• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/392

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

392 Cards in this Set

  • Front
  • Back
Principles of Body Mechanics
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
Trochanter Rolls
Prevents external rotation of legs when pt. are in the supine position
Foot Boots
Maintain feet in dorsiflexion
Sandbags
Provide support & shape to body contours.
Fowlers
Supine, elevated 40-60
Semi-fowlers
30
Prone
pt. on abdomen
Lateral Bed Positions
Pt. suported on rt. & lft. side
Arms r flexed toward shoulders
Hips & knees are slightly flexed
Sims
Semi-PRONE on side w/ thigh, & knee flexed and resting on bed.Underneath arm behind, protect abdomen
Supine
Back flat against bed
Dorsal Recumbent
Supine position with pillow supports head & upper shoulders; hips & knees slightly flexed w/ supporting pillow
Trendelenburg
Prone or Supine; pt. rest on inclined surface w/ head lower than heart, legs, & feet.
Reverse Trendelenburg
Entire bed frame tilted downward with foot of bed down; promotes gastric emptying, prevents esophageal reflux
TB Symptoms
Cough (poss bleeding)
Spit brownish
weight loss
fever
night sweats
loss of appetite
chest pain
scratching
Fire Safety
Rescue
Alarm
Contain
Evacuate & Extinguish
restraints time period
skin / 30 minutes
skeletalmuscular / 2 hours
remove every 2 for 30 min.
electrical fire ( your actions)
Activate
Evacuate
Confine
Extinguish
Principles - Restraints
How to apply
use least restrictive restraint possible
tie to frame not rails
What causes shearing force
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
Calcium loss for Immobility can be noted within
two weeks
What is Osteoporosis?
Porous bone
Decrease in bone mass & structural deterioration
Often no signs or symptoms until break
DO NOT give to immobile pt (intake)
Calcium & phosphate
Negative nitrogen balanced caused by
poor nutrition
lab work routinely done prior surgery
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.
nursing obligation about informed consent
if pt. is confused or uncertain about procedure; ethical obligation to inform dr. prior to surgery
postoperative exercises taught postoperative
daiphragmatic breathing
incentive spirometry
controlled coughing
turning
leg exercises
postoperative assessment;
respirations
circulations
infection control
gastrointestinal function
comfort
postoperative assessment; respiration
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
postoperative assessment; circulation
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
postoperative assessment; infection control
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
postoperative assessment; gastrointestinal function
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
postoperative assessment; comfort
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)
common problems post op
airway compromise
cardiac/circulatory compromise
neurological compromise
gastrointestinal compromise
hypothermia
pain
skin/wound problems
ineffective airway post op
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
Nursing interventions for ineffective airway Post OP
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
Cardiovascular/circulation compromise Post OP
bp
heart rate
peripheral pulses
skin temp & color
post op dehydration (blood loss, bleeding)
DVT's
Cardiovascular Nursing Intervention Post Op
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
Gastrointestinal compromise Post Op
inspect for abdominal distension
observe for nausea/vomiting
check for return of bowel function
* bowel sounds
* advance diet as bowel function returns
* flatus
neurological functional assessment
pulilary reflexes
orientation
hand grasp
movement
LOC/sudden change in consciousness
gentirourinary compromise
observe for bladder distension
* restlessness, agitation, increased bp
watch for adequate urine output (foley)
Pain post op
behavior symptoms
*restlessness
*grimacing
*vital signs
pain scale
review pain medication orders in PACU with anesthesiologist or CRNA
PCA pump most often utilized
problems with skin or wound Post Op
rashes
drainage
dehiscense
evisceration
circulating nurse (non-sterile)
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
scrub nurse (sterile)
sets up sterile field
dresses surgical team
assist in draping
hands instrument and supplies to surgeon
anticipates what surgeon needs
counts laps, needles & instruments
surgical assistant (sterile)
hold retractors, suction wound, cut tissue, suture & dress wound
can be another surgeon, resident, intern, nurse practioner, PA, RN
complication from general aneshesia
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
complication from regional anesthesia
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
classifications of surgery
serious
urgency
purpose
purposes of surgery
diagnostic
ablative
palliative
reconstructive
procurement for transplant
constructive
cosmetic
included in pre-op teaching
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
gate control theory
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
Physiology of pain (how it works)
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
types of pain stimuli
mechanical
thermal
chemical
transmission/perception of pain
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
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
modulators of pain

continuation of physiology of pain
modify the transmission by either exciting or inhibiting the pain transmission & perception
modulators for pain increase or decrease; name 5
substance P inhances
serotonin inhibit
norepineprhrine inhibit
endorphins inhibit
bradykinin enhance
autonomic NS stimulated
flight or fight for lower intensity & superficial pain
parasympathetic NS stimulated
deep, visceral, unrelenting, severe pain
reactions to pain are either physiological or behavioral
autonomic NS
parsympathetic NS
anticipation of pain
aftermath of pain
Variables influencing a person's pain (pain assesment)
physiological
psychological
sociocultural
environmental
pain assessment
onset
duration
location
severity
quality
pattern of pain
relief
concomitant symptoms
physical s/s
alterations of ADL
expectations
quality of pain
tell me what your pain feels like
burning
stabbing
aching
vice like
sharp
severity of pain
Numerical scale
Verbal description
Visual scale (helpful w/ children & uncommunitive pt)
pain interventions
reduce reception & perception
cutaneous stimulation
* back rub, warmth or ice
* TENS (electrical nerve simulation)
* distraction
* relaxation
anticiapatory guidance
analgesics
non-narc pain meds
ibuprofren
naproxen (alleve)
toradol
tolectin
narcotic meds
demerol
morphine
codeine
types of loss
external objects
of know environment
of significant other
of life
aspects of self
characteristics of normal grieving
physical
cognitive
emotional
behavioral
physical responses to loss
tightness in throat
heavy chest
fatigue
cognitive responses to loss
inability to concentrate
forgetfulness
daydreaming
emotional responses to loss
sadness
isolation
anger
frequent crying
behavioral responses to loss
inability to sleep
loss interest in sex
restlessness
use of alcohol or drugs
imagine seeing person
factors that affect greif
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
complicated greiving
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
purpose of hospice
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
kubler-ross stages of dying
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)
coping with loss TEAR
to accept
experience the pain
adjust to the new environment
reinvest in new reality
comfort measures for loss
pain management
management of symptoms of disease
comfortable environment
religious rituals
prevent isolation
what are the non-medicine treatments
Nurtition
exercise
water (internally & externally)
sunlight
temperance
fresh air
rest
trust in god
Heat Therapy Goal
Vasoldilation
Vasodilation does
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
Heat therapy
dry heat
moist heat
dry heat is used for heat conduction
hot water bottles
electric pad
aquathermia pad
disposable pad
moist heat is used for systemic effects (greater risk for burns & maceration, but penetrates deeper)
sitz bath
tepid baths
hot pack/back fomentations
fever treatments
whirlpools
rebound phenomena occurs for both heat & cold
heat produces vasoldilitation
cold vasconstricts

after an hour homeostasis goes into effect to and the opposite will happen
prolonged exposure to cold results in
impaired circulation
cell deprivation
damage to tissues from lack of o2 & nutrients
signs of symptoms of tissue damage due to cold (similiar to hypothermia)
bluish-purple appearances
numbness
stiffness
pallor
blisters
pain
dry cold - administered for local effect
ice bags 2/3 full to release air
ice collars
ice gloves
disposable cold pack
moist cold - administered for either local or systemic effects
wet cold sheet wrap
hot/cold shower
cold produced maxiumum vasoconstirction when skin temp reaches
60 degrees
below 60 degrees vasodilation
during cold bp can
blood is shunted from cutaneous circulation to internal vessels
variables which affect pt tolerance to heat or cold
impaired mental status
impaired circulation
neurosensory impairment
open wounds
recent injury/surgery
in open wound heat/cold can
heat increases bleeding
cold decreased blood flow to wound, but can inhibit healing
decrease in or lack of meaningful stimuli caused by
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)
sensory overload
occurs when an individual is unable to process or manage the amount of intensity of sensory stimuli
sensory overload caused by
increase stimuli in external environment
increase stimuli in internal environment
inability to distinguish stimuli selectively
people at risk for sensory overload
pain
accutely ill pt. in accute setting
pt. being closed monitored in ICU
CNS disturbances
cerumen accumulation
build up of earwax in the external auditory canal
sensory intergrative disorders
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.
sensory modulation
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
sensory modulation disorder
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.
Sensory Discrimination Disorder
have difficulty distinguishing between various sensory inputs, therefore inappropriately responding to stimuli. They have difficulty in their social interactions and functioning in their environment
normall sensory changes occuring in age
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.
interventions for preventing sensory deprivations
reorient pt. to reality
assist or encourge pt. to wear glasses, hearing aids, etc
arrange environment that offsets deficit
interventions for preventing or controlling sensory overload
adjust lighting
less disruptions
respond quickly
preoperative assesment
physical
patient history
risk factors
preoperative care & teaching
pre-op checklist
diagnostic screening
informed consent
pre-op teaching
intraoperative team
surgeon
surgical assistant
scrub tech/Nurse
Circulating RN
Anestheiologist/CRNA
anesthesia
general
regional
local
conscious sedation
complications from general anesthesia
complications of intubation
malignant hyperthermia
overdose
unrecognized hypoventilation
complications related to anesthetic agent
risk for altered body temp
anesthetic agents interfere w/ the body's temp regulating mech.

hypothermia
hyperthermia
hypothermia during surgery
cool environment
decreased metabolic rate
medications
cold IV fluids
hyperthermia during surgery
malignant hyperthermia
ineffective airway post op
respiratory rate
patency of airway
patterns of respiratory work
breath sounds
neuro checks after surgery
pupilary reflexes
orientation
hand grasp
movement
LOC/Sudden change in consciousness
pain after surgery
behavior symptoms
pain scale
review pain meds
PCA pump
gallblader pain can be felt
in right shoulder
heart pain can be felt in
back
chest area
head
left shoulder
kindney pain can be felt in
right thigh
back
liver pain can be felt
in right kneck
lungs & diaphragm pain can be felt
in left kneck
pain has two functions
protective - remove parts from harm
warns against possible tissue damage
types of pain stimuli
mechanical
thermal
chemical
acute pain
usually treated more agressively
can threaten pt recovery
rapid onset, brief duration
pt. expects relief quickly
chronic pain
usually treated less aggressively
varies in intensity, usually last months
exacerbations
body doesn't adapt to pain
variables influencing person's pain
physiologic
sociocultural
psychological
environmental
legal considerations w/ dying
end of life decisions
POA
cornoner/death examinier
post mortem
organ donations
end of life decisions
life sustaing procedures
living will
DNR
death with dignity act
Virchows triad
Impaired venous return to heart
hypercoagulability of the blood
injury to vessel wall
Symptoms of DVT
tenderness
pain
swelling
warmth
discoloration of skin
Benefits of Mobility
Maintain body's normal physiological functioning
Reasons for Immobility
Severe pain
Impairment of musculoskeletal or nervous system
Disorders causing weakness
Psychosocial problems
Surgery
Therapeutic rest
Musculoskeletal Changes due to Immobility
*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
Musculoskeletal Nursing Interventions due to Immobility
Body repositoning
Weight bearing activities
Independence of ADL;s
ROM
Cardovascular Changes due to Immobility
Orthostatic (postural) hypotension
Increased workload on heart
Rapid heart rate
Edema
Thrombus Formation
Cardovascular Nursing Interventions due to Immobility
Movement & Excercise
Regain peripheral vasoconstriction with vertical postures
Elastic stocking
Respiratory Changes due to Immobility
Decreased lung expansion
Co2/o2 Imbalance
Respiratory muscle weekness
stasis of secretions
Increased accumalation of secretions
Respiratory Nursing Inverventions due to Immobility
Fluid intake of at least 2000 ml per day
Coughing & deep breathing
Diaphragmatic-abdominal breathing
Turning, positioning & exercise
Gastrointestinal & Metabolic changes due to Immobility
Anorexia
Negative Nitrogen Balance
Dyspepsia
Constipation
Gastrointestinal & Metabolic Nursing interventions due to Immobility
Diet
Vitamin & Mineral Suppements
Weight-bearing exercises
Movement & exercises
Urinary & Endocrine Changes due to Immobility
Urinary stasis
Renal calculi
Urinary incontinence
Urinary reflux
Increased UTI
Urinary & Endocrine Nursing Interventions due to Immobility
Turning, repositiong & exercise
Improving hydration
Perineal hygiene
Acidifying the Urine
Position & relaxation for urination
Urinary catherization
Preventing urinary incontinence
Integumentary Changes due to Immobility
Decubitus (pressure) Ulcers
Causes - Pressure, friction, and shearing
Pressure Ulcer stages
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
Preventing Skin Damage
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
Psycho/Social Effects of Immobility
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
Psycho/Social Nursing Interventions due to Immobility
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
Assesment for Body Mech. & Joint Mobility
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
Pathological influences on alignement, exercises & activity
Congental defects
Disorders of bones, joints, muscle
contractures
central nervous system damage
musculoskeletal trauma
Pressure Ulcer Prevention
regulary turning
clean & dry skin
lift sheets or devices to turn pt
mantain head below 30 degr. if poss.
avoid massage
maintain adequate nutrition
Virchow's triad describes
the three broad categories of factors that are thought to contribute to thrombosis
Virchow's triad
Hypercoagulability
Hemodynamic changes (stasis, turbulence)
Endothelial injury/dysfunction
Thrombosis
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]
Hypercoagulability
tendency for excessive blood clotting: a potentially dangerous condition in which blood coagulates excessively, even within the blood vessels
Virchow's Triad - Causes of Thrombosis
1] Changes in the blood vessel wall
2] Changes in the blood flow
3] Changes in the blood composition
Name the Immune Responses
Active & Passive
Active Immunity is
• 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
Passive Immunity is
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
Symptoms of Localized Infection
Redness
Swelling
Pain
Heat
Drainage
Symptoms of Systemic Infection
Fever
vomiting
diarrehea
body aches
Increased white blood cell
Links of Chain of Infection
Infections agent (etiologic)
Reservoir
Portal of Exit
Mode of Transmission
Portal of Entry
Susceptible Host
Standard Precautions apply to
blood
body fluids
secretions
excretions (not sweat)
non-intact skin
mucous membranes
Infection Interventions
hand hygiene
gloves
mask
gowns
cleaning
linen bags
sharpy containers
private room
Defense against infection (naturally)
Normal Flora
Body Systems Defenses
Inflammation
Immune Response
Categoriies for Sterilization, Disinfection, & Cleaning

Critical Items
Sterilization
Categoriies for Sterilization, Disinfection, & Cleaning

Semicritical Items
Disinfection
Categoriies for Sterilization, Disinfection, & Cleaning

Noncritical Items
Cleaning
Health Promotion (concerning Infection control)

Preventions
Nutrion
Immunization
Personal Hygiene
Regular Rest & Exercise
Normal Flora
Microorganisms normal on body that usually help
Infectious Agent
Any microorganism capable of producing an infecious process
systemic infection
infection in which the pathogen is distributed throughout the body rather than concentrated to one location
Bacteremia
Infection of the blood
Nosocomial
Infection associated with Health Care
Factors that increase risk of infection
Age
Heredity
Stress
Nutrional Status
Current Medical therapy
Pre-exsisting disease
Mode of Transmission
Contact
- Direct
- Indirect
- Droplet
Air
Vehicles
Vector
Break Chain of Infection
Medical asepsis
Surgical asepsis
Hand Hygiene
-Hand washing
-Antiseptics
-Alcohol based handrub
What can massages do for pt.?
lower Bp
feel more relaxed
relieve tension
soothe away headaches
relax tense muscles
increase alterness
types of massages
swedish
deep tissue
remedial
sports
reflexology
swedich massage
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
deep tissue massage (drink lots of water before and after)
released chronic patterns of tension in the body through slow strokes and deep finger pressure on contracted areas
remedial massage
helps restore function to injured tissues
may involve the use of various types of massage
may be coordinated with physical therapy
sports massage (not a specific technique)
combines different massage techniques to enhance sports performance and recuperation
reflexology theory
use thumb and finger pressure on the reflex points of the body to assist in achieving balance within the body
spefic massage techniques
effleurage
petrissage
tapotement
Don't massage over
reddened area
varacous veins
Diabetic Foot Care Do's & Don't
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
assesment of skin
turgor & condition
areas of breakdown or potential
texture, thickness, temperature
tissue perfusion (purple, blue)
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
components of diet history
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
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
respiration includes
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)
gas exchange
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
regulation of blood pH
respiratory system can alter blood pH by changing blood carbon dioxide levels
Kubler-Ross 5 stages of dying
Denial
Anger
Bargaining
Depression
Acceptance
Kubler-Ross - during denial
an individual acts as though nothing has hapened & refuses to believe or understand that a loss occured
Kubler-Ross - in anger
the individual resists the loss & sometimes strikes out at eveyone & everything
Kubler-Ross - during bargaining
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.
Kubler-Ross - during depression
a person realizes the full impact & significance of the loss when the person feels lonely & withdrawn
Kubler-Ross - during acceptance
the individual accepts the loss & begins to look to the furture
purpose of hospice
concept for family-centered care designed to assist the pt. in being comfortable & maintaining a satisfactory lifestyle until death.

alternative for the terminally ill.
the gate control theory of pain gives you away
to understand pain-relief measures
gate control theory suggest
that pain impulses can be regulated or even blocked by gating mechanism along the central nervous system.
Evaporation is
The transfer of heat energy when a liquid is introduced to a gas.
Normal Heat Production from
Metabolism
Shivering
Rest
Movements
Normal Temp
98.6 - 100.4
Normal Pulse
60 - 100
Normal BP
120/80
Normal Respiration
12 - 16
What are Vital Signs
Temp
Pulse
BP
Respiration
Kortkoff Sounds
Sharp Thump
Blowing or Whooshing
Softer thump
Softer blowing sound that fades
Silence
Pulse sites
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Dorsalis pedis
Popliteal
Posterial tibial
Femoral
Physiology of BP
cardiac output
peripheral vascular resistence
blood volume
blood viscosity
artery elasticity
Body Temp. Regulation
(Nervous sytem & BP system)
Neural & Vascular control
Heat Production
Heat Loss
Behavioral control
Cuff over client clothes causes what
artificially raise BP
Blood Pressure is
force exerted on walls of an artery created by the pulsing blood under pressure from the heart
Rythm rates
Regular
Regular - irregular
Irregular - irregular
Pathologic Pulses
Pulses Alterans
Pulses Bisferians
Corrigans Pulse
Respiration Process
Ventilation
Diffusion
Perfusion
Assesment of Pulse
Rate
Rhythm
Strenth (amplitude)
Blood Pressure Physiology
Cardiac Output
Peripheral resistance
Blood Volumne
Viscosity
Elasticity
basal metabolic rate BMR
Basal Metabolism accounts for the heat produced by body at absolute body rest
Kortkoff meanings
Systolic
distension of artery
crisp
preg., child, vosodilation, card (diastolic)
Normal diastolic sound done
Pathologic Pulse
Pulses Alterans
Pulses Bisferians
Corrigans Pulse
Heat Loss
Radiation
Conduction
Convection
Evaporation
Heat Production
Increase Metabolism
rest
shivering
movements