End-of-Life Care and Grief Management, Exams of Nursing

Download End-of-Life Care and Grief Management and more Exams Nursing in PDF only on Docsity! lOMoARcPSD|21742172 lOMoARcPSD|21742172 nur 111 cumulative notes 2024 study guide review exam with complete solutions ❖ Sources of Infection Chain ➢ Agent  reservoir  Exit  Transmission  Entry  Host ❖ 3 stages of Inflammation ➢ Vascular and cellular response ▪ Redness, heat, pain, swelling ➢ Inflammatory exudates (drainage) ➢ Tissue repair ❖ ASEPSIS ➢ Medical = clean technique ➢ Surgical = sterile technique ❖ UTI = Most common hospital acquired infection ❖ Functions of skin ➢ Protection, sensation, temp. regulation, and excretion and secretion ❖ Must have Dr. order to put pt. in shower or tub ❖ Nurses cannot cut nails in hospital ➢ Get consult for podiatrist ❖ Do not soak a diabetic’s feet ❖ Do not offer heart pt. a back rub ❖ Lemon glycerine swabs dry the mucous membrane and erodes enamel ❖ Normal saline rinses for chemo pt. ❖ Oral hygiene for unconscious pt. ➢ Assess for gag reflex ➢ Sims position ➢ Suction available ➢ Never use your finger to keep mouth open ➢ Need more frequent oral care ➢ Petroleum jelly on lips ❖ Bed positions ➢ Fowlers – 45 degrees ➢ Semi fowlers – 30 degrees ➢ Trendelenburg – head of bed down ➢ Reverse trendelenburg – foot of bed down ➢ Flat ❖ Questions asked in class ➢ What is the difference in the scope of practice of RN’s and LPN’s ▪ A RN can function independently, LPN can do an assessment, but must report to RN ➢ What would an RN who has been inactive for more than 5 years need to do to be removed from the inactive list ▪ Prove she’s been active in another state or apply and take an approved refresher course lOMoARcPSD|21742172 ➢ How many times per year, is the licensure exam for RN’s administered ▪ 2 times a year ❖ HIPPA ➢ Protects confidentiality and privacy of pt. health information ➢ 4 areas ▪ Portability of healthcare coverage ▪ Privacy regulation ▪ Security regulation ▪ Administrative provisions for transmissions of electronic protected health information ❖ Patient self-determination act ➢ Requires health care agencies to provide written info. to clients about their right to make decisions about their care ❖ Legal aspects of pt. rights ➢ Informed consent ▪ Nurse cannot obtain consent ➢ Leaving against medical advice ▪ Explain dangers and risks of leaving ➢ Physical restraints ▪ Last resort ▪ Expires every 24 hr. ❖ Diagnostic related groups (DRG’s) ➢ Payment is predetermined based on diagnosis ❖ Advance directives ➢ Living will ▪ Documents a person’s wishes will still living ➢ Durable power of attorney ▪ Allows a designee to make decisions if pt. becomes incapacitated ❖ ANA code of ethics for nurses ➢ Advocacy ➢ Responsibility ➢ Accountability ➢ Confidentiality ❖ Ethical principles ➢ Autonomy – self-determination; acting on one’s own ➢ Beneficence – doing or actively promoting good ➢ Confidentiality – respecting privileged info. on pt. ➢ Justice – being fair or equal in one’s action ➢ Non-maleficence – the duty to do no harm to a pt. ➢ Veracity – the duty to tell the truth ➢ Fidelity – keep promises ❖ Antibiotic key terms ➢ Colonization – the establishment and growth of microorganisms on the skin, open wounds, or mucous membranes, or in secretions without causing adverse clinical signs or symptoms ➢ Community associated infection – acquired by persons who have not been hospitalized or had a medical procedure recently (within the past year) ➢ Definitive therapy – the administration of antibiotics based on known results of culture and sensitivity testing identifying the pathogen causing infection lOMoARcPSD|21742172 ➢ Study design ➢ Conducting the study ➢ Data analysis ➢ Use of the findings ❖ Quality and performance improvement ➢ Quality improvement – an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others ➢ Performance improvement – an organization analyzes and evaluates current performance to use results to develop focused improvement actions ➢ Model for QI and PI ▪ Plan ▪ Do ▪ Study ▪ Act ❖ Value formation and moral development ➢ A value is a personal belief about worth that acts as a standard to guide behavior; a value system is an entire framework on which actions are based and is the backbone to how one thinks, feels and takes action ❖ Essential nursing values and behaviors ➢ Altruism – concern for the welfare of others ➢ Autonomy – right to self-determination ➢ Human dignity – respect for inherent worth and uniqueness of individuals and populations ➢ Integrity – acting in accordance with an appropriate code of ethics ➢ Social justice – acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability or sexual orientation ❖ Ethical principles ➢ 3 principles have been proven to be highly relevant in bioethics ▪ Autonomy ▪ Beneficence, nonmalefience ▪ Veracity – was thought that telling the truth could be harmful, but now people expect the complete truth ❖ Nursing care delivery models ➢ Total pt. care ▪ Nurses are responsible for planning, organizing and performing all care • Nurse maintains high degree to practice autonomy • RN performs many tasks that could be performed by caregiver with less training at a lower cost ➢ Functional nursing ▪ Staff members are assigned to complete certain tasks for a group of pt. rather than care for specific pt. • Tasks are completed quickly and little confusion about job responsibilities • Care may be fragmented • Caregiver may feel unchallenged ➢ Team nursing ▪ RN functions as a team leader and coordinates a small group of ancillary personnel to provide care to a small group of pt. • Each member of the team is able to participate in decision making and problem solving • Pt. is confronted with many different caregivers lOMoARcPSD|21742172 • Team leader may not have leadership skills ➢ Primary nursing ▪ RN assumes 24 hour responsibility for planning, directing and evaluating the pt. care from admission through discharge • High degree of autonomy and feel challenged and rewarded ➢ Partnership model ▪ Coprimary nursing ▪ Modification of primary nursing ▪ RN is partnered with an LVN, LPN or NAP and the pair work together consistently to care for an assigned group of pt. ➢ Pt. centered care ▪ Providing care that is respectful of and responsive to individual pt. preferences, needs and values and ensuring that pt. values guide all clinical decisions ▪ Includes family and significant others in decision making ➢ Telehealth nursing ▪ Using the nursing process to provide care and access to health care over the telephone ❖ Clinical pathways ➢ Provides a means of standardizing care for pt. with similar diagnoses ❖ Health care plans ➢ Managed care organization – provides comprehensive preventive treatment services to a specific group of voluntarily enrolled persons ➢ Medicare – seniors ➢ Preferred provider organization – limits an enrollee’s choice to a list of preferred providers ➢ Exclusive provider organization – limits an enrollee’s choice to providers belonging to one organization ➢ Medicare – for 65 years and older ➢ Medicaid – low income families, long term care disabilities ➢ Private insurance – traditional fee-for-service plan ➢ Long term care insurance – supplemental insurance for coverage of long-term care services ❖ Preventive and primary health care ➢ Schools, physical offices, occupational health clinics and nursing centers ➢ Health promotion is key ❖ Secondary and tertiary care ➢ Hospitals, intensive care, psychiatric facilities, rural hospitals ❖ Restorative care ➢ Help individuals regain max. functional status and to enhance quality of life through promotion of independence and self care ▪ Home health ▪ Rehab ▪ Extended care facilities ❖ Continuing care ➢ Provided over a prolonged period ➢ For pt. who are disabled, who never were functionally independent, or who suffer a terminal disease ➢ Nursing homes, group homes, retirement communities, adult day care, assisted living, respite care, hospice ❖ Infection control ➢ Airborne lOMoARcPSD|21742172 ▪ Occurs by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent ▪ Measles, varicella and TB ➢ Droplet ▪ Transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth • Coughing, sneezing, or talking • Travel short distances, usually 3 feet ➢ Contact ▪ Direct- contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person ▪ Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object in the pt. environment ➢ Effective hand washing includes wetting, soaping, lathering, applying friction under running water for at least 15 seconds, rinsing and adequate drying ➢ Cohorting – the practice of grouping pt. who are colonized or infected with the same pathogen ➢ Personal protective equipment ▪ Gloves, gown, mask, eye protection ❖ Precautions in addition to standard precautions ➢ Airborne precautions ▪ Private room with negative airflow ➢ Droplet precautions ▪ Private room preferred ▪ Maintain distance of at least 3 feet ▪ Mask ➢ Contact precautions ▪ Private room preferred ▪ Gloves ▪ Wash hands before leaving pt. room ▪ Gown – remove before leaving pt. room ❖ Standard precautions ➢ Reflect that all body excretions, secretions and moist membranes excluding perspiration are potentially infectious ❖ Nature of infection ➢ Infectious – may not pose a risk for transmission ➢ Communicable – can be transmitted from one person to another ➢ Symptomatic – pathogens multiply and cause clinical signs and symptoms ➢ Asymptomatic – clinical signs and symptoms are not present ❖ Chain of infection ➢ An infectious agent or pathogen ➢ A reservoir or source for pathogen growth ▪ Most common reservoir is the human body ➢ A portal of exit from the reservoir ➢ A mode of transmission ▪ Major route for pathogens in the health care setting is the unwashed hands ➢ A portal of entry to a host ➢ A susceptible host ❖ Potential for microorganisms or parasites to cause disease depends on … lOMoARcPSD|21742172 • Monitoring the client’s response ▪ Implementation - putting the plan of care into action ▪ Evaluation • Determining the client’s progress • Monitoring the client’s response ❖ Assessment ➢ Cues – pieces of information that you gather, can see it, feel it, hear it etc. ▪ Concrete information ➢ Inferences – what you decide ▪ Should never be documented as so, document the data you obtain ➢ Subjective data - what the client reports, believes or feels ➢ Objective data – what can be observed ➢ Data sources ▪ Primary = client ▪ Secondary = family, health care team, medical records, literature review, nurses experience ➢ Collection methods ▪ Interview, nursing health history, physical exam, labs/diagnostic test results ▪ Interview • Phases ◆ Orientation – introduce yourself and role ◆ Working – gathering the info. ◆ Termination – end the interview • Communication during interview ◆ Empathetic listening ➢ Sit at eye level, maintain eye contact (be aware of culture), do not interrupt, wait during a pause, avoid long silences, use repetition after long pause if appropriate, touch when appropriate • Interview questions ◆ Open ended – elicit info. opportunity ◆ Close-ended – can be answered shortly ❖ IF IT IS NOT DOCUMENTED, IT DOES NOT COUNT ❖ Diagnosis ➢ NIC – deals with interventions ➢ NOC – deals with outcomes ➢ Steps of data analysis ▪ Recognize a pattern/trend ▪ Compare with norms ▪ Make a reasonable conclusion ➢ Components ▪ P – problem ▪ E – etiology • Four categories ◆ Pathophysiology ◆ Treatment ◆ Situation ◆ Maturational ▪ S – signs and symptoms (support of the statement) lOMoARcPSD|21742172 ➢ Variations ▪ Unknown etiology – nurse does not know the cause or contributing factors ▪ Complex factors – too many etiologic factors to list them all out ▪ Secondary to – to divide the etiology into 2 parts ❖ Planning - prioritize, come up with objective, measurable goals and outcomes, then define nursing interventions ➢ Establish priorities ▪ Assigning priorities ▪ Setting priorities • High • Intermediate • Low ➢ Determine client centered goals and outcomes ▪ A specific and measurable behavior or response representing the client’s highest possible level of wellness and independence in function ▪ Long term goals ▪ Short term goals ▪ Expected outcomes • Guidelines ◆ Client centered, singular, specific, measurable/observable, attainable/mutual, realistic, time limited ➢ Selecting nursing interventions ▪ Any treatment or action, based upon clinical judgment and knowledge, that nurses perform to enhance the client’s outcomes ▪ Nursing initiated – independent ▪ Physician initiated ❖ THE NUMBER ONE INTERVENTION IS ALWAYS, ALWAYS, ALWAYS TO ASSESS ❖ Implementation ➢ Protocol ▪ Plan is sort of standard for everybody ➢ Standing order ▪ Give the nurse a little bit of autonomy • Example (if pt. has chest pain, then I can give them nitro) ◆ Common on floors that have the same type of pt. coming in ➢ Direct care ▪ ADL’s, instrumental ADL’s (teaching pt. essentially how to be productive in society), physical care techniques, counseling, teaching, controlling for adverse reactions, preventive measures ➢ Indirect care ▪ Communicating nursing interventions (change of shift report), delegating, supervising and evaluation ❖ Evaluation ➢ Planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress toward goals/outcomes and the effectiveness of the nursing care plan ➢ Everything revolves around outcomes lOMoARcPSD|21742172 ❖ Vital signs ➢ 5 vital signs ▪ Temp, pulse, respirations, blood pressure (always in that order TPR BP), pain ➢ Body temp ▪ Controlled by hypothalamus ▪ Heat produced – heat loss = body temp. ▪ Diaphoretic – when you sweat a lot ▪ Anhydrosis – can’t sweat ▪ Surface vs. core temperature ▪ Factors influencing • Newborns (can’t shiver, lose body temp through head), everything slows down in elderly, exercise, hormones, circadian rhythm (temp. is lower at night), stress (increases metabolism), environment, temp. alterations ▪ Excessive hot or cold • Heat exhaustion (cramps, get dizzy, give fluids, need to replace electrolytes), heat stroke (heat loss mechanisms stop working, will not sweat), hypothermia (blood pressure drops, heart rate drops, vessels constrict, fingers blue, use warm blankets, soup), malignant hyperthermia (genetic, when person gets general anesthesia), frostbite ▪ Heat loss • Radiation – transfer of heat from the surface of one object to the surface of another without direct contact • Conduction – transfer of heat from one object to another with direct contact • Convection – transfer of heat away by air • Evaporation – transfer of heat energy when a liquid is changed to a gas ➢ Pulse ▪ Character of pulse • Tachycardia – faster • Bradycardia – slower • Rhythm – regular/irregular • Strength – strong (3+)/weak/thready/bounding(4+) • Equality – never carotids (cut off circulation to brain) ▪ Count for 30 seconds and multiple by 2 • If irregular check apical and count for full minute • PMI – point of maximal impulse ▪ Pulse deficit • Compare radial for a min. against apical for a min. • Greater than 2 beats off, then there is some alteration ➢ Respirations ▪ Hypoxic drive – low oxygen level stimulates urge to breathe fv. CO2 levels ▪ 12-20 = normal ▪ Count for 30 seconds and multiple by 2 • If irregular count for a min. ▪ Observe if using accessory muscles • Retraction – using all those muscles ▪ Pulse ox • Evaluates diffusion and perfusion lOMoARcPSD|21742172 ▪ Guidelines for goals and expected outcomes • Client-centered • Singular goal or outcome • Observable • Measurable • Time limited • Mutual factors • Realistic ▪ Critical pathways – are multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition ▪ Consultation – a process in which you seek the expertise of a specialist, to identify ways to handle problems in client management or the planning and implementation of therapies ➢ Implementation ▪ Clinical guideline or protocol – a document that guides decisions and interventions for specific health care problems or conditions ▪ Standing order – a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines and/or diagnostic procedures for specific clients with identified clinical problems ➢ Evaluation ▪ You conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completed ▪ Five elements • Identifying criteria and standards • Collecting evaluative data • Interpreting and summarizing findings • Documenting findings • Care plan revision ❖ Quality improvement – the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge ❖ Quality management – a term for managing the individual outcomes of clients as a result of prescribed treatments ❖ Documentation and informatics ➢ Documentation is anything written or printed you rely on as record or proof for authorized persons ➢ Consultations – form of discussion whereby one professional caregiver gives formal advice about the care of a client to another caregiver ➢ Referrals – an arrangement for services by another care provider ➢ Purposes of documentation – communication, legal documentation, financial billing, education, research and auditing-monitoring ➢ Legal guidelines for recording ▪ Review these if you must, examples: not erasing, black ink, correcting errors promptly etc. ➢ Methods of recording ▪ Narrative documentation ▪ Problem-oriented medical record - lOMoARcPSD|21742172 • Database • Problem list • Nursing care plan ▪ Progress notes • SOAP ◆ Subjective ◆ Objective ◆ Assessment ◆ Plan ◆ Sometimes I and E are added ➢ Intervention ➢ Evaluation • PIE ◆ Problem ◆ Intervention ◆ Evaluation • Focus charting ◆ Narrative format ◆ DAR ➢ Data ➢ Action ➢ Response of the client ➢ Charting by exception ▪ Focuses on documenting deviations from the established norm or abnormal findings ➢ Common record-keeping forms ▪ Admission nursing history forms ▪ Flow sheets and graphic records ▪ Home care documentation ▪ Long term health care documentation • Residents – individuals living in a facility for the rest of their lives ➢ Reporting ▪ Change of shift reports ▪ Telephone reports ▪ Telephone or verbal orders • Emergency situations • Read back complete order • Write TO (telephone order) or VO (verbal order) • Physician must sign order within the time frame (usually 24 hours) ▪ Transfer reports ➢ Kardex – a portable “flip-over” file or notebook ❖ Activity and exercise ➢ Body alignment – the relationship of one body part to another body part along a horizontal or vertical line lOMoARcPSD|21742172 ➢ Body balance – occurs when a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support ➢ Friction – a force that occurs in a direction to oppose movement ▪ The greater the surface area of the object you are moving, the greater the friction ➢ Exercise and activity ▪ Isotonic – cause muscle contraction and change in muscle length ▪ Isometric – involves tightening or tensing of muscles without moving body parts ▪ Resistive isometric – individual contracts the muscle while pushing against a stationary object or resisting the movements of an object ➢ Mobility ▪ ROM ▪ Gait ▪ Exercise ❖ Client safety ➢ Freedom from psychological and physical injury, is a basic human need that must be met ➢ Individual risk factors ▪ Lifestyle ▪ Impaired mobility ▪ Sensory or communication impairment ▪ Lack of safety awareness ➢ Nine lifesaving pt. safety solutions ▪ Be aware of look alike, sound alike med names ▪ Use pt. identification ▪ Communication during pt. handover ▪ Perform correct procedure at correct body site • “time out” ▪ Control concentrated electrolyte solutions • Six rights of medication administration ▪ Ensure med. Accuracy at transitions in care ▪ Avoid catheter and tubing misconnections ▪ Do not reuse single-use injection devices ▪ Improve hand hygiene ➢ Falls ▪ Risk higher in older clients ▪ One of the more common factors precipitating a fall is pt. attempt to go to bathroom ➢ Client-inherent accidents ▪ Accidents where the client is the primary reason for the accident ➢ Seizure ▪ Generalized tonic-clonic or grand mal seizure lasts approx. 2 min and is characterized by a cry, loss of consciousness with falling, tonicity (rigidity), clonicity (jerking) and incontinence ▪ Status epilepticus • Prolonged or repeated seizures • Medical emergency and requires intensive monitoring and treatment ➢ Procedure related accidents ▪ Include med and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures ➢ Equipment related accidents ▪ Malfunction, disrepair, or misuse of equipment or from an electrical hazard lOMoARcPSD|21742172 • Skin, hair and nails ◆ Skin ➢ Assessment of skin reveals changes in oxygenation, circulation, nutrition, local tissue damage and hydration ➢ Pallor (decrease in color) – reduced amount of oxyhemoglobin ➢ Vitiligo – loss of pigmentation ◆ Hair ➢ Terminal hair – long, coarse, thick hair ➢ Vellus hair – small, soft tiny hairs • Abdominal ◆ Bowel motility ➢ Sounds occur irregularly 5-35 times per min. ➢ Normally takes 5-20 seconds to hear a bowel sound ➢ Takes 5 minutes of listening before determining that bowel sounds are absent • Musculoskeletal ◆ Common postural abnormalities ➢ Kyphosis – hunchback ➢ Lordosis – increased lumbar curvature ➢ Scoliosis – lateral spinal curvature ➢ Osteoporosis • Neuro ◆ Two types of aphasia ➢ Sensory (or receptive) ▪ Person cannot understand written or verbal speech ➢ Motor (or expressive) ▪ Can understand written and verbal speech but cannot write or speak appropriately ❖ Communication and physical assessment of the child ➢ Communicating with families ▪ Communicating with parents • Encourage parents to talk • Directing the focus • Listening and cultural awareness • Using silence • Being empathic • Providing anticipatory guidance • Avoiding blocks to communication ◆ Blocks to communication ➢ Barriers ▪ Socializing ▪ Giving unrestricted and sometimes unasked for advice ▪ Offering premature or inappropriate reassurance ▪ Giving overready encouragement ▪ Defending a situation or opinion ▪ Using stereotyped comments or clichés ▪ Limiting expression of emotion by asking directed, close-ended questions ▪ Interrupting and finishing a person’s sentence ▪ Talking more than the interviewee lOMoARcPSD|21742172 ▪ Forming prejudged conclusions ▪ Deliberately changing the focus ▪ Communicating with families through an interpreter • Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore the interpreter • Post questions to elicit only one answer at a time ▪ Communicating with children • Active attempts to make friends with children before they have had an opportunity to evaluate an unfamiliar person tends to increase their anxiety • Continue to talk to the child and parent but go about activities that do not involve the child • Communicating with children ◆ Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may seem threatening ◆ Communicate through transition objects such as dolls etc. ◆ Assume a position that is at eye level with the child ◆ Be honest ➢ History taking ▪ Identifying information • Informant ◆ The person who furnishes the information ◆ Chief complain ➢ the specific reason for the child’s visit to the clinic, office or hospital ❖ Drug order should include ➢ Patients name ➢ Date the drug order was written ➢ Name of drug ➢ Drug dosage amount and frequency ➢ Route of administration ➢ Prescribers signature ❖ Six rights of medication administration ➢ Right drug ➢ Right dose ➢ Right time ➢ Right route ➢ Right patient ➢ Right documentation ❖ Medication error ➢ Any preventable event that may cause or lead to inappropriate medication use or pt. harm while the medication is in the control of the health care professional, patient or consumer ❖ Pharmacologic principles ➢ Chemical name – the name that describes the chemical composition and molecular structure of a drug ➢ Generic name – name given to a drug by the US adopted names council ➢ Trade name – the commercial name given to a drug product by its manufacturer ➢ Therapeutic equivalence – the drugs must have been proven to have the same therapeutic effect in the body before one drug can be therapeutically substituted for another ➢ Pharmaceutics – the science of preparing and dispensing drugs, including dosage form design lOMoARcPSD|21742172 ➢ Pharmacokinetics – the rate of drug distribution among various body compartments after a drug has entered the body. Includes absorption, distribution, metabolism and excretion of drugs ▪ Absorption • The movement of a drug from its site of administration into the bloodstream for distribution to tissues • Bioavailability – a measure of the extent of drug absorption for a given drug and route • First past effect – the initial metabolism in the liver of a drug absorbed from the GI tract before the drug reaches systemic circulation through the bloodstream ▪ Distribution • The transport of a drug by the bloodstream to its site of action ▪ Metabolism • Involves the biochemical alteration of a drug into an inactive metabolite, a more soluble compound, a more potent active metabolite or a less active metabolite ▪ Excretion • Elimination of the drug from the body • Primary organ is the kidney ➢ Pharmacodynamics – the study of the biochemical and physiologic interactions of drugs at their sites of activity ➢ Pharmacotherapeutic – the treatment of pathologic conditions through the use of drugs ▪ Defines the principles of drug actions • Drug actions – the cellular processes involved in the interaction between a drug and body cells; also called mechanism of action ➢ Dosage forms ▪ Enteral ▪ Parenteral ▪ Topical ➢ Toxicology – the study of poisons, including toxic drug effects and applicable treatments ➢ Pharmacology – the study of drugs that are obtained from natural plant and animal sources ➢ Half-life- time required for half of an administered dose of drug to be eliminated by the body, or the time it takes for the blood level of a drug to be reduced by 50% ➢ Onset, peak and duration ▪ Onset of action – time required for a drug to elicit a therapeutic response after dosing ▪ Peak effect – the time required for a drug to reach its max. therapeutic response in the body ▪ Duration of action – the length of time the concentration of a drug in the blood or tissues is sufficient to elicit a response ▪ Peak level – the max. concentration of a drug in the body after administration, usually measured in a blood sample ▪ Trough level – the lowest concentration of drug reached in the body after it falls from its peak level ▪ Toxicity – the condition of producing adverse bodily effects due to poisonous qualities ▪ Therapeutic index – ratio of a drug’s toxic level to the level that provides therapeutic benefits ➢ Adverse drug event – any undesirable occurrence related to administering or failing to administer a prescribed medication ➢ Adverse drug reaction – any unexpected, unintended, undesired or excessive response to a medication give at therapeutic dosages ➢ Allergic reaction – an immunologic hypersensitivity reaction resulting from the unusual sensitivity of a pt. to a particular medication; a type of adverse drug event lOMoARcPSD|21742172 ▪ Buccal – med goes against the mucous membrane of check until dissolves • Switch sides to avoid breakdown of membrane ➢ Nasal ▪ Inspect nose first ▪ Blow nose before procedure ➢ Eye drops and ointments ▪ After administration gently press on the medial nasolacrimal canthus with a tissue to prevent systemic drug absorption ➢ Inhalers ▪ Make sure pt. rinses out mouth after use ➢ Suppositories ▪ Use water soluble lubricant ▪ Do not place suppository in stool, must dissolve against rectal wall ❖ Spirituality ➢ BELIEF ▪ Belief systems ▪ Ethics ▪ Lifestyle ▪ Involvement ▪ Education ▪ Future events ➢ Spirituality is unique, subjective and personal ❖ Nutrition ➢ Water ▪ Muscle contains water so leaner people have a higher concentration of water compared to obese people and infants have most % of water ➢ Metabolism ▪ Anabolism – building ▪ Catabolism – breakdown ➢ Lab tests ▪ Plasma proteins – albumin – chronic • Pre-albumin – acute ◆ Shows sudden changes ▪ Hemoglobin – shows if there is iron deficiency ➢ Aspiration risk ▪ Dysphagia – difficulty swallowing ▪ 2 people with a big risk • Poor gag reflex • LOC ➢ Must have bowel sounds before you feed someone ➢ Assisting patients ▪ Assess lOMoARcPSD|21742172 • Gag reflex, LOC, environment of room (smells, urinals, bedpans), pain, fatigue, minimize interruptions, oral hygiene ▪ Position • Upright • Leave upright for at least 30 min so food can digest ▪ Stroke patients • Food on strong side ➢ Enteral nutrition ▪ Candidates – stroke, brain injury, head and neck surgeries ▪ Nutrients via GI tract ➢ Nose ▪ Nasogastric – nose to stomach ▪ Nasointestinal – nose to jejunum ➢ Surgically ▪ Jejunostomy ▪ Gastrostomy ➢ Tube placement must be verified by x-ray before the initial feeding ▪ Also check pH before sending to x-ray ➢ Enteral feeding ▪ Feeding – gavage ▪ Suction – lavage ▪ Bolus vs. continuous • Bolus – intermittent ◆ Before feeding insert 30 cc of air, then aspirate back 5 cc, us pH strip to test • Continuous ◆ Check every 4-6 hours ▪ Residuals • 200 mL or more don’t give the food back and discontinue the feed ▪ Flushes • 30 cc of water before and after feeding ▪ Timing • Every 24 hours hang a new bag ◆ Never hang more than 8 hrs of feed at a time ▪ Overall goal • Use the GI tract, if you don’t it will atrophy ❖ Care of pt. with malnutrition and obesity ➢ Malnutrition ▪ Hypoproteinemia – decrease in serum proteins – occurs as protein synthesis in the liver decreases ▪ Anorexia nervosa – self-induced starvation ▪ Bulimia nervosa – episodes of binge eating and followed by some form of purging behavior ❖ Culture ➢ Cultural assessment lOMoARcPSD|21742172 ▪ Is there anything I need to know about you to make this better for you? ➢ Population diversity ▪ Visible • Clothing, jewelry, tattoos ▪ Invisible • Beliefs and ideas ➢ Nursing goal ▪ Must understand your own limitations and why you hold those views ➢ Definitions ▪ Culture • The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making ▪ Ethnicity • Shared identity such as ◆ Values, geographical area, social and cultural values, language ▪ Acculturation • The process of adapting to and adopting a new culture/modification ▪ Assimilation • Incorporation of the dominant culture ➢ Trans-cultural nursing ▪ Cultural awareness – simply aware ▪ Cultural sensitivity – I may not agree but I am sensitive to the pt. needs ▪ Cultural competence - incorporation of cultural values ➢ Test questions ▪ Within transcultural nursing, sensitivity to the social organization is the recognition of the client’s • Answer: status and expected role in the family ▪ Traditional western medicine, in contrast to alternative therapy, uses • Answer: medication administration ▪ The nurse recognizes the following as an appropriate strategy for communicating with clients who are not fluent in English • Answer: interaction with an interpreter for all communication ▪ One aspect of culture is invisible or less observable to others. A nurse wanting to develop an awareness of the practices of different cultures within that community would have which of the following as an example of this component? • Answer: wearing an amulet or charm ◆ Because you don’t know what the amulet means ▪ From culture to culture time often takes on different meanings, in exploring the relationships of time to nursing interventions, the nurse should • Answer: maintain a flexible attitude when the client request procedures to be done at specific times ▪ Following a surgical procedure, an older Chinese woman refuses to perform the ROM and breathing exercises requested, in addition is hesitant to complete the hygienic care and grooming. The nurse recognizes that this is most likely related to • Answer: reliance upon family members to assist with care lOMoARcPSD|21742172 • B or T cells ▪ T-lymphocytes • Cell mediated immunity ▪ B-lymphoctyes • Humoral response ➢ Immunoglobulins ▪ IgG = most common ▪ IgM – first to increase in immune response ▪ IgA = found in secretions ▪ IgE = bound to mast cells ▪ IgD = activates B cells ➢ Test question? ▪ Which health problem would the nurse expect to see in a client who cannot synthesize T- suppressor lymphocytes? • Answer: leukemia ▪ The nurse notes that the client has a “left shift of their WBC count” which lab result supports this conclusion? • Answer: BANDS outnumber the segmented neutrophils ➢ Sequence of inflammatory response ▪ Vascular • Constriction • Hyperemia and edema ▪ Cellular exudates – neutrophilia, pus ▪ Tissue repair and replacement ➢ Assessment of inflammation ▪ Warmth ▪ Redness ▪ Swelling ▪ Pain ▪ Decreased function ❖ Pain and children ➢ Nonnutritive sucking – reduces behavior, physiologic and hormonal responses to pain from procedures ➢ Kangaroo care – skin-to-skin holding of infants dressed only in diapers against their mother or father’s chest ➢ Distraction ➢ Relaxation ➢ Guided imagery ➢ Positive self-talk ➢ Thought stopping ➢ Behavior contracting ❖ Sleep ➢ Sleep – a cyclical physiological process that alternates with longer periods of wakefulness ➢ Circadian rhythm ▪ Influence the pattern of major biological and behavioral functions ➢ Stages of sleep ▪ Stage 1 Non-REM • Lightest level of sleep, lasts 10-30 min., easily aroused lOMoARcPSD|21742172 ▪ Stage 2 Non-REM • Sound sleep, relaxation progresses, arousal relatively easy , 10-20 min. ▪ Stage 3 Non-REM • Initial stages of deep sleep, difficult to arouse, muscles completely relaxed, 15-30 min ▪ Stage 4 Non-REM • deepest stage of sleep, very difficult to arouse, 15-30 min ▪ REM sleep • Vivid dreaming, begins about 90 min. after sleep has begun, very difficult to arouse, duration of REM sleep increases with each cycle and averages about 20 minutes ➢ Newborns and children spend more time in deep sleep ➢ Functions of sleep ▪ Brain restoration – brain filters stored info. about the day’s activities ➢ Sleep disorders ▪ Insomnia – difficulty falling asleep, frequent awakenings and/or a short sleep or non- restorative sleep • Pt. usually gets more sleep than he or she realizes • More frequent in women ▪ Sleep apnea • Lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep • Central – impulse to breathe temporary fails ◆ Common in pt. with brain stem injury, muscular dystrophy and encephalitis and people who breathe normally during the day • Obstructive ◆ Most common ◆ Structures of oral cavity or throat relax during sleep ◆ Obesity, smoking, alcohol and positive family history greatly increase risk ▪ Narcolepsy • Excessive daytime sleepiness is most common complaint • REM sleep occurs within 15 min. of falling asleep • Cataplexy – sudden muscle weakness during intense emotions occurs at any time during the day • Falling asleep uncontrollably at inappropriate times ▪ Sleep deprivation ❖ Client education ➢ Teaching – an interactive process that promotes learning ▪ Most effective when it responds to the learner’s needs ➢ Learning – the purposeful acquisition of new knowledge, attitudes, behaviors and skills ➢ Functional illiteracy – inability to read above 5th grade level ➢ Domains of learning ▪ Cognitive learning • Includes all intellectual behaviors and requires thinking ▪ Affective learning • Deals with expression of feelings and acceptance of attitudes , opinions, or values ▪ Psychomotor learning • Involves acquiring skills that require the integration of mental and muscular activity, such as the ability to walk or to use an eating utensil ➢ Motivation lOMoARcPSD|21742172 ▪ Mild level of anxiety motivates learning ▪ Social motive – need for connection, social approval or self-esteem ▪ Task mastery motives – based on needs such as achievement and competence ▪ Physical motive – some pt. are motivated to return to a level of physical normalcy ➢ Self-efficacy – a concept included in social learning theory ▪ Refers to a person’s perceived ability to successfully complete a task ➢ Teaching methods based on client’s developmental capacity ▪ Infant • Be consistent, hold firmly while speaking softly, have infant touch textures ▪ Toddler • Use play, picture books, simple words ▪ Preschooler • Role play, imitation and play, encourage questions, offer explanations, encourage children to learn together ▪ School age child • Teach psychomotor skills needed to maintain health, offer opportunities to discuss health problems and answer questions ▪ Adolescent • Allow them to make decisions ▪ Young or middle adult • Encourage participation and setting mutual goals ▪ Older adult • Teach when alert and rested • Keep sessions short ➢ Material needs to progress from simple to complex ideas ▪ Begin any instruction with essential content because clients are more likely to remember information that the nurse teaches early in the teaching session • Complete the teaching session with informative but less critical content ➢ Repetition reinforces learning ➢ Teaching approaches ▪ Telling • There is no opportunity for feedback ▪ Participating • The nurse and pt. set objectives and become involved in the learning process together ▪ Entrusting • Provides the client the opportunity to manage self-care • Nurse observes pt. progress and remains available to assist without introducing more new information ▪ Reinforcing • Requires using a stimulus that increases the probability for a response • Feedback is a common form of reinforcement • Are positive or negative ➢ Instructional methods ▪ One-on-one discussion ▪ Group instruction ▪ Preparatory instruction ▪ Demonstrations • Return demonstration – have a chance to practice the skill lOMoARcPSD|21742172 ➢ Territoriality and personal space ▪ Zones of personal space • Intimate zone (0-18 in) • Personal zone (18 in-4ft) ◆ Sitting on bedside • Social zone (4-12 ft) ◆ Making rounds with physician • Public zone (12ft and greater) ▪ Zones of touch • Social zone (permission not needed) ◆ Hands, arms, shoulders, back • Consent zone (permission needed) ◆ Mouths, wrists, feet • Vulnerable zone (special care needed) ◆ Face, neck, front of body • Intimate zone (great sensitivity needed) ➢ Therapeutic communication techniques ▪ Active listening • SOLER ◆ Sit facing the client ◆ Observe an open posture ◆ Lean toward the client ◆ Establish and maintain intermittent eye contact ◆ Relax ▪ Sharing observations ▪ Sharing empathy ▪ Sharing hope ▪ Sharing humor ▪ Sharing feelings ▪ Using touch ▪ Using silence ▪ Providing information ▪ Clarifying ▪ Focusing ▪ Paraphrasing ▪ Asking relevant questions ▪ Summarizing ▪ Self-disclosure ▪ Confrontation ❖ Pain ➢ Self-report always the most reliable indication of pain ➢ 100% subjective ➢ Acute or chronic ➢ Nociceptive pain – either visceral or somatic ➢ Neuropathic pain – results from some type of nerve injury ➢ Some terms ▪ Addiction – a primary, chronic neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations lOMoARcPSD|21742172 ▪ Pseudoaddction – an iatrogenic syndrome created by the undertreatment of pain ▪ Tolerance – state of adaptation in which exposure to a drug induces changes that result in a decrease in one or more of the drug’s effects over time ▪ Physical dependence – adaptation manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist ➢ Non-opioid analgesics ▪ First-line therapy for mild to moderate pain ▪ Ceiling effect ➢ Opioid analgesics ▪ Oral route is preferred ▪ Morphine – gold standard ▪ Hydromorphone (dilaudid) • 8 times more potent than morphine ▪ Fentanyl ▪ Be concerned if you see pt. on Demerol • Considered to be outdated • Accumulation of toxic metabolite can cause central nervous system toxicities ➢ Level of pain ▪ Level 1 pain (1-3 rating) – use non-opioids ▪ Level 2 pain (4-6 rating) – use weak opioids alone or in combo with adjuvant drug ▪ Level 3 pain (7-10 rating) – use strong opioids ➢ Side effects of opioids ▪ Constipation, nausea, vomiting, urinary retention, itching, sedation, respiratory depression ➢ Sedation scale ▪ 1 = alert and awake ▪ 2 = slightly drowsy, but easy to arouse ▪ 3 = always drowsy, but arousable ▪ 4 = somnolent, little or no response to stimuli ➢ PCA pump ➢ Non-pharmacologic interventions ▪ Massage, imagery etc. ➢ Test questions ▪ PCA true or false • Meperidine (Demerol) is the drug most commonly used in PCA therapy ◆ False • The demand is ordered by the health care provider and is only available within specific intervals ◆ True • During the lockout interval, a dose will be delivered if a client presses the button more than twice ◆ False • Continuous or basal infusion of an opioid in addition to demand dosing causes overmedication ◆ False ▪ When a smiling and cooperative client complains of discomfort, nurses caring for this client often harbor misconceptions about the client’s pain. To properly care for clients in pain, nurses need to remember that… lOMoARcPSD|21742172 • Answer: clients are the best judges of their pain ▪ Established pain management guidelines direct nurses to frequently assess the client’s pain. The most appropriate action for the nurse to take when assessing the client’s reaction to pain is to .. • Answer: offer the client a pain scale to objectively identify the pain ▪ A client has just undergone an appendectomy. When discussion with the client several pain relief interventions, the most appropriate recommendation would be • Answer: PCA pain management ▪ A postoperative client is using a PCA. You will evaluate the effectiveness of the medication when • Answer: you compare assessed pain with baseline pain ▪ True or false: a patient experiencing chronic pain is in danger of experiencing respiratory depression when taking opioids as a long-term therapy • False ▪ Which patient would benefit most from the use of a patient-controlled PCA pump • A. a 75 yr. old woman in the last stages of the dying process who is experiencing occasional episodes of confusion • B. a 60 year old man who is mentally alert and experiencing left-sided weakness after a stroke • C. a 42 year old man that is mentally alert and recovering from a fractured femur • D. a 15 yr old girl who is recovering from a head injury • Answer = C ▪ The pt. is receiving his first dose of an opioid analgesic for pain. The nurse expects that another medication will prob. Be ordered concurrently for this pt. will be… • Answer: laxative ▪ When setting up a PCA pump, the nurse should question which opioid order? • Answer: Meperidein (Demerol) ❖ Understanding responses to stress and anxiety ➢ General adaptation syndrome ▪ The alarm stage • Initial, brief, adaptive response (fight or flight) ▪ The resistance stage • Sustained and optimal resistance to the stressor occurs • If stressors are not overcome the organism may experience the exhaustion stage ▪ Exhaustion stage • Occurs when attempts to resist the stressor prove futile • Resources are depleted, and the stress may become chronic ➢ Mediators of the stress response ▪ Stressors • Physical and psychological ▪ Perception ▪ Personality ▪ Social support lOMoARcPSD|21742172 ▪ Severe to panic anxiety • SAFETY!! • Firm, short simple statements ❖ Grief and loss ➢ A normal dynamic, individualized process which pervades every aspect of persons experiencing the loss of a significant other ➢ Mourning – one’s cultural response to grief ➢ Bereavement – period of mourning ➢ Grief models ▪ Kubler-ross • Denial • Anger • Bargaining • Depression • Acceptance ➢ Anticipatory grieving ▪ Can be useful, but also can have a downfall when things don’t go as schedule ➢ Disenfranchised grief – when it’s not a socially accepted loss ➢ It’s not how can I make them feel better but how can I better help them ➢ Intervening ▪ If in doubt, keep your mouth shut and your arms open ▪ Active listening • Ears open and mouth shut • Mind active ▪ Validating feelings/normalizing grief process ▪ Providing accurate information ▪ Suggesting options • Not the same as giving advice • Do not use the phrase “you should” or “you shouldn’t” ➢ Signs of impeding death ▪ Breathing pattern change • Pattern may slow, periods of apnea • Disorientation • Restlessness • Coolness of extremities and mottled • Increased sleeping • Fluid and food decrease ◆ Do not force foods, will cause more discomfort • Incontinence • Congestion and gurgling ◆ “the death rattle” ➢ Place them on their side with a towel under mouth ➢ Clinical signs of death ▪ Cessation of apical pulse ▪ No respirations ▪ No blood pressure ▪ Irreversible brain damage ➢ Nurses role lOMoARcPSD|21742172 ▪ Practice the art of presence ▪ Assess for spiritual issues ▪ Provide palliative symptom management ▪ Promote dignity and self-esteem ▪ Become an effective communicator ▪ Counsel about anticipatory grieving/end of life decision making ➢ Dyspnea management ▪ Treat primary cause, and relieve the psychological distress ▪ Medications • Opioids etc. ▪ Cool air ▪ Wet cloths to pt. face ▪ Positioning ▪ Imagery and deep breathing ➢ Questions ▪ A client recently diagnosed with a terminal illness is asking the nurse about organ and tissue donation at the time of death. The nurse should • Answer: assist the client to obtain the necessary information to make the decision ▪ During postmortem care the nurse should give priority to • Answer: providing culturally and religiously sensitive care in body preparation ▪ A client has recently been told he has terminal cancer as the nurse enters the room, he yells “my eggs are cold, and I’m tired of having my sleep interrupted by noisy nurses” the nurses may interpret the client’s behavior as • Answer: an expression of anger stage of dying ▪ When helping a person through grief work, the nurse knows that • Answer: the stages of grief may occur in the standard order, they may be skipped, or they may reoccur ▪ Which of the following is a primary concern for the nursing care for a dying patient • Answer: promote dignity and self-esteem  was a test question ❖ The experience of loss, death and grief ➢ Other theories (we weren’t tested on them, but you might want to look them up in your book) ▪ Bowlby’s attachment theory ▪ Grief tasks model ▪ Dual process model ➢ Factors influencing loss and grief ▪ Human development ▪ Personal relationships ▪ Nature of loss ▪ Coping strategies ▪ Socioeconomic status ▪ Culture and ethnicity ▪ Spiritual and religious beliefs ▪ Hope ➢ Palliative care ▪ Prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness, including care of the dying and bereavement follow-up for the family ▪ Primary goal is to help clients and families achieve the best possible quality of life lOMoARcPSD|21742172 ▪ Hospice – final phase designated to clients who no longer benefit from medical treatments, who will likely not live more than 6 months, or who are actively dying ➢ Care after death ▪ Requesting organ or tissue donation ▪ Autopsy ▪ Certifying and documenting the occurrence of a death ▪ Providing safe and appropriate postmortem care • Ask family if they would like to spend time with the body to come to terms with what has happened and to say their goodbyes (before cleaning and bagging and after cleaning if they choose not to do it themselves) • Before preparing the body ask the physician whether an autopsy will be ordered ➢ Sense of hearing is last to go ❖ End of life care for children ➢ Is now widely understood that terminally ill children develop an awareness of the seriousness of their diagnosis, even when protected from the truth ➢ Give honest and accurate information ➢ Clarify misconceptions and let the child know that he or she did not cause the illness or death ➢ Communicating with dying children ▪ Eye level ▪ Let the child’s questions guide ▪ Provide opportunities for the child to express feelings ▪ Encourage feedback ▪ Use other resources ▪ Use the child’s natural expressive means to stimulate dialogue ➢ Children’s understanding of and reactions to dying ▪ Infants and toddlers • Likely they have no concept of death • Regression to less independent behavior ▪ Preschool • Egocentric • 3-5 years have usually heard the word death and had some sense of its meaning • Dead person in coffin still breathes, eats and sleeps • Take the literal meaning of words • May conceive illness as punishment • Separation from parents is biggest fear ▪ School-aged • May feel intense guilt and responsibility for the event • Respond to logical explanations and comprehend the figurative meanings of words • Have a deeper understanding of death in the concrete sense • May fear the reason for illness, communicability of the disease to themselves or others ▪ Adolescents • Most have a mature understanding of death • Tend to think they will not die as a young person • Least likely of all age groups to accept cessation of life, particularly their own was a test question • More worried about physical changes than death itself ❖ Skin integrity and wound care ➢ Pressure ulcers lOMoARcPSD|21742172 ❖ Urinary elimination ➢ Nocturia – awakening to void one or more times at night ➢ Polyuria – excessive output of urine ➢ Oliguria – urine output that is decreased despite normal intake ➢ Anuria – no urine is produced ➢ Dieresis – increased urine formation ➢ Insensible water loss ➢ Fever causes an increase in body metabolism and accumulation of body wastes ▪ Highly concentrated ➢ Urinary retention ▪ Accumulation of urine resulting from an inability of the bladder to empty properly ➢ UTI ▪ Most common health care associated infection ▪ Residual urine in bladder becomes more alkaline and is an ideal site for microorganism growth ▪ Hematuria – blood tinged urine ▪ Urine appears cloudy because of presence of WBC or bacteria ➢ Urinary incontinence ▪ Involuntary leakage of urine that is sufficient to be a problem ▪ Stress incontinence ▪ Urge incontinence ➢ Common types of urinary alterations ▪ Urgency – feeling of need to void immediately ▪ Dysuria – painful or difficult urination ▪ Frequency – voiding at frequent intervals ▪ Hesitancy – difficulty initiating urination ▪ Polyuria – voiding large amounts ▪ Dribbling – leakage of urine despite voluntary control of urination ▪ Incontinence – involuntary loss of urine ▪ Hematuria – blood in urine ▪ Retention – accumulation of urine in the bladder, with inability of bladder to empty fully ➢ Stimulating micturition reflex ▪ Men stand, women sit ▪ Sound of running water ▪ Stroking inner aspect of the thigh ▪ Pour warm water over client’s perineum ➢ Need to drink 2000-2500 mL fluid daily • Unless they have heart or kidney disease ▪ 1200-1500 is usually adequate unless the client has a history of UTI’s ➢ Avoid fluids 2 hours before bedtime ➢ Catheterization ▪ Intermittent and indwelling retention cauterizations • Intermittent – introduce a straight single use cath. Long enough to drain bladder • Indwelling or Foley cath remains in place for a longer period ▪ Coude cath – used on male clients who may have enlarged prostates ▪ Sterile technique ▪ Bag hangs on bed frame without touching floor ▪ Do not raise bag higher than pt. bladder lOMoARcPSD|21742172 ▪ Perineal hygiene at least 3 times a day ➢ Restorative care ▪ Kegel exercises ▪ Bladder retraining • Suppress urination and increase time by 15 min. every week ▪ Minimize tea, coffee or other caffeine drinks and alcohol ▪ Habit training ▪ Self-catheterization ▪ Maintenance of skin integrity • Warm water and mild soap – best way to remove urine from skin ▪ Promotion of comfort • Sitz bath ❖ Bowel elimination ➢ Factors affecting bowel elimination ▪ Age, diet, fluid intake, physical activity, psychological factors, personal habits, position during defecation, pain, pregnancy, surgery and anesthesia, medications, diagnostic tests ➢ Common problems ▪ Constipation • Symptom not a disease ▪ Impaction • Obvious sign is the inability to pass stool for several days, despite the repeated urge to defecate • Loss of appetite ▪ Diarrhea • Increase in number of stools and passage liquid, unformed feces ▪ Incontinence ▪ Flatulence ▪ Hemorrhoids ▪ Bowel diversions • Ostomies ➢ Enemas ▪ Limit is 3 ➢ Nutritional considerations for clients with ostomies ▪ Low fiber diet for first weeks ➢ Give yourself time to defecate! ❖ Bowel and bladder – lecture notes ➢ Bladder ▪ Terminology • Dysuria – painful • Polyuria – excess • Oliguria – small, sporadic, under, low volume • Nocturia – urinating at night • Anuria – no urine output • Hematuria – bloody ▪ Factors influencing urination • Disease, sociocultural, psychological, muscle tone, fluid balance, surgery, growth and development, medications, diagnostic exams ▪ Stress incontinence – void wile coughing, sneezing, laughing etc. lOMoARcPSD|21742172 ▪ Urge incontinence – can’t control the need to go ▪ Overflow incontinence – bladder can’t hold anymore ➢ Bowel ▪ Factors influencing bowel elimination • Age, infection, diet, fluid intake, physical activity, diagnostic tests, psychological, personal habits, position, pain, surgery/anesthesia, medications, disease ▪ Elimination problems • Constipation • Impaction • Diarrhea • Incontinence • Flatulence • Hemorrhoids ❖ Fluid and electrolytes ➢ Homeostasis ▪ No body system works well if 2 liters of blood volume are gained or lost ➢ Fluid balance ▪ Min amount of urine per day needed to excrete toxic waste products is 400-600 mL ▪ In healthy adult, insensible water loss is about 500-1000 mL/day ➢ Hormonal regulation ▪ Aldosterone • Prevents Na and H2O loss ▪ Antidiuretic hormone • Prevents H2O loss ▪ Natriuretic peptides • More Na secreted, faster filtration = more urine ➢ Fluid imbalances ▪ Dehydration • Assessment ◆ Gordon’s functional health patterns ➢ Patterns that most affect fluid status are the nutritional-metabolic pattern and the elimination pattern ◆ Weight change of 1 pound corresponds to fluid volume change of about 500 mL • Interventions ◆ Management aims to prevent injury, prevent further fluid losses and increase fluid compartment volumes to normal ranges ◆ Pt. safety, fluid replacement and drug therapy ▪ Fluid overload • Most common is hypervolemia • Assessment ◆ Pitting edema • Interventions ◆ Pt safety include preventing fluid overload from becoming worse, leading to pulmonary edema and heart failure ◆ Risk for skin breakdown ◆ Drug and nutrition therapy ➢ Electrolyte balance and imbalances ▪ Sodium lOMoARcPSD|21742172 ◆ Begins to communicate likes and dislikes ◆ Increasingly independent in thoughts and actions ◆ Appreciates body appearance and function • Initiative vs. guilt (3-6 years) ◆ Identifies with a gender ◆ Enhances self-awareness ◆ Increases language skills, including identification of feelings • Industry vs. inferiority (6-12 years) ◆ Incorporates feedback from peers and teachers ◆ Increases self-esteem with new skill mastery ◆ Aware of strengths and limitations • Identity vs. role confusion (12-20 years) ◆ Accepts body changes/maturation ◆ Examines attitudes, values, and beliefs; establishes goals for the future ◆ Feels positive about expanded sense of self • Intimacy vs. isolation (mid-20s to mid-40s) ◆ Has stable, positive feelings about self ◆ Experiences successful role transitions and increased responsibilities • Generativity vs. self-absorption (mid-40s to mid-60s) ◆ Able to accept changes in appearance and physical endurance ◆ Reassesses life goals ◆ Shows contentment with aging • Ego integrity vs. despair (late 60s to death) ◆ Feels positive about life and its meaning ◆ Interested in providing a legacy for the next generation ▪ Identity • Involves the internal sense of individuality, wholeness, and consistency of a person over time an in different situations ▪ Body image • Involves attitudes related to the body, including physical appearance, structure or function ▪ Role performance • Is the way in which individuals perceive their ability to carry out significant roles • Individuals develop and maintain behaviors that society approves through the following processes ◆ Reinforcement-extinction ➢ Certain behaviors become common or are avoided, depending on whether they are approved and reinforced or discouraged and punished ◆ Inhibition ➢ An individual learns to refrain from behaviors, even when tempted to engage in them ◆ Substitution ➢ An individual replaces one behavior with another, which provides the same personal gratification ◆ Imitation ➢ An individual acquires knowledge, skills or behaviors from members of the social or cultural group ◆ Identification lOMoARcPSD|21742172 ➢ An individual internalizes the beliefs, behavior and values of role models into a personal, unique expression of self ▪ Self-esteem • Is an individual’s overall feeling of self-worth or the emotional appraisal of self-concept • It is the most fundamental self-evaluation because it represents the overall judgment of personal worth or value ◆ Altered self-concept/self-esteem ➢ Body image ▪ Stroke, colostomy, anorexia, arthritis, incontinence, obesity, multiple sclerosis, amputation, scarring, aging, pregnancy, mastectomy, rape, assault ➢ Role performance ▪ Inability to balance career and family, physical, emotional, or cognitive deficits preventing role assumption, loss of satisfying role, transition from school to work setting, promotion or demotion, changing work environment, empty nest, assuming responsibility for aging parent ➢ Identity ▪ Job loss, change in marital status, abuse or neglect, dependency on others, sexuality concerns, repeated failures, societal attitudes, conflict with others ▪ Role performance stressors ◆ Role conflict ➢ Results when a person has to simultaneously assume two or more roles that are inconsistent, contradictory, or mutually exclusive ➢ The sick role involves the expectations of others and society regarding how an individual behaves when sick ◆ Role ambiguity ➢ Involves unclear role expectations, which makes people unsure about what to do or how to do it, creating stress and confusion ◆ Role strain ➢ Combines role conflict and role ambiguity ➢ Some express role strain as a feeling of frustration when a person feels inadequate or unsuited to a role, such as providing care to a family member with Alzheimer’s disease ◆ Role overload ➢ Involves having more roles or responsibilities within a role than are manageable ❖ Health and wellness ➢ The two overarching goals for Health People 2010 are ▪ To increase quality and years of health life ▪ To eliminate health disparities ➢ Definition of health ▪ A state of complete physical, mental and social well-being, not merely the absence of disease or infirmity ➢ Health belief model ▪ Addresses the relationship between a person’s beliefs and behaviors ▪ It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies ▪ First – individuals perception of susceptibility to an illness ▪ Second – the individual’s perception of the seriousness of the illness lOMoARcPSD|21742172 • Is influenced and modified by demographic and sociopsychological variables, perceived threats of the illness, and cues to actions ▪ Third – the likelihood that a person will take preventive action – results from the person’s perception of the benefits of and barriers to taking action ▪ A client’s perception of susceptibility to disease as well as his or her perception of the seriousness of an illness, helps to determine the likelihood that the client will or will not partake in health behaviors ➢ Health promotion model ▪ Was designed to be a “complementary counterpart to models of health protection” ▪ Id defines health as a positive, dynamic state, not merely the absence of disease ▪ The health promotion model describes the multidimensional nature of persons as they interact within their environment to purse health ▪ Focuses on the following three areas • Individual characteristics and experiences • Behavior specific knowledge and affect • Behavioral outcomes ▪ Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development ➢ Basic human needs model ▪ Basic human needs are elements that are necessary for human survival and health ▪ Maslow’s hierarch of needs • Physiological (oxygen, fluids, nutrition, body temp, elimination, shelter, sex)  safety and security (physical safety, psychological safety)  love and belonging needs  self- esteem  self-actualization • Certain human needs are more basic than others; that is, some needs must be met before other needs • Self-actualization is the highest expression of one’s individual potential and allows for continual discovery of self • It is unrealistic to always expect a client’s basic needs to occur in the fixed hierarchical order ➢ Holistic health models ▪ The holistic health model of nursing attempts to create conditions that promote optimal health ▪ In this model, nurses using the nursing process consider clients the ultimate experts regarding their own health and respect clients’ subjective experience as relevant in maintaining health or assisting in healing ➢ Levels of preventive care ▪ Primary prevention • Is true prevention; it precedes disease or dysfunction and is applied to clients considered physically and emotionally health • Includes all health promotion efforts, as well as wellness education activities that focus on maintaining or improving the general health of individuals, families and communities ▪ Secondary prevention • Focuses on individuals who are experiencing health problems or illness and who are at risk for developing complications or worsening conditions • Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the client to return to a normal level of health as early as possible ▪ Tertiary prevention lOMoARcPSD|21742172 ➢ Development of intimate peer relationships ➢ Establishment of self-work • Joining of families through marriage: newly married couple ◆ Commitment to new system ➢ Formation of marital system ➢ Realignment of relationships with extended families and friends to include spouse • Family with young children ◆ Accepting new generation of members into system ➢ Adjusting marital system to make space for children ➢ Taking on parental roles ➢ Realignment of relationships with extended family to include parenting and grand parenting roles • Family with adolescents ◆ Increasing flexibility of family boundaries to include children’s independence ➢ Shifting of parent-child relationships to permit adolescents to move into and out of system ➢ Refocusing on midlife material and career issues ➢ Beginning shift toward concerns for older generation • Launching children and moving on ◆ Accepting multitude of exits from and entries into family system ➢ Adjusting to the reduction in family size ➢ Developing adult to adult relationships between grown children and their parents ➢ Realigning relationships to include in laws and grandchildren ➢ Dealing with disabilities and death of parents • Family later in life ◆ Accepting shifting of generational roles ➢ Maintaining own or couple functioning and interests in the face of physiological decline; exploration of new familiar and social role options ➢ Making room in system for wisdom and experience of older adults; supporting older generations without over functioning for them ➢ Dealing with retirement ➢ Dealing with loss of spouse, siblings, and other peers and preparation for own death, a life review, in which one reviews life experiences and decisions ➢ Attributes of families ▪ Structure • Structure and function are closely related and continually interact with one another • Structure is based on the ongoing membership of the family and the pattern of relationships, which are often numerous and complex ▪ Function • Specific functional aspects include the way a family reproduces, interacts to socialize its younger, cooperates to meet economic needs and relates to the larger society • Family functioning also focuses on the processes used by the family to achieve its goals ◆ These processes include communication among family members, goal setting, conflict resolution, care giving, nurturing and use of internal and external resources ➢ Attributes of healthy families lOMoARcPSD|21742172 ▪ The crisis proof, or effective, family is able to combine the need for stability with the need for growth and change • This type of family has a flexible structure that allows adaptable performance of tasks and acceptance of help from outside the family system ➢ Family nursing • Family nursing is based on the assumption that all people regardless of age are a member of some type of family form • There are different approaches for family nursing practice • Family nursing practice has three levels of approaches ◆ Family as context ◆ Family as client ◆ Family as system ▪ Family as context • When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the client’s family) ◆ Although the focus is on the individual’s health status, assess how much the family provides the individual’s basic needs ▪ Family as client • When the family as client is the approach, family processing and relationships (e.g., parenting or family care giving) are the primary focuses of nursing care ▪ Family as system • It is important to understand that although you are able to make theoretical and practical distinctions between the family as context and the family as client, they are not necessarily mutually exclusive ◆ Often times you will use both simultaneously • When viewing the family as system, use elements from both of the above perspectives ❖ Complementary and alternative therapies ➢ The therapies are organized into two types ▪ Nursing accessible therapies • A nurse can begin to learn and apply in client care ▪ Training specific therapies • A nurse cannot perform without additional training and/or certification ➢ Nursing accessible therapies ▪ Relaxation therapy ▪ Meditation and breathing ▪ Imagery ➢ Training specific therapies ▪ Biofeedback ▪ Therapeutic touch ▪ Chiropractic therapy ▪ Traditional Chinese medicine ▪ Acupuncture ▪ Herbal therapies ➢ Nursing role in complementary and alternative therapies ▪ Allopathic physicians and more conventional practitioners need to begin to understand the benefits of therapies that encourage active participation by their clients in preventing or managing illness rather than relying solely on surgery or drugs lOMoARcPSD|21742172 ▪ Clients who benefit from these groups are those who have chronic health problems that have historically been difficult to treat using traditional allopathic medicine ❖ Delirium ➢ Increased intracranial pressure ▪ Cranial skull is fixed • Can’t handle anything else ◆ If anything is added it can’t be accommodated resulting in change in LOC ➢ First place, then time, then self ➢ LOC ▪ Alert – awake, interactive, oriented X 4 ▪ Lethargic – drowsy, easily awakened ▪ Stuporous – arouses with noxious stimuli • Sternal rub – most common ▪ Comatose – cannot be aroused ▪ LOC is the first sign that CNS has declined ➢ Localizes to pain – reach up and knock away painful stimuli ➢ Withdraws to pain – cannot identify where the pain is, they are just trying to get away from it ➢ Abnormal flexion ▪ Decortications – back arches up off of bed, hands up, thumbs rotate out and toes point ▪ Decerebration – back arches, hands extend out, thumbs rotate out and toes point ➢ No response = brain dead ➢ Delirium – clinical picture ▪ Onset = short ▪ Cause or contributing factors • General medical problem, drug or alcohol withdrawal, lack of oxygen, hypoglycemic, head injury, high fever, hypotension, change in environment ▪ Cognition • Memory and judgment is impaired, attention span will fluctuate ▪ Activity • Can be increased or decreased • Hypervigilant – watching everything, asking questions, paranoid • Sundowning – later in day their confusion begins ▪ Emotional state • Rapid swings, very anxious, illusions and hallucinations, angry, agitated, act out ▪ Prognosis • Reversible ▪ Assessment • Four cardinal features ◆ Acute onset and fluctuating course ◆ Inattention ◆ Disorganized thinking ◆ Disturbance of consciousness • Cognitive and perceptual disturbances ◆ Illusions ➢ Misinterpret their environment ▪ You can explain it to your patient ◆ Hallucinations ➢ Visual or tactile lOMoARcPSD|21742172 • Presbycusis, otosclerosis, Meniere’s disease, certain drugs, exposure to loud noise and other inner-ear problems • When no cause can be found or the disorder is untreatable, therapy focuses on ways to mask the tinnitus with background sound, noisemakers, and music during sleeping hours • Ear mold hearing aids can amplify sounds to drown out the tinnitus during the day ➢ Vertigo and dizziness ▪ Dizziness is a disturbed sense of a person’s relationship to space ▪ True vertigo is a real sense of whirling or turning in space ▪ Factors affecting the ear that cause vertigo include • Meniere’s disease, labyrinthitis, acoustic neuromas, motion sickness, and drug or alcohol ingestion • Manifestations of vertigo include nausea, vomiting, falling, nystagmus, hearing loss and tinnitus • Until the cause of the vertigo can be treated, each manifestation is treated • Teach pt. these strategies to reduce manifestations ◆ Restrict head motions and move more slowly ◆ Maintain adequate hydration, especially after vomiting ◆ Take drugs that reduce the vertigo effects • Teach pt. to maintain a safe, uncluttered environment to prevent accidents during periods of vertigo and to use a cane or walker to maintain balance ➢ Labyrinthitis ▪ An infection of the labyrinth, which may occur as a complication of acute or chronic otitis media ▪ Infection results from an erosion of the bony capsule, allowing organisms to invade the inner ear ▪ Labyrinthitis often results from the growth of a cholesteatoma (benign overgrowth of squamous cell epithelium) from the middle ear into the semi-circular canal ▪ Manifestations include • Hearing loss, tinnitus, nystagmus to the affected side, and vertigo with nausea and vomiting • Meningitis (infection of the brain covering) is a common complication of labyrinthitis ▪ Treatment of the disease includes the use of systemic antibiotics ▪ Advice pt. to stay in bed in a darkened room until manifestations are reduced ➢ Meniere’s disease ▪ Pathophysiology • Meniere’s disease has three features ◆ Tinnitus ◆ One-sided sensorineural hearing loss ◆ Vertigo, occurring in attacks that can last for several days • The pathology of Meniere’s disease is an excess of endolymphatic fluid that distorts the entire inner canal system • At first hearing loss is reversible, but repeated damage to the cochlea from increased fluid pressure leads to permanent hearing loss • The exact cause is unknown, but it often occurs with infections, allergic reactions, and fluid imbalances • Long term stress may also have a role in the disease ➢ Acoustic neuroma ▪ A benign tumor of cranial nerve VIII lOMoARcPSD|21742172 ▪ Depending on the size and exact location of the tumor, damage to hearing, facial movements, and sensation can occur ▪ Manifestations begin with tinnitus and progress to gradual sensorineural hearing loss in most patients ▪ Later, patients have constant mild vertigo ▪ As the tumor enlarges, nearby cranial nerves are damaged ▪ Surgical removal via a craniotomy is performed and the remaining hearing is lost ➢ Hearing loss ▪ Pathophysiology • Hearing loss is one of the most common handicaps in North America • It may be conductive, sensorineural, or a combination of the two • Conductive hearing loss occurs when sound waves are blocked from contact with inner ear nerve fibers because of external ear or middle ear disorders • If the inner ear sensory nerve fibers that lead to the cerebral cortex are damaged, the hearing loss is termed sensorineural • Combined hearing loss is known as mixed conductive-sensorineural ▪ Etiology and genetic risks • Conductive hearing loss can be caused by an inflammation or obstruction of the external or middle ear by cerumen or foreign objects • Otitis media with effusion is the commonest cause of acquired hearing loss in children • Sensorineural hearing loss occurs when the inner ear or auditory nerve is damaged • Prolonged exposure to loud noise can damage the hair cells of the cochlea • Many drugs are toxic to the inner ear structures • Older pt. are especially at risk for ototoxicity because of reduced kidney function • Presbycusis is a sensorineural hearing loss that occurs as a result of aging ◆ This hearing loss is caused by breakdown or atrophy of the nerve cells in the cochlea, loss of elasticity of the basilar membrane or a decreased blood supply to the inner ear