care plan progress notes |
|
SOAP documentation; is one format for entering a progress notes (SOAP stands for?)
|
S - subjective data
O - Objective data A - Assessment P - Plan |
|
PIE documentation similiar to soap but with a nursing orgin
|
P - problem or nursing diagnosis
I - Interventions or actions taken E - Evaluation of the outcomes of nursing interventions |
|
advantage of narrative recording
|
benefial in ER situations because of the chronological order
|
|
disadvantages of narrative recording
|
tendancy to be repetitous and time consuming, requiring reader to sift through a lot of info to locate desired pt. info
|
|
Basic charting principles
|
Use black ink, non-erasable
record neatly, legible, spell correctly sign or initial each entry chart promptly & after procedure is done use only hosp. approved abbreviations correct errors in proper manner correct pt. chart chart only care u provide don't leave blanks doc. what's reported to doc. don't doc u filed out incident report report noncompliance |
|
types of records
|
source record
narrative documentation charting by exception problem-oriented medical records |
|
source records
|
organized by discipline
non-intergrated charting |
|
narrative documentation
|
uses story-like format to doc. info specific to pt. conditions & nursing care.
|
|
adavantae of narrative
|
most flexible
strongly conveys nursing intervention ideal for presenting info collected over a long period places events in chronological order |
|
Basic charting principles
|
Use black ink, non-erasable
record neatly, legible, spell correctly sign or initial each entry chart promptly & after procedure is done use only hosp. approved abbreviations correct errors in proper manner correct pt. chart chart only care u provide don't leave blanks doc. what's reported to doc. don't doc u filed out incident report report noncompliance |
|
types of records
|
source record
narrative documentation charting by exception problem-oriented medical records |
|
source records
|
organized by discipline
non-intergrated charting |
|
narrative documentation
|
uses story-like format to doc. info specific to pt. conditions & nursing care.
|
|
adavantage of narrative
|
most flexible
strongly conveys nursing intervention ideal for presenting info collected over a long period places events in chronological order |
|
disadvantage of narrative
|
you may have to read entire record to find outcome
trouble tracking problems no inherent guide to whats important to doc lengthy, repetitive |
|
advantages source record
|
able to easily locate the proper section of the record
|
|
disadvantages to source record
|
record is fragment; record not organized by pt. problems so problems appear in multiple areas.
|
|
charting by expection
|
completion of flow sheet which includes crucial assessment areas & nursing interventions. A narrative note is only made when something is out of ordinary
|
|
advantatges of charting by exceptions
|
saves time
eliminates repetition decreases subjectivity in charting |
|
problem oriented record
|
data is organized by problem or dx
all healthcare workers contribute to single list of problems five part format |
|
what is 5 part format to problem oriented record
|
database
problem list care plan progress notes discharge summary |
|
advantages of computerized documentation
|
stadardization, accuracy, easy access for multiple uses, acquisistion & transfer of client info.
|
|
challenges for computerized documentation
|
learning the computer
complicated process for correcting errors maintaining security maintaining 24 hr computer support |
|
Progress note (SOAP)
|
subjective -pt says
objective - u can measure or observe assessment - conclusion based on subjective & objective date plan - strategy for relieving pt. problems Intervention - what u do to achieve outcome evaluation - the effectiveness of your intervention revisions - changes from original plan |
|
stages 1 of pressure ulcers
|
Intact skin that shows evidence of tissue ischemia related to pressure
one or more change to the skin compared to the other side skin temp (warm or cold) tissue consistency (firm boggy) sensation (pain, itching) The ulcer appears as a persistent redness or blue or purple hues |
|
stage 2 pressure ulcer
|
partial thickness skin loss (epidermis, dermis, or both) superficial present as abrasion, blister, or shallow crater
|
|
stage 3 pressure ulcer
|
full thickness, skin loss, damage to or necrosis of subcutaneous tissue that extends down to but not through underlying fascia. Presents as a deep crater with or without underming of surrounding tissue
|
|
stage 4 pressure ulcer
|
full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure. Underming & sinus tracts are also associated with stage 4 pressure ulcers
|
|
skin wounds integerity are classified by
|
open
closed |
|
surgical wounds are classified as:
|
clean
clean-contaminated contaminated dirty/infected |
|
depths of wounds are classified as
|
partial thickness
full thickness |
|
wounds classified by time
|
acute
chronic |
|
wounds classified by descriptive qualities
|
Incision
contusion abrasion puncture wound laceration penerating |
|
partial thickness
|
loss of epidermis and/or part of dermis
|
|
full thickness
|
loss of epidermis, dermis and possible extension into subcutaneous layers, bone, and/or muscle
|
|
stages of healing by secondary intention
|
Inflammation phase
proliferative phase remodeling phase |
|
Passive drains
|
accomplished by gravity or capillary action.
penrose drain, foley, malecot & word catheters (open systems) |
|
active drains
|
accomplished by suction from a simple bulb device or a suction pump
hemovac, jackson-pratt |
|
secondary intention wounds
|
burns
pressures sores brown recluse spider bites |
|
Inflammation phase
|
hemostatis (hopefully bleeding will stop)
|
|
proliferative phase
|
production of new tissue, epithelialization, and contraction
|
|
remodeling phase
|
reorganizes collagen
|
|
factors contributing to pressure ulcer development factors
|
shear
friction moisture nutrition infection edema age |
|
risk assessment (braden risk assessment scale)
|
sensory perception
moisture activity mobility nutrition friction & shear |
|
First steps to heal any wound
(chronic wounds in particular) |
Diagnose & remove the cause
remove the necrotic tissue optimize the environment of healing |
|
optmize environment for wound healing
|
reduce edema
reduce systemic/local problems clean wound bed optimal moisture -avoid maceration -avoid dryness |
|
RYB color code
|
red - granulaton tissue
yellow -i nfectious tissue black - escare |
|
principles of aseptic technique
|
only sterile are used within the sterile field
tables waist high avoid reaching over sterile field edges within I inch unsterile sterile areas continually in view |
|
braden scale
|
sensory perception
moisture activity mobility nutrition friction & shear |
|
the # indicate what on braden scale
|
hosp pt. below 16 / 18 for elderly are at risk for pressure ulcer development
|
|
different kinds of wound care
|
vacumm wound closure
electrical stimulus enzymes leeches ointments growth factor dressings |
|
different kinds of dressings
|
gauze
hydrophilic occulusive hydrogel interactive (added drugs, bio agents) |
|
hydrophilic dressing
|
water loving
cover wounds absorbs exudate |
|
alginate dressing
|
from seaweed, minimize bacterial contamination
|
|
occulsive dressing
|
wound breaths
synthetic polymetric material w or w/out backing covers wound allows exchange of gases & water vapor |
|
hydrogel dressing
|
cross-linked polymer
increase moisture content clean & debride necrotic tissue non-adherent & can be removed w/out trauma to the wound soothing effect not very absorptive |
|
interactive dressing
|
SilvaSorb, an antimicrobial silver wound dressing; sustained antimicrobial release & effective moisture management
|
|
gauze advantages
|
Readily available in many sizes and forms, gauze can be used on infected wounds and can be combined with other topical products. It's effective for packing wounds with tunnels, tracts, or undermining.
|
|
gauze disadvantages
|
Gauze must be held in place by a secondary dressing, and fibers may shed or adhere to the wound bed.
Gauze dressings should be changed frequently—if it dries out, it may stick to the wound bed and disrupt wound healing. Gauze isn't recommended for effective moist wound treatment or bacterial barrier. Although research supports moist wound healing, the old standard of wet-to-dry gauze dressings is still being used in some places. |
|
Transparent film
|
this type of dressing has a porous adhesive layer that lets oxygen pass through to the wound and moisture vapor escape from the wound.
Partial-thickness wounds, Stage I and II pressure ulcers, superficial burns, and donor sites. It also can be used as a secondary dressing. |
|
advanatages transparent film
|
This dressing doesn't have to be removed when you examine the wound.
Transparent film also is impermeable to external fluid and bacteria, promotes autolytic debridement, and prevents or reduces friction. Available in numerous sizes, it conforms to the body. Change the dressing every 5 to 7 days, or if it becomes soiled, wet, or starts to leak fluid. |
|
diadvantages transparent film
|
The dressing may stick to some wounds.
Most transparent dressings don't absorb moisture and aren't indicated for draining wounds. However, some of the newer transparent films have absorption properties. Fluid retention under the dressing may lead to periwound maceration. This dressing can't be used on third-degree burns |
|
foam care
|
Nonadherent and nonocclusive, foam is an absorptive dressing consisting of hydrophilic polyurethane or film-coated gel.
Stages II through IV pressure ulcers, partial- and full-thickness wounds with minimal to heavy drainage, surgical wounds, dermal ulcers, and under compression wraps. Check the package insert to determine if the product can be used in infected wounds or those with tunneling or sinus tracts. |
|
foam advanatges
|
Many sizes, shapes, and forms are available.
Foam is conformable, easy to apply, and easy to remove because it's nonadherent. The frequency of dressing changes depends on the amount of wound drainage |
|
foam disadvantages
|
A secondary dressing or tape may be needed to secure some of the first foam dressings.
Newer versions have an adhesive border to help keep them in place. Foam isn't recommended for nondraining wounds or dry eschar. Some foams can't be used on infected wounds or those with tunneling or tracts. Always read the package insert to determine if you can use the product for a particular wound type. If not changed appropriately, foam dressings can let excess moisture accumulate, macerating periwound skin. |
|
Composites wound care
|
Manufactured as a single dressing, composites are combinations of two or more different products. Features may include a bacterial barrier, absorptive layer, foam, hydrocolloid, or hydrogel. The dressing may have semi-adherent or nonadherent properties.
Use composites as primary and secondary dressings for partial- and full-thickness wounds, for minimally to heavily draining wounds, dermal ulcers, and surgical incisions. Check the package insert to see if the dressing is suitable for pressure ulcers |
|
Advantages: Composites
|
facilitate autolytic debridement, are conformable, and are available in many sizes and shapes.
Most include an adhesive border, so they're easy to apply and remove. Check the package insert for frequency of dressing change |
|
Disadvantages: Composite
|
dressings are contraindicated for Stage IV pressure ulcers.
The adhesive borders of composites may limit their use on fragile skin. Not all composite dressings provide a moist healing environment, so monitor frequently for desiccation. |
|
Hydrocolloid
|
This dressing consists of hydrophilic colloid particles bound to polyurethane foam that's impermeable to bacteria and other contaminants
Stages I through IV pressure ulcers, partial- and full-thickness wounds, dermal ulcers, and necrotic wounds. Hydrocolloids also can be used under compression wraps or stockings, as a secondary dressing, or as a preventive dressing for areas at high risk for friction. |
|
Advantages: Hydrocolloids
|
come in numerous sizes, shapes, forms, and thicknesses.
They're minimally to moderately absorptive, reduce pain, and facilitate autolytic debridement. The dressing also is self-adherent, conformable, and provides thermal insulation. Because hydrocolloids can be worn for 3 to 5 days, fewer dressing changes are needed |
|
Disadvantages: Hydrocolloids
|
Some of these dressings may adhere to the wound bed or be difficult to remove.
The odor they produce can be mistaken for infection, and some dressings may leave a residue in the wound bed. Hydrocolloids aren't recommended for heavily draining wounds, sinus tracts, or fragile skin. Some are contraindicated for full-thickness wounds or infected wounds—check the package insert |
|
Hydrogel
|
Water- or glycerin-based, this dressing can consist of 80% to 99% water on a nonadherent, cross-linked polymer. The dressing has variable absorptive properties.
Indications: Stages II through IV pressure ulcers, partial- and full-thickness wounds, dermabrasion, painful wounds, dermal ulcers, radiation burns, donor sites, and necrotic wounds. |
|
Advantages: Hydrogels
|
rehydrate the wound bed and reduce wound pain.
They can be used on infected wounds and with topical medications. These dressings also promote autolytic debridement. Nonadherent, they're easy to remove, and usually are changed daily |
|
Disadvantages: Hydrogel
|
Not vey absorptive
Because hydrogels are nonadherent, they may need to be secured by a secondary dressing. They aren't recommended for heavily draining wounds, and their absorptive properties mean they may macerate periwound skin. |
|
Alginate
|
A nonwoven composite of cellulose-like fibers, alginate dressings are made from brown seaweed. The dressing material forms a soft gel when mixed with wound fluid.
Indications: Moderate to heavily draining wounds, partial- and full-thickness wounds, pressure ulcers (Stages III and IV), dermal wounds, surgical incisions or dehisced wounds, sinus tracts, tunnels, cavity wounds, and infected wounds. Alginates also can be used for hemostasis on postoperative wounds. |
|
Advantages: Alginates
|
are highly absorptive and nonocclusive, and have hemostatic properties for minor bleeding.
Removal is trauma-free, and the frequency of dressing changes often is reduced. When beginning treatment, change alginates daily; thereafter, they can be changed every other day or when saturated. Available in sheets, ropes, and in other composite dressings, alginates can be used on infected wounds. |
|
Disadvantages: Alginates
|
A secondary dressing may be needed to secure an alginate, and the dressing tends to have a distinctive odor noticeable during dressing changes.
Alginates are contraindicated for dry eschar, third-degree burns, surgical implantation, and heavy bleeding. |
|
Hydrofiber
|
Similar to an alginate, a hydrofiber consists of sodium carbomethylcellulose that interacts with wound exudate to form a gel.
Indications: Moderate to heavily draining wounds, partial- and full-thickness wounds, pressure ulcers (Stages III and IV), surgical wounds, donor sites, dehisced wounds, cavity wounds, and wounds with sinus tracts or tunnels. |
|
Advantages: Hydrofiber
|
Highly absorptive, hydrofibers don't need to be changed frequently, and are available in sheets and ribbons.
Removal is trauma-free |
|
Disadvantages: Hydrofiber
|
Because the dressing is nonadherent, you'll need a secondary dressing to secure it. Hydrofibers are contraindicated for dry eschar, nonexudating wounds, third-degree burns, and heavy bleeding.
|
|
Antimicrobial dressings
|
These dressings are impregnated with cadexomer iodine for immediate and controlled release, and protect against bacteria or reduce bacterial load in a wound.
Indications: Any type of infected wound, including colonized chronic nonhealing wounds. |
|
Advantages: Antimicrobial dressings
|
reduce the risk for infection
|
|
Disadvantages: Antimicrobial dressings
|
Because they're nonadherent, a secondary dressing is needed. Also, these dressings can't be used in patients sensitive to iodine
|
|
Silver dressings
|
These dressings contain ionic silver for immediate and controlled release. Transparent film, hydrocolloids, hydrogels, foams, alginates, hydrofibers, and composites all are available with silver.
Indications: Infected or highly colonized wounds. Some silver dressings can be used under compression wraps or stockings. Contraindicated for Stage I pressure ulcers, third-degree burns, and nonexudating wounds. See the specific product information for details |
|
Advantages: Silver dressing
|
Inhibits pathogen growth, especially of antibiotic-resistant strains.
Cost-effective antimicrobial action for up to 7 days |
|
Disadvantages: Silver dressing
|
A secondary dressing is needed to secure silver dressings in place.
These dressings can't be used in patients sensitive to silver and must be removed (and the wound cleaned) before the patient has magnetic resonance imaging. Silver dressings aren't recommended for use together with topical medications. Because silver turns black when it oxidizes, it may stain or discolor periwound tissue. |
|
Maggot Debridement Therapy (MDT)
|
They clean the wounds by dissolving dead and infected tissue ("debridement");
They disinfect the wound (kill bacteria); They speed the rate of healing |
|
types of drainage
|
serous - clear, watery plasma
sanguineous: fresh bleeding serosanguineous: plate, more watery, a combination of plasma & red cells, may be blood soaked purulent: thick yellow, green, or brown indicating the presences of dead or living organisms & white blood cells |
|
primary intention heals what wounds
|
surgical incisions
injuries |
|
abnormal urination patterns
|
renal failure
-perenal (problems w/ blood flow) -intrarenal (exposure to meds, tubular necrosis) -postrenal (obstructions) oliguria anuria nocturia dysuria |
|
medication in urine can
|
produce more fluid (diuretics)
dhyration (antihistamines & anticholinergics) changes in color |
|
catheter care
|
maintain a closed urinary drainage system
prevent pooling of urine in tubing avoid raising the bag above the bladder avoid prolonged clamping of tube make sure no kinks in the tubing empty bag at least every 8 hrs tape or secure tubing to pt remove as soon as possible perform routine peri care, at least every 8 hrs |
|
assessment of urine
|
I&O
color clarity odor |
|
urine testing
|
clean catch urine speciman
24 hour urine sterile speciman routine urinalysis |
|
clean catching test
|
fewer contaminants
|
|
sterile speciman testing
|
catheterize the pt
*straight - Intermittent (place end of cath in sterile container) *Indwelling - foley (w/d urine form port - transfer urine to sterile contianer) |
|
intermittent catheters
|
don't stay in; just put in and drain
|
|
24 hour urine
|
requires large container
ice post sign on bathroom door discard the first speciman void again close to end of 24 hrs determines renal function also commonly used in pregnancy for determination of protein |
|
urine color indications
|
normal - pale yellow to amber
dark cola - hepatitis, meds dark red - blood |
|
urine clarity indications
|
normal - clear to slightly cloudy
cloudy- protein, bacteria |
|
urine odor indications
|
normal - faint
fruity - acetone from diabetes, starvation strong/fishy - possible UTI |
|
factors affecting urination
|
medications
mobility environmental barriers sensory restrictions major surgery habits fluid intake age past illness |
|
What checked in pt. urine
|
pH (4.6-8) indicated acid base balance
Protein (0-8mg/100ml) increase seen in kidney disease glucose - (none) diabetes ketones - (none) starvation, diabetes, dehydration blood - up to 2 RBC trauma, surgery, menstrual fluid specific gravity - (1.010-1.025) increased dehydration, reduced renal blood flow WBC's - (0-4) Increase indicates UTI |
|
other diagnositic test
|
KUB
IVP Renal Scan Renal ultrasound cystoscopy |
|
measures to decrease UTI
|
routine voidine patterns
- empty bladder completely adequate hydration (2000-2500ml) good hygiene acidify urine - eating meat, eggs, whole grains, cranberries, prunes |
|
measures to promote normal Micturition
|
Provide privacy, time, & position that is comfortable
Sensory stimulation (running water, placing hand in warm water) routine time maintain adequate hydration kegel exercise manual bladder compression |
|
reasons for straight cathterization
|
relief of distension
obtaining a sterile specimen assessing for residual after voiding administration of medication |
|
reasons for indwelling catheter
|
obstruction
surgery need for srict I&O prevent incontinence bladder irrigation |
|
UTI signs & symptoms
|
dysuria
urgency fever & chills concentrated, cloudy, smelly altered mental status in elderly frequent & urge sensation to void possible nausea & vomiting catheters poor hygiene urinary retention |
|
catheter techniques
|
Need a physician order
sterile Insert until u obtain urine, then 1-2 inch before bloon inflation if resistance to bloon inflation, advance |
|
collection of medstream sample
|
wipe the meatus
wipe only once & discard urinate small amount than catch specimen don't touch inside of container lab within 1 hour |
|
normal urine output
|
1-2L per day
30cc or less in hour for 2 hours is a concern bladder stores 100-1800ml desire to void 200-300 95% water 5% (urea, uric acid, creatinine, amonia) normally sterile |
|
abnormal urine consituents
|
retaining over 25% of bladder capacity
|
|
types of catheters
|
Indwelling - folley
intermittent - straight suprapubic condom |
|
why use indwelling - folley
|
pt voiding to much & or over an extended period. when pt require frequent intermittent catheterizaion.
|
|
why use an intermittent - straight
|
for short term use or to minimize infection
|
|
why use suprapubic cath.
|
used for short periods w/ pt. that had surgery or males requring long term cath.
|
|
why use condom
|
incontinent or comatose pt.
|
|
KUB (flat plate, abdominal roentgenogram, plain film)
|
assesses the gross structures of the urinary tract for abnormalities
|
|
IVP (intravenous pyelogram)
|
to view the entire urinary system and to assess some renal functions with an excretory urogram or IVP
|
|
renal scan
|
allow indirect visualizaion of urinary tract sturctures aftern injection of radioactive isotopes
|
|
renal ultrasound
|
checking urinary disorders by bouncing sound waves of uderlying body structures; abnormatlities of the kidneys or lower urinary tract
|
|
cystoscopy
|
looks like urine cath. fiberoptic to view interior of bladder and urethra (not flexible)
|
|
Kidneys
|
are responsible for maintainng normal RBC volume by producing erthropoietin
helps convert vit D to active form right lower than left nephrons |
|
common alterations in elimination
|
constipation
impaction diahhera incontinence flatulence hemorrohoids bowel diversions |
|
factors that influencing bowel elimination
|
age
pregnancy activity diet surgery anxiety depression |
|
enema technique
|
sims position on left side
lubricate tube Insert 3-4 inches towards umbilicus use warm fluids - water, saline, or prepared enemas if cramping, lower cotainer or clamp temporarily |
|
guaiac (hemoccult test)
|
detect blood in stool
ulcers, inflammatory bowel disease, colon cancer, hemorrhoids upper GI bleed - stool black which is a reaction of hemoglobin & gastric acid lower GI bleed - bright red false positive -red meats, horseradish, certain medications (steroids, ASA, iron) ollect specimen 3 times from 3 different defecations |
|
fecal occult blood
|
void first
defecate in required container test immediately smear small amount of stool in designated spot add developer to opposite side blue indicated positive results |
|
diagnostic test
|
occult blood
endoscopy colonscopy sigmoidoscopy upper GI barium enema |
|
signs & symptoms fecal impaction
|
unrelieved constipation resulting in a collection of hardened feces wedged in the rectum
liquid stool may seep around fecal mass may need to be evacuated in small pieces results in - Anorexia - Abdominal distension - Cramping - N/V - Rectal pain |
|
physiology of respiration
|
heart disease (ineffective pump)
lung disease (ineffective gas exchange) |
|
oxygen delivery
|
Piped in to wall units
cannulas face masks tents transtracheal concentrators tanks humidifiers |
|
oxygen safety
|
place "no smoking" or "oxygen in use" signs
know where fire extinguishers are educate the pt. about fire hazard have the pt avoid wearing synthetic & wool clothing check electrical devices use water based lubricant |
|
signs & symptoms of hypoxia
|
a lowered o2-carrying capacity, as in anemia or carbon monoxide poisoning
diminshed concentrations of inspired o2, as in high altitudes & airway obstruction the inability of the tissues to extract o2 from blood, as in septic shock & cyanide poisoning decreased diffusion of o2 from the lung (alveoli) into the blood, as in pneumonia or atelectasis poor tissue perfusion with oxygenated blood as in hypovolemic shock, cardiogenic shock, or cardiomypathy Impaired ventilation from mupltiple rib fractures, chest trauma, spinal cord injury, or head trauma |
|
respiratory volumes & capacitites
|
Tidal Volume (TV)
Inspratory Reserve Volume (IRV) Expiratory Reserve Volume (ERV) Residual Volume (RV) Inspiratory Capacity (IC) Vital Capacity (VC) Total Lung Capacity Functional Residual Capacity |
|
Interventions w/ respiratory problems
|
Coughing
Suctioning fluids humidifiers fowlers - semi fowlers chest percussion vibration respiratory muscle training breathing exercises |
|
breathing exercises
|
pursed-lip breathing
diaphragmatic breathing |
|
coughing techniques
|
cascade cough
huff cough quad cough |
|
Hydration promotes
|
removing of mucus. adequate hydration secretions are thin, white, watery & easily removable with minimal coughing. 1500-2000ml will help keep secretions thin & easy to expectorate.
|
|
purpose of incentive spirometer
|
is a method to encourage deep breathing by providing visual feedback. pt. inhales slowly with even flow to elevate ball and to keep it floating for as long as possible
|
|
respiratory system
|
allows the exchange of o2 & carbon dixiode between the air & the blood. The cardiovascular system transports them between the lungs& the cells of the body
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respiration includes
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ventilation, movement of air into and out of lungs
gas exchange between the air in the lungs & blood (external respiration) transport of o2 & carbon dioxide in the blood gas exchange between the blood & tissues (internal respiration) |
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gas exchange
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o2 enters blood & carbon dioxide leave the blood enter the air. cardovascular system transports o2 from lungs to cells & carbon dioxide from cells to lungs
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regulation of blood pH
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respiratory system can alter blood pH by changing blood carbon dioxide levels
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Kubler-Ross 5 stages of dying
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Denial
Anger Bargaining Depression Acceptance |
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Kubler-Ross - during denial
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an individual acts as though nothing has hapened & refuses to believe or understand that a loss occured
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Kubler-Ross - in anger
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the individual resists the loss & sometimes strikes out at eveyone & everything
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Kubler-Ross - during bargaining
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the individual postpones awareness of the reality of the loss & tries to deal with it in a subtle or overt way as though the loss can be prevented.
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Kubler-Ross - during depression
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a person realizes the full impact & significance of the loss when the person feels lonely & withdrawn
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Kubler-Ross - during acceptance
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the individual accepts the loss & begins to look to the furture
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purpose of hospice
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concept for family-centered care designed to assist the pt. in being comfortable & maintaining a satisfactory lifestyle until death.
alternative for the terminally ill. |
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the gate control theory of pain gives you away
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to understand pain-relief measures
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gate control theory suggest
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that pain impulses can be regulated or even blocked by gating mechanism along the central nervous system.
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Evaporation is
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The transfer of heat energy when a liquid is introduced to a gas.
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Normal Heat Production from
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Metabolism
Shivering Rest Movements |
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Normal Temp
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98.6 - 100.4
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Normal Pulse
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60 - 100
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Normal BP
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120/80
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Normal Respiration
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12 - 16
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What are Vital Signs
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Temp
Pulse BP Respiration |
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Kortkoff Sounds
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Sharp Thump
Blowing or Whooshing Softer thump Softer blowing sound that fades Silence |
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Pulse sites
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Temporal
Carotid Apical Brachial Radial Ulnar Dorsalis pedis Popliteal Posterial tibial Femoral |
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Physiology of BP
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cardiac output
peripheral vascular resistence blood volume blood viscosity artery elasticity |
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Body Temp. Regulation
(Nervous sytem & BP system) |
Neural & Vascular control
Heat Production Heat Loss Behavioral control |
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Cuff over client clothes causes what
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artificially raise BP
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Blood Pressure is
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force exerted on walls of an artery created by the pulsing blood under pressure from the heart
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Rythm rates
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Regular
Regular - irregular Irregular - irregular |
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Pathologic Pulses
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Pulses Alterans
Pulses Bisferians Corrigans Pulse |
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Respiration Process
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Ventilation
Diffusion Perfusion |
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Assesment of Pulse
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Rate
Rhythm Strenth (amplitude) |
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Blood Pressure Physiology
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Cardiac Output
Peripheral resistance Blood Volumne Viscosity Elasticity |
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basal metabolic rate BMR
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Basal Metabolism accounts for the heat produced by body at absolute body rest
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Kortkoff meanings
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Systolic
distension of artery crisp preg., child, vosodilation, card (diastolic) Normal diastolic sound done |
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Pathologic Pulse
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Pulses Alterans
Pulses Bisferians Corrigans Pulse |
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Heat Loss
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Radiation
Conduction Convection Evaporation |
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Heat Production
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Increase Metabolism
rest shivering movements |