NURS 3130 Test 1-4 Notes
NURS 3130 Test 1-4 Notes NURS 3130
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This 170 page Bundle was uploaded by Hope Gulley on Sunday August 16, 2015. The Bundle belongs to NURS 3130 at Auburn University taught by Amy Curtis in Spring 2015. Since its upload, it has received 61 views. For similar materials see Fundamentals of Nursing in Nursing and Health Sciences at Auburn University.
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Date Created: 08/16/15
Thursday January 15 2015 Unit 1 Safety Infants and Toddlers Car Seat the 1 thing we have to make sure of before a parent can bring home their child is that they have a car seat They have expiration dates so make sure they know that Crib Next they have to have a crib standard and up to date Sleeping with newborn is dangerous Babyproof a home Crawl around and make sure that everything is safe for the child As the child gets older we must think of choking hazards as well objects and food Doornob covers are useful Pools use gates covers and alarms to warn you if the child wanders near the poolout of the house Educate parents about age specific dangers Infants and toddlers are very oral and harmful substances should be kept locked in a cabinet or out of reach Toddlers fall often May wander into woods pool etc if not being supervised Climb on things unaware of dangers accidental poisonings may occur put things in mouth be cautious of foods they can easily choke on hot dogs peanuts grapes Preschoolers Street Safety supervision teach children about safety issues and the road Stranger Danger try not to monogram If a child comes home and suddenly do not like a person who they used to spend time with quotthey39re meanquot crying Investigate it could be abuse Physical Safety don39t run with scissors or with a lollipop we have to keep reinforcing these things because the more repetition the more they will remember Forget about rules when ball rolls into street etc Remind them of rules and go with them or watch them Don t walk with suckers in mouth don t walkrun with scissors teach them name address and phone number Don t talk to strangers don t personalize items listen to children s concerns about someone s behavior SchoolAge Bicycle Safety helmet safety They are the 1 thing that protects from TBI traumatic brain injury Same with cars and seatbelt safety Some kids may need to be in a carbooster seat Sports Safety protect yourself in any sport that you play Make sure that the equipment has been inspected Home Safety oven stoves carbon monoxide alarms guns fire alarms when home alone make sure they don39t answer the door have a safe house that they can go to mock fire drills water safety is also important swimming lessons don39t swim alone wait 30 minutes after eating before swimming don39t dive in shallow water Teach road safety for bicycles make sure bike is correct size for child Thursday January 15 2015 Wear appropriate protective equipment for bicycles amp sports Home safetyelectrical equipment stoves firearms home alone Establish a safe house for kids when you are not home or if something comes up they can go to that house Establish a plan for home safetyin case of firemeeting place stay low don t leave room if fire is outside door etc Water safetyteach child to swim don t swim alone don t dive in shallow water Burnscooking only with supervision water heaters set at 120 degrees don t play with matches or lighters Adolescent Adults Driving getting license rarely use seatbelts no texting and driving Drugs and Alcohol don39t get in the car with someone who has been drinking or doing drugs don39t drive when doing this either Sex Education it39s uncomfortable for parents to talk about this with children Make sure that they are conveying correct information Risk of MVA s highest for 1619 year olds than any other age group Teens have lowest rate of seat belt use Texting amp driving Keep open communication Don t get in car with someone who has been drinking Lifestyles what is their occupation for their occupational hazards diet exercise nutrition how often do they get checkups pap smears for women testicular examprostate exams Some adults and older adults don39t get checkups because of the cost so look up free places with free screeningmedication for them be the advocate for the patient SleepRest Adut safety risks related to lifestyle choicesalcohol addiction drunk driving loss of income smoking cancer CV disease stress gambling Older adultFalls related to physical changes urgencyfall on way to bathroom decreased muscle strength less mobile joints decreased range of motion vision amp hearing impairments What kind of questions from this information What would you do to promote safety for an older adult living alone Non skid rugs night lights avoid pm drinking phone within reach etc Older Adults Falling talk to them about safety in the home rugs tables suggest to add adhesive under the bottom of the furniture look into rails for tub nonskid socks Medication pill boxes it will organize their drug intake make sure that someone is responsible for refilling the box Lighting make sure their home is welllit so they don39t trip Joint Commission gt their job is to make sure that the hospital is safe for everyone They determine whether or not a hospital can stay open Safety Goals check patient with 2 ie wristband and chart communication ID patients fall risk arm band something look at notes under this slide you cannot put up more than 3 rails if you put up 4 it39s considered a restraint Thursday January 15 2015 Fire Safety RACE Rescue Activate fire alarm Contain use fireproof doors shut off oxygen for patients Extinguish the fire with appropriate fire extinguisher a combustibles paper wood b any flammable liquid c electrical equipment PASS Pull pin Aim at base of the fire Squeeze the trigger Sweep side to side SafetyRisks in Healthcare Falls According to IOM at least 50000100000 Americans die each year as a result of medical errors This is the 8th leading cause of death Falls account for 90 of all reported incidents in hospitals Older adults are at higher risk but also those on various medications such as pain meds There are a number of assessment tools available to assess a patient s risk for falls One example is the fall assessment tool on page 373 Place client near nursing station Close supervision of confused patients Cal light Tablesequipment close to client Remove clutter Bed locked Trips to bathroom scheduled Fall prevention measures page 830 EnvironmentRestraints restraints must be for the bst of the patients reduce risk of injury to patients to others to their therapyequipment In order to chemically or physically restrain someone you must meet one of the criteria Alternativesfamily stay patient placed close to nurses station regular ambulation frequent bathroom trips Types Skill Book 271 p390392 1 Chemical Last resort sedatives danger drugs too much allergies respiratory depression high risk for hypotension and low BP could kill fetus if given to pregnant woman 2 Physical can cause injury or death Mittens if they pick at things You could even give them washcloths to fold to distract them 3 Seclusion confined along and cannot leave 4 Medical Surgical REstraint medically induced coma so they have direct support fo rmedical healing Legal Implications governed by the Joint Commission Behavioral Healthcare Restraint and Seclusion Standards you39re checked to see if restraints were necessary have to have a physicians order to do restraints and they have to come and see the patient within an hour Thursday January 15 2015 Restraint Assessment must check on restrained patients every 2 hours sings of injury nutrition and hydration sweat a lot circulation release extremity one at a time vital signs hygiene elimination overall physical and psych status readiness for discontinuation we want to stop restarints ASAP Every 2 hoursrelease restraints and provide ROM Documentation should include order for restraint results of patient monitoring results of reassessment for continued need for restraint significant changes in patient condition during use of restraint Seizures padded side rails wrap a blanket around suction gloves pillows oral airway at bedside and oxygen don39t need a pillow now just keep the head situated has caused suffocation before patient positioned on side if possible so they don39t choke on saliva be sure to note the time is starts how long it lasts what body parts were affected stay with patients call for help monitor vital signs Accidents where the patient is the primary reason for the accident and include selfinflicted injuries and seizures If seizure occurs Stay with client call for help If not in bed assist to floor amp protect head with your lap or pillow If in bed raise side rails add padding amp put bed in lowest position Turn on side Move items in the way to avoid injury Suction as needed Apply oxygen by mask Time and note progression of seizure Administer anticonvulsants Insert oral airway for patients who have continual seizures without interruption ProcedureRelated Accidents med error improper performance of procedure show picture of scissors left in patient before surgery we now have patients initial wherever they ar getting surgery to make sure it is the right patient Equipment Related Accidents IV pump malfunctions etc One Minute Safety Check you and instructor will come in tell patient what you are doing have paper write down everything that you would assess on that patient ex oxygen tank look at IV fluid trace IV tube to body is skin at IV sight swelling etc Thursday January 15 2015 Infection gtinvasion and proliferation of microorganis in the body tissues Infectious organisms include Bacteria Staphylococcus aureus Viruses Human Immunodeficiency Virus Fungi Candida albicans Parasites Plasmodium falciparum Types colonization organism may grow but does not cause disease local wound infection use what is called quotstandar precautionsquot look for PPE Personal Protective Equipment signs limitd to specific area systemic organisms spread and damage different part of the body can travel throughout the body acute apears suddenly but ends quickly chronic occur slowly and can last months or years Nonsocomial and occur during hospital stay or after discharge can also affect healthcare professionals Most commone surgical traumatic wounds etc Can occur 1 out of every 20 patients 90100000 deaths occur because of this Iatrogenic from a procedure ex lung biopsy exogenous microorganism form outside of the body salmanilall endogenous when pateint39s normal body flora is altered and an overgrowth occurs Chain of Infection Etiologic Agent microorganismgt reservoirgt portal of exit from reservoir coughgtmethod of transmission object you coughed ongt portal of entry to the susceptible hostgtsusceptible host 1Etiologic Agent number virulence potency ability to enter and survive int he body susceptibility of the host chemo AIDS HIV their immune system is compromised so the agent can easily infect host this chain can be broken by hand washing and washing stethoscope Infectious Process 4 stages 1 Incubation time between entrance of pathogen in the body and first symptom chicken pox 1021 days 2 Prodromal time of onset symptoms nonspecific malase i don39t feel good low fever small body aches or more specific herpes has itching and burning 3 Illness when signs and symptoms are present that are specific to that infection 4 Convalescence when the acute symptoms of the infection disappear 2 Reservoir where the pathogen survives humans are most common but can be in animals and plants 3 portal of exit how microorganism leaves the body Sneezing coughing breathing talking saliva stool urine emesis semen vaginal discharge drainage from wound blood 4methods of transmission Direct person to person persontouching kissing sex sneezing coughing biting Thursday January 15 2015 ndirect personal contact of host with contaminated inanimate object ima or insect handkerchief toy soiled clothing eating utensils stethoscope surgical instruments surgical dressings Airborne droplet dust Droplet breathed in after coughing sneezing talking etc Droplets may be carried on dust particles 5 Portal of Entry broken skin respoiratry ttac new host age heredity level of stress nutritional status immunization status current medical therapy preexisting disease processes past or recent surgical interventions Nursing Diagnoses anyone who comes into the hospital is at risk for infection risk for injury altered nutrition less than body requirements pain social isolation impaired tissue integrity Planning Major Goals done in lab Interventions prevent infection by breaking chain read on won Etiologic agentclean contaminated objects disinfect sterilize ReservoirHygiene change soiled dressings dispose of used syringes clean table surfaces empty suction containers Portal of exitcover cough sneeze avoid talking directly over sterile field appropriate handling of urine blood stool Transmissionstandard or isolation based precautions dedicated equipment hand hygiene Asepsis gt absence of pathogenic or diseaseproducing microorganisms Types Medical normal hand washing clan technique procedures used to reduce and prevent spread of microorganisms do hand hygiene before during and after SurgicalSterile advanced hand washing and sterile gloves operating rooms labordelivery diagnostic procedures rare general procedures injections dressing changes IV therapy urinary catheterization Usually ordered to to sterile handwashing all objects used in a sterile field must be sterile they become unsterile if it is out of your sight consider a 1 inch border around the field to be unsterile fluids flow in direction of gravity cannot get wet skin can39t be sterilized so that39s why they are covered head to toes in garments Thursday January 15 2015 Hand washing wash before during and after seeing patients for 30 seconds 0 more 15 seconds of washing 15 seconds of rinsing Types routine soap and water done before and after contact with contaminated sunaces antimicrobial use when hands are visibly soiled or dealt with CDIFF patient alcoho based rubs use any time unless hands are visibly soiled or if you are working with a patient with CDIFF Nursing Interventions not tested on pages Isolation Precautions CDC and PIG Standard precautions CDC Isolation Guidelines Standard Precautions Tier one Pg 414 Table 286 PampP Wash hands between patients after touching contaminated objects after removing gloves Wear gloves for contact with fluids or non intact skin Masks goggles face shields if splashing is possible Properly cleanse patient care equipment Do not touch contaminated linens to clothes place in leak proof bag Dispose of sharps in punctureresistant container Transmission based precautions 1 Airbornedroplet nuclei smaller than 5 mcg measles chicken pox TB Private room with negative pressure airflow mask Special mask for pts with TB must be fit tested 2 Dropletdroplets larger than 5 mcg danger if within 3 feet of patient use mask private room Pneumonia Streptococcal pharyngitis mumps rubella 3 ContactPrivate room gloves gowns dedicated equipment multidrug resistant organism colonizationMRSA or VRE clostridium difficile RSV scabies draining wounds where secretions are not contained Isolation Precautions Applying isolation equipment gown mask gogglesgloves Removing isolation equipment gloves goggles gown mask Hygiene Bathing and Skin Care videos on Evolve total care you are totally involved assist care assisting in hard to reach places self care patient does all on their own types of baths complete bed bath partial bed bath sponge bath at sink tub bath shower Thursday January 15 2015 Guidelines provide privacy close door pull curtains cover what isn39t being washed maintain safety side rails up call light in reach bed in lowest position maintain warmth room warm cover dry each area as you go promote independence encourage patient to do what they can anticipate needs provide teaching Bathing Order fill basin eyes face arms chest abdomen legs feet back buttocks genetalia female dorsal recumbent position front to back male supine position Oral Hygiene supine position with head to side or Sim39s position place towel under head use oral airway if needed clean with toothbrush or toothette suction if needed chapstick assess for halitosis Linen Change review changing an occupiedunoccupied Fowler s position45 degrees SemiFowler s position3O degrees Trendelenburg s positionbed tilted with head down Reverse Trendelenburg s positionbed tilted with foot of bed down Flatpretty selfexplanatory different positions Thursday January 15 2015 Unit 2 The Interview Subjective Data what the patient states the patient39s verbal description of what is going on What the patient describes use quotations Collection of this results in a good interview Objective Date observationsmeasurements that the provider nurse doctor ex vital signs lab values medications Goals of interview 1 to get a patient history they want optima heath as do you 2 ID health strengths and problems as bridge to physical examination first and most important part of data collections collects subjective data what person says about hisher perceived case 3 gather as much complete and accurate data hope patient is reliable ask questions several different ways if same answers reliable 4 establish rapport or trust so person feels accepted and free to share all relevant date 5 teach person about health state so that heshe may participate in lDing problems don39t diagnose tell them the observed trend tell them the standard quotBP is higher than it has been beforequot if no previous recorded history just go by what they say 6 Build rapport to continue therapeutic relationship and to facilitate future diagnoses planning and treatment 7 Consider interview a contact bt you and the patient spokenunspoken rules what person needs and expects they want to get rid of the earache i was to help get rid of the earache if you don39t have a mutual goal then it will not work 8 Contract consists of spoken and unspoken rules for behavior What person needs and expects from health care and what health professional has to offer Mutual goal is optimal health for patient 9 Communication Sending communication is behavior conscious and unconscious verbal and non verbal al behavior has meaning body language posture gestures facial expression eye contact foot tapping touch even where you place your chair keep in mind different cultures eye contact isn39t acceptable some times Receiving receiver attaches meaning determined by hisher past experiences culture selfconcepts and current physical and emotional state successful communication requires mutual understanding Thursday January 15 2015 patients39 heath problems intensify communication because patients depend on you to get better communication can be learned and polished when you are beginning communication is a tool as basic to quality health care as tools of inspection or palpation External Factors ensure privacy refuse interruptions unless another patient is coding physical environment turn off tv quiet dress look for psych issues note taking may be unavoidable not encouraged but do shorthand tapevideo recording not common Techniques of communication introducing the interview working phase data gathering phase verbal skills include questions to patient and responses to what is said Types of Questions 1 Open ended asks for a narrative response unbiased leaves patient free to answer in any way that they feel can answer a lot of your other questionsquotwhat brings you in todayquot quotwhat39s going onquot to begin interview introduce new section of questions whenever the patient introduces a new topic 2 closed ended yes or no when looking for specific information quotare you headaches on one side or bothquot Give them forced choice Avoid asking a lot of these because it makes the patient feel unappreciated After opening narrative to fill in details person may have left out When you need many specific facts about past health problems or during review of systems To move the interview along Responses assisting the narrative Facilitation quotI39m listeningquot encourages patients to say more and show you are interest and will listen further Silent Attentiveness gives patient time to think and organize what to say without interruption from you Reflection echoes patent39s words repeating what person has jst said focuses further attention on a specific phrase and helps person continue in his or her own way Empathy recognize a feeling and puts in into words Name the feeling and allows expression of it Patient feels accepted and can deal with feeling openly Clarification quottell me what you mean by blurred visionquot Confrontation frame of reference shifts from patent39s perspective to yours may focus on discrepancy or inconsistency in person39s narrative you have observes a certain action feeling or statement Give honest feedback ex history says they stopped smoking but he smells like smoke quotmr jones you told me that you quit smoking about a year ago but you smell like smokequot 1O 11 Thursday January 15 2015 lnterpretation based on you inference or conclusion link events makes associations implies cause assures feelings Explanation inform person that your share factual and objective information offering reasons for requirements or actions direct and to the point Summary summarization of interview what you39ve collected what you39ve seen and what they have told you signals the end of the interview Book Ten Traps of Interviewing never provide false assurance or reassurance giving unwanted advice using authority using avoidance language engaging and distancing using professional jargon using leading or biased questions quotyou don39t smoke do youquot talking too much or interrupting using why questions Tips nonverbal skills physical appearance posture gestures facial expression eye contact voice Jouch closing the interview Overcoming Communication Barriers Working withwithout interpreters nonverbal crosscultural communication touch some cultures dont some do Touching patients is a necessary component of comprehensive assessment Physical contact with patients conveys various meanings crossculturally Patient s significant others may exert pressure on nurses by enforcing culturally meaningful norms in health care setting Thursday January 15 2015 Health History Adult Biographical data Source of history Reason for seeking care Present health or history of present illness Past health Family history Review of systems Functional assessment including activities of daily living ADLs Biographical Data Name Address and phone number Age and birth date Birthplace Sex Marital status Race Ethnic origin Occupation usual and present primary language CDVOUU ILOON L Source of history record who gives the info judge reliability the same way as the interview notate if a trained interpreter is used Reason for Seeking Care quotthe chief complainerquot Brief spontaneous statement in person s own words describing reason for visit Symptom subjective sensation person feels from disorder What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person s exact words Sign objective abnormality that can be detected on physical examination or in laboratory reports we don39t want to label our patients as complainers subjective data this is what the patient says it is use direct quotations Present Health or History of present illness 12 ocation be specific have them point at exact location character or quality specific description throbbing burning aching quantityseverity quantify give number rate on scale of 010 timing find onset frequency how often and duration how long setting what brought this on what were you doing when it happened aggravating or reliving factors what makes it worsebetter associated factors is there anything else that goes on at the same me patient39s perception exactly how they feel PQRSTU pneumonic Thursday January 15 2015 provocativepalliative qualityquantity regionradiation severity scale 1 to 10 timingonset understand patient39s perception of problem Past Health childhood illnesses measles mumps chicken pox rubella pertussis strep throat accidents or injuries motor vehicle accident broken bones head injury lose consciousness serious or chronic asthma depression diabetes heart disease etc hospitalization name of place date year why physician39s name operations name operation obstetric history how many abortions live births pregnancies immunizations important with children with school agedcollegeadults HPV allergies food drug fabric environment what is reaction last exam date current medications what are they on over the counter vitamins Family History age and health or cause of death of relatives health of close tam members heart disease high bp stroke diabetes blood disorders cancer sickle cell anemia arthritis allergies obesity alcoholism mental illness seizure disorderkidney disease and tb psych disorders genogram p 53 CrossCultural Care biographical data know when came to US and where they came from what year spiritual resource and religion see if certain procedures cannot be done past health what shots heath perception how does person describe health and illness how does person see problems heshe is now experiencing nutrition taboo foods or food combos Review of systems 13 general overall health state skin hair head eyes ears nose and sinuses mouth and throat neck breast axilla resp system cv peripheral vascular gastrointestinal urinary malefemale genital system sexualhea h musculoskeletal system Thursday January 15 2015 neurological system hematologic system endocrine system Functional Assessment ADL39S Selfesteem selfconcept Activity and exercise Sleep and rest Nutrition and elimination lnterpersonal relationships and resources Spiritual resources Coping and stress management Personal habits Alcohol CAGE Test Have you ever thought you should Cut down your drinking Have you ever been Annoyed by criticism of your drinking Have you ever felt Guilty about your drinking Do you drink in the morning an Eye opener lllicit or street drugs Environment and work hazards lntimate partner violence Occupational health Perception of Health Ask questions such as How do you define health How do you view your situation now What are your concerns What do you think will happen in the future What are your health goals What do you expect from us as nurses physicians or other health care providers Developmental Care children health history adapted to include information specific to rage and developmental stage of child biographic date source of history person providing information and relation to child your impression of reliability any special circumstances use of an interpreter reason for seeking care Children history of present illness Severity of pain note effect on usual behavior eg does it stop child from playing Associated factors such as relation to activity eating and body position Parent s intuitive sense of problem often accurate even if proven otherwise this gives an idea of parent s area of concern Parent s coping ability and reaction of other family members to child s symptoms or illness 14 Thursday January 15 2015 Children past health same as adult but add prenatal care did mom have it what trimester labor and delivery vaginal or csections postnatal blue spells Prenatal status Labor and delivery Postnatal status Childhood illnesses Serious accidents or injuries Serious or chronic illnesses Operations or hospitalizations lmmunizations and allergies Medications Developmental History growth weight height walking crawling etc milestones current development for children 1monthpreschool school aged child run jump ride bike tie shoes vocab nutritional history fam history same as adult Adolescent HEEADSSS psych interview home who lives with you own room own bed Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety Older Adult same as adult with positive health measures going to check ups taking medications lncludes same format described for younger adult plus additional ques ons These questions address ways in which ADLs are affected by normal aging processes or by effects of chronic illness or disability No specific age at which to ask these additional questions use them when it seems appropriate lmportant to recognize positive health measures what they are doing to help themselves stay well Older people have spent a lifetime with traditional health care that searches only for pathology and what is wrong with their health May be pleasant surprise to have a health professional affirm things they are doing right and note health strengths Thursday January 15 2015 Older Adult Reason For Seeking Care May take time to figure out why older person has come for an examination Aging person may shrug off symptoms as evidence of growing old and be unsure whether it is worth mentioning Some older people have a conservative philosophy toward their health status and come for care only when something is seriously wrong Older person may have many chronic problems such as diabetes hypertension or constipation Final statement should be person s reason for seeking care not your assumption of problem Other Things spent a lifetime with traditional heath care that searches longer interview don39t have the best long term memory than it would for young adult Older Adult Past Health ask general health win past 5 years last exam anything hearing dental whatever accidents or injuries serious or chronic illnesses hospitalizations operations last examination obstetric status sexual history current medications may be on two or three of the same medications but get them to bringwrite down so you can go through them family history may not remember know that they have some form of social networksecurity systemsomeone who checks on them functional assessment including ADL39s occupation volunteer retired what do they do Current Medications Also consider following issues Some older persons take large number of drugs prescribed by different physicians Person may not know drug name or purpose Ask person to bring in drug to be identified When person is unable to afford drug he or she may decrease dosage or not refill immediately Travel to pharmacy may present a problem May use overthecounter medications for selftreatment Some share medications with neighbors or friends Older Adult Family History Not as useful in predicting which familial diseases person may contract because most of those will have occurred at an earlier age Useful to assess which diseases or causes of death of relatives person has experienced 16 17 Thursday January 15 2015 Also describes person s existing social network Older adult functional assessment including ADLs Selfconcept selfesteem Occupation Activity and exercise Sleep and rest Nutrition and elimination lnterpersonal relationships and resources Coping and stress management Environment and home safety hazards Thursday January 15 2015 The Health Assessment Process Hea h gt a complete physical mental and social wellbeing health is a continuum between wellness and death position on the continuum changes throughout life when assessing physical social cultural mental emotional and religious factors 5 Step Nursing Process 1assess 2 diagnose we don39t necessarily diagnose a patient legally we give a quotnursing diagnosisquot we will be doing our own diagnoses from NANA 3 plan goals opposite of whatever my nursing diagnosis is all goals must give a time frame quotduring their stayquot quotduring my shiftquot 4 implement how do we get the patient to achieve these goals me PT etc 5 evaluate evaluate goals did youpatient accomplish goals previously set label as met partially met not met and explain why if needed redo goals Health Assessment gt a systematic method of collecting data about a client for the purpose of determining the clients current and ongoing health status predicting risks to health and identifying promoting activities assessment is like a snapshot I will do a headtotoes assessment every minimum 4 hours in general in ICU every 1 hour or more Safety checks are about every 2 hours look at chart at patient touching patient listening to patient physical emotional religious dietary assessment 1 Assessment is a quotfeelingquot process involving effective communication 2 Assessment is a quotdoing processquot involving physical assessment skills inspect looking palpate touching patient percuss thumping look for resonance tympani auscultate listening with stethoscope and ears always order except for GI where you auscultate after inspect 3 Assessment is a quotthinkingquot process involving the use of critical thinking skills I will learn to think quotwhy am i listening to 5 different areas for the heartbeatquot think why then once I get my data what do I do with it after collect analyze think planning what do i need to do first evaluate always see if what you plan works if not why did it not work 18 Thursday January 15 2015 we consider a fever to be higher than 101 degrees but you have to know your patient39s baseline temp ex on post op surgical floor patient spikes a fever check would for infection all good check their lungs since they have been sitting down all day critically think outside the box the goal of nursing to diagnose and treat human responses to actual or potential health problems the goal of medicine to diagnose and treat disease we are there to cause no harm to the patient we are also there for patient education we must educate them before they leave the hospital this being said if you do educate the patient you must document it or it didn39t happen this includes hadn washing and educating the family Physical Assessment 1lnspec on survey client39s appearance begin with general overview and advance to specific detail good lighting positioning use your sense of smell compare upper vs lower right vs left etc when assessing body systems drainage COAT color odor amount type wound BREAST bleeding redness exudatedrainage approximation swelling tenderness 2 Palpation assessing through sense of touch ight used to asses the surface characteristics pulse texture etc moderate used to determine depth size shape mobility deep used especially with obese use in normal person to palpate spleenkidney Tell patient what you39re doing and to take a deep breath if patient says a certain section of body hurts palpate last fingertips use them to palpate pulsations skin texture lumps swelling fingers and thumb use to get position shape consistency of organs and masses dorsal aspect of hand back of hand use to assess temperature base of fingersulnar side use to check vibration usually in respiratory system also when palpating you can check for mobility check range of motion temp moisture texture etc we judge an edema by depth ranging form 1 to 4 1 2mm 2 4mm 3 6mm 4 8mm easiest to check on the top of the foot and the top of the tibia 19 Thursday January 15 2015 3 Percussion the tapping of the body to produce sound waves direct tapping with fingertips sinus check on thorax of infant blunt lay hand on lower back and lightly strike for kidney infection indirect most common tapping with hands ex on clavicle vs tissue sounds include look up on youtube tympany resonance hyperresonance dullness hear more dull over fluid flatness more flat over bones lungs are easy to percuss because sound travels great through the air the denser the tissue the quieter the sound 4 Auscultation listening to sounds of the body with stethoscope make sure tubing of stethoscope doesn39t rub against BP tubing quotdo not let your stethoscope become a staphoscopequot Stethoscope large side diaphragm small side bell as of right now use diaphragm Stethoscope blocks out other noises not by amplifying sounds Try to eliminate other outside noises tv etc Do not touch stethoscope tubing or rub against clothes 5 General Survey physical appearance mobilityposture ask them to walk a couple of steps do they use assistance cane person walker cient39s behavior are clothes appropriate do the smile look you in the eyes do they articulate or slur do they laugh inappropriately nervous overall picture of clientanything you can observe by just looking at or talking to patient gender race age level of consciousness speech distress skin color facial features stature nutritional status symmetry posture 6 Obtain heigh and weight determine BMI Adults lt185 underweight 185249 normal 25299 overweight 30399 obesity gt 4O extreme obesity make sure that when I record the weight it will be in pounds or kg 22 compare weight to previous visits how much how quickly a weight gain of 5le in one day is associated with fluid retention 20 Thursday January 15 2015 a weight loss of 5 of body weight in one month is considered significant or 10 in 6 months height shoeless have them stand straight up shoulders back give them an object to focus on straight ahead if recording weight at home by themselves in morning have the same amount of clothing at the same time every day Objective Data 1 Body Structure stature normal heightweight for age nutrition does their weight appear in the normal range for heightbody build symmetry are their muscles symmetrical if not they may be over working the bigger muscles stroke hurt posture slumped over or straight up remember that the spine curves with age Physical Assessment Vital Signs General Principles gather appropriate equipment thermometer red rectal blue oral BP cuff oxygenations finger select equipment base don patient age and condition know patients usual vital sign ranges if in hospital look at old past charts for trends if they don39t have charts ask patient and then doctor be aware of current conditions medications and treatments contro environmental factors that may affect vital signs USE THE VITAL SIGNS The most frequent assessment is the vital signs and they evaluate the circulatory respiratory neural and endocrine systems A change in VS signifies an alteration in physiological function and a need for intervention WHY Monitor condition ldentify problems Evaluate response to intervention Current conditions medications treatmentsthese may affect vital signs and cause substantial changes The patient s condition establish when where how and by who VS are to be measured When to Assess Vital Signs new admissions upon return to unit before giving certain medications specific ones we will learn later 21 Thursday January 15 2015 also if BP reaches a certain point we have orders to push meds status change if their personality shifts patient reports feeling different or physical condition changes experiencing chest pain etc monitoring during procedures surgery endoscopy invasive or not remember age change vital signs age affects internal temp too Temperature normal 986 range 964991 for rectal temps insert probe 115 inches only use when necessary for tympanic temps make sure probe is in contact with the ear surface fastest but not very affective for oral temps probe must e under the tongue with the lips closednothing to drink prior to temp if drank anything hotcold must wait at least 15 minutes if smoked wait 2 minutes place thermometer at base of tongue in sublingual pocket Must be able to hold in mouth Not for infants or small children unconscious or uncooperative BLUE probe Rectal ubricate side lying position inserted 2 3 cm 1 to 1 12 inch into anus rectal temp measures about 1 degree higher than oral never force RED probe for axillary the probe must be in contact with the skin for young children least accurate measures about 1 degree less than oral Tympanic most comfortable least invasive very rapid 2 3 secs more variability noted due to incorrect placement amp other factors use disposable tips never reuse exercise hormones menopause circadian rhythm high temp in late afternoon early night take temp last in childreninfants done rectally Mercury thermostats not used in healthcare currently may still be in use in homes Advise to discard Factors affecting Agevery old and very young more likely to have fluctuations new borns need caps due to heat loss through the head Exerciseincreases temp Hormoneslow progesterone low temp With ovulation progesterone increases temp increases Menopauseincreased temp 7 degree increase during hot flash Circadian rhythmtemp lowest during night 01000400 Highest in late afternoon early evening Stresslncreased stress increased metabolism therefore increased temp 22 23 Pulse Thursday January 15 2015 Ambient temperature Physical activity Don t check BP after walking in hall 4Hness Foodfluid consumption normal resting adult 60100 8 sites perry and potter p453 know radial ulnar and brachial higher in infants and children radial most commonly used in adults wrist apical most accurate for children count for entire minute count for 30 seconds and double if regular pulse count for 60 seconds if irregular well conditioned athletes will have a lower pulse lt60 ess than 60 bradycardia over 100 tachycardia in emergency carotid and if head trauma femoral Place finger pads on anterior wrist along radial bone Do not use thumb Count 30 seconds and multiply by 2 if regular If not regular count for full minute Many things affect pulse exercise meds fever If they just finished activity wait 510 minutes to assess Perry amp Potter Table 294 pg 455 Always do apical pulse in kids less than 2 count for full minute Apical pulselocate suprasternal notch just below that is angle of Louis slide hand to patient s left that is 2nd intercostal space PMI felt at 5th listen for apical pulse there In addition to rate assess strength of pulse 14 or 03 and compare pulses bilaterally as part of physical assessment not VS Pulse deficitif pulse is irregular count apical pulse while another nurse counts radial pulse Count apical out loud to simultaneously assess If differs by more than 2 pulse deficit exists suggesting alterations in cardiac output chart p454 potter and perry infant 120160 bpm apical auscultate toddler 90140 bpm preschooler 80110 bpm school age 75100 bpm adolescent 6090 bpm adult 60100 bpm will be tested on adult values Oxygen Saturation pulse oximeter finger nail polish can get in the way so use earlobes normal level 90 in hospitals the alarm value whenever it goes under 92 ideal level 95 and above normal adult with no lung disease 97 98 saturation on normal air factors to consider 24 Respirations Thursday January 15 2015 edema impaired skin integrity peripheral vascular disease hypothermia even if their hands are just cold warm up or use earlobes nail polish latex allergy smoking can interfere not enough hemoglobin earlobe toe and bridge of the nose can be used earlobebridge shouldn39t be used on infants and older adults because they have fragile skin Assesses arterial oxygen saturation Pulse oximeter uses sensor and photodetector to determine light sent and absorbed by hemoglobin represents light absorbed by oxygenated and deoxygenated hemoglobin Correlates well with the Sa02 Percentages less than 70 the pulse ox is less accurate lnterfering factorsnail polish Smoking jaundice PVD poor circulation movement dark skin pigment hypothermia peripheral edema taking vasoconstrictors hypotension low cardiac output probe too tight Can use earlobe toe or bridge of nose if fingers can t be used Do not use earlobe or bridge of nose for infants amp toddlers due to skin fragility Attaching probe to area with edema or impaired skin integrity can lead to skin breakdown or further breakdown Disposable probes may be latex based normal 12 20minute count for 30 sec and double if regular respiration count for 60 sec if irregular Newborn 3540 infant6mo3050 toddler2yr2532 Child2030 adolescent1620Adult12 20 Rate may be affected if client is aware they are being counted Can place patient s arm across their abdomen to assess pulse and when pulse is done assess resp Less than 12bradypnea greater than 20tachypnea Blood Pressure gtis the force exerted on the walls of an artery by the pulsing blood under pressure from the heart The heart s contraction forces blood under high pressure into the aorta The peak of maximum pressure when ejection occurs is the systolic pressure BP is an interrelationship of the cardiac output peripheral vascular resistance blood volume blood viscosity and artery elasticity Systolic pressurepressure of blood when left ventricle contracts Diastolic pressurepressure of blood between ventricular contraction when heart is at rest Pulse pressuredifference between systolic and diastolic reflection of stroke volume Thursday January 15 2015 Mean arterial pressurepressure forcing blood into the tissues It is a value closer to the diastolic pressure than the systolic pressure plus one third the pulse pressure Measured in mmHg Normal lt12080 systolic top number SBP pressure of blod when LV contracts diastolic bottom number DBP ventricular contraction when heart is at rest normal lt12080 factors age BP increase with age gender females tend ot have a lower BP until menopause and then it reverses race black people tend to have higher BP than whites obesity tend to have higher BP stressanxietysmoking increase BP medications can either decrease or increase BP BP determined by Cardiac outputif there is higher blood volume heart is pumping more the pressure will be higher and vice versa CO increases as result of increases in HR greater heart muscle contractility increase in blood volume Peripheral vascular resistanceopposition to blood flow more resistance more pressure to push through blocked arteries Volume of bloodincreased volume increased pressure Normal circulating blood volume is 5000 ml Viscositythickness thicker bloodhigher pressure Hematocrit percentage of red blood cells in the blood Elasticity of vessel wallsless elasticity stiff rigid wallsmore pressure BP Guildelines Classification Normal Prehypertension Hypertension stage 1 Hypertension stage 2 stage 1 confirmed readings 35 times every 2 months SBP DBP lt120 lt80 120139 8089 140159 9099 gt1 so gt100 Physical Assessment BP 25 Need sphygmomanometer and stethoscope Width of the cuff is 40 of the circumference or 20 wider than the diameter of the midpoint of the limb on which the cuff is being used Allow at least 5 minutes before taking blood pressure so patient has time to calm down If need to repeat BP wait 2 minutes between Support arm bare arm uncross legs Palpate brachial artery Place cuff about 1 inch above brachial artery Thursday January 15 2015 lnflate cuff until artery pulsation is obliterated and then 20 30 above that May skip this step Take BP using diaphragm or bell but may be able to hear better with bell Deflate slowly about 2 mmHg per heartbeat Note when you first heard sound muffling of sound and disappearance ofsound Read pg 462 common errors in BP measurementTable 2911 Talking to patient while assessing BP can raise BP 1040 Discuss electronic BP cuffs manual is better because they depend on batteries and such Box 2912 pg 464 Procedural Guidelines for Electronic Blood Pressure Measurement Box 2913 pg 465 Patient Conditions Not Appropriate for Electronic Blood Pressure Measurements lrregular PV obstruction shivering seizures excessive tremors uncooperative lt90 SBP Clean cuffs or use disposable Repeat any abnormal values to verify then REPORT to primary RN and clinical instructor even if this is the trend Orthostatic hypotension ow BP due to transition from lying sitting to standing f patient is too weak just do lying and sitting with feet dangling off the bed Don t give an odd number for vital signs Korotkoff s sounds Named after Russian surgeon who first described them Table 2914 pg463 Phase lTapping sharp thump systolic Phase llSwooshing blowing sound Phase IllKnocking a little faster Phase lVmuffling a softer blowing sound heard before the sHence Phase VSilence diastole Thigh Pressure prone or supine position popliteal artery usually can39t find it so place the cuff near where it should be large cuff Wrap around lower third of the thigh f supine bend knee slightly Systolic value is usually 1040 mmHg higher in the thigh than arm Thigh used if arm contraindicated or to check for coarctation of aorta compare arm to thigh If you are told to do orthostatic VS or BP that means to take it lying sitting and standing in that order Should see decrease in systolic of 10 mmHg Thursday January 15 2015 Developmental Considerations in Vital Signs Weight weigh infant on platform type scale by age 23 use upright scale Length until age 2 measure infants body length supine by using horizontal measuring board Head circumference begin at birth and at each well visit up to age 2years then yearly up to 6 years circle tape around head at prominent frontal and occipital bones widest span is correct newborns head measures about 3238 cm avg 34cm and about 2 cm larger than chest circumference chest grows at faster rate than cranium between 6 months and 2 years both measurements about same after age 2 chest circumference greater than head circumference Temperature axillary route safermore accessible than rectal however accuracy and reliability have been questioned typically do rectal in infants and children but do it last Use oral route when child is old enough to keep mouth closed usually age 56 Use rectal route with infants or with other age groups when other routes are not feasible child is not cooperative agitated unconscious critically ill prone to seizures rectal temp is usually higher in infantschildren with an avg 100 degrees F at 18 months also temp normally elevated in late afternoon after vigorous playing or after eating Pulse palpate or auscultate an apical rate with infants and toddlers in children older than 2 use radial site count pulse for a full minute to take into account for irregularities Respirations watch infants abdomen for movement more diaphragmatic than thoracic breathe more with abdomen than chest Blood Pressure in children age 3 and older and in younger children at risk measure a routine BP at least annually most common error is cuff size must cover 23 of upper arm and cuff bladder must completely encircle it allow crying infant to become quiet for 510 min before measuring BP crying can elevate the systolic pressure by 3050 mm Hg Physical Assessment Pain Pain History Loca on Have them point to specific location use body outline chart for kids Use specific explanations pain in substernal area 3 cm below xiphoid process 27 Thursday January 15 2015 lntensity Pain rating scales Another example on page 167 Jarvis Quality what if you have a patient who does not know how to describe Offer terms amp let them answer yes or no Burning stabbing knifelike throbbing Pattern Radiation Onset and duration constant or intermittent Precipitating factors Activity exercise temperature stress or anxiety Alleviating Factors Actions to relieve Meds position changes home remedies evaluate effectiveness of these Coping strategies Exercise prayer support groups Emotional response Depression anxiety exhaustion PQRST palliative or provoking factors quality region or radiation severity timing constant intermittent For newborns See CRIES Pain measurement score Pg 170 Jarvis Observation Behavior guarding facial expression crying restlessness Physiological response sympathetic nervous system is stimulated leading to increased heart rate blood pressure respirations pallor diaphoresis Types of Pain Pain may be acute or chronic lasting longer than 6 months Cutaneousoriginates in skin or subQ tissue scrape or cut Deep somatic ligaments tendons bones blood vessels nerves ankle sprain Visceralabdominal cavity cranium thorax obstructed bowel Radiating extends to nearby tissues heart attack radiates to left shoulder and arm Referred felt in part of body removed from source of pain figure 85 lntractable highly resistant to pain relief measures Neuropathic result of current or past damage to peripheral on CNS long lasting burning dull aching with episodes of sharp shooting pain Phantomperceived in body part that is missing or paralyzed Nursing Care of Pain ask about pain regularly believe the patient choose the appropriate pain control methods deliver interventions in a timely manner empower patients to participate in pain management Pay special attention to those who are unable to voice paincognitively impaired newborns children Observe body positions pacing rubbing restless tense not moving a part guarding Thursday January 15 2015 Observe facial expressions grimace teeth clenched biting lip Observe irritability changes in mental status vocalizations moaning crying grunting avoiding conversation Pulse Pressure SBP DBP Pulse Pressure normal about 40 not used much this semester 29 Thursday January 15 2015 Unit4 Medication Administration Pharmacological Concepts Drug Names Generic name given when the drug is developed by manufacturer Ex lbuprophen Chemical name by which a chemist knows it this name describes the constituents of the drug precisely Trademark or brandname under which a manufacturer markets a medication and the name we know the medication by Ex Advil Classification medications are classified by their therapeutic effect the response we would expect the medication to have on the body and symptoms they relieve Ex aspirin classified as pain reliever and fever reducer Form Oral Solid Pills Capsule in a gel shell TabletCaplet hard coated Enteric coated special type of coating that wont dissolve in the stomach Dissolves and is absorbed in the small intestine Liquid Elixir Syrup Extract Read in Textbook Topical Ointment drops lotions and transdermal patch applied to mucous membranes skin eyes ears Parenteral Solution powder administered through IV IM SubQ as a liquid or powder that you have to reconstitute the medication by adding liquid to the powder Pharmacokinetics Absorption passage of medications into the blood stream from site of administration Route can affect how quickly medication is absorbed IV is absorbed the fastest orally is not so fast because it has to be broken down to be absorbed Mucous membrane medications are given through respiratory tract and are absorbed quickly because of the blood vessel supply Dissolvability liquid dissolved quicker than pill form Blood flow areas of the body where there are lots of blood vessels things are absorbed betterquicker Body surface area Lipid solubility some medications don t absorb well when taken with food and some do better when taken with food Also does the medication have any special type of interactions with other medications 30 Thursday January 15 2015 Distribution Circulation pt with poor circulation wouldn t have very good distribution of medication Membrane permeability some membranes let things pass through placental membrane some don t let anything pass through BBB Protein binding some medications bind with proteins in the blood which helps distribution Metabolism Mostly occurs in the liver can occur in lung kidneys blood and intestines Pt with bad liver function can become at risk for toxicity because they re not able to break down and metabolize the medication Excretion Typically occurs via the kidneys bowel lungs and exocrine glands When pt is taking multiple medications always promote exertion or they could become toxic For kidney excretion you want to promote oral fluid intake drink a lot of fluids For lung excretion you want to promote deep breathing and coughing Exocrine gland excretion you want to promote good hygiene Effects of drugs Therapeutic effect Also referred to as the desired effect The expected response a medication causes Ex giving Tylenol to a pt with a fever The therapeutic effect would be to decrease their temperature Typically a positive effect Side effect Usually predictable and may be either harmless or potentially harmful Can be tolerated others may warrant discontinuing the drug Some patient thinks of side effects as an allergy have to explain to them that a side effect is a normal effect but can be hard to deal with Ex Nitroglycerine given for high blood pressure but a side effect is a headache Some patients can handle it some can t Another example is a Diuretic and one of its side effects is increased urine output Adverse effect Unintended undesirable possibly unpredictable Usually requires the patient to discontinue medication immediately Toxic patient cannot excrete the medication so buildup Elderly have weaker kidneys so they have higher risk for toxicity ldiosyncratic patient underreacts or over reacts to a medication or patient has a different reaction than normal Ex Benadryl makes you usually sleepy so an idiosyncratic effect would be that it makes you hyper Aergic Drug Allergy Develops when your immune system becomes sensitive to a drug and the body develops antibodies against it Reactions can be either mild skin rashes to diarrhea to severe death table 31 2 The degree to which the patient reacts to the medication depends on the patient and the medication Make sure you ask patients what their reaction is to the medicine 31 Thursday January 15 2015 A severe allergic reaction usually occurs immediately after the administration of the medication Also called an anaphylactic reaction Early symptoms acute shortness of breath acute hypotension and tachycardia wheezing requires immediate medical attention Drug Tolerance Exists in a person who has unusually low physiologic activity in response to a drug and who requires increases in the dosage to maintain a given therapeutic effect Drugs that commonly produce tolerance are opiates barbiturates ethyl alcohol and tobacco Drug Interaction Occurs when the administration of one drug before at the same time as or after another drug alters the effect of one or both drugs May be harmful or beneficial Giving two medications at the exact same time and they counteract each other or one of them Synergistic effect typically seen as positive drug interaction combined effect of giving two medications together is better than giving them separately Ex vasodilator and a diuretic to treat high BP both work together to lower BP Polypharmacy when patient takes two or more medications to treat the same problem With this interaction your going to see an increase in harmful effects Iatrogenic disease Disease caused unintentionally by medical therapy Example StevensJohnson Syndrome syndrome that occurs when taking excessive over the counter medications like Tylenol and Advil Patient looses top layer of their skin Medication Actions page 570 table 31 3 Onset Peak Trough Duration Plateau Assessment prior to Medication Administration Medical history Allergies food seasonal medications etc Medications what when for how long Diet history day to day Patient adherence to therapy are they compliant Patient s perceptual or coordination problems are they able to take the pill out of the box and get it into their mouth Patient s current condition mental status do they remember to take medication Patient s attitude about medication use Patient s understanding of and adherence to medication therapy do they understand why they are taking the medication Patient s learning needs mental illness hearing issue 32 Thursday January 15 2015 Carvedilol Example Brand name Coreg Generic name Caryedilol Classification beta blocker Forms available tablets ER Therapeutic effect Side effects peripheral vasodilation hypotension decrease in HR bradycardia What happens when given with insulin Your adult patient is taking 25 mg twice a day Is this within the safe range What assessment criteria should you complete before administering Carvedilol Medication Orders Types of Medication Orders Stat one time immediate order typically an emergency Now one time medication should be given within 90 minutes Single order one time order only given once at specified time Ex preoperative medications Standing order routine medication continue to be given until ended by prescriber Ex antibiotics normal home medications PRN order as needed only given when patient needs it document why patient needed it and how it worked Ex pain medication after surgery Essential Parts of a Drug Order Full name of the client Date and time the order is written Name of the drug to be administered Dosage of the drug Route of the administration Time and frequency of administration Signature of the person writing the order Can be written telephone verbal or computer Prescribed by the physician nurse practitioner or physician s assistant Most institutions only licensed nurses are permitted to accept telephone and verbal orders Physician must sign order within 24 hours or it expires As RN you need to also sign telephone orders with the time and date you received it and your initials B Booth RN 2115 1423 Example Telephone Order Nurse Hello Dr Smith This is Laurie Harris the RN taking care of Mrs Glenn in room 501 Mrs Glenn is a 52 year old who is 1 day postop right total knee replacement We are giving Demerol 50 mg IV every 4 hours PRN It makes her too drowsy and she s still having a lot of soreness She has NKA no known drug allergies Can we give her Toradol 30 mg IV Dr Smith Yes she can have Toradol 30 mg IV push every 6 hours PRN for 48 hours Nurse Okay that s Toradol 30 mg IV push every 6 hours PRN as needed for 48 hours 33 Thursday January 15 2015 Medication Orders and Abbreviations Avoid using abbreviations see pages 579581 Do not use trailing zeros for doses expressed in whole numbers use 1 mg NOT 10 mg Always write out COMPLETE drug name MgSO4 Magnesium sulfate can be mistaken as Morphine Sulfate Appropriate abbreviations and dose designations mcg for microgram Use zero before decimal point when dose is not a whole number use 05 mL NOT 5 mL Medication Errors lnaccurate prescribing Administering the wrong medication Giving a medication to the wrong patient Giving medication at the wrong time or via wrong route Administering extra doses or not giving medication at all REPORT ALL ERRORS Eight Rights of Medication Administration PMDTRDEE use any time your pulling out the medication Clients rights on page 587 Right patient use patients name and another identifier Right medication Right dose Right time 30 min before or after Right route Right documentation Right effect Right education Note right to refuse CDVOUU ILOON L x Nurse s 6 Rights for Safe Medication Administration 1 The right to a complete and clearly written order 2 The right to have the correct drug route and dose dispensed 3 The right to have access to information 4 The right to have policies on medication administration 5 The right to administer medications safely and to identify problems in the system 6 The right to stop think and be vigilant when administering medications Dosage Administration Schedule 34 Before mealsAC After mealsPC As neededPRN lmmediatelystat Thursday January 15 2015 Medication Administration Record MAR or EMAR Patient s name Medical record number MR number Room and bed number Drug and food allergies DOB Medication Order Medication name Dose Frequency Route Time of administration Medication is added to MAR by pharmacist after order is checked for accuracy Before giving ANY medication refer to MAR Administering medications In the Medication Room Verify the order for accuracy Hand hygiene Obtain appropriate medication Automated medication dispensing systems Pyxsis Prepare the medication if you draw up the medication YOU need to be the one to give it to the patient Wasting medications you need to have another nurse witnessing you wasting or not using the last 2mg of medicine if you don t give the full dose of the medication Administering medications In the Patient s Room Hand hygiene Identify the client Check ID band with the MAR amp Check allergies Inform the client Perform any preassessments take BP before giving BP medicine Administer the medication Check fst 5 rights before administering Document the medication administered label and initial Provide education Evaluate amp chart client s response to medication Recording Medication Administration 35 Follow all agency policies when documenting medication administration Important to document IMMEDIATELY Computer eMAR vs Written MAR Signature of RN Charting not given if pt was off the unit and you were not able to give it IF YOU DON T DOCUMENT YOU GAVE IT IT WASN T GIVEN Thursday January 15 2015 Implementation Health Promotion and Education Teach the patient and family Medication benefit How to take the medication correctly Symptoms of side effects Safe use and storage of medications Help the patient and family establish a medication routine Refer them to community resources for transportation as needed Planning Always organize your care activities to ensure the safe administration of medications Provide the most important information about the medications first On discharge ensure that patients know where and how to obtain medications Evaluation Value patients participation in evaluation Ensure that patients understand their medication schedules and are able to safely administer their medications Be alert for reactions in patients taking several medications Evaluate patient responses Physiological measures Behavioral responses Rating scales Patient statements Special Considerations See Box 3112 Tips for administering medications to children Also Box 3113 Focus on older adults Box 3114 Protecting the patient from aspiration food medication enters respiratory when its supposed to enter Gi tract can cause choking only let patients take one pill at a time Routes of Administration 36 See page 571 Table 31 5 Oral PO by mouth Sublingual Buccal Parenteral ntradermal ID Subcutaneous ntramuscular IM Intravenous IV Topical Transdermal patch Mucous membrane Instillation Irrigation Inhalation Intraocular Thursday January 15 2015 Oral Medications Most common route medications are given typically reach therapeutic action around 30 minutes 1 hour before meals and can also take that long for them to even start working Orals medications and feeding tubes 594 table 31 15 Contraindications Vomiting Gastric or intestinal suction Unconscious lnability to swallow Administering Oral Medications 37 Assemble equipment Medication tray Medication cups MAR Drinking glass and water or juice Pill crusher Syringe for child s mouth Straws to administer meds that may discolor the teeth Verify the client s ability to take medication orally Tablets capsules Liquid Shake unless contraindicated Pour medication away from the label Place cup on level surface to pour If less than 5 ml of liquid prepare in a sterile syringe Sublingual Placed under tongue and allowed to dissolve completely Buccal Placed against mucous membranes of cheek and allowed to dissolve completely don t drink anything swap sides of mouth Powdered Mix with liquid at bedside Tips when giving Oral Medications If the client is unable to hold the pill cup If the client is at risk for aspiration If the medication has an objectionable taste Your patient states I ve never seen that pill before That doesn t look like what I normally take at home What do you do double check the MAR explain that the hospital may use different manufacturer and may look a little different Stay with the client until all medications have been swallowed Administering oral medications to children Determine appropriate equipment Plastic medication cup Plastic syringe without needle Dropper Thursday January 15 2015 Dilute the oral medication if not contraindicated Crush mediations not supplied in liquid form Mix with substances available on most pediatric units such as honey flavored syrup jam or a fruit puree Present medication to the child honestly and not as a food or treat Ask parents about how best to give medications Preventing nausea lnfants and medication Follow all medications with a drink or water juice a soft drink or a Popsicle Praise the child Topical Medications 38 Skin Use gloves Use sterile technique if the patient has an open wound Clean skin first Follow directions for each type of medication Transdermal patches Remove old patch before applying new Document the location of the new patch and removal of the old patch Ask about patches during the medication history birth control nicotine Apply a label to the patch if it is difficult to see Nasal lnstillation decongestant spray or drop caution pt to abusing this because it can cause congestion to get worse position for best instillation pg 595596 administration Eye lnstillation Techniques when giving ophthalmic medications Avoid the cornea Avoid the eyelids with droppers or tubes to decrease the risk of infection can scratch the eye Use only on the affected eye Never allow a patient to use another patient s eye medication lntraocular instillation Disk resembles a contact lens lower conjunctival sac lasts about a week Teach patients how to insert and remove the disk Teach about adverse effects Ear lnstillation Structures are very sensitive to temperature don t want too cold of drops can cause dizziness nausea etc Use sterile solutions Drainage may indicate eardrum rupture Never occlude the ear canal with the dropper Do not force medication into an occluded ear canal Up and back for children 4 years and up down and back for children younger than four Thursday January 15 2015 Vaginal Instillation body temp melts medication usually inserted while cold pg 598 for administration Rectal Instillation issues with defecation constipation melt in body from body temp don t want to stick strait into feces you want to stick it kind of to the side wall of the rectum An enema might be needed for a quick fix of extreme cons pa on Administering via Irrigation Sterile water saline or antiseptic solutions are used in the Eye Ear Throat Vagina Urinary tract Use clean technique when the cavity is not sterile vagina use clean technique but urinary tract is sterile tech Administering via Inhalation Aerosol spray mist or powder via handheld inhalers Used for respiratory rescue and maintenance for respiratory distress or to prevent Produce local effects such as bronchodilation Parenteral Medications directly into the body tissue Intradermal ID dermis under epidermis tb skin test Subcutaneous subcut below dermis fat tissue Intramuscular IM below subQ muscle Intravenous IV directly into blood stream Equipment Syringes Needles Medication Alcohol pads Order MAR Syringes Three most common types of syringes 1 Hypodermic syringe all sizes all types of medications most common 2 Insulin syringe measured in units only to be used for insulin come in 50100 unit syringes 3 Tuberculin syringe Marked in hundredths 01 of a millimeter Can hold up to 1mL Good to use for pediatric doses used for small amounts of medications 39 Thursday January 15 2015 Tips of syringes Needles Bevel shaft Hub Leuerlok twist onoff Non Luerlok slide needle onto place no twisting Bevel face up for intradermal injection Length of the shaft length chosen depending on patient range from M to 3 inches M 11 12 inches SubQ 38 to 58 inch Gauge or diameter the larger the gauge number the smaller the diameter of the shaft 16 to 28 common gauges 16 is larger in diameter than a 28 gauge Needles Minimizing patient discomfort with injections Use a sharpbeveled needle in the smallest suitable length and gauge Select the proper injection site using anatomical landmarks Apply a topical anesthetic to the injection site before giving the medication when possible Divert the patient s attention from the injection through conversation using open ended questioning lnsert the needle quickly and smoothly to minimize tissue pulling Hold the syringe steady while the needle remains in tissues nject the medication slowly and steadily Preventing needle stick injuries Only use needles if you must NEVER RECAP USED NEEDLES UNLESS YOU HAVE TO Use single hand recap or scoop method to place cap on needle after drawing up medication Never place needles in your pocket to transport Use appropriate punctureproof disposal containers to dispose of uncapped needles and sharps Never throw sharps in regular wastebasket Use safety devices on syringes ALWAYS WEAR GLOVES Sharps container never force any needles in empty sharps container Preparing lnjectable Medications Ampules open away from you Filter needles use with ampules to prevent glass from getting in syringe Vials Singledose vial use all at one time Multi dose vial save rest to use later time date time initial when used Reconstituting powder form medication nject air first into via 40 Thursday January 15 2015 Some hospitals want you to use a filter needle with vials Always wipe top with alcohol swab Change needle for injection after getting medication out of vial Mixing medications from 2 vials Make sure medications are compatible call pharmacist Wipe both tops with alcohol Inject amount of air equal to dose to be withdrawn into vial A Inject amount of air equal to dose to be withdrawn into vial B Withdraw dose from vial B Inject syringe into vial A and withdraw ordered dose Insulin preparation Administered by injection because the GI tract breaks down and destroys an oral form of insulin Classified by rate of action Rapid short intermediate and longacting Know the onset peak and duration for each of your patients ordered insulin doses Sliding scale insulin or correction insulin given in hospital setting Do not mix insulin with any other medications or diluents Verify insulin doses with another nurse while drawing up and after dose is drawn up Clear to Cloudy which to draw up first or second alcohol swab both tops withdraw clear first and then cloudy lntradermal Injections Administration of a drug into the dermal layer of the skin just beneath the epidermis Typically done for skin testings allergies tb 1mm tuberculin syringe needle 252627 gauge 15 degree angle with bevel facing up to create bleb in skin want to see needle underneath skin Do not massage Subcutaneous Injections Pg 628 in book Given in subcutaneous tissue heparin prevent blood clots and given in the abdomen best absorbed Iovanox also prevents blood clots given in the lovehandles about 15mm injected absorbed slower than IM injections 45 or 90 degree angle depending on how much SubQ fat rotate sites do sites that are usually hard for patient to get to Sites Outer aspect of upper arms Anterior aspect of thigh Abdomen Between scapula Upper ventrogluteal and dorsogluteal areas Equipment Syringe Needle adult normal size and weight if given at 45degree angle use a 25gauge needle 58 inches long if given at 90degree angle use 12 inch needle To determine the needle length Pinch the tissue at the site and select a needle length 12 the width of the skinfold To determine the needle angle Insert at 45degree angle if you can grasp 1 inch of tissue Insert at 90degree angle if you can grasp 2 inches of tissue 41 Thursday January 15 2015 No need to aspirate pull back on plunger with SubQ bcuz not a lot of blood vessels Intramuscular Injections 42 lnjection into muscle Very vascular so must aspirate for 5 seconds assess for blood Higher level of risk for harm to patient Needle size 2025 gauge 12 to 3 inches Angle of insertion is 90 degrees like holding a dart Amount of medication normal well developed adult is 5ml of medication 1ml in small child common for adult is 2ml Always aspirate before giving medication 5sec Ztrack method for IM injections Method used to seal medication in muscle tissue and avoid local skin irritation Recommended with ALL IM injections Displace skin tissue clean area for injection take off cap inject needle aspirate inject medication leave needle in for 10 seconds take out and apply pressure Sites for IM injections Deltoid Easily accessible May not be well developed in infants and children Use for small volumes Potential for injury to the axillary radial brachial and ulnar nerves May puncture brachial artery Have patient sit or stand locate acromion process and place 3 fingers right below acromion process then create a V with your other hand and right in the middle of that triangle you give your IM deltoid shot Sites for IM injections Vastus Lateralis Middle 3rd of the Anterior lateral aspect of thigh Extends from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur Lacks major nerves and blood vessels Thick and welldeveloped May administer up to 3 ml per injection vaccines common in babies in this area Sites for IM injections Ventrogluteal Composed of gluteus medius muscle Free of major nerves amp blood vessels Used for volumes greater than 2 mL Position the patient in a lateral position and flex the knee Landmarks Place palm of hand over the greater trochanter of the hip Point thumb towards the groin femoral artery Place index finger on the anterior superior iliac spine Place middle finger back along the iliac crest towards the buttock The index finger middle finger and iliac crest make a V Give injection in the middle of the V into the gluteus medius muscle 43 Thursday January 15 2015 Saturday February 21 2015 NURS 3130 Test 2 Respiratory System Part One Anterior Thoracic Landmarks Sternumbreast bone Angle of Louissternal angle marks site where trachea splits into right and left bronchi Count ribs of pt Each intercostal space is below the number of rib above it Costal angle Zyphoid Process 90 degrees or less Anterior posterior diameter to transverse diameter of chest twice the size of AP diameter Posterior Thoracic Landmarks Vertebra prominence helps identify where C7 begins T1 Flex head feel most prominent bony spur C7 right below is T1 Lowest tip of scapula 7th or 8th rib count upward to T3 CH18 Landmarks Locate different ribs and intercostal spaces and where to put stethoscope Mid Clavicle bisects the center of each clavicle Mid Axillary runs down apex of axilla Anterior Axillary anterior axillary fold fold of skin where pectoralis major inserts Posterior Axillary Line posterior axillary fold where lortis dorsis intersects Posterior Chest Wall inferior angle of scapula when arms are at the side of the body Review of Respiratory System Crosssection of thorax pleura serous membrane that forms envelope between lungs and chest wall Vis plura outside of chest wall Par pleura inside of chest wall Functional respiratory unit that consists of alveoli Gas exchange occurs across respiratory membrane and ducts and alveoli Lungs are responsible for exchanging C02 and 02 inhales 02 Is absorbed C02 is exhaled Lungs and kidneys homeostasis of the body Normal C02 3545 Kidneys respond slower Hyper increased C02 exhalation Hypo C02 buildup Normal stimulus to breathe hypercapnea increase C02 in bloodstream Decrease in 02 in bloodstream increase respoiration hypoxia Lung Lobes Apex highest point of lung tissue 34 cm above the inner 3rd of clavicles Base rests on diaphragm 6th rib mid clavicular line Right side 3 lobes Left side 2 lobes Anterior thorax upper and middle lobe Posterior thorax lower Saturday February 21 2015 Anterior chest Right oblique fischer Mid axillary and mid axillary line 5th and 6th rib Left oblique fischer Starts at 6th rib of mid clavicular line Horizontal line Right upper and middle lobes extending from 5th rib in right midaxillary and 3rd intercostal space at sternal border Posterior chest All lower lobe T10 on expiration and T12 on inspiration Division between upper and lower lobes is about level of scapula Axilla to 7th or 8th rib Right side Upper lobe apex of axilla to horizontal fischer of Middle lobe horizontal fischer to 6th rib at mid clav line Lower lobe 5th8th rib at mid ax line Left Side Upper apex of axilla to 5th rib at axillary line Lower lobe 8th rib at mid axil line Respiratory Muscles lntercostal muscles in diaphragm assist with breathing process with inspiration increasing size of thoracic cavity increase in AP diameter contraction of diaphragm lift sternum and ribs raise increasing AP diameter Expiration passive action Exercise and respiratory distress cause other muscle to assist Forced expiration accessory neck muscles sternomastoids scleny trapezius muscles Forced expiration abdominal muscles contract to push up on diaphragm Adult males more abdominal movement Adult females more thoracic movement History Subjective Data p418 421 Jarvis Biographical data subjective data what pt tells you Age marital status insurance Current health status how are they doing at the present time Past health history history of surgery med tests allergies environmental allergies Family history TB allergies CF smoking cancer Review of systems what type of symptoms Psychosocial history do they have support systems at home Are they coping with issues at home Smoking Environmental conditions are they around people that smoke Pollutants hazards Drug and alcohol consumption Weight changes fever and night sweats signs of TB Saturday February 21 2015 Physical Assessment Respiratory Patterns p457 295 Potter and Perry Normal Eupnea rate 1220 even volume and rhythm comfortable Depth of breathing Bradypnea rate lt 12 Abnormally slow Tachypnea rate gt 20 Abnormally rapid Hyperventilation rate and depth increase extreme exercise anxiety alkalosis Hypoventilation irregular shallow pattern caused by an overdose of narcotics or anesthetics Can occur with prolonged bed rest respiratory pain splinting their chest Sighing frequently interspersed deeper breath Protective physiological mechanism for expanding alveoli not ventilated during normal breath Apnea cessation of breathing Just a few secs Can result in respiratory arrest CheyneStokes respiratory rate and depth are irregular with alternating periods of apnea and hyperventilation Slow shallow breaths that gradually increase to abnormal rate and depth breathing slows climaxing at apnea before normal is resumed Biot respirations are abnormally shallow for 2 or 3 breaths followed by irregular periods ofapnea Kussmaul s respirations are abnormally deep regular and increased in rate Physical Assessment Preparation position patient sitting upright chest exposed drape as necessary Males undress to waist Females drape over shoulders never auscultate over clothes Assess anterior posterior and lateral work apex to base compare side to side Inspect palpate percuss auscultate Posterior and lateral thorax FIRST then anterior General Inspection Objective Data Skin lips mucous membranes nails Cyanosis or pallor blue lips mucous membranes Tissue hypoxia Clubbing of nails inner edge of nail elevates and is greater than 180 degrees Chronic issue Risk for thrombosis blood clot Signs of respiratory distress nasal flaring retractions use of accessory muscles reduced mental alertness Body position tripod position leaning over in order to breathe Saturday February 21 2015 The Physical Exam Objective Data Stand midline behind patient Posterior Chest Inspect Shape and configuration of chest wall Symmetric certain skeletal abnormal Can change that Retraction of intercostal spaces during inspiration and bulging during expiration great effort to breathe Anteroposteriortransverse diameter AP should be less than transverse lf equal barrel chest Note posture ethnic background and color related Posterior Chest Palpate Symmetric chest expansion T9 or T10 Tactile fremitis palpable vibration ulnar surface of hand say 99 and palpate vibration start over lung apexes and move side to side down the back feel symmetrical vibrations between scapula stronger on right side Fremitis is decreased if obstruction of sound ncreased if lung tissue is consolidated pneumonia More tissue impedes sound transmission Obeseless vibration Avoid over scapula bone dampens sound Chest wall should not be tender Crepidid crackling sensation over skin surface Posterior Chest Percuss Note whether lung tissue is healthy consolidated or mucous filled Stroke yields sounds One hand stays still press middle finger firmly on the skin other middle finger as strong one Aim just below nail bed Tip of finger not finger pad 2 times per location Resonance low pitched clear hollow sound that predominates over healthy lung tissue in adults Dull abnormal density in the lungs pneumonia over liver and other organs Flat over bone Start at apex and move downward through intercostal spaces Diaphragmatic Excursion Percuss to map out lower lung border on inspiration and expiration Exhale and hold it percuss down scapular line until it changes from resonant to dull lung tissue to other tissue May be higher on right side because of liver Have pt take deep breath percuss down from first mark and find where it changes to dull Equally bilateral and 35 cm in adults longer in athletes Saturday February 21 2015 Posterior Chest Auscultate Use diaphragm of stethoscope Ask client to breath in and out slowly and deeply through mouth Listen systematically to one breath in at each position comparing side to side and move downward from apex Assess for normal breath sounds adventitious breath sounds and vocal resonance Assess movement of air tracheobronchial tree and detects mucous or obstructed airways Assess bases of lungs first in older adults Listen to at least one full respiration at each site compare side to side Adventitious breath sounds and vocal resonance Bronchophony Abnormal clarity of spoken word when auscultating with the stethoscope Ninety nine if you can clearly hear lncrease in lung density that will enhance voice sounds Egophony Patient says but sounds like AY when auscultating Whispered pectoriloquy Patients whispers one two three While auscultating you should hear puff puff puff lf hear one two three clearly through your stethoscope this is present Lateral Thorax Palpate and auscultate Sit and raise arms Anterior Chest Inspect Shape and configuration of chest wall Ribs sloping downward Angle within 90 degrees Abdominal muscle Facial expression Relaxed Unconscious level of breathing Level of consciousness Cerebral hypoxia RESTLESSNESS EARLIEST SIGN OF HYPOXIA Skin color and condition Quality of respirations Regular respirations barely audible chest should expand equally no retraction or bulging of inner spaces lntercostal spaces Accessory muscles move very little with normal passive breathing Anterior Chest Palpate Symmetric Chest expansion Anterior lateral wall thumbs along costal margins pointing toward zyphoid process Note smooth chest expansion with fingers Any lag in expansion pneumonia or Atelectasis a collapsed shrunken section of alveoli Saturday February 21 2015 Tactile fremitis Palpate over lung supraclavicular area Avoid breast tissue dampens sound Palpate anterior chest wall Look for tenderness mobility masses turgor moisture Assess tracheal position Suprasternal notch and inner border of sternocleidomastoid Anterior Chest Percuss Begins at apex supraclavicular areas Easier on anterior than posterior Breast tissue gets in way Note dullness but don t confuse with pathology Dullness of liver Typhony over gastric space Anterior Chest Auscultation Breath sounds Adventitious sounds Auscultate down to 6th rib Side to side as you move downward Any abnormalities further asses what type of abnormality Breath Sounds 1 Bronchial trachial high pitch loud inspriation is shorter than expiration harsh quality can hear over trachea and larynx 2 Bronchovesicular moderately pitched moderate volume inspexp over major bronchi posteriorly between scapula anteriorly around upper sternum in 12 intercostal spaces 3 Vesicular low pitched inspgtexp poteriorly in lower lobes upper middle and lower lobes anteriorly 4 Obstruction of bronchial tree 5 Silent chest 6 Increased breath sounds louder than normal pneumonia allows for easy transmission of sounds Adventitious Breath Sounds Crackles rales fluid in the airways discontinuous Fine heard during inspirations can t be cleared through coughing Coarse loud low pitched gurgling sounds may clear with cough but not completely Pulmonary edema Atelectatic sound like fine crackles but aren t pathologic and don t last right before pt clears throat Rhonchi Continuous loud low pitch noises Wheezes Continuous high pitched musically noises heard during both louuder on expiration constriction of the airways acute asthma attack Stridor elloringial upper airway obstruction acute epiglottis obstructed airways tracheal and bronchial distress Saturday February 21 2015 Friction Rub pleural layers inflamed and losing grading sound Pregnancy Variations Diaphragm rises Ligaments of chest cage relax leading to increased chest diameter Fetus increases oxygen demands and deeper breathing occurs as a result Placenta performs fetal gas exchange before 37 weeks gestation lungs not fully ready for function outside of the uterus Ligaments relax to increase horizontal diameter doesn t affect breathing Hormones allow relaxation of ligaments ncrease in awareness of need to breathe not shortness of breath Little change actually occurs Costal angle may feel wider Placenta performs gas exchange In utero babies aren t inflating and deflating lungs UNTIL BIRTH Pediatric Variations Newborn amp infant Chest circumference equal to head circumference Obligatory nose breathers abdominal breathers Brief periods of apnea common in newborn If apnea is greater than 15 seconds need evaluation for cardiopulmonary or CNS disorder Observe for nasal flaring retractions or grunting AP diameter changes to 21 at age 6 During assessment Allow parent to hold child Take every opportunity to assess when quiet or sleeping Inspec on chest will be more round than oval intercostal breathers at age 2 when it will start to change no sternal or intercostal contractions ots of retractions resp distress abdomen bulges with each inspiration count respi For a full min 3040 may go as high as 60 Palpation note tenderness masses etc Auscultation fine crackles louder because of thin chest walls smoking high health risk bc of immaturity of respiratory and lungs SIDS ear infections asthma etc Saturday February 21 2015 Geriatric Variations Chest wall stiffens and expansion is decreased Respiratory muscle strength decreases Decreased number of alveoli so less room for gas exchange Lung bases become less ventilated lncreases dyspnea Mental status changes often first sign of respiratory problems ncreased risk for respiratory infections due to decreasing immunity ncreased risk of post operative pulmonary complications bc of decreased ability to cough Decrease in mobility of the thorax p421 Jarvis Cyphosis Decrease in chest expansion Pt may fatigue easily during auscultation Documentation of Findings Within Normal Limits Respiratory Exam Subjective data no cough SOB or chest pain with breathing No history of respiratory diseases Has one or no colds per year Denies smoking Works in wellventilated office Objective Data nspection AP lt transverse diameter RR 16min relaxed breathing Palpation Symmetric chest expansion tactile fremitis equal bilaterally no tenderness to palpation no lumps or lesions Percussion resonant to percussion over lung fields diaphragmatic excursion 5 cm and bilaterally Auscultation vesicular breath sounds clear over lung fields No adventitious breath sounds Saturday February 21 2015 Respiratory System Part Two Abnormalities in Chest Configuration 1 Barrel Chest the anterioposterior diameter is equal to the transverse diameter and the ribs are horizontal 2 Pectus excavatum or funnel chest depression of the sternum and adjacent costal cartilage Congenital issue Can be fixed later on in life most people are embarrassed by this 3 Pectus carnivatum or pigeon chest forward displacement of the sternum with depression of the adjacent costal cartilage 4 Scoliosis uneven scapular height S shape in back uneven hips one shoulder will be higher enough If severe enough can impair CV and Resp systems 5 Kyphosis spine curved at top a dowager s hump usually in older Pts especially women their body is too heavy for their spine Also for younger women who don t get enough exercise Diagnostic Testing related to the Respiratory System RBC4761 men amp 4254 women oxygenation Hemoglobin amp hematocrit Hgb M 1418 F 1216 Hct M 4252 F 3747 if low hemoglobin anemic can39t carry 02 as well so body can try to overcompensate for lack of 02 ABG Arterial blood gases tells us how much 02 is in the blood Chest Xray help with diagnosis of pneumonia fluid in the lungs masses in lungs ID TB etc CT Scan amp MRI Identify masses further types of specific imaging we can use to ID tumorsmasses Diagnostic Testing Pulmonary Function Test Forced expiratory time Spirometer ID number of seconds your pt takes to breath completely out exhale completely From TLC air in lungs after inspiration to RV whats left in lungs after pt has exhaled TB skin test allergy testing do allergies affect respiratory rate 6 minute distance walk how well elderly pts are able to perform ADL s safe inexpensive we want to see how far our pt can walk in 6 minutes Have someone next to them in case they fall 300m or more is fine Saturday February 21 2015 Throat Culture Hand hygiene 2 Identify patient 3 Apply clean gloves 4 Position appropriately 5 Open patient s mouth depress tongue with tongue blade 6 7 8 L Swab tonsillar area side to side Insert swab into culture tube amp crush bottom to release culture medium Attach label amp send to lab Tests for strep Culture before antibiotics Can t delegate this you have to do it as the RN Supplies 2 sterile swabs light tongue depressor gloves lab requisition form has pt name and what to do with the culture Have pt sit up and tilt their head back Gagging sensation is normal Pu swab straight out can t hit the sides of the mouth or else it will contaminate it Have to have the pt label so in case anything happens the lab will know who s culture it belongs to Include time date and initials Sputum Analysis Culture amp sensitivity what antibiotic would this bacteria be sensitive to done for blood urine etc Acid fast bacillus detects TB Cytology lets us know if there are lung cancer cells in the sputum Procedure 1 Hand hygiene 2 Identify patient 3 Apply clean gloves 4 Rinse mouth with water 5 Inhale deeply 34 times 6 Follow last deep inhale with forceful cough to expectorate sputum into sterile container 7 Close container label amp send to lab immediately Can be delegated to a tech just make sure they know how to correctly collect the specimen Also need a red biohazard bag to carry specimen to the lab Pulse Oximetry Sp02 Sa02 measure of Hgb that is bound with 02 in the arteries Sp02 reliable estimate of Sa02 if Sa 02 is gt 70 Assessed arteriole oxygen pressure Probe Locations Nail Eanobe Bridge of nose Heel 95100 o desirable 1O Saturday February 21 2015 Signs amp Symptoms of Hypoxia Restlessness Apprehension Anxiety Disorientation Decreased LOC lncreased fatigue ncreased pulse BP respiratory rate Dyspnea Arrhythmias Pallor Cyanosis late Clubbing chronic Oxygen Administration Treat or prevent hypoxemia Delivery devices Nasal cannula Simple face mask Face mask with reservoir Partial rebreather Nonrebreather Venturi mask See more than reservior Each Fi02 flow rate administers a certain amount of 02 Room air20 o oxygen 1 L Fi02 24 know liter amounts and percentage equivalents P851 potter and perry on test Hazards amp Complications of Oxygen Administration Combustion Oxygeninduced hypoventilation Hypercarbia retention of COZ extra COZ in blood COZ narcosis loss of sensitivity to high levels of COZ Oxygen toxicity Drying of mucous membranes lnfection caused by open sores due to dry mucous membranes Make sure electrical equipment is safely covered sparks 02 Tanks make sure th tank is secure when transferring PT make sure there is enough 02 in the tank Oxygen AdministrationNasal Cannula Flow rates of 16 Lmin 02 concentration of 2444 Assess patency of nostrils Assess for changes in respiratory rate and depth Can be used for all age groups 11 Saturday February 21 2015 Prongs tilt so make sure it s going back into their nostrils Tech can put on the cannula but RN has to do any adjustments to the 02 flow Check for skin breakdown especially with the elderly and when they have 02 for a long period of time Look around the ears lf notice skin issues provide skin care Don t use petroleum based lotions potentially flammable Provide oral care as well Don t usually administer over 6 L of 02 through a cannula lf over 4L have it humidified Oxygen AdministrationSimple Face Mask Delivers 02 of up to 40 o60 o with flow rate of 58Lmin Minimum of 5 Lmin Mask fits securely over nose and mouth Always assess for skin breakdown Oxygen AdministrationVenturi Face Mask Can deliver 24 o60 o at 412 Lmin Delivers precise 02 concentration Switch to nasal cannula during mealtimes Administers highermore precise amount of 02 Nurse s Role in Oxygen Administration Assess respiratory status Monitor for vital sign or LOC changes Verify order for oxygen Properly position nasal cannula or mask Ensure bag remains inflated on masks with reservoir Nurse s Role in Oxygen Administration Verify setting on flowmeter Reassess respiratory status at least every 2 hours Assess for skin irritationbreakdown Assess drying of nasalupper airway mucosa amp epistaxis Incentive Spirometer Encourages deep breathing by providing visual feedback about performance Nursing treatment Perform 510 breaths per session every hour while awake Flow oriented vs Volume oriented Flow trying to elevate the ball Second most important thing a nurse can do besides hand washing Surgery pts have the most issues with this After surgery it s painful to breathe They then take shallow breaths which builds up secretions which an lead to pneumonia In addition shallow breaths don t let the alveoli inflate which can lead to a lung collapsing called atelectasis 12 Saturday February 21 2015 Incentive Spirometer Procedure Position patient in upright position Exhale completely through mouth amp place lips around mouthpiece Slow deep breath as long as can inhale Hold for at least 3 seconds then exhale May need to give pain meds before doing this Promotion of Lung Expansion Ambulation lmmobility and pulmonary complications The longer a PT lys there the higher the risk for them to have a respiratory issue This is why ambulation is so important Effects of early ambulation Always have a helper If the pt is on pain meds been laying down for a long time so you need someone to help you prevent them from falling esp elderly people do small distances at first make sure to have a physician s order to ambulate Promotion of Lung Expansion Positioning The healthy mobile person maintains adequate ventilation and oxygenation by frequent position changes during activities of daily living ADLs Frequent position changes Modified SemiFowler s at 45 degrees promotes lung expansion and reduces pressure on diaphragm Turn pts a lot If you don t frequently change their position they will develop a bedsore Usually every 2 hours turn them if they cannot move them selves Promotion of Lung Expansion Cough and Deep Breathing Techniques Coughing is effective for maintaining a patent airway Helps remove secretions from both the upper and lower airways Promotes lung expansion Deep inhalation increases the lung volume and airway diameter Evaluating the effectiveness of coughing Frequency of coughing and deep breathing every two hours quotPulmonary toiletquot f coughing up a lot of sputum keep them going people die from pneumonia Suctioning Necessary when the patient is unable to clear respiratory secretions from the airways by coughing or other procedures Oropharyngeal and nasopharyngeal Only suction as necessary because it can create hypoxia due to the pressure exerted on the pts lungs Equipment is sterile so suction the mouth last if there are secretions Bottom picture is a yaunker suction catheter 13 Saturday February 21 2015 Orotracheal and nasotracheal through ET tube Tracheal Open Suctioning vs Closed Suctioning Open when you use a different sterile catheter every time you suction Baby is an example of open suctioning Closed used when pt is on ventilator and you have to frequently suction They remain on oxygen while we suction Suctioning Procedure Check 2 patient identifiers Assess for need for suction ss related to hypoxia contraindications to type of suctioning Explain the procedure to the patient Place pulse oximeter on patient Perform hand hygiene Prepare equipment Apply gloves Connect suction catheter to tubing and test Perform suction according to location Skill 401 Place suction in clean dry area if reusing with suction vacuum off Assess patient AII catheters have a thumb hole Place thumb over the hole and this starts the suction Don t want to hold down for more than 5 seconds can start hypoxia Inhaled medications Dry Powder Inhalers DPls Prepare dry powder inhaler for administration Place lips over mouthpiece lnhale quickly amp deeply Hold breath for 10 seconds then exhale Rinse mouth with water Do not shake these inhalers Most pt who use inhalers have been using them for a long time However there will be pts who don t know how to use some So be able to teach pts most pts will be able to selfadminister this However we do need to chart it still WATCH them Metered Dose Inhalers MDls 14 Remove mouthpiece cover Shake inhaler Hold inhaler in dominant hand PosMon PT must coordinate breathing in with the quotpuffquot of medicaiton Saturday February 21 2015 Metered Dose Inhalers MDls Deep breath amp exhale lnhale slowly amp deeply for 35 seconds while depressing canister Hold breath for about 10 seconds They can t exhale with inhaler Exhale slowly through nose or pursed lips Rinse mouth after dosing Clean inhaler Get PT to show RN how to use it Metered dose inhalers with spacer Remove mouthpiece cover Shake inhaler lnsert inhaler into spacer device Hold inhaler in dominant hand Place spacer mouthpiece in mouth Press canister to spray one puff in spacer lnhale slowly amp deeply for 35 seconds Hold breath for about 10 seconds Exhale slowly through nose or pursed lips Rinse mouth after dosing Clean inhaler amp spacer Nebulizer Treatments Nurse s Role Be aware of type amp action of medications Encourage patient to take slow deep breaths during treatment Monitor patient during treatment Assess lung sounds before amp after treatment Encourage cough deep breathing amp expectoration following treatment Rinse mouth following steroid treatments Health Promotion Vaccinations flu shots pneumonia shot elderly or chronic patients Maintaining a health lifestyle diets low fat high fiber watching cholesterol ldentifying and eliminating risk factors Exercise Avoiding infection Box 406 pg 841 Potter and Perry Avoiding environmental pollutants 15 Saturday February 21 2015 Nursing Diagnosis Ineffective Airway Clearance rt impaired cough incisional pain decreased LOC excessive tenacious secretions Goal Mobilize pulmonary secretions Impaired Gas Exchange rt decreased lung expansion presence of pulmonary secretions inadequate O2 intake Goal Maintain and improve tissue oxygenation Ineffective Breathing Pattern rt immobility depressed ventilation neuromuscular damage airway obstruction Goal Maintain patent airway Risk for Infection rt stasis of pulmonary secretions Goal Absence of infection Case Study Ms Jones is a 62 year old sales clerk admitted with an elevated temperature productive cough rapid labored respirations and mild dehydration Her chest x ray confirms pneumonia Physical Exam Vitals T 1022 F P 92 R 26 BP 12274 SpO2 88 Skin pale amp cheeks flushed reports chills has nasal flaring using accessory muscles inspiratory crackles with diminished breath sounds on right base frequent cough with thick yellow sputum production Diagnostic data Chest xray reveals right lobar pneumonia WBC 14000 Nursing Diagnosis Ineffective airway clearance rt thick sputum secondary to pneumonia Goal Clear the secretions this would improve respiration Nursing Interventions Ambulate patient sit upfowler s give 02 nebulizer treatment have her cough suction lower fever Tylenol fluids if not contraindicated dehydrated Ms Jones begins to become irritable and anxious She can t lay still in the bed Nursing Interventions Anxietyhypoxic Put on her pulse ox to see if it has dropped since admission Questions 1 Percussion over healthy lung tissue normally elicits what sound A Tympany B Resonance C Dullness D Hyperresonance 16 Saturday February 21 2015 2 A patient is to have a sputum for CampS collected The nurse plans to A collect the specimen in the morning before breakfast B collect the specimen in the evening after supper C Use the patient s saliva if sputum cannot be obtained D ask the patient to use a mouthwash before the specimen is collected 3 The patient has a bronchodilator and an inhaled steroid scheduled for the same time What teaching should the nurse provide to the patient about administering these medications A Inhale the bronchodilator wait 20 to 30 seconds then inhale the steroid B Inhale the bronchodilator wait 2 to 5 minutes then inhale the steroid C Inhale the steroid wait 20 to 30 seconds then inhale the bronchodilator D Inhale the steroid wait 2 to 5 minutes then inhale the bronchodilator 4 A hospitalized patient is ordered very precise oxygen concentrations delivered due to respiratory problems Which equipment would you expect to use A Nasal canula B Simple mask C Venturi mask D Meter dose Inhaler 17 Saturday February 21 2015 Cardiovascular System Part One FluidElectrolyteAcidBase Balance Fluid balance consists of Fuid intake and absorption Fuid distribution Fuid output Fluid intake Drinking and foods Metabolismcreates additional water Regulator Thirst conscious desire for water Triggered by hypothalamus Fluid distribution Movement of fluid Extracellularlntracellular Osmosis Vascularlnterstitial ECF Filtration All are constantly working together to maintain fluid balance What s going in has to equal what is going out Fuid output Normal output Skin insensible we don t notice it sweat Lungs GI tract 34 L are moved throughout bodyday feces also do this Kidneys Abnormal output Vomiting Wound drainage Hemorrhage ADH RAAS ANP pg 886887 Potter amp Perry Fluid Imbalances Extracellular fluid volume ECV Imbalances ECV Deficit lnsufficient amount of isotonic fluid Signssymptoms due to lack of volume in vascular and interstitial Hypovolemia ECV Excess Excess amount of isotonic fluid Osmolality imbalances Na135145 follow lab values from potterperry Signs cerenral dysfunction Hypernatremia water deficit hypertonic Hyponatremia water excess hypotonic Clinical dehydration ECV deficit and hypernatremia Reference Table 41 3 on pg 889 18 Saturday February 21 2015 Electrolyte Balance ntake and absorption Distribution Plasma concentrations of K Ca2 Mg and phosphate P04 are very low compared with concentrations in cells and bone Differences are necessary for normal function of Muscle Nerve Lab values serum levels Output Urine feces and sweat Vomiting drainage and fistulas Electrolyte lmbalances complete the fluid and electrolyte tutorial on Evolve Potassium K 355 Hypokalemia Hyperkalemia Calcium Ca2 84105 Hypocalcemia Hypercalcemia Magnesium Mg2 1525 Hypomagnesemia Hypermagnesemia lnterventions Nursing Knowledge Use scientific knowledge base in clinical decision making Nursing knowledge includes Eliciting risk factors for fluid electrolyte Clinical assessment for 88 of imbalances lnterventions to maintain or restore balance Critical Thinking Synthesis of knowledge experience info from patients critical thinking attitudes intellectual and professional standards lntegrate knowledge of physiology pathophysiology and pharmacology and previous experience and info from patient Nursing Process Assessment Nursing history Age total body volume increases with age Environment weather If it39s hot you sweat moreaffects H20 intake Dietary intake Lifestyle Medications Medical Hx Recent surgery Gl output 19 Acute illness or trauma Respiratory disorders Burns Trauma Chronic illness Cancer Heart failure Oliguric renal disease Physical Assessment Daily weights lndicator of fluid status Same time same scale similar clothes Best if in the morning Fluid intake and output IampO 24hour IampO compare intake versus output lntake Liquids eaten Drinks Feeding tubes V Blood Saturday February 21 2015 Can be popsicles milkshake and things that would not normally be considered as liquids Output Unne Diarrhea Vomitus Gasric suction Wound drainage Note everything that the PT puts out Laboratory studies Nursing Diagnosis Case Study Decreased cardiac output Acute confusion ex sodium issue Risk for electrolyte imbalance Deficient fluid volume Excess fluid volume lmpaired gas exchange Risk for injury Deficient knowledge regarding disease management applies to familycaretaker as well lmpaired oral mucous membrane mpaired skin integrity lneffective tissue perfusion 20 Saturday February 21 2015 Implementation Health promotion Fluid replacement education Teach patients risk factors and 88 of imbalances Acute care Enteral replacement of fluids Do not perform if PT is at risk for aspiration impaired swallowing stroke GI Track issues Ice chipspopsicles are helpful Restriction of fluids Think of cultural aspects some have to drink fluids at a specific temp Parenteral replacement of fluids and electrolytes Parenteral nutrition or TPN total parenteral nutrition Thick smells but it is nutritious Crystalloids electrolytes Colloids blood and blood components IV devices Peripheral catheter tip lies in vein of extremity Central catheter tip lies in central circulatory system vena cava close to RA Parenteral Nurtrition Complex highly concentrated solution Contains nutrients and electrolytes Tan thick pharmacy can make it special or your PT pertaining to what they need Solutions Lower osmolality peripheral IV best if a central line is used High osmolality central IV Intravenous IV Therapy Direct access to vascular system Continuous infusion over a period of time To provide safe and appropriate therapy Knowledge of ordered solution Reason solution was ordered Equipment needed Procedures required to initiate infusion How to regulate infusion rate and maintain system How to identify and correct problems Assess site and know when it is not good anymore How to discontinue the infusion Need to know why we are putting the IV in to correctprevent fluid electrolyte balance 21 Saturday February 21 2015 Vascular Access Devices VAD Catheters or infusion ports For repeated access to vascular system Shortterm peripheral Longterm Central line enters thru subclavjugular lmplanted port Surgically placed into a small subcutaneous pocket usually on the upper chest Peripherally inserted central catheter PICC enters thru peripheral arm veins and extends to the vena cava Used with clients with chronic illness who require longterm IV therapy IV therapy 22 Equipment Clean gloves Tourniquet Dressingtape Gauze V catheter typical cath size depends on the hospital ranges from 18 22 V tubing V fluid nfusion pump Peripheral VAD vascular access deviceV Short catheter length Smaller gaugelarger needle diameter Catheter is a plastic tube that is threaded over the needle OvertheNeedle Catheter picture Orange12g Gray14g Green18g Pink20g Blue22g Assessment Plan Collect supplies ldentify patient using 2 identifiers Verify order with MAR Explain rationale for IV to patientfamily Positioning lmplement Don39t use a site with a graftfistulamastectomy Don39t use arm on side where PT got a mastectomy Document Saturday February 21 2015 Maintaining the line Keep line sterile and intact Change fluids tubing and contaminated site dressings Assist with selfcare activities Monitor for complications Hand hygiene before and after handling Avoid disconnecting for unnecessary reasons Never let tubing touch the floor Always clean injection port before accessing it nitiating IV Therapy Complications Fluid overload lnfiltration Extravasation Phlebitis Local infection Bleeding at the infusion site Discontinuing IV therapy Reference Table 41 12 pg 910 Crystalloids KNOW THESE lsotonic NS Normal Saline 09 sodium chloride LR Lactated Ringer s D5W Dextrose 5 in water Hypotonic put water into cells 12NS 12 Normal Saline 045 sodium chloride 1ANS Mr Normal Saline 0225 sodium chloride not common Hypertonic pull water out of cellscells shrivel 3 or 5 sodium chloride D5LR Dextrose 5 in lactated ringers D1 OW Dextrose 10 in water D512NS Dextrose 5 in 045 sodium chloride D5NS Dextrose 5 in 09 sodium chloride Colloids Albumin Hetastarch Dextran Whole blood Blood component Packed RBC Platelets Plasma Objectives ncrease circulating blood volume due to surgery trauma hemorrhage ncrease number of RBC s and Hbg levels due to anemia Provide cellular components as replacement therapy 23 Saturday February 21 2015 Blood Transfusion Blood must be compatible ncompatible BBC destruction immune response ABO system Presence or absence of A and B antigens Type AB universal blood recipients Type O universal blood donor Rh factor 18 20 gauge catheter From book but never give blood with 20 1418g usually Tubing for blood administration contains a filter Prime with 09 NaCl Remain with client for at least first 15 minutes In case of reaction Rate set by physician order but ideally 1 unit should infuse over 2 hours no more than 4 Take VS before and 1015 minutes after giving blood Autologous transfusion Using the patient s own blood They can donate their own blood up to 6 weeks prior to operation and the doctors can use your own blood Would do this to reduce the risk of reaction to someone s else s blood reduce risk of blood borne pathogens Transfusing blood Patient safety check patient identifier s medical record number blood group and complete name Patient assessment before during after Transfusion reactions and other adverse effects SS to watch for chills nausea vomiting skin rash tachycardia Transfusion reactions stop it immediately get new bag of saline and put through IV to flush out blood tel doctor stay with patient be prepared to do CPR and that there could be possible death if this happens you have absolutely everything Blood tubing everything Donations tested in USA for HIV Hepatitis Syphilis Intravenous Medications Medication enters the bloodstream directly by way of a vein Appropriate when rapid effect is required If we can give orally do it Methods of administration IV push or bolus continuous bolus a quick amount of meds IV piggyback Intermittent IV give fluids but don39t give all the time Large volume infusion 24 Saturday February 21 2015 Intravenous Push IV administration of an undiluted drug directly into the systemic circulation Undiluted is a matter of opinion You should dilute certain meds that can destroy veins down the road Sometimes you don t need to it all depends Saline Loc flush with saline Hep Loc flush with heparin prevents blood clots from forming so that the IV line stays good Second pic IV push with needless injection Intermittent IV infusions Piggyback to IV line or intermittent infusion line Usually 50150 cc nstilled over a short period of time at regular intervals Miniinfusion Pump 637 common for morphine in ICU settings VolumeControl Infusions 927929 Buretrol Soluset Volutrol Pediatrol Controls how fast the fluid goes in Rare Potential complications Rapid severe reactions to the medication Not wrong meds could be too much Fluid volume overload Infiltration When catheter becomes dislodged and vein ruptures Can cause fluid to enter subQ tissues If IV site is cool swelling and pale skin this has happened Phlebitis Usually due to med going in mechanical aspect where cath was pt moving a lot so inflammation bacteria equip wasn t sterile Hot to touch red extremely painful to pt Infection Prior to adding any medication to an IV the nurse should inspect and palpate IV site Reference Table 4112 p910 Venipuncture Venipuncture with syringe Venipuncture with vacutainer Central Venous Catheter collection Blood glucose Allows for selfmanagement of diabetes Capillary blood use reduces frequency of needlesticks Less painful Patient can perform independently Many different meters on the market Accucheck Inform II video in Panopto Recordings Clinical Nursing Skills amp Techniques Skill 439 pg 10851090 25 Blood Glucose Chart Normal person 70100 mgdL 1 Minimum fasting value 70 mgdl 2 Maximum fasting value 99 mgdl 3 PostPrandial lt14O mgdl 2 hours after finish eating Prediabetic 1 Minimum fasting value 100 mgdl 2 Maximum fasting value 125 mgdl 3 PostPrandial 140199 mgdl Diabetic 1 Minimum fasting value lt126 mgdl 2 Maximum fasting value gt126 mgdl 3 PostPrandial gt200 mgdl lggy chapter 67 26 Saturday February 21 2015 Saturday February 21 2015 Cardiovascular System Part Two Heart and Neck Muscles Heart muscular pump and blood vessels Blood vessels 2 continuous loops Pumonary circulation Systemic circulation Both circulations are pumped by the heart simultaneously Structure and Function Position and surface landmarks Precordium part that overlies the heart and great vessels Mediastinum between the lungs Apex and base of heart Apical Impulse PMI Great vessels Superior and Inferior Vena Cava Pumonary Artery Pumonary Veins Aorta Normal heart size is about 6cm long 8cm wide Heart Wall Pericardium tough fibrous tissues double wall sack surrounds and protects the heart Technically has two layers contain pericardial fluid this fluid allows the heart to move smoothly and without friction Myocardium physical muscle wall of the heart Makes it pump Endocardium thin layer of endothelial tissues Lines inside of heart chambers and walls Chambers Atrium RL Thin walled Considered to be reservoirs hold the blood Ventricle thick walled Pumps the blood out RV 3mm pumps to pulmonary system LV 1013mm pumps to systemic system Valves gtseparate the four chambers prevent backflow of blood open one way makes blood unidirectional open and close passively in response pressure gradients to the moving blood Atrioventricular AV Separate atrium and ventricles Tricuspid Right Mitral Left Chordae Tendinae Diastole filling phase Allow ventricles to fill up with blood Systole Pumping phase AV valves closing to prevent regurgitation of blood into atrium 27 Saturday February 21 2015 Semilunar SL Between the ventricles and the arteries Pulmonic Right pulmonary artery and right ventricle Aortic Left left ventricle and aorta Systole SL valves are opening to allow blood to pump ejected from ventricles Rhythmic movement of blood 2 Phases Diastole 23 of cycle ventricles are relaxed with AV valves open The pressure in atria rn is higher than that of the ventricles this allows the blood to rapidly pour into the ventricles this concept is known as early filling the atria then contract and push the very last amount of blood into the ventricles concept known as active filling or presystole This causes a small rise in the pressure in the LV Systole 13 of cycle So all the blood has been pumped from atria to ventricles So pressure is now higher in V and Atria This pressure causes the mitral and tricuspid valves to close which marks the beginning of systole Sf first heart beat For a very small amount of time all valves are close The heart then beats which causes a huge amount of pressure in the heart The ventricles empty pressure falls eventually falls to below the pressure of aorta When this happens some blood starts to flow back into ventricles which causes the atria to shut End of systole is 82 second sound Then restart with diastole Mitral valve closes just before the tricuspid valve Aortic valve closes just before the pulmonary valve Blood flows from an area of high pressure to an area of low pressure unless flow is blocked by a valve Atrial systole occurs during ventricular diastole Heart Sounds Normal Heart Sounds Heard all over chest wall through stethoscope Sf AV valves close M1 mitral valve precedes T1 tricuspid valve Loudest at apex SZ SL valves close A2 preceeds P2 Loudest at base Split 82 Occurs because aortic valve is closing much earlier than the pulmonary valve 28 Saturday February 21 2015 Extra Heart Sounds Normally diastole is silent event Vibrations heard over the chest Ventricles are resistant to filling 83 AV valve opens amp atrial blood first pours into ventricles When ventricles are resisting during the early filling phase Occurs immediately after 82 S4 Atria contract and push blood into noncompliant ventricle Occurs just before 81 Murmurs Turbulent blood flow and collision currents within heart Gentle blowing swooshing sound Heard on chest wall Caused by Velocity of blood increases exercise thyrotoxicosis Viscosity of blood decreases anemia Structural defects in valves narrow valve dilated chamber Characteristics of heart sounds Frequency pitch high or low Auscultate Able to hear higher pitch with bell lower pitch with diaphragm lntensity loud or soft Duration how long is the sound Should be short Timing how is it related to systole and diastole Conduction Automaticity Can contract by itself due to electrical current Electrical system stimulates heart to contract Specialized cells in sinoatrial SA node initiate the electrical impulse SA node pacemaker Orderly sequence SA nodegtAV nodegtbundle of HisgtRight amp Left bundle branchesgt Purkinje fibers picture slide 16 ECGEKG electrocardiograph P wave depolarization contraction of atria PR interval beginning of P wave to beginning of QRS complex QRS complex depolarization contraction of ventricles T wave repolarization relaxation of ventricles Pumping Ability Cardiac Output amount of blood ejected from LV in 1 min Stroke volume X HR Stroke volume amount of blood ejected Rate number of beats per min Normal is 46Lmin Preload Length ventricular muscle is stretched at end of diastole just before contraction 29 Saturday February 21 2015 Venous return that builds during diastole Afterload Opposing pressure ventricle generates to open aortic valve against higher aortic pressure Resistance against which ventricle must pump PreloadAfterload affects the heart39s ability to increase CO Frank Starling Law states that the greater the stretch then the stronger the heart39s contraction which leads to increased SV Neck Vessels Vascular structures in neck Carotid artery Produces pulse Pressure wave that s generated by each systole pumping into the aorta Timing of carotid coincides with the timing of systole Jugular veins internal and external Empty deoxygenated blood into superior vena cava The internal jugular veins are typically not visible External are more visible but you can the pulsation sometimes The jugular veins provide info about the right side of the heart Reflect efficiency of cardiac function Subjective Data Chest pain is it present where does it hurt the most onset radiation type of pain how long what makes it worsebetter does it hurt more after eating does weather affect it medicine sitting uplaying down vomiting Dyspnea unexpectedly does rolling on different sides helpmake worse wake up without breath does it interfere with your ADLs Orthopnea Cough dry mucous filled cough more when your activeresting Fatigue get tired easily when does it start is it a change from your normal activity level is it related to time of day Cyanosis or pallor does face turn blue or ashen Usually found with mycardial infarction Edema are you swollen when does it start wake up with it go to sleep with it has it gotten worse does it come and go on a daily basis Usually with cardiac swelling it s worse in evening better in morning if legs hav been elevated Is it on both sides or unilateral Nocturia have to pee a lot at night Cardiac history high cholesterol heart disease how was it treated last time surgery medicine had imaging before Family cardiac history heart issues obestiy Personal habits cardiac risk factors smoking high cholesterol diet obesity exercise stress drink drugsillegal or over the counter 30 Saturday February 21 2015 Objective Data 31 Preparation Position and draping female breast Room preparation room should be quiet amp warm Order of examination Pulse amp BP Extremities Neck vessels Precordium Equipment needed Marking pen Small centimeter ruler Stethoscope with diaphragm and bell endpieces Alcohol swab Carotid Arteries Palpate At separate times Don t want to occlude it Auscultate Bruit swish sound due to turbulent blood flow outside heart within arteries Get PT to inhale exhale and hold With bell for higher pitch sounds Jugular Veins nspect the jugular venous pulse Estimate the jugular venous pressure how efficient is your heart as a pump how efficiently is the heart pumping Should be 2cmlt If it s 3cm or more it could indicate heart failure Palpate for hepatojugular reflux displaces venous blood out of the liver Carotid vs Jugular Table p472 Jarvis Precordium Inspect the anterior chest look for heave or liftsustained forceful thrusting of the ventricle during systole lf able to see it RV if over sternal border and LV will be seen over the apex Palpate the apical impulse palpate down to 5th intercostal space Palpate across the precordium palpate with one finger across the precordium Feeling for any kind of palpable vibrationsthrills Usually coincide with Percuss to outline the cardiac borders don39t use much because of xrays Auscultate the heart sounds using the diaphragm and bell Aortic Right 2nd ICS 82 is louder than 81 Pulmonic Left 2nd ICS 82 is louder than 81 Erb s point Left 3rd ICS Sf and 82 are heard equally Tricuspid Left 4th ICS Sf is louder than 82 Apexmitral Left 5th ICS at the midclavicular line Sf is louder than 82 Saturday February 21 2015 Auscultation Note the rate and rhythm Sinus arrhythmia Pulse deficit ldentify Sf and 82 Sf is louder than 82 at the apex Sf coincides with carotid artery pulse Sf coincides with R wave on ECG SZ is louder than Sf at the base usually heard in 2nd L IC space Listen to Sf and 82 separately Splitting of 82 Normally heard during inhalation Extra heart sounds Midsystolic click mitral valve prolapse MVP Third heart sound ventricular gallop indicated heart failure or V overload Fourth heart sound atrial gallop associated with coronary artery disease Murmurs blowing swooshing sound Timing Loudness Pitch Pattern Quality Loca on Radiation Posture Abnormal Findings Systolic Heart Sounds Ejection click short highpitched Occurs during systole results in the opening of semilunar valves Aortic prosthetic valve sounds when people have had a valve replacement Midsystolic click associated with mitral valve prolapse when mitral valve leaflets are closing with contraction and balloon back up into atrium Diastolic Heart Sounds Opening snap Mitral prosthetic valve sound Third heart sound earliest sound in heart failure Summation sound Fourth heart sounds Pacemakerinduced sound Thrill at the base Right pulmonic stenosis Left aortic stenosis quotSee a heave feel a thrillquot Volume overload at the apex Mitral or aortic regurgitation due to volume overload Caused by cardiac enlargement Pressure overload at the apex 32 Saturday February 21 2015 The Aging Adult Structure amp Function ncreased SBP due to stiffening and calcification of arterial walls Not normal to have a DBP rise LV wall thickness increase Decreased ability to augment CO with exercise SV and CO decrease during exercise Dysrhythmias ECG changes Abnormal findings Orthostatic hypotension Avoid pressure when auscultating carotid artery Rising SBP with DBP remaining same leads to increased pulse pressure Pulse pressure SBPDBP 84 present without cardiac disease Systolic murmurs common in 50 Dysrhythmiasectopic beats increases Lifestyle is a huge modifying factor Cut out smoking cholesterol exercise etc Nursing Diagnosis 33 Activity Intolerance Risk for or Actual lneffective breathing pattern Decreased cardiac output lmpaired gas exchange Altered tissue perfusion Diagnostic Testing Telemetry different types Make sure you assess which telemetry my pt has 12 Lead EKG Echocardiogram Stress Test CTMR Angiography Cardiac cath TEE Doppler CXR Laboratory Test Electrolytes Cardiac Profile BNP Vascular Doppler Venogram Saturday February 21 2015 Chapter 20 Peripheral Vascular System Structure and Function Vascular system consists of vessels of body Vessels are tubes for transporting fluid such as blood or lymph Disease creates problems with Delivery of oxygen and nutrients to tissues Elimination of waste products from cellular metabolism Arteries Pump oxygenated blood to ALL body tissues Highpressure system Elastic fibers allowing for stretch systole and recoil diastole Muscle fibers control amount of blood delivered Heartbeat creates pressure wave Recoil propels blood through artery lschemia don39t have enough oxygen in blood in tissues Accessible on examination Temporal Carotid Brachial Unar Radial Femoral Popliteal Dorsalis pedis Posterior tibial Arteries in arm Radial Unar not always palpable in adult Brachial major artery that supplies the arm Arteries in leg Femoral main artery for the leg Popliteal hard to find Veins Course of the veins parallels that of arteries Body has more veins and they lie closer to skin surface Accessible on examination Jugular veins Veins in arm each arm has 2 sets Superficial subcutaneous tissue responsible for most of venous return in body Deep Veins in leg 3 types Deep femoral amp popliteal Superficial great amp small saphenous 34 Saturday February 21 2015 Perforators connecting veins with oneway blood flow connects superficial and deep veins Venous flow Drain deoxygenated blood and waste products Lowpressure system Thin walled large diameter and more distensible Compensatory mechanism to decrease stress on heart Capacitance vessels Have to have mechanism to keep blood moving Contracting skeletal muscle move blood proximally back to heart If skeletal muscle is not contracting at risk for the blood to pool Pressure gradient caused by breathing ntraluminal valves ensure unidirectional flow Lymphatics Separate vessel system Lymphatic capillaries start as openended tubes Capillaries converge to form vessels Vessels drain into larger ones Flow is unidirectional from tissue spaces into bloodstream Flow is slow propelled by Contracting skeletal muscles Pressure change secondary to breathing Contraction of vessel walls Func ons Conserve fluid and plasma proteins that leak out of capillaries Form part of immune systems that defends body against disease Absorb lipids from intestinal tract Ducts and Drainage Patterns Right lymph duct drains R head neck arm thorax lung pleura heart right side of liver Thoracic lymph duct empties into L subclavian vein trains everything that right lymph duct doesn t drain Lymph Nodes Small oval clumps of tissue at intervals along vessels Arranged in groups Deep and superficial Filter fluid before it returns to bloodstream Filter out microorganisms that could be harmful Superficial nodes Cervical drain head and neck Axillary drain breasts and upper arm Epitrochlear drain hand and lower arm lnguinal drain most of lower extremities external genitalia and anterior abdominal wall 35 Saturday February 21 2015 Can be swollen or tener related to inflmamation lmmuneRelated Organs Tonsis Pharyngeal adenoid Palatine Lingual ALL respond to local inflammation Lymph Nodes Thymus gland important in developing TLymphocytes of immune system relatively large in fetus and young child atrophies after puberty serves no function in adults Spleen destroy old RBC make antibodies store RBC filter microorganisms from blood Lymphoid tissue in the intestines Peyer39s patches Bone marrow Subjective Data 1 Leg pain and cramps How bad is it relief factors stimulating factors what brought it on exercise resting etc how long does it last location in leg radiate what type of pain is it throbbing aching stabbing interfere with ADL s does it wake you up at night what time of day for males does leg pain affect sexual func on 2 Skin changes on arm or legs Color temperature nodes hair 3 Swelling both legs or one come and go or is it constant in morning bad at night 4 Lymph node enlargement Been there for a long time tenderness hard or soft to touch movablenon movable is this a change 5 Medications Females birth control or hormone replacement therapy Objective Data Preparation Arms at beginning with VS Legs after abdominal exam Compare all findings with opposite extremity Compare R to L Temperature of room can affect certain parts of the assessment Equipment needed occasionally Paper tape measure to measure swollen extremity Tourniquet or blood pressure cuff Stethoscope 36 Saturday February 21 2015 Doppler ultrasonic stethoscope 1 Arms Inspect and Palpate Skin Turger moisture color lesions Profile sign Capillary refill Check to see how fast color comes back when you let end of finger go Should return almost immediately Temp important here if they have edema anemia or if they smoke Symmetry Pulses 1 Radial 2 Ulnar 3 Brachial Rate number of bpm Rhythm regular or irregular Symmetry same on both sides of body Amplitude 4bounding 3increased 2normal 1weak Oabsent Epitrochlear lymph node Not normally palpable If you could feel it it could indicate an infection in armforearm Modified Allen test Depress radial and ulnar arteries PT opens and closes fist Normalblood returns via ulnar artery Abnormalno blood returnoccluded ulnar artery 2 Legs Inspect and Palpate Skin and hair Symmetry Temperature Calf muscle lnguinal lymph nodes Small less than 1 cm should be movable and shouldn t hurt pt Skin lesionsulcers Venous ulcer due to bacterial infections due to drainage issues On leg around calf area Arterier ulcers on tips of toes or metatarsals Chronic Venistasis constant pooling of blood will be a brown coloring Varicose veins Pulses 1 Femoral 2 Popliteal 3 Posterior tibial 4 Dorsalis pedis Same criteria as arms Check for pretibial edema Abnormal Findings lf makes indentation grade it Grade edema 1 to 4 Saturday February 21 2015 1 lt2mm mildslight indentation no perceptible swelling 2 4mm moderate indentation subsides rapidly 3 6mm deep indentation remains for short time leg swollen 4 gt 8mm very deep indentation lasts for a long time leg grossly swollen and distorted Pretibial edema Bilateral edema hepatic cirrhosis pregnant women Unilateral edema DVT not normally have pitting edema Assess veins Manual Compression Test Color changes Doppler ultrasonic stethoscope Anklebrachial index ABI Raynauds Phenomenon Tricolor white to blue to red Due to stress temperature etc first palor spasm GET NOTES Lymphedema High protein swelling of limb Most times due to breast cancer treatment Fluid buildup in interstitial spaces Arterial Disease vs Venous Disease Loca on Character OnsetDuration Aggravating Factors Relieving factors 38 Arterial varies usually calf but may involve the entire leg sharp cramp numbness tingling throbbing claudication acute sudden onset within 1 hr chronic gradual after exertion activity elevation pain at rest indicates severe involvement rest dangling the extrmity Venous calf lower leg aching tiredness tender to touch intense sharp acute sudden onset within 1 hr chronic increases at end of day prolonged standing sitting dorsiflexion of foot elevation lying walking Saturday February 21 2015 Associated Symptoms acute pain pallor acute red warm swollen leg pulselessness parenthesis chronicedema varicosities coldness polar paralysis weeping ulcers chronic cool pale skin dry ulcers Abnormal Flndings continued Peripheral Artery disease Atherosclerosis Reduction of blood flow Risk factors Obesity Smoking Hypertension Diabetes mellitus bc thicker blood Sedentary lifestyle Family Hx of hyperlipidemia The Aging Adult Structure amp Function Peripheral vessels grow more rigid Progressive enlargement of intramuscular calf veins Loss of lymphatic tissue Assessment Dorsalis pedisposterior tibial pulse may be more difficult to find Trophic changes arterial insufficiency Thin shiny skin Thick rigid nails Loss of hair on lower extremities Progressive enlargement of calf vessels can lead to DVT or PE Arteriosclerosis rigid more rigid in older adults Healthy People 20102020 HTNSTROKE Key Objectives for High Blood Pressure lncrease blood pressure screening lncrease the number of adults who know their blood pressure reading lncrease the number of people with hypertension who have blood pressure underconUol lncrease the number of people with hypertension who take actions to reduce blood pressure Key Objectives for Stroke Reduce stroke deaths lncrease awareness of early warning signs of stroke 39 Saturday February 21 2015 Chapter 17 Breast and Lymphatic System Structure and Function Surface anatomy Between 2nd and 6th ribs extending from side of sternum to midaxillary line Axillary tail of Spence Projects up and laterally towards the armpit Nipple Areola smooth muscle fibers causes nipple to be erect when stimulated Contains Montgomery glands small elevated sebaceous gland that secrete a protective lipid during lactation Color of breast tissue is different for each individual Internal anatomy Glandular tissues 1520 lobules with clusters of alveoli these clusters produce milk Lobes empty into lacteous ducts which form a collecting duct system behind the system where the milk is stored Fibrous tissue Bands that extend vertically to attach to the chest wall muscles Adipose tissue Bqu of breast is embedded in this Lymphatics Axillary nodes Central high Pectoral anterior lateral side of pectoralis major muscle Subscapular posterior posterior lateral edge of pect muscle Lateral inside upper arm Male breast Thin disk of undeveloped tissue Areola wall developed but nipple is small Gynecomastia Common in adolescence May reappear in aging male due to testosterone deficiency Subjective Data Pain all other questions is it effected by menstrual cycle does breathing affect it Lump ever noticed one when do they notice them do lumps relate to cycle Discharge when did they notice what medicines are they taking color consistency Rash when do you first notice it does it form a pattern Swelling as related to menstrual cycle 40 Saturday February 21 2015 Trauma History of breast disease pt family how old was person when they had that disease Surgery implants mastectomy what kind reduction Selfcare behaviors self breast exam not indicative of breast disease mammogram Axilla tenderness lump swelling rash Objective Data Breast Inspect General appearance usually slight difference bt R and L Skin Lymphatic drainage areas Nipple on same plane flat or inverted supernuberary nipple extra nipple that occurs on thoraxabdomen Maneuvers to screen for retraction Axillae Inspect and Palpate Skin Palpation technique Lymph nodes Get them to put arms up hand on hips palms together Move together Breasts Palpate Use 3 fingers PosMon Palpation patterns Expected findings Never been pregnant firm Been pregnant looser Nipple Bimanual palpation If a lump is present note Location divide breast into 4 quads nipple at center Size how wide and thick it is Shape Consistency Mobility Distinctness Nipple retraction Overlying skin Tenderness Lymphadenopathy Abnormal Findings Retraction amp Inflammation Table 173 Pg 404 Dimpling Nipple retraction 41 Edema Fixation Deviation in nipple pointing Nipple Discharge Mammary duct ectasia ntraductal papilloma Carcinoma Paget s disease Table 176 Pg 407 The Aging Adult Structure amp Function Women Breast glandular tissue atrophies Decreased breast size and elasticity Axillary hair decreases Assessment Change in size contour or firmness Pendulous flat sagging Feel more granular Culture and Genetics Pubeny Can start at 820 years old Breast cancer Saturday February 21 2015 BRCA1 and BRCA2 looked at to determine change of genetic risk of developing cancer Obesity Caucasian higher incidence than AfricanAmerican starting at 45 years of age AfricanAmerican higher incidence than Caucasian prior to 45yo AfricanAmerican more likely to die of disease AsianAmerican Hispanic and AmericanIndian lower incidence and death rates than Caucasian and AfricanAmerican Those who don t have health insurance recent immigrants or poor knowledge 42 43 Saturday February 21 2015 44 Saturday February 21 2015 45 Saturday February 21 2015 Tuesday March 17 2015 Head Ears Eyes Nose and Throat Objectives ldentify and describe anatomical structures of head eyes ears neck and throat ldentify assessment techniques for structures of head eyes ears neck and throat Discuss sensory function across the lifespan Head Structure amp Function Rigid box protecting brain Bones Frontal Parietal Occipital Temporal Cranial Nerve Vll Salivary glands Parotid Submandibular Sublingual Temporal Artery Head Objective Data lnspection Size shape symmetry Check skintissue integrity Facial Structure Facial expressions Behavior Varies among races Should be symmetrical Eyebrows Nasolabial folds Sides of mouth Palpation Place fingers in hair and palpate scalp Can you feel any cranial protrusions Palpate temporal artery Palpate temporomandibular joint TMJ Done as patient opens mouth Smooth movement without limitation or tenderness Range of Motion Tuesday March 17 2015 Head Subjective Data Health History Headache Dizziness Head injury or surgery Jaw pain nfants amp Children Maternal alcohol or drug use Vaginal or CS birth Growing pattern Aging Adult Dizziness Neck pain Head Infants amp Children Skull Newborn molding due to birth Fontanels Gentle palpation in upright position Firm and even Slight pulsation Anterior diamond shaped closes between 924 mo Posterior triangle shaped closes at 12 mo Head Infants amp Children Head Growth Measure head circumference until age 2 Abnormal increasedecrease in size Failure to grow suture lines Posture amp Control Face varied facial bone growth Symmetry of wrinkling when crying Head Pregnancy Facial swelling Chloasma Can appear in 2nd trimester Blotchy hyperpigmented area on cheeks and forehead Fades after delivery Head Aging Adult Temporal arteries may appear twisted and prominent Loss of skin elasticity Decreased subcutaneous fat Decreased skin moisture Cartilage in noseears grows Tuesday March 17 2015 Neck Structure amp Function Conduit of structures Muscles innervated by CN Xl Thyroid gland Preauricular Posterior auricular mastoid Occipital Submental Submandibular Jugulodigastric Superficial cervical Deep cervical Posterior cervical Supraclavicular Objective Data lnspect amp Palpate Symmetry Head is centered Accessory neck muscles are symmetrical Held erect and still Swelling Thyroid enlargement Obvious Pulsations Range of Motion Motion should be smooth and controlled Limitation of movement Test Cranial Nerve Xl Normal Lymph Nodes Movable Discrete Soft Nontender Abnormal Nodes Loca on Size Shape Delimitation Mobility Consistency Tenderness lnflammation Neoplasm Requires prompt attention Always follow up Tuesdaylwan 1172015 Trachea Midline Palpate for tracheal shift Note deviation from midline Thyroid gland Difficult to palpate Enlargement Consistency Symmetry Nodules Auscutation lf thyroid is enlarge auscultate for bruit Neck lnfants amp Children lnfancy Neck looks short Lengthens during first 34 years ROM Cradle head in hands and turn side to side Testing flexion extension and rotation Note resistance Children Palpable lymph nodes lt 3mm is normal Higher incidence of infection Neck Aging Adult Concave curve Occurs when head and jaw are extended forward Compensates for kyphosis of spine ROM Have patient perform slowly May experience dizziness with side movements Submandibular gland prolapse Can be mistaken for tumor Will feel soft and be present bilaterally Abnormalities of Head amp Neck Hydrocephalus Paget s disease osteitis deformans Acromegaly Torticollis wryneck Thyroid multiple nodes Thyroid single nodule Pilar cyst wen Parotid gland enlargement Pediatric Abnormalities Fetal alcohol syndrome Congenital hypothyroidism Down syndrome Atopic facies allergic Allergic salute Eyes Facial Abnormalities with Chronic Illnesses Parkinson Syndrome Cushing Syndrome Graves Disease Hyperthyroidism Myxedema Hypothyroidism Bell s Palsy Brain attack or cerebrovascular accident Cachectic appearance Scleroderma Eyes Structure amp Function External Anatomy Bony orbital cavity Palpebral fissure Canthus Tarsa plates Conjunctiva Lacrimal apparatus Extraocular muscles lnternal Anatomy Outer Layer Sclera Cornea Middle Layer Choroid lris PupH Lens nner Layer Retina Optic Disc Macula Eyes Objective Data nspection and Palpation Eyebrows Lids amp Lashes Symmetric Even distribution of eyelashes No redness discharge or lesions Ptosis drooping of upper lid CN lll opening of eyelids Conjunctiva pink Sclera white Tuesdaylwan 1172015 Tuesday March 17 2015 Lacrimal Apparatus Pupils Pupillary Light Reflex Accommodation PERRLA Cornea amp Lens Eye position amp symmetry Exophthalmos protruding eyes Enophthalmos sunken eyes Snellen alphabet chart Distance 2020 Patient can read 20 ft from chart Can only read from 15ft 1520 Read smallest line of letters possible 2020 Distance the normal eye can read Can only read down to line 2 20100 OU both eyes OD right eye 08 left eye CN ll vision Confrontation test visual fields Extraocular Muscle Function Corneal Light Reflex Hirschberg test Cover Test Diagnostic Positions Test CN IV amp Vl Ocular Fundus Ophthalmoscope Enlarges view of eye Contains set of lenses to control focus Diopter unit of strength of each lens Black number is positive diopter near objects Red number is negative diopter far objects Darken room to help dilate pupils Have patient look at mark on wall Note red reflex Optic disc Systematically inspect structures Optic disc Retinal vessels Background macular Eyes Eyes Eyes Subjective Data Vision Difficulty Pain Strabismus diplopia Redness swelling Watering discharge Ocular problems Glaucoma GlassesContacts Selfcare behaviors nfants amp Children Vaginal infection at delivery Developmental milestones Routine vision testing Safety measures Aging adult Visual difficulty Glaucoma Cataracts Drynessburning Decrease activities Infants amp Children Limited function at birth Age determines screening measures Achieves 2020 vision by 67 years old Color blindness Xlinked recessive trait 8 o caucasion males 4 African American males Test between ages 4 and 8 years old lris Fundoscopic exam Perform between 2 6 months Must get red reflex Aging Adult Loss of peripheral vision Loss of eyebrows Orbital fat Arcus senilis Zanthelasma Slowed pupillary light reflex Cataracts Glaucoma Macular degeneration Tuesday March 17 2015 Eyes Abnormal Findings Ears Pages 311321 Blepharitis Hordeolum Stye Dacryocystitis Basal Cell Carcinoma Mydriasis vs Miosis Ectropion vs Entropion Ears Structure amp Function Func on Hearing Equilibrium CN VIII Ears Objective Data Inspection amp Palpation Size and shape Skin condition Tenderness External auditory meatus Otoscope Exam External ear Tympanic membrane Whispered Voice Test Shield lips Stand 12ft from patients ear Exhale and whisper slowly Patient should repeat word correctly Tuning Fork Test Weber Test Rinne Test Romberg Test Ears Subjective Data Earache Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo SeltCare behaviors Tuesday March 17 2015 Tuesday March 17 2015 Ears Infants amp Children Note ear position Otoscopic Exam Occur at end of complete exam Mandatory for illness or fever Pull pinna down for infant 3 years old Review developmental concerns Pg 334337 Note behavioral manifestations Review structure and function Pg326 Ears Aging Adult Pendulous earlobes Otosclerosis Cilia lining becomes coarse and stiff Presbycusis Ear Abnormalities External Ear Frostbite Otitis externa Sebaceous cyst Keloid Carcinoma Ear Canal Otitis externa Osteoma Furuncle Perforation Tympanostomy tubes Scarred drum Fungal infection Otomycosis Acute otitis media Nose Mouth amp Throat NMT Structure amp Function Nose 1 st segment of respiratory system Upper 13 is bone rest of cartilage Mouth 1 st segment of digestive system Lips palate cheeks tongue salivary glands Throat or Pharnyx Tuesdaylwan 1172015 Nose Objective Data Inspection and Palpation Symmetry Lesions Patency of nostrils Sense of smell ON I Nasal cavity Sinus areas Mouth Objective Data nspection and Palpation Mouth Lips Teeth amp Gums Tongue Buccal Mucosa Palate CN V mastication Throat Tonsis Posterior pharyngeal wall CN X Throat Objective Data Inspection and Palpation Tonsils graded in size 1 visible 2 halfway between tonsillar pillars and uvula 3 touching uvula 4 touching each other Pharyngeal wall NMT Subjective Data Nose Discharge Frequent colds Sinus pain Trauma Epistaxis nosebleeds Allergies Altered smell Mouth amp Throat Sores or lesions Sore throat Bleeding gums Toothache Hoarseness Dysphagia Altered taste Smokingalcohol 1O Tuesday March 17 2015 Selfcare behaviors NMT Developmental Competence nfants amp Children Salivation Teeth Nose Pregnant Women Nasal stuffiness Gums NMT Abnormalities Nose Choanal Atresia Perforated septum Allergic rhinitis Nasal polyps Mouth Cleft lip Herpes Simplex l Gingivitis Carcinoma Throat Tonsillitis Pharyngitis Medications Topical medications Ophthalmic lnstillations p 596 616619 Medication for eyes are usually in the form of liquids or ointments Otic lnstillations To soften earwax so that it can be readily removed To provide local therapy to reduce inflammation destroy infective organisms in the external ear canal or both To relieve pain To administer p 597 Medication must be at room temperature Apply clean gloves Need syringe towel basin for irrigation For an infant pull the pinna down and back For an adult or a child older than 3 pull the pinna upward and backward Straighten the adult ear canal by pulling pinna upward and backward Nasal lnstillation Nose drops and sprays lnstilled to oosen secretions and facilitate drainage treat infections of the nasal cavity or sinuses 11 Tuesday March 17 2015 To administer drops p 595596 Apply clean gloves Place patient in supine position Head back for ethmoid amp sphenoid sinuses Head back and turned to side for maxillary amp frontal sinuses Breathe through mouth Hold dropper 12 inch above nares administer drops Remain in position 5 minutes Do not blow nose lrrigations lavage Washing out of a body cavity by a stream of water or other fluid Performed to Clean the area Remove foreign object or excessive secretions or discharge If done in a sterile body area use aseptic technique clean technique for other body areas Normal saline at body temperature is used unless specified otherwise Terminology Senses Sightvisual Hearingauditory Touchtactile Smellolfactory Tastegustatory Position and motionkinesthetic Stereognosis is a sense that allows a person to recognize the size shape and texture of an object 12 13 Tuesday March 17 2015 Tuesday March 17 2015 The Neurologic System Review the anatomy and physiology of the Nervous system on your own Central Nervous System Brain Cerebral Cortex frontal parietal occipital temporal Diencephalon thalamus hypothalamus epithalamus Cerebellum Brainstem midbrain pons medulla Spinal Cord Meninges Vertebrae Cerebrospinal Fluid Regions of the Brain Cerebral Cortex Frontal Lobe Personality behavior emotions intellectual function ability to write words speech Broca s area When damaged expressive aphasia occurs person cannot talk understands and knows what they want to say but cannot produce understandable words Parietal Lobe Primary center for sensation ability to recognize body parts left versus right Temporal Lobe Primary auditory reception center language comprehension Wernicke s area When damaged receptive aphasia occurs person hears sound but it has no meaning Occipital Lobe Primary visual reception center understanding of written material 14 Tuesday March 17 2015 Peripheral Nervous System 15 Reflexes basic defense mechanism of nervous system involuntary below level of conscious control help maintain balance amp muscle tone you can test reflexes when you39re unconscious Types Deep tendon patellar or knee jerk Superficial corneal reflex Visceral pupillary response to light amp accommodation Pathologic abnormal such as Babinski in adults Spinal Nerves 31 pairs cervical thoracic lumbar sacral coccygeal Arise from the length of the spinal cord and supply the rest of the body Contain dermatomesskin area supplied from one spinal cord segment through a particular spinal nerve Biologic insurance If one nerve is severed most sensations can be transmitted by the one above and the one below adjacent to Cranial Nerves 12 pairs Originate in the brain Contain both sensory and motor fibers Control many activities in the body The student is responsible for identification by 1 Name of cranial nerve 2 Number of cranial nerve 3 Function of cranial nerve chart in Jarvis pg627 4 How to assess the cranial nerve 5 Remember On Old Olympus Towering Tops A Finn And German Viewed Some Hops Some Say Marry Money But My Brother Says Bad Business Marry Money Function Ssensory Mmotor Bboth Nerves Olfactory Sensory Smell Optic Sensory Vision Oculomotor Mixed EOM pupillary reflex opening of eyelids Trochlear Motor Eye muscles movement down and inward Trigeminal Mixed Muscles of mastication sensations of face scalp cornea MM of mouth and nose Abducens Motor Later movement of eye Facial Mixed Facial muscles close eye close mouth take anterior 23 of tongue saliva secretion tear secretion Acoustic Sensory Hearing and equilibrium Glossopharyngeal Mixed Gag and swallowing reflexes posterior 13 of tongue for taste Vagus Mixed Talking and swallowing carotid reflex Tuesday March 17 2015 Spinal accessory Motor Movement of trapezius and sternomastoid muscles Hypoglossal Motor Movement of tongue Developmental Considerations Infants System not fully developed at birth Neurons not yet myelinated Movements directed primarily by primitive reflexes Gradual myelination cephalocaudalproximodistal Head neck trunk extremities Lifts head head and shoulders rolls over moves whole arm uses hands walks Aging Adult Loss of neurons in brainspine AEB Loss of muscle bulk tone in faceneckspine Decreased strength mpaired fine coordinationagility Loss of vibratory sense at ankle decreasedabsent achilles reflex peripheral neuropathydiabetes lrregular pupil shapedecreased pupillary reflexes Sensation of paintouchtastesmell diminished Slowing of motor system Possible muscle tremors Decrease in cerebral blood flow causing dizziness and loss of balance with position change Remember that diabetics do not have to be old to have peripheral neuropathy at ankle and great toe abnormal on a young person without diabetes 3 types of Neuro exams 1 Screening Wel persons wo significant subjective findings in health hx 2 Complete Persons with neurological concerns headachesweaknessloss of coordination 3 things that warrant complete examination found in health history 3 Neuro recheck Already had a complete screeningbeing seen for flu care or the hospitalized patient Already have neuro deficits ie neuro surgery and require periodic assessments Level of Consciousness Motor function Pupillary response Vital signs especially if they just had surgery 16 17 Tuesday March 17 2015 LOC Single most imp factor in examination earliest indication of change in neuro status Personname occupation Placelocation city state Timeday of week month year If pt intubated ask to nod head is this a hospita home etc If pt not fully alert Name called Light touch on arm Vigorous shake of shoulder Pain applied pinch nail bed pinch trapezius muscle rub knuckles on sternum Record stimulus and pt response to it Motor Function Check voluntary movement of each extremitygiving commands Lift eyebrows frown show teeth Check hand grasps deficitUMNLMN disease or arthritis carpal tunnel syndrome Hold arms straight out with palms facing up with eyes closed should be able to do this for 1020sec wo drifting downward Lower extremitiesstraight leg raises Pupillary Response Note size shape and symmetry of both pupils Shine pen light to note direct and consensual light reflex constrict briskly Record size of pupil in millimeters ln brain injurysudden unilateral dilated and nonreactive pupil is ominous increased ICP causing uncal herniation brain herniation of medial part of temporal lobe protrudes over the edge of the tentorium are you at Vital Signs Temp Pulse Respirations Blood pressure Pain Any changes in these usually are late indications of rising ICP Tuesday March 17 2015 Sequence of Neuro Exam Mental Status may be assessed during history Cranial Nerves Motor system Exam Reminders Remember patient PRIVACY Provide for PROPER LIGHTING Gather Equipment Penlight Tongue blade Cotton swab ball Tuning Fork Percussion hammer Sharpdull object paper clip CoinKey Fragrance vanilla Sweetsour substance Ophthalmoscope Neuro Exam 1 Assess Mental Status Level of consciousness awake alert responds to stimuli and responds appropriately Thought processes memory orientation logical Appearance and behavior dress grooming hygiene Speech quality of speech articulation clear understandable Glasgow Coma Scale Describes level of consciousness with numeric valueexample on page 663 in Jarvis textbook Eyes open 4spontaneously speech pain no response1 Best Motor Response6verbal command localizes pain flexion withdrawal flexion abnormal extension abnormal no response 1 Best Verbal Response5orientedx3 conversation confused speech inappropriate sounds incomprehensible no response 1 The 3 numbers are added together total score reflects brain s functional level Fully alert normal person15 Score of 7 or less reflects coma Obtain History Ask questions regarding 18 Headache Head injury Dizzinessvertigo Dizziness lightheaded swimming sensation Vertigo rotational spinning caused by neurological dysfunction or problem in the brain stem Seizures Tremors Weakness Lack of coordination Tuesday March 17 2015 Numbnesstingling Difficulty swallowing Difficulty speaking Environmentaloccupational hazards Specific Questions 19 Headaches Unusually frequentsevere When did it start How often do they occur Where in your head do you feel the pain f pt states this is the worst headache of their life referral to ER to screen for cerebrovascular cause Could be a sign of a stroke Head injury Past history of injury What part of head Loss of consciousness and for how long Questions cont Dizzinessvertigo Vertigo Rotational spinning sensation problem in the vestibular apparatus in the ear Lightheadedswimmy headedfeel faint When does this occur How often Suddengradual Seizures occur with epilepsy Convulsions Start Frequency Course and duration Warning signs Aura lnvolve entire body Where does it originate Precipitating factors Tremors ln hands or face When did it start Grow with anxietytension Relieved with restactivity or alcohol Affect AD L s Weakness In any body part Generalized or localized Does it occur with any particular movement Paralysis Loss of motor function due to lesion in neuromuscular system or loss of sensory innervation lncoordination Problem with coordination Problem with balance when walking More on one side versus the other Any falling Which side Clumsy movements Tuesday March 17 2015 Legs seem to give way Numbnesstingling Paresthesiaabnormal sensation burningtingling Noted in any body part Feel like pins and needles When did it start Occur with activity Difficulty swallowing Any problems swallowing Occur with solids or liquids Any excessive saliva or drooling Difficulty speaking Dysarthriadifficulty forming words Dysphasiadifficulty with language comprehension When did you first notice How long did it last Past history Stroke CVA Spinal cord injury Meningitis or encephalitis Congenital defect Alcoholism Environmental or occupational hazards Exposure to insecticides organic solvents lead Current meds anticonvulsants antitremor antivertigo pain meds How much alcohol use Recreational drugs Testing Cranial Nerves Cranial Nerve l Olfactory Nerve Sense of smellcoffeevanillapeppermint Don t test routinely only if there is a reported loss of smell head trauma abnormal mental status or intracranial lesion is suspected Usually don39t test unless they have a problem Cannot test if pt is experiencing upper respiratory infection or when nasal passages are obstructed Abnormalities of ON Anosmialoss or decrease in sense of smell Can occur from smoking cocaine use and allergic rhinitis Other causes URI nasal fracture frontal lobe lesion tumor in olfactory bulb or tract 20 21 Tuesday March 17 2015 Cranial Nerve ll Optic Nerve NOT ON TEST Test visual acuity and visual fields review ch14 in Jarvis starting on page 287 Use ophthalmoscope to view ocular fundus for size shape and color of optic disc Do need to know how to read a sneIen chart Top number is the distance the person is standing from the chart Bottom number is the distance that normal eye can read the same line that you re reading Norma distance is 20 ft Abnormalities of CN ll Visual acuitydefect or absent central vision Visual fieldsdefect in peripheral vision Shine light in eyeabsent light reflex Direct inspectionpapilledema llCP optic atrophy glaucoma retinal lesions diabetes Some other causescongenital blindness acquired vision loss from multiple dz s stroke diabetes trauma to orbit etc Cranial Nerves III IV and VlOculomotor Trochlear and Abducens Check pupils for size regularity equality light reaction and accommodation Assess extraocular movements by the cardinal positions of gaze Cat Whiskers Jarvis p 291 ch 14 Nystagmusback and forth oscillation of eyes can indicate disease of vestibular system cerebellum or brainstem Ptosisdrooping Myasthenia gravis Strabismusdeviated gaze or limited movement lazy eye Know difference between Nystagmus Ptosis Strabismus Abnormalities CN lll lnspectiondilated pupil ptsosis eye turns out and slightly down from paralysis from carotid aneurysm tumor lesions herniation from llCP Extraocular muscle movementfailure to move eye up in down ptosis from MG oculomotor nerve palsy Horner Syndrome Shine light in eyeabsent light reflex blindness drug influence llCP circulatory arrest CNS syphilis Abnormalities of CN IVampV CN lVExtraocular muscle movementfailure to turn eye down or out fracture of orbit brainstem tumor CN VlExtraocular muscle movement to right and left sidesfailure to move laterally diplopia on lateral gaze brainstem tumor or trauma fracture of orbit Cranial Nerve V Trigeminal Nerve Have pt clench teeth and palpate the temporal and masseter musclesstrong bilaterally attempt to separate the jaws by pushing down on chin motor Have pt close eyeslightly touch forehead cheek and chin with cotton ball note they can feel equallysensory Corneal reflexonly if abnormalities noted lightly touch cornea with cotton ball to illicit blinking Tuesday March 17 2015 Abnormalities of CN V Superficial touch3 divisionsabsent touch and pain paresthesias trauma tumor pressure from aneurysm dequelae of alcohol injection for trigeminal neuralgia Corneal reflexno blink same poss causes as listed above Clench teethweakness of masseter or temporalis muscles unilateral weakness with CN V lesion bilateral weakness with upper or lower motor neuron disorder Cranial Nerve VIIFacial Nerve Motor Look for symmetry when asking the patient to smile frown close eyes tightly lift eyebrows show teeth and puff cheeks press puffed cheeks and note amt of air escaping should be equal Loss of movement and asymmetry occur with CNS lesions brain attack or stroke and with PNS lesions Bell s palsy Sensory Not routinely only if injury suspected use cotton applicator and place on tongue small amount of sugar salt or lemon juice for taste id Abnormalities of CN Vll Wrinkle forehead close eyes tightly absent or asymmetric facial movement uneven lifting of eyebrows sagging of lower eyelids Bell s Palsylower motor neuron lesion which causes paralysis of entire half of face Smile puff cheeks identify taste loss of taste or escape of air when nurse presses against right puffed cheek upper motor neuron lesions like CVA tumor inflammatory which cause paralysis of lower half of face leaving forehead intact or possible meningeal infection Cranial Nerve VIIIAcoustic Vestibulocochlear NOT ON TEST Test hearing acuitynormal conversation whispered voice see pg 333 Jarvis and Weber amp Rinne tests Weber and Rinne tests utilize tuning forks evidence has shown these are inaccurate and do not yield precise or reliable data If hearing loss is suspected refer pt for audiometric testing Weber Test Use when pt reports hearing better with one ear Place tuning fork in the middle of pt s skull ask pt if the tone sounds better in one ear or the same in both The person should hear the tone by bone conduction through the skull equally in both Rinne Test Compares air conduction with bone conduction Air conduction is 2x as long as bone conduction Place tuning fork on mastoid process and ask them to signal when they stop hearing the sound quickly invert the fork so the vibrating end is near the ear canal the person should still hear the sound Strike on hand and put behind PT ear on mastoid process Normallysound is heard twice as long by air conduction next to ear canaD 22 Tuesday March 17 2015 Abnormalities of CN VIII Hearing acuitydecrease or loss of hearing Possible causes inflammation occluded ear canal otosclerosis overgrowth of bone in ear causing hearing loss presbycusis bilateral symmetrical hearing loss due to aging drug toxicity tumor Cranial Nerves IX and XGlossopharyngeal and Vagus Nerves Depress tongue with depressor and have the person say ahhh or yawn note midline uvula and soft palate also test gag reflex motor CN IX does mediate taste on posterior one third of tongue but is too difficult to test Abnormalities of CN IX amp X CN IX Gag reflexno gag reflex vocal cordsoft palate weakness unilateral CN X lesion CN X phonates ahh uvula deviates to side brainstem tumor neck injury CN X lesion Gag reflex note voice qualityno gag reflex hoarse or brassy nasal twang husky vocal cord weakness soft palate weakness unilateral CN X lesion Note swallowingdysphagia fluids regurgitate through nose bilateral CN X lesion Cranial Nerve XISpinal Accessory Nerve Examine sternomastoid and trapezius muscles Note size should be equal Have person shrug shoulders against resistance Have person turn head side to side against resistance Weakness or paralysis occur with stroke or following injury to peripheral nerve ie surgical removal of lymph nodes Abnormalities of CN XI Turn head shrug shoulders against resistanceabsent movement of sternomastoid or trapezius muscles neck injury torticollisstiff neck associated with a muscle spasm tend to draw neck to one side forcing head to turn that way Cranial Nerve XIIHypoglossal Nerve Inspect tongue Say light tight dynamite listen to sounds of I t d n making sure it is clear and distinct Lesions of this nerve can make tongue deviate to side Abnormalities of CN XII Protrude tongue wiggle tongue from side to sidedeviates to side slowed rate of movement Possible causeslower motor neuron lesion bilateral upper motor neuron lesion 23 Tuesday March 17 2015 Cerebellar Function Balance Tests Gait don39t need to know types Watch the person walk straight line 1020ft turn then return back to origination should be smooth rhythmic effortless Ataxia uncoordinated or unsteady gait See pg 672 Jarvis for table of abnormal gaits Have pt perform tandem walking heel to toe quotSobriety Testquot used by police Romberg test Feet together arms at side close eyes and hold that position slight swaying may occur but no fall loss of balance is positive Romberg may be due to ETOH or Multiple Sclerosis PT will fall if they have a neurological problem Stand on one leg Coordination and Skilled Movements Rapid Alternating Movements Finger to finger test Finger to nose test Heel to shin test Any deviation could be due to cerebellar dysfunction or abnormality or possible ETOH intoxication Assessing the Sensory System Spinothalamic Tract pain sharp versus dull Temperaturetest tubes filled with water test only when pain sensation is abnormal Graphesthesia read number when traced in hand Vibration tuning fork vibrations dec sensationno sensation at anklegreat toe Loss of this sensation occurs with peripheral neuropathy diabetes alcoholism Stereognosisability to determine an object with eyes closed in their hand key paper clip Kinesthesiaposition move a finger of the pt s up and down or side to side and ask to tell you which way it is moved Light touchwith wisp of cotton apply to skin gently and assess the pt s ability to feel Hypoesthesia decreased touch sensation Anesthesiaabsent touch sensation Hyperesthesiaincreased touch sensation Assess Reflexes Scale 4very brisk hyperactive indicative of disease 3brisker than average may indicate dz probably normal 2average normal 1diminished low normal Ono response Utilize reinforcement to relax the muscles and enhance response distraction technique 24 Tuesday March 17 2015 Clonusset of rapid rhythmic contractions of the same muscle see pg 649 in Jarvis Hyperreflexiaexaggerated reflex occurs with upper motor neuron lesions eg brain attack Hyporeflexiaabsence of reflex lower motor neuron problem eg spinal cord injury Biceps Reflex Triceps Reflex Brachioradialis Quadriceps Achilles Reflex Clonus Superficial Reflexes Abdominal Stroke handle of reflex hammer from corner of abdomen toward the midline should feel contraction of umbilicus towards the stroke Plantar Upside down J on sole of foot should have flexion of toes no fanning in adult Fanning of toes is normal in an infant but abnormal in an adult Cremasteric On male lightly stroke the inner aspect of thigh with reflex hammer note elevation of testicle Not routinely done Abnormal Reflex findings Superficial reflexes are absent with diseases of the pyramidal tract on the contralateral side with brain attack With plantarabnormal response except infants is dorsiflexion of the big toe and fanning of all toes Babinski sign positive in adults occurs with upper motor neuron disease Protective Reflexes Gag Cough Swallow Blink Primitive Reflexes Babinski Sucking PalmarPlantar Grasp Rooting Moro startle Abnormal infant Shrill high pitched cry cat sounding cry Lethargy hypo reactivity hyperirritability Occurs with CNS damage All of these warrant referrals Disorders of the Neuro System 25 Tuesday March 17 2015 Seizures and Epilepsy Spinal Cord injuries lnfections Meningitis Nuchal rigidityinvoluntary muscle spasm limits passive flexion of neck pt cannot put chin on chest Kernig s Signflexion of knee and hip 90 degrees hold hip immobile straighten leg Positive if resistance to extension of knee or pain in hamstrings is felt Brudzinski s Signflex neck chin to chest involuntary hip flexion is POSITIVE SIGN Alzheimer s Disease Difficulty remembering newly learned information Disorientation moodbehavior changes Deepening confusion about events time and dates Unfounded suspicion about family friends caregivers 10 Warning Signs of Alzheimer s Disease Memory loss Losing track Forgetting words Getting lost Poor judgment Abstract failing Losing things Mood swings Personality change 10 Growing passive Parkinson s Disease Resting tremor Slow movement Rigidity lmpaired balancecoordination Depression Small shuffling steps Stooped posture Drooling Unknown cause GDCIgtIOUO lIgtQOI L Multiple Sclerosis 26 Demyleinating disease Autoimmune disorder of the CNS No cure Exact cause still unknown Blurred vision diplopia Loss of sensitivity Tinglingnumbness Clonusspasticity Loss of balance Weakness in one or more limbs 27 Tuesday March 17 2015 Sunday April 19 2015 Skin Integrity and Wound Care Scientific Knowledge Base Skin Dermalepidermal junction Separates dermis and epidermis Epidermis Top layer of skin The epidermis has several layers within it The stratum corneum is the thin outermost layer that is flattened with dead keratinized cells The basal layer divides proliferates and migrates toward the epidermal surface The thin stratum corneum protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents The stratum corneum allows evaporation of water from the skin and permits absorption of certain topical medications Dermis Inner layer of skin Collagen The dermis provides tensile strength mechanical support and protection to underlying muscles bones and organs The dermis is made of collagen blood vessels and nerves Collagen is a tough fibrous protein Fibroblasts which are responsible for collagen formation are the only distinctive cell type within the dermis Pressure Ulcers Pressure sore decubitus ulcer or bed sore A pressure ulcer is a localized injury to the skin and underlying tissue usually over a bony prominence It results from pressure in combination with shear andor friction Pressure is the major contributor to pressure ulcers Pathogenesis Pressure intensity Tissue ischemia lf pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time tissue ischemia occurs If left untreated tissue death results Blanching Blanching occurs when the normal red tones of skin are absent Blanching does not occur in darkskinned patients Pressure duration Pressure duration assesses low and extended pressures Low pressures over a prolonged time can cause tissue damage Extended pressure occludes blood flow and nutrients and contributes to cell death Tissue tolerance The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures Risk Factors for Pressure Ulcer Development 1 lmparied sensory perception 2 Alterations in level of consciousness 3 Impaired mobility 4Shear Sunday April 19 2015 5 Friction 6 Moisture These six factors contribute to pressure ulcer formation Any patient who is experiencing decreased mobility decreased sensory perception fecal or urinary incontinence andor poor nutrition is at risk for pressure ulcer development Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations Patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance friction between the patient and a surface Friction is the force of two surfaces moving across one another such as the mechanical force exerted when the body is dragged across another surface The presence and duration of moisture on the skin reduce the skin s resistance to other physical factors Classification of Pressure Ulcers Stage 1 intact skin with nonblanchable redness Stage 2 patialthickness skin loss involvoing epidermis dermis or both Stage 3 fullthickness tissues loss with visible fat Stage 4 full thickness tissue loss with exposed bone muscle or tendon The National Pressure Ulcer Advisory Panel NPUAP has defined pressure ulcers The European Pressure Ulcer Advisory Panel EPUAP and the NPUAP have developed a definition for an ulcer in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of injury is unknown An unstageable ulcer is a fullthickness tissue loss in which the actual depth of the ulcer is completely obscured by slough yellow tan gray green or brown andor eschar tan brown or black in the wound bed Suspected deeptissue injury is a purple or maroon localized area of discolored intact skin or bloodfilled blister caused by damage to underlying soft tissue from pressure andor shear Granulation tissue is red moist tissue composed of new blood vessels the presence of which indicates progression toward healing Slough is a stringy substance attached to the wound bed it must be removed by a skilled clinician before the wound is able to heal Black or brown necrotic tissue is eschar which also needs to be removed before healing can proceed Sunday April 19 2015 Wounds Classification Two methods are currently used to classify skin wounds 1 Describe the status of skin integrity the cause of the wound the severity or extent of injury or damage and the cleanliness of the wound 2 Describe qualities of the wound tissue such as color Wound exudate should describe the amount color consistency and odor of wound drainage and is part of the wound assessment Wound healing Wound healing occurs by primary or secondary intention Primary intention occurs when the edges are approximated Secondary intention occurs when the wound heals with scar tissue The surgical incision heals by primary intention Fig 486 A p 1182 The skin edges are approximated or closed and the risk of infection is low In contrast a wound involving loss of tissue such as a burn pressure ulcer or severe laceration heals by secondary intention The wound is left open until it becomes filled by scar tissue It takes longer for a wound to heal by secondary intention The form that wound repair takes depends on the wound s thickness Partial thickness will heal via the inflammatory response epithelial proliferation and migration with reestablishment of epidermal layers Fullthickness wounds heal via inflammatory response proliferation and remodeling Hemostasis is a series of events designed to control blood loss establish bacterial control and seal the defect that results when an injury occurs Clots form a fibrin matrix that later provides a framework for cellular repair In the inflammatory stage damaged tissue and mast cells secrete histamine resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues With the appearance of new blood vessels as reconstruction progresses the proliferative phase begins and lasts from 3 to 24 days Main activities during this phase include filling of the wound with granulation tissue contraction of the wound and resurfacing of the wound by epithelialization Remodeling or maturation the final stage of healing sometimes takes place for longer than a year depending on the depth and extent of the wound Complications include hemorrhage infection dehiscence evisceration and fistulas Wound Colors Black wound Yellow wound Red wound Mixedcolor wound You need to assess the type of tissue in the wound base and this information is used to plan appropriate interventions Assessment of tissue type includes the amount percentage and appearance color of viable and nonviable tissue Recall that granulation tissue is red moist tissue composed of new blood vessels the presence of which indicates progression toward healing soft yellow or white tissue is characteristic of slough stringy substance attached to the wound bed and it must be removed by a skilled clinician before the wound is able to heal Sunday April 19 2015 black or brown necrotic tissue is eschar which also needs to be removed before healing can proceed Primary and Secondary Intention Wound healing by primary intention such as a surgical incision Wound healing edges are pulled together and approximated with sutures or staples healing occurs by connective tissue deposition Wound healing by secondary intention Wound edges are not approximated and healing occurs by formation of granulation tissue and contraction of wound edges Complications of Wound Healing Hemorrhage or bleeding from a wound site is normal during and immediately after initial trauma A hematoma is a localized collection of blood underneath the tissues Wound infection is the second most common health care associated infection The edges of the wound appear inflamed lf drainage is present it is odorous and purulent and causes a yellow green or brown color depending on the causative organism Dehiscence is the partial or total separation of wound layers A patient who is at risk for poor wound healing is at risk for dehiscence With total separation of wound layers evisceration or protrusion of visceral organs through a wound opening occurs The condition is an emergency that requires surgical repair Wound Drainage SEROUS clear watery plasma PURULENT Thick yellow green tan or brown SEROSANGUINEOUS Pale pink watery mixture of clear and red fluid SANGUINEOUS Bright red active bleeding Nursing Knowledge Base Prediction and prevention of pressure ulcers Risk assessment Braden scale Sensory perception moisture activity mobility nutrition and friction and shear Prevention Economic consequences Notes When a patient develops a pressure ulcer the length of stay is extended and the overall cost of care increases Prevention includes special beds and mattresses good hygiene good nutrition adequate hydration and impeccable nursing care The Centers for Medicare and Medicaid Services CMS implemented a policy effective October 1 2008 whereby hospitals no longer receive additional reimbursement for care related to eight conditions including stage III and IV pressure ulcers that occur during the hospitalization Sunday April 19 2015 Factors Influencing Pressure Ulcer Formation and Wound Healing 1 Nutrition For maintenance of skin and wound healing patients need 1500 kcalday At times enteral or parenteral nutrition may need to be provided Patients need vitamins A and C calories and proteins to heal 2 Tissue perfusion Tissue perfusion occurs when tissue oxygenation fuels cellular function Patients who are in shock or who are diagnosed with diabetes mellitus are at risk for poor tissue perfusion 3 Infection Wound infection prolongs the inflammatory phase delays collagen synthesis and prevents epithelialization and tissue destruction Signs of wound infection include pus change in odor volume or redness of tissue fever and pain 4 Age Increased age affects all phases of wound healing A decrease in functioning of the macrophage leads to a delayed inflammatory response delayed collagen synthesis and slower epithelialization 5 Psychosocial impact of wounds Body image changes caused by a wound may lead to problems with selfconcept Factors that affect the patient s perception of the wound include the presence of scars drains drains are often necessary for weeks or even months after certain procedures odor from drainage and temporary or permanent prosthetic devices Assessment Skin Pressure ulcers Predictive measures Mobility Nutritional status Body fluids Pain Notes Baseline assessments and continual assessments provide valuable data that indicate skin integrity as well as any risks for pressure ulcer development When you suspect abnormal reactive hyperemia outline the affected area with a marker to make reassessment easier These signs are early indicators of impaired skin integrity but damage to the underlying tissue is sometimes more progressive Tactile assessment enables you to use palpation to acquire further data about induration and damage to the skin and underlying tissues A benefit of predictive instruments is improved early detection by nurses of patients at greatest risk for ulcer development Assessment includes documenting the level of mobility and the potential effects of impaired mobility on skin integrity Continual exposure of the skin to body fluids increases a patient s risk for skin breakdown and pressure ulcer formation Malnutrition is a risk factor for pressure ulcer development Maintaining adequate pain control and patient comfort increases the patient s willingness and ability to increase mobility which in turn reduces pressure ulcer risk Sunday April 19 2015 Assessment Ctd Wounds Notes Penrose Drain Emergency setting Stable setting Wound appearance Character of wound drainage Drains Wound closures Palpation of wound Wound cultures You see wounds in any setting including clinics emergency departments youth camps and your own backyard The type of wound determines the criteria for inspection For example you do not need to inspect for signs of internal bleeding after an abrasion but you should inspect in the event of a puncture wound An abrasion is superficial with little bleeding and is considered a partial thickness wound A laceration sometimes bleeds more profusely depending on the depth and location of the wound Puncture wounds bleed in relation to the depth and size of the wound When a patient s condition is stabilized assess the wound to determine progress toward healing Observe whether wound edges are closed A surgical incision healing by primary intention should have clean wellapproximated edges Note the amount color odor and consistency of drainage Types of drainage include the following serous sanguineous serosanguineous and purulent Table 485 on p 1190 gives assessment examples of abnormally healing primary and secondary intention wounds The health care provider inserts a drain into or near a surgical wound if a large amount of drainage is noted Surgical wounds are closed with staples sutures or wound closures When inspecting a wound observe swelling or separation of wound edges While wearing gloves lightly press the wound edges detecting localized areas of tenderness or drainage collection If pressure causes fluid to be expressed note the character of the drainage If you detect purulent or suspiciouslooking drainage obtaining a specimen of the drainage for culture may be necessary A Penrose drain lies under a dressing at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into the wound JacksonPratt Drainage Device Evacuator units such as a Hemovac or JacksonPratt shown here exert constant low pressure as long as the suction device bladder or container is fully compressed Wound Culturette Tube Sunday April 19 2015 Nursing Diagnosis and Planning Diagnosis Risk for infection lmpaired tissue integrity Acute or chronic pain lmbalanced nutrition less than body requirements lmpaired skin integrity lmpaired physical mobility lneffective peripheral tissue perfusion Risk for impaired skin integrity Notes Consider that the nature of a wound can cause problems unrelated to wound healing Alteration in comfort and impaired mobility are problems that have implications for the patient s eventual recovery Write patient goals and outcomes specific to the patient s needs Implementation Health promotion Topical skin care and incontinence management Protect bony prominences skin barriers for incontinence Positioning Turn every 1 to 2 hours as indicated Support surfaces Decrease the amount of pressure exerted over bony prominences Notes Support surfaces include mattresses integrated bed systems mattress replacement and an overlay or set cushion Shearing force is a force that acts perpendicular to the plane of interaction When positioning a patient with light skin observe for normal reactive hyperemia and blanching Avoiding Pressure Points 30degree lateral position at which pressure points are avoided Acute Care Sunday April 19 2015 Management of pressure ulcers Wound management Notes Debridement removal of nonviable necrotic tissue Mechanical autolytic chemical or sharpsurgical Education Nutritional status Protein status Hemoglobin You will want to take a holistic approach to wound management You will want to work with the dietitian the wound care nurse and the pharmacist to ensure that all patient needs are met An individualized plan of care must be developed for each patient taking into account age nutrition present medical conditions and other contributing factors A wound does not move through the phases of healing if it is infected Preventing wound infection includes cleaning and removing nonviable ssue Mechanical debridement includes wound irrigation highpressure irrigation and pulsatile highpressure lavage and whirlpool treatments Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be selfdigested by the action of enzymes that are present in wound fluids Chemical debridement may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue Depending on the type of enzyme used the preparation digests or dissolves the tissue These preparations require a health care provider s order Dakin s solution breaks down and loosens dead tissue in a wound Surgical debridement is the removal of devitalized tissue by using a scalpel scissors or other sharp instrument A moist environment supports the movement of epithelial cells and facilitates wound closure You need to impress on the patient and the patient s family the importance of nutrition fluids and body positioning The Joint Commission 2008 recommends nutritional assessment within 24 hours of admission Patients with pressure ulcers who are underweight or are losing weight need enhanced caloric and protein supplementation A patient can lose as much as 50 g of protein per day from an open weeping pressure ulcer A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia When possible maintain hemoglobin at 12 g1OO mL Wound Irrigation lrrigation is a common method of delivering a wound cleaning solution to the wound Sunday April 19 2015 First Aid for Wounds Hemostasis Control bleeding Allow puncture wounds to bleed Do not remove a penetrating object Bandage Cleaning Gentle Normal saline Notes In an emergency setting use first aid measures for wound care Under stable conditions a variety of interventions ensure wound healing When a patient suffers a traumatic wound first aid interventions include stabilizing cardiopulmonary function see Chapter 40 promoting hemostasis cleaning the wound and protecting it from further injury After assessing the type and extent of the wound control bleeding by applying direct pressure on it with a sterile or clean dressing such as a washcloth After bleeding subsides an adhesive bandage or gauze dressing taped over the laceration allows skin edges to close and a blood clot to form Normally allow a puncture wound to bleed to remove dirt and other contaminants such as saliva from a dog bite When a penetrating object such as a knife blade is present do not remove the object The presence of the object provides pressure and controls some bleeding The process of cleaning a wound involves selecting an appropriate cleaning solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue Gently cleaning a wound removes contaminants that serve as sources of infection However vigorous cleaning using a method with too much mechanical force causes bleeding or further injury According to Wound Ostomy and Continence Nurses Society WOCN guidelines normal saline is the preferred cleaning agent Regardless of whether bleeding has stopped protect a wound from further injury by applying sterile or clean dressings and immobilizing the body part A light dressing applied over minor wounds prevents entrance of microorganisms Dressings are discussed on subsequent slides Protect a wound from microorganism contamination Aid in hemostasis Promote healing by absorbing drainage and debriding a wound Support or splint the wound site Protect patients from seeing the wound if perceived as unpleasant Promote thermal insulation of the wound surface Protection Purposes of Dressings Protect a wound from microorganism contamination Aid in hemostasis Promote healing by absorbing drainage and debriding a wound Support or splint the wound site Protect patients from seeing the wound if perceived as unpleasant Dressings Dry or moist 10 Sunday April 19 2015 Promote thermal insulation of the wound surface Notes For surgical wounds that heal by primary intention it is common to remove dressings as soon as drainage stops In contrast when dressing a wound that is healing by secondary intention the dressing material becomes a means for providing moisture to the wound or assisting in debridement The dressing technique varies depending on the goal of the treatment plan for the wound If the goal is to maintain a moist environment for a clean granulating wound it is important to not let the salinemoistened gauze dressing dry and stick to it This is in direct contrast to the dressing technique that you use if the goal of care is to mechanically debride the wound using a saline wet todry dressing When wounds such as a necrotic wound require debriding use a wettodry dressing technique Place the moist dressing contact dressing into the wound and allow it to dry The contact dressing debrides necrotic tissue and debris In this case the contact dressing is allowed to dry so it sticks to underlying tissue and debridement occurs during removal Gauze Film dressing Hydrocolloid protects the wound from surface contamination Hydrogel maintains a moist surface to support healing Wound vacuum assisted closure VAC uses negative pressure to support healing Transparent film dressing Notes The use of dressings requires an understanding of wound healing and factors that influence healing A variety of dressing materials are available You will learn various dressing techniques in the nursing skills lab The choice of dressings and the method of dressing a wound influence healing Before placing a dressing on a pressure ulcer it is important to know the stage of the pressure ulcer to have done a thorough assessment of it and to understand the goal of the treatment the mechanism of action of the dressing and principles of wound care Gauze sponges are absorbent and are especially useful in wounds to wick away the wound exudate Gauze is available in different textures and in various lengths and sizes 4 x 4 is the most common size Gauze can be saturated with solutions and used to clean and pack a wound When used to pack a wound the gauze is saturated with the solution usually normal saline wrung out unfolded and lightly packed into the wound Use a film dressing as a secondary dressing and for autolytic debridement of small wounds It has the following advantages Adheres to undamaged skin Changing Know type of dressing placement of drains and equipment needed Prepare the patient for a dressing change 11 Notes Sunday April 19 2015 Serves as a barrier to external fluids and bacteria but still allows the wound surface to breathe because oxygen passes through the transparent dressing Promotes a moist environment that speeds epithelial cell growth Can be removed without damaging underlying tissues Permits viewing a wound Does not require a secondary dressing Hydrocolloid dressings are dressings with complex formulations of colloid elastomeric and adhesive components They are adhesive and occlusive The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds they are available in a variety of sizes and shapes This type of dressing has the following functions Absorbs drainage through the use of exudate absorbers in the dressing Maintains wound moisture Slowly liquefies necrotic debris s impermeable to bacteria and other contaminants s selfadhesive and molds well Acts as a preventive dressing for highrisk friction areas May be left in place for 3 to 5 days minimizing skin trauma and disruption of healing Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerinbased amorphous gel Hydrogel has the following advantages s soothing and can reduce wound pain Provides a moist environment Debrides necrotic tissue by softening necrotic tissue Does not adhere to the wound base and is easy to remove Transparent film dressing is ideal for small superficial wounds such as partial thickness wounds and to protect highrisk skin Evaluate pain Describe procedure steps Gather supplies Recognize normal signs of healing Answer questions about the procedure or wound A complete patient and wound history is essential in determining when a clean dressing technique is appropriate For example chronic pressure ulcer wounds use a clean technique On the other hand a fresh surgical wound requires sterile technique so as not to introduce microorganisms into a healing wound Follow health care facility for policies and procedures Document findings and report to other staff members Sunday April 19 2015 For very complex dressing care consult with the wound careenterostomal nurse or carefully develop a stepbystep procedure to provide consistent wound care Make sure to offer pain medications before beginning wound caredressing changes During a Dressing Change Assess the skin beneath the tape Perform thorough hand hygiene before and after wound care Wear sterile gloves before directly touching an open or fresh wound Remove or change dressings over closed wounds when they become wet or if the Notes Dressings Packing a wound 12 patient has signs or symptoms of infection and as ordered The health care provider s order for changing a dressing indicates the dressing type the frequency of changing and any solutions or ointments to be applied to the wound An order to reinforce dressing prn add dressings without removing the original one is common right after surgery when the health care provider does not want accidental disruption of the suture line or bleeding The medical or operating room record usually indicates whether drains are present and from what body cavity they drain After the first dressing change describe the locations of drains and the types of dressing materials and solutions to be used in the patient s care plan Follow the guidelines on the slide during a dressing change procedure Often it is necessary to teach patients how to change dressings in preparation for home care In this situation demonstrate dressing changes to the patient and family and then provide an opportunity for them to practice Assess size depth and shape Securing Tape ties or binders Comfort measures Notes Carefully remove tape Gently clean the wound Administer analgesics before dressing change Wound size depth and shape are important in determining the size and type of dressing used to pack a wound The dressing needs to be flexible and in contact with the entire wound surface Make sure that the type of material used to pack the wound is appropriate Many new dressing materials such as alginates are also used for packing If gauze is the appropriate dressing material saturate it with the ordered solution wring out unfold and lightly pack into the wound The entire wound surface needs to be in contact with part of the moist gauze dressing It is important to remember not to pack the wound too tightly Sunday April 19 2015 A treatment modality for wounds is negativepressure wound therapy NPWT or vacuumassisted closure one brand name is VAC It is discussed on the next slide NPWT is the application of subatmospheric negative pressure of a wound through suction to facilitate healing and collect wound fluid Use tape ties or a secondary dressing and cloth binders to secure a dressing over a wound site The choice of anchoring depends on the wound size and location the presence of drainage the frequency of dressing changes and the patient s level of activity To remove tape safely loosen the ends and gently pull the outer end parallel with the skin surface toward the wound Apply light traction to the skin away from the wound as the tape is loosened and removed Traction minimizes pulling of the skin Adhesive remover also loosens the tape from the skin If tape covers an area of hair growth the patient experiences less discomfort if you pull it in the direction of the hair growth Montgomery ties are discussed on a later slide Another method to protect the surrounding skin on wounds that need frequent dressing changes is to place strips of hydrocolloid dressings on either side of the wound edges cover the wound with a dressing and apply the tape to the dressing To provide even support to a wound and immobilize a body part apply elastic gauze or cloth bandages and binders over a dressing Use several techniques to minimize discomfort during wound care Carefully removing tape gently cleaning wound edges and carefully manipulating dressings and drains minimize stress on sensitive tissues Careful turning and positioning also reduce strain on a wound Administering analgesic medications 30 to 60 minutes before dressing changes depending on the time of peak action of a drug also reduces discomfort VAC VacuumAssisted Closure 13 The vacuumassisted closure VAC is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together Modifications have been made to the VAC The VAC lnstill allows intermittent instillation of fluids into the wound especially those wounds not responding to traditional negativepressure wound therapy NPWT NPWT is used in treating acute and chronic wounds The schedule for changing NPWT dressings varies depending on the type of wound and the amount of drainage Wear time for the dressing is anywhere from 24 hours to 5 days As the wound heals granulation tissue lines its surface The wound has a stippled or granulated appearance The surface area sometimes increases or decreases depending on wound location and the amount of drainage removed by the NPWT system NPWT is also used to enhance the take of splitthickness skin grafts It is placed over the graft intraoperatively decreasing the ability of the graft to shift and evacuating fluids that build up under it An airtight seal must be maintained Sunday April 19 2015 Montgomery Ties Montgomery ties are shown in these photos A Each tie is placed at side of dressing B Securing ties encloses dressing To avoid repeated removal of tape from sensitive skin secure dressings with pairs of reusable Montgomery ties Each section consists of a long strip half contains an adhesive backing to apply to the skin and the other half folds back and contains a cloth tie or a safety pin and rubber band combination that you fasten across a dressing and untie at dressing changes A large bulky dressing often requires two or more sets of Montgomery ties Cleaning Skin These three principles are important when cleaning an incision or the area surrounding a drain 1 Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin 2 Use gentle friction when applying solutions locally to the skin 3 When irrigating allow the solution to flow from the least to the most contaminated area Cleaning Skin and Drain Sites 1 Cleaning apply non cytotoxic solution 2 irrigation to remove exudates use sterile technique with 35mL syringe and 19G needle 3 Suture Care consult health care facility policy 4 Drainage Evacuators portable units exert a safe constant lowpressure to remove and collect drainage Notes Wound cleaning removes surface debris Wound cleaning requires good hand hygiene and aseptic techniques Clean surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation After applying a solution to sterile gauze clean away from the wound Never use the same piece of gauze to clean across an incision or wound twice You sometimes use irrigation to remove debris from a wound Irrigation is a special way of cleaning wounds Use an irrigating syringe to flush the area with a constant lowpressure flow of solution The gentle washing action of the irrigation cleans a wound of exudate and debris Always refer to health care facility policy and procedures for wound care and wound irrigation The patient s history of wound healing the site of surgery the tissues involved and the purpose of the sutures determine the suture material used Policies vary within institutions as to who is able to remove sutures If it is appropriate that the nurse remove them a health care provider s order is 14 Sunday April 19 2015 required An order for suture removal is not written until the health care provider believes that the wound has closed usually in 7 days When drainage interferes with healing evacuation is achieved by using a drain alone or a drainage tube with continuous suction You may apply special skin barriers including hydrocolloid dressings similar to those used with ostomies around drain sites The skin barriers are soft material applied to the skin with adhesive Drainage flows onto the barrier but not directly onto the skin If available consult the enterostomalwound care nurse Methods for Cleaning a Wound Site Methods for cleaning a wound site are diagrammed in this slide Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin Cleaning a Drain Site Clean in a direction from an isolated drain site to the surrounding skin Staples and Remover To remove staples insert the tips of the staple remover under each wire staple While slowly closing the ends of the staple remover together squeeze the center of the staple with the tips freeing it from the skin Types of Sutures lntermittent Continuous Blanket continuous Retention Removal of Intermittent Suture Removal of intermittent suture A Cut suture as close to skin as possible away from the knot B Remove suture and never pull contaminated stitch through tissues To remove sutures first check the type of suturing used With intermittent suturing the surgeon ties each individual suture made in the skin Continuous suturing as the name implies is a series of sutures with only two knots one at the beginning and one at the end of the suture line Retention sutures are placed more deeply than skin sutures and nurses may or may not remove them depending on agency policy The manner in which the suture crosses and penetrates the skin determines the method for removal Never pull the visible portion of a suture through underlying tissue Sutures on the surface of the skin harbor microorganisms and debris The portion of the suture beneath the skin is sterile Pulling the contaminated portion of the suture through tissues can lead to infection Clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side 15 Sunday April 19 2015 Drainage Evacuators This photo shows setting of suction on the drainage evacuator 1 With drainage port open raise level on diaphragm 2 Push straight down on lever to lower diaphragm 3 Closure of port prevents escape of air and creates vacuum pressure Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe constant lowpressure vacuum to remove and collect drainage Ensure that suction is exerted and that connection points between the evacuator and the tubing are intact The evacuator collects drainage Assess for volume and character every shift and as needed When the evacuator fills measure output by emptying the contents into a graduated cylinder and immediately reset the evacuator to apply suction Bandages and Binders Functions create pressure immobilize andor support a wound reduce or prevent edema secure a splint secure dressings Bandages Rolled gauze elasticized knit elastic webbing flannel and muslin Binder application Breast abdominal sling Notes At times simple gauze dressings do not supply adequate immobilization or support to a wound Bandages and binders are applied over or around dressings to provide extra protection andor therapeutic benefits by creating pressure over a body part immobilizing a body part supporting a wound reducing or preventing edema or securing a splint or dressing When binder or bandages are applied an assessment must be made Ask students what responsibilities nurses have before applying a bandage or binder Answers may include nspect skin for abrasions edema discoloration exposed wound edges Cover exposed wounds or open abrasions with a sterile dressing Assess the condition of underlying dressings and change if soiled Assess the skin of underlying areas that will be distal to the bandage for signs of circulatory impairment coolness pallor or cyanosis diminished or absent pulses swelling numbness and tingling to provide a means for comparing changes in circulation after bandage application After applying a bandage the nurse assesses documents and immediately reports changes in circulation skin integrity comfort level and body func on Binders are especially designed for the body part to be supported The most common type of binder is the abdominal binder Wellfitting bras are now replacing breast binders Both provide support after breast surgery or exert pressure to reduce lactation in a woman after childbirth 16 Sunday April 19 2015 Securing Binders The left drawing shows securing an abdominal binder with Velcro On the right is a diagram of a sling An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs Secure an abdominal binder with safety pins Velcro strips or metal stays May also use an incentive spirometer in addition to the binder Slings support arms with muscular sprains or fractures A commercially manufactured sling consists of a long sleeve that extends above the elbow with a strap that fits around the neck In the home patients can use a large triangular piece of cloth The patient sits or lies supine during sling application Instruct him or her to bend the affected arm bringing the forearm straight across the chest The open sling fits under the patient s arm and over the chest with the base of the triangle under the wrist and the point of the triangle at his or her elbow One end of the sling fits around the back of the patient s neck Bring the other end up and over the affected arm while supporting the extremity Tie the two ends at the side of the neck so the knot does not press against the cervical spine Fold the loose material at the elbow evenly around the elbow and pin Always support the lower arm and hand at a level above the elbow to prevent the formation of dependent edema Heat and Cold Therapy Assessment for temperature tolerance Assess the skin and skin integrity Assess the patient s response to stimuli Assess the equipment being used ldentify any contraindications Bodily responses to heat and cold Local effects of heat and cold Factors influencing heat and cold tolerance Application of heat and cold therapies Notes You will need to identify and understand normal body responses to localized temperature variations Heat and cold applied to an injured body part provide therapeutic benefit However level of consciousness influences the ability to perceive heat cold and pain If a patient is confused or unresponsive the nurse needs to make frequent observations of skin integrity after therapy begins Contraindications are reviewed on the next slide Bodily responses A person initially feels an extreme change in temperature but within a short time hardly notices it This is dangerous because a person insensitive to heat and cold extremes can suffer serious tissue injury You need to recognize patients most at risk for injury from heat and cold applications Local effects of heat Heat generally is quite therapeutic improving blood flow to an injured part However if heat is applied for 1 hour or longer the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area Periodic removal and reapplication of local heat restore 17 Sunday April 19 2015 vasodilation Continuous exposure to heat damages epithelial cells causing redness localized tenderness and even blistering Local effects of cold The application of cold initially diminishes swelling and pain Prolonged exposure of the skin to cold results in a reflex vasodilation The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia The skin initially takes on a reddened appearance followed by a bluishpurple mottling with numbness and a burning type of pain Skin tissues freeze from exposure to extreme cold Short exposures are more easily tolerated The very young and the very old are most sensitive to temperature changes The body responds best to minor temperature changes over smaller body areas Uneven temperature distribution suggests equipment malfunction A prerequisite to using any heat or cold application is a health care provider s order which includes the body site to be treated and the type frequency and duration of application Consult agency procedure manual for correct temperatures to use Contraindications to Cold and Heat Cold is contraindicated If the site of injury is edematous In the presence of neuropathy If the patient is shivering If the patient has impaired circulation Heat is contraindicated For areas of active bleeding For an acute localized inflammation Over a large area if a patient has cardiovascular problems Notes Cold further retards circulation to the area and prevents absorption of the interstitial fluid If the patient has impaired circulation eg arteriosclerosis this further reduces blood supply to the affected area Do not cover an active area of bleeding with a warm application because bleeding will continue Warm applications are contraindicated when the patient has an acute localized inflammation such as appendicitis because heat causes the appendix to rupture If a patient has cardiovascular problems it is unwise to apply heat to large portions of the body because the resulting massive vasodilation disrupts the blood supply to vital organs 18 Sunday April 19 2015 Evaluation 19 Was the etiology of the skin impairment addressed Were the pressure friction shear and moisture components identified and did the plan of care decrease the contribution of each of these components Was wound healing supported by providing the wound base with a moist protected environment Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine whether the patient has met the identified outcomes or goals If the identified outcomes are not met for a patient with impaired skin integrity possible questions to ask are shown on the slide Care of patients with a pressure ulcer or wound requires a multidisciplinary team approach Sunday April 19 2015 Skin Hair and Nails Structure and Function Think of skin as body s largest organ system Covers 20 square feet of surface area in adults Skin is sentry that guards body Environmental stresses eg trauma pathogens dirt Adapts it to other environmental influences eg heat cold Skin has two layers Epidermis outer highly differentiated layer Basal cell layer forms new skin cells Outer horny cell layer of dead keratinized cells Derivation of skin color Dermis inner supportive layer Connective tissue or collagen Elastic tissue Beneath these layers is a subcutaneous layer of adipose tissue Epidermal appendages Structures formed by tubular invagination of epidermis down into underlying dermis Hair Sebaceous glands Sweat glands important for fluid balance and thermoregulation Eccrine glands Apocrine glands Nails Skin is waterproof protective and adaptive Protection from environment Prevents penetration Perception Temperature regulation ldentification Communication Wound repair Absorption and excretion Production of vitamin D Subjective Data 20 Health History Questions Past history of skin disease allergies hives psoriasis or eczema Change in pigmentation or color Change in mole size shape color tenderness Excessive dryness or moisture Pruritus or skin itching Excessive bruising Rash or lesions Sunday April 19 2015 Medications prescription and overthecounter Edition Change Incidence of melanoma in whites is noted to be 20 times higher than in blacks and 4 times higher than in Hispanics Edition Change Skin conditions that are noted to be specific to black patients are as follows Keloids Pigmentary disorders Pseudofolliculitis Melasma Hair loss Change in nails shape color or brittleness Environmental or occupational hazards Selfcare behaviors Additional history for infants and children Does child have any birthmarks Any change in skin color as a newborn Physiologic jaundice Cyanosis Does child have any rash or sores Does child have diaper rash Does child have any burns or bruises Where How did it happen Has child been exposed to Contagious skin conditions scabies impetigo lice Communicable diseases measles chicken pox scarlet fever Toxic plants poison ivy Does child have habits such as nailbiting or twisting hair What steps are taken to protect child from sun exposure Additional history for adolescents Skin problems such as pimples blackheads Additional history for aging adults What changes have you noticed in your skin in last few years Any delay in wound healing Any change in feet toenails bunions wearing shoes Falling bruises trauma History of diabetes or peripheral vascular disease Objective Data Physical Examination Preparation Consciously attend to skin characteristics the danger is one of omission Equipment needed Strong direct lighting gloves penlight and small centimeter ruler For special procedures Wood s light Magnifying glass 21 Sunday April 19 2015 Materials for laboratory tests potassium hydroxide KOH and glass slide Variables that influence skin color include emotional states temperature cigarette smoking prolonged elevationdependent position of extremities and prolonged inactivity Complete Physical Examination Skin assessment integrated throughout examination Scrutinize the outer skin surface first before you concentrate on underlying structures Separate intertriginous areas areas with skinfolds such as under large breasts obese abdomen and groin and inspect them thoroughly These areas are dark warm and moist and provide perfect conditions for irritation or infection Always inspect feet toenails and between toes Regional Examination lndividuals may seek health care for skin problems and assessment focused on skin alone Assess skin as one entity getting overall impression helps reveal distribution patterns nspect lesions carefully With a rash check all areas of body as you cannot rely on the history that rash is in only one location Skills used are inspection and palpation because some skin changes have accompanying signs that can be felt nspect and palpate skin Color General pigmentation freckles moles birthmarks Widespread color change Note color change over entire body skin such as pallor pale erythema red cyanosis blue or jaundice yellow Note if color change transient or due to pathology Temperature Use backs of hands to palpate person Skin should be warm and temperature equal bilaterally warmth suggests normal circulatory status Hands and feet may be slightly cooler in a cool environment Hypothermia Hyperthermia Moisture Diaphoresis Dehydration Texture Thickness Edema Mobility and turgor Vascularity or bruising Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse Sunday April 19 2015 Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae forearms or on any available vein Lesions if any are present note Color Elevation Pattern or shape Size Location and distribution on body Any exudate note color and odor Use a Wood s light ultraviolet light filtered through special glass to detect fluorescing lesions nspect and palpate hair Color Texture Distribution Lesions nspect and palpate nails Shape and contour Profile sign view index finger at its profile and note angle of nail base it should be about 160 degrees Consistency Color Capillary refill Depress nail edge to blanch and then release noting return of color indicates status of peripheral circulation Color return is normally instant Sluggish color return takes longer than 1 or 2 seconds Promoting health and selfcare Teach skin selfexamination using ABCDE rule to detect suspicious lesions A asymmetry B border C color D diameter E elevation and enlargement Abnormal Findings 23 Shapes and configurations of lesions Annular or circular Confluent Discrete Grouped Gyrate Target or iris Linear Sunday April 19 2015 Polycyclic Zosteriform Polycyclic Primary skin lesions Macules Papules Patches Plaques Nodules Wheals Tumors Urticaria hives Vesicles Cysts BuHas Pustules Macule Papule Nodule Wheal VesicleBulla Cyst Pustule Secondary skin lesions Debris on skin surface Crusts Scales Break in continuity of skin surface Fissures Erosions Ulcers Excona ons Scars Atrophic scars Lichenifications Keloids Vascular Lesions Hemangiomas Portwine stain nevus flammeus Strawberry mark immature hemangioma Cavernous hemangioma mature Telangiectases Spider or star angioma Venous lake Purpuric lesions Petechiae Purpura 25 Sunday April 19 2015 Lesions caused by trauma or abuse Pattern injury Hematoma Contusion bruise Common skin lesions in children Diaper dermatitis lnterigo candidiasis lmpetigo Atopic dermatitis eczema Measles rubeola German measles rubella Chickenpox varicella Common skin lesions Primary contact dermatitis Allergic drug reaction Tinea corporis ringworm of the body Tinea pedis ringworm of the foot Psoriasis Tinea versicolor Labial herpes simplex cold sores Herpes zoster shingles Erythema migrans of Lyme disease Malignant skin lesions Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Metastic malignant melanoma Skin lesions associated with AIDS AlDSrelated Kaposi s sarcoma A vascular tumor is most common tumor in persons infected with HIV Considered an AIDSdefining illness Can occur at any stage of HIV infection Abnormal conditions of hair Seborrheic dermatitis cradle cap Tinea capitis scalp ringworm Toxic alopecia Alopecia areata Traumatic alopecia traction alopecia Trichotillomania Pediculosis capitis head lice Folliculitis Hirsutism Furuncle and abscess Abnormal conditions of nails Scabies Paronychia Beau s line Splinter hemorrhages Late clubbing Sunday April 19 2015 Onycholysis Pitting Habittic dystrophy Topical Medications Applied to skin or mucous membranes usually with local effects but may have systemic effects Use gloves and applicators May be administered by Directly applying liquid or ointment lnserting into a body cavity suppository lnstilling fluid into a body cavity ear drops rectal instillation lrrigating a body cavity flushing eye ear bladder Spraying medication into a body cavity nose throat Types Ointment salve or cream semisolid containing one or more meds Liniment usually alcohol oil or soapy emollient applied to skin Lotion liquid suspension that usually protects cools or cleanses skin Paste Thick ointment absorbed more slowly than ointment used for skin protection Transdermal disk or patch medicated disk or patch absorbed through skin slowly over long period of time 12 hours to 7 days Examples Nitroglycerin and Estrogens Guidelines for Transdermal td and Topical Medications Document where medication placed on MAR Whenever applying td patch ask patient if he has an existing patch Don t assume patch has fallen off or has been taken offAssess skin thoroughly before administering the medication When taking a medication history or reconciling medications Specifically ask patient if he takes medications in form of patches topical creams or any route other than oral lf dressing or patch are difficult to see apply a noticeable label to patch Document removal of patch or med on the MAR 26 Thursday March 19 2015 Unit 11 Chapter 12 Skin Hair and Nails Structure and Function Think of skin as body s largest organ system Covers 20 square feet of surface area in adults Skin is sentry that guards body Environmental stresses eg trauma pathogens dirt Adapts it to other environmental influences eg heat cold Structure and Function cont Skin has two layers Epidermis outer highly differentiated layer Basal cell layer forms new skin cells Outer horny cell layer of dead keratinized cells Derivation of skin color Dermis inner supportive layer Connective tissue or collagen Elastic tissue Beneath these layers is a subcutaneous layer of adipose tissue Structure of Skin Structure and Function cont Epidermal appendages Structures formed by tubular invagination of epidermis down into underlying dermis Hair Thursday March 19 2015 Sebaceous glands Sweat glands important for fluid balance and thermoregulation Eccrine glands Apocrine glands Nails Structure of Nails Structure and Function cont Skin is waterproof protective and adaptive Protection from environment Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Production of vitamin D Subjective Data Health History Questions Past history of skin disease allergies hives psoriasis or eczema Change in pigmentation or color Change in mole size shape color tenderness Excessive dryness or moisture Pruritus or skin itching Excessive bruising 2 Rash or lesions Medications prescription and overthecounter Subjective Data cont Health History Questions cont Hair loss Change in nails shape color or brittleness Environmental or occupational hazards Selfcare behaviors Subjective Data cont Additional history for infants and children Does child have any birthmarks Any change in skin color as a newborn Physiologic jaundice Cyanosis Does child have any rash or sores Does child have diaper rash Does child have any burns or bruises Where How did it happen Subjective Data cont Additional history for infants and children cont Has child been exposed to Contagious skin conditions scabies impetigo lice Communicable diseases measles chicken pox scarlet fever Thursday March 19 2015 Thursday March 19 2015 Toxic plants poison ivy Does child have habits such as nailbiting or twisting hair What steps are taken to protect child from sun exposure Subjective Data cont Additional history for adolescents Skin problems such as pimples blackheads Additional history for aging adults What changes have you noticed in your skin in last few years Any delay in wound healing Any change in feet toenails bunions wearing shoes Falling bruises trauma History of diabetes or peripheral vascular disease Objective Data Physical Examination Preparation Consciously attend to skin characteristics the danger is one of omission Equipment needed Strong direct lighting gloves penlight and small centimeter ruler For special procedures Wood s light Magnifying glass Materials for laboratory tests potassium hydroxide KOH and glass slide Objective Data Physical Examination cont Complete Physical Examination Skin assessment integrated throughout examination 4 Thursday March 19 2015 Scrutinize the outer skin surface first before you concentrate on underlying structures Separate intertriginous areas areas with skinfolds such as under large breasts obese abdomen and groin and inspect them thoroughly These areas are dark warm and moist and provide perfect conditions for irritation or infection Always inspect feet toenails and between toes Objective Data Physical Examination cont Regional Examination Individuals may seek health care for skin problems and assessment focused on skin alone Assess skin as one entity getting overall impression helps reveal distribution patterns Inspect lesions carefully With a rash check all areas of body as you cannot rely on the history that rash is in only one Ioca on Skills used are inspection and palpation because some skin changes have accompanying signs that can be felt Objective Data Physical Examination cont Inspect and palpate skin Color General pigmentation freckles moles birthmarks Widespread color change Note color change over entire body skin such as pallor pale erythema red cyanosis blue or jaundice yellow Note if color change transient or due to pathology Objective Data Physical Examination cont Inspect and palpate skin cont 5 Thursday March 19 2015 Temperature Use backs of hands to palpate person Skin should be warm and temperature equal bilaterally warmth suggests normal circulatory status Hands and feet may be slightly cooler in a cool environment Hypothermia Hyperthermia Moisture Diaphoresis Dehydration Objective Data Physical Examination cont Inspect and palpate skin cont Texture Thickness Edema Mobility and turgor Vascularity or bruising Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae forearms or on any available vein Objective Data Physical Examination cont Inspect and palpate skin cont Lesions if any are present note Color Thursday March 19 2015 Elevation Pattern or shape Size Location and distribution on body Any exudate note color and odor Use a Wood s light ultraviolet light filtered through special glass to detect fluorescing lesions Objective Data Physical Examination cont Inspect and palpate hair Color Texture Distribution Lesions Objective Data Physical Examination cont Inspect and palpate nails Shape and contour Profile sign view index finger at its profile and note angle of nail base it should be about 160 degrees Consistency Color Capillary refill Depress nail edge to blanch and then release noting return of color indicates status of peripheral circulation Color return is normally instant Sluggish color return takes longer than 1 or 2 seconds Thursday March 19 2015 Objective Data Physical Examination cont Promoting health and selfcare Teach skin selfexamination using ABCDE rule to detect suspicious lesions A asymmetry B border C color D diameter E elevation and enlargement Abnormal Findings Shapes and configurations of lesions Annular or circular Confluent Discrete Grouped Gyrate Target or iris Linear Polycyclic Zosteriform Annular or Circular Confluent Discrete Gyrate Grouped Unear Target Zosteriform Polycyclic AbnonnathK ngscont Primary skin lesions Macules Papwes Patches Plaques Nodmes mews Tumors Urticaria hives Vesicles Cysts BwMS Pusu es Macule Papwe Nodum mmem VesicleBulla Cyst Pustule Thursday March 19 2015 Abnormal Findings cont Secondary skin lesions Debris on skin surface Crusts Scales Break in continuity of skin surface Fissures Erosions Ulcers Excona ons Scars Atrophic scars Lichenifications Keloids Crust Scale Fissure Erosion Ulcer Excona on Scar Atrophic Scar Lichenification Keloid 10 Thursday March 19 2015 Abnormal Findings cont Vascular Lesions Hemangiomas Portwine stain nevus flammeus Strawberry mark immature hemangioma Cavernous hemangioma mature Telangiectases Spider or star angioma Venous lake Purpuric lesions Petechiae Purpura Lesions caused by trauma or abuse Pattern injury Hematoma Contusion bruise Lesions Caused by Trauma or Abuse Pattern Injuries Lesions Caused by Trauma or Abuse Hematomas Lesions Caused by Trauma or Abuse Contusions Abnormal Findings cont Common skin lesions in children Diaper dermatitis lnterigo candidiasis Impetigo Atopic dermatitis eczema 11 Thursday March 19 2015 Thursday March 19 2015 Measles rubeola German measles rubella Chickenpox varicella Abnormal Findings cont Common skin lesions Primary contact dermatitis Allergic drug reaction Tinea corporis ringworm of the body Tinea pedis ringworm of the foot Psoriasis Tinea versicolor Labial herpes simplex cold sores Herpes zoster shingles Erythema migrans of Lyme disease Abnormal Findings cont Malignant skin lesions Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Metastic malignant melanoma Abnormal Findings cont Skin lesions associated with AIDS AIDSrelated Kaposi s sarcoma A vascular tumor is most common tumor in persons infected with HIV 12 Considered an AIDSdefining illness Can occur at any stage of HIV infection Abnormal Findings cont Abnormal conditions of hair Seborrheic dermatitis cradle cap Tinea capitis scalp ringworm Toxic alopecia Alopecia areata Traumatic alopecia traction alopecia Trichotillomania Pediculosis capitis head lice Folliculitis Hirsutism Furuncle and abscess Abnormal Findings cont Abnormal conditions of nails Scabies Paronychia Beau s line Splinter hemorrhages Late clubbing Onycholysis Pitting Habittic dystrophy Topical Medications 13 Thursday March 19 2015 Thursday March 19 2015 Applied to skin or mucous membranes usually with local effects but may have systemic effects Use gloves and applicators May be administered by Directly applying liquid or ointment Inserting into a body cavity suppository lnstilling fluid into a body cavity ear drops rectal instillation lrrigating a body cavity flushing eye ear bladder Spraying medication into a body cavity nose throat Topical Medications cont Ointment salve or cream semisolid containing one or more meds Liniment usually alcohol oil or soapy emollient applied to skin Lotion liquid suspension that usually protects cools or cleanses skin Paste Thick ointment absorbed more slowly than ointment used for skin protection Topical Medications cont Transdermal disk or patch medicated disk or patch absorbed through skin slowly over long period of time 12 hours to 7 days Examples Nitroglycerin and Estrogens Guidelines for Transdermal td and Topical Medications Document where medication placed on MAR Whenever applying td patch ask patient if he has an existing patch 14 Thursday March 19 2015 Don t assume patch has fallen off or has been taken offAssess skin thoroughly before administering the medication When taking a medication history or reconciling medications Specifically ask patient if he takes medications in form of patches topical creams or any route other than oral If dressing or patch are difficult to see apply a noticeable label to patch Document removal of patch or med on the MAR 15 VVednesdayApnl222015 Nutrition amp Nutritional Assessment Enteral Nutrition Client is unable to ingest foods or transport of food to small intestine is interrupted Nasogastric tubes Nasoenteric tubes Gastrostomy tubes Jejunostomy tubes Nasogastric Tubes LevinSalem Sump Used for clients with intact gagcough reflex with adequate gastric emptying Short term feedings Nasogastric Tube Insertion Clean technique Obtain supplies Assess patient s nares Determine ability to assist with procedure Prepare equipment Place patient in High Fowler s Measure for placement of tube Mark with tape Curl end of tube around finger Lubricate 34 inches Ask patient to tilt head back lnsert tube past nasopharynx Stop allow patient to relax give cup of water Ask patient to swallow while you advance Tilt head forward advance to mark Verify placement Secure tube Verify Tube Placement When do you verify placement At insertion Before each feeding At least once per shift when continuous feeding being administered How do you verify placement Radiography Mark the tube with indelible ink or tape at its exit point from the nose Document the length of visible tubing for baseline data Wednesday April 22 2015 Verify Tube Placement Using the AAA system Assess Abdomen Nostril amp skin Tube Throat Air lnject 30 ml of air into the tube Aspirate Test pH Note color amp consistency Nasoenteric Tubes Longer tube than nasogastric tubes lnserted to upper small intestine Long term use For those at risk for aspiration GastrostomyJejunostomy Tubes Long term nutritional support Placed surgically May be inserted through endoscopy Tube Feedings lntermittent 300500 ml of feeding several times per day Continuous Administered over a 24hour period using an infusion pump Cyclic Feedings administered in less than 24 hours Feedings often administered at night and client tries to eat during the day Tube Feeding Methods Administering the feeding Clean technique Gather supplies Semi to High Fowler s position Verify placement Check residual Reinstill gastric contents Flush with 30 ml water Administer feeding Tell client feeding should not be uncomfortable but they may feel a quness Syringeintermittent feeding Continuous feeding Wednesday April 22 2015 Additional Nursing Considerations Blood glucose Monitor intake amp output Daily weight Respiratory assessment Gl assessment Skin assessment for PEG tube Monitor for NND NasogastricGastrostomy Medications Check with pharmacy to see if medication comes in liquid form If not may need to crush pills Dissolve crushed tablets in warm waterother liquid DO NOT ADMINISTER WHOLE OR UNDISSOLVED MEDICATIONS f tube connected to suction disconnect suction amp keep tube clamped for 2030 min after giving the medication Always check and confirm NGT placement before administering medications Flush the tube with at least 1530 ml 510 ml for children of water before administering medications If there are several meds administer each one separately and flush with at least 15 ml 3 ml for children of water between each When you have finished administering all medications flush with another 15 to 30 ml of water to clear the tube Nutritional Assessment Subjective Eating patterns number of mealssnacks kindamount of food eaten diets where is food eaten food preferencesdislikes culturalreligious restrictions able to feed self Usual Weight eight change desiredundesired did you try to lose weight Changes in appetite taste smell chewingswallowing what kind when Recent surgery trauma burns infection when type treatment Chronic illness type treatment recent chemoradiation Vomiting diarrhea constipation Allergies type of reaction and for how long Medications nutritional supplements prescriptions over counter daily Selfcare behaviors income transportation who preparesshops Alcohol or illegal drug use Exercise Family history cardio osteoporosis cancer gout GI disorders obese diabetes Wednesday April 22 2015 Bowel Elimination Factors Affecting Bowel Elimination Age Table 461 Pg 1090 Diet Fluid intake Physical activity Psychological factors Personal habits Position during defecation Pain Pregnancy Surgeryanesthesia Medications Diagnostic tests Assessment Nursing History Elimination pattern Characteristics of stool Routines Use of medications or enemas Presence of bowel diversion Changes in appetite Diet and fluid intake Subjective Prior medical history and use of medications Emotional state Exercise patterns Presence of discomfort Social history Mobility and dexterity Objective Mouth Abdomen Rectum Laboratory Tests Fecal occult blood testing Wednesday April 22 2015 Common Bowel Elimination Problems Constipation lmpaction Diarrhea 4ncon nence Flatulence Constipation Evaluate individual s pattern of stooling Promoting Regular Defecation Privacy Timing Nutrition and fluids Exercise Positioning Medications Cathartics or Laxatives Drugs that induce defecation Contraindicated if patient has nausea cramps colic vomiting or undiagnosed abdominal pain Do not overuse May be given as suppositories Enemas Cleansing Remove feces Prevent escape of feces during surgery Prepare intestine for diagnostic tests colonoscopy Remove feces in instances of constipation or impaction Types of Solutions Fleet phosphate enemahypertonic commercially prepared Tap water hypotonic can cause circulatory overload Normal Salineisotonic considered safest to use Soapsuds stimulate peristalsis by increasing the volume in the colon and irritating the mucosa High Enemas Cleanse as much of the colon as possible Turn from the left lateral to the dorsal and then to the right lateral during administration Low Enemas Clean the rectum and sigmoid colon only Left lateral position during administration Wednesday April 22 2015 Diarrhea lncrease in frequency of stools or liquid stools TreatmentPrevention of Diarrhea lntake of fluids and bland food Small amounts Avoid excessively hot or cold fluids Avoid highly spiced foods and insoluble fiber foods lncrease intake of foods high in potassium and sodium Avoid caffeine and alcoholic beverages Limit fatty foods Antidiarrheal Medications Slow the motility of the intestine or absorb excess fluid in the intestine lf last more than 34 days determine cause Over the counter medications Prescription opiates Flatulence Measures to prevent Limit carbonated beverages Don t use straws or chewing gum Avoid gas producing foods Exercise Bowel Diversion Ostomies Permanent Temporary Pages 10931096 Pictures and Care of Ostomy Bowel Diversion Ostomies Bowel Diversion Ostomies Bowel Diversion Ostomies Sunday April 19 2015 Putting It All Together Complete Health Assessment The art of arranging all the steps you have learned so far You may have to pause and think of what comes next rather than just gather data Repeated rehearsals will make it smoother You will come to the point at which the procedure flows naturally Even if you forget a step you will be able to insert it gracefully into next logical place The following sequence is one suggested route It is intended to minimize the number of position changes for the patient and for you Sequence 1 Patient walks into room sits the examiner sits facing the patient the patient is in street clothes Look at how they are dressed smell for body odors do they look the age they are stated as being 2 Collect the history Physical Examination General appearance Appears stated age Level of consciousness Skin color Nutritional status do they appear malnourished Dietary restrictions Posture and position comfortably erect kyphosis Stooped over appearance Are they sitting erect Obvious physical deformities is the nose midline or off to the side broken nose Mobility ask them to stand up and walk back Gait Use of assistive devices Range of motion ROM of joints No involuntary movement ticks twitches hand trimmers Able to rise from a seated position easily need to use side rails or need your help Facial expression Mood and affect Speech articulation smooth slurring pattern content appropriate native language need interpreter Hearing do you have to speak up Personal hygiene smell body odor clean shaven Measurement Weight Height Compute body mass index system will do it for you Vision using Snellen s eye chart or E chart Pediatric chart with pictures Sunday April 19 2015 Skin Examine both hands and inspect nails capillary refill clubbing color blue purple or healthy pink For the rest of the examination examine skin with corresponding regional examination Vital signs Radial pulse Respirations count even though they have already been done Blood pressure is it high or low Is it always high or low Environmental factors Time of day Temperature if indicated Head and face nspect face expression symmetry CN Vll PERRLA Pupil equal round and reactive to light and accomidation Neck lnspect neck for symmetry lumps and pulsations nspect and palpate carotid pulse one side at a time if indicated listen for carotid bruit Palpate trachea in midline nspect mouth and throat too Teeth mouth uvula tonsils tongue bucal mucosa Chest posterior and lateral nspect the posterior chest configuration of thoracic cage skin characteristics and symmetry of shoulders and muscles Respiratory rate Auscultate breath sounds note any adventitious sounds clear wheezing Move around to face patient patient remains sitting For a female breast examination ask permission to lift gown to drape on shoulders exposing anterior chest For male lower gown to the lap Heart Ask person to lean forward and exhale briefly auscultate cardiac base for any murmurs Auscultate all areas with bell and diaphragm nspect precordium for any pulsations or heave lift Palpate apical impulse and note location LAYING OR TURNED TO LEFT SIDE Palpate precordium for any abnormal thrill Auscultate apical rate and rhythm is it regualr or irregular Does it skip a beat Is it fast tachycardic Upper extremities Test ROM and muscle strength of hands arms and shoulders Pulses Capillary refill Abdomen nspect for contour symmetry skin characteristics umbilicus and pulsations Auscultate bowel sounds Auscultate for vascular sounds over aorta and renal arteries Percuss all quadrants Palpate all quadrants Sunday April 19 2015 Lower extremities lnspect for symmetry skin characteristics hair distribution and edema grade it 1 234 pitting Does it stay depressed when you press down Palpate pulses posterior tibial and dorsalis pedis pulses Palpate for temperature and sensation Assess capillary refill Assess ROM and strength bilaterally Reassessment of the Hospitalized Adult Starts Assessment of PT Patient does not require a complete headtotoe physical examination as just described during every 24hour stay Specialized examination at least every 8 hours Also remember that many assessments must be done frequently throughout course of a shift Safety check q 2 hours Assessments q 4 hours More frequently on specialized units after a procedure or in ICU Note that some measurements such as daily weights abdominal girth or circumference of a limb must be taken very carefully and recorded in the medical record Outline of initial assessment As you perform this sequence take note of anything that will need continuous monitoring such as a blood pressure or pulse oximetry reading that is not what you expect or breath sounds suggesting difficult respiratory effort If there is no protocol in place for a particular assessment situation then decide for yourself how often you need to check on person s status It is very easy to be distracted by ringing bells and alarms as shift progresses but your judgment about patient needs is just as important as any electronic alert or alarm Reassess abnormalities at least every 2 hours Your assessments must be thorough and accurate yet you must be able to complete them rapidly without seeming hurried Basic reassessment applies to adults in medical surgical and in cardiac step down care areas Each assessment must then be specialized to each adult and findings must be integrated into your complete knowledge base regarding patient This includes what you read in chart what you hear in reports and results of any laboratory tests and diagnostic imaging that are available Health History On your way into room First of allNote and verify that necessary markers or flags are in place at doorway regarding such conditions as isolation precautions latex allergies or fall precautions Once in the room is when your inspection begins FRST Introduce yourself as patient s nurse for next shift Sunday April 19 2015 Make direct eye contact and ask how he or she is feeling how he or she spent previous shift and if he or she is having any pain or discomfort Start your safety check Refer to what you have heard from previous shift in process of your own questioning This alleviates person s frustration at answering same questions every time a new staff member enters Offer waterice if appropriate as a courtesy and note data this gives you Person s level of consciousnessresponsiveness ability to hear follow directions speech and especially ability to swallow As you collect this and subsequent history note general appearance Complete your initial overview by verifying that correct name band has been applied to wrist Objective Data General appearance Facial expression Body position amplor posture Level of consciousness Skin color Nutritional status Speech Hearing Measurement Temperature Pulse Respiration Blood pressure Pulse oximetry at least 92 don t want to chart any abnormalities if below this talk to nurse don t chart it Rate pain level on 1 to 10 scale pain tolerance lf pain medication given note response 15 minutes for IV administration to note any change in pain level REASSESS PAIN LEVEL Up to 1 hour for oral administration REASSESS AFTER AN HOUR Neurologic system Eyes open spontaneously to name Eye contact Motor response Verbal response Pupi size in mm and reaction right and left Muscle strength right and left upper right and left lower Any ptosis facial droop Sensation Communication Ability to swallow Sunday April 19 2015 Respiratory system Oxygen delivery method Liters per minute or FIOZ Respiratory effort Auscultate breath sounds comparing side to side No need for egophony bronchophony whispered pectoriloquoy unless abnormal breath sounds or consolidation Ask patient to cough and deep breathe any mucus Just know that it is abnormal and you tell the nurse Check color and amount pt states this color save it next time so you can see it Productive Unproductive With a post op surgical client keep in mind a sign of lack of oxygen to the brain or potential clot formation can be seen with increased restlessness with your patient Cardiovascular system Auscultate rhythm at apex Is it regular Check apical pulse against radial pulse noting perfusion of all beats Assess radial dorsalis pedis and posterior tibialis comparing right to left Check popliteal pulse Assess heart sounds in all auscultatory areas first with diaphragm repeat with bell Check capillary refill for prompt return and clubbing Assess for JVD you can do it with tongue depressors Will be obvious they have it Check pretibial edema Verify that the proper IV solution is hanging and flowing at the proper rate according to the physician s orders and assess the IV site Skin Note skin color consistent with person s racial heritage Palpate skin temperature expect warm and dry Pinch up a fold of skin under clavicle or on forearm to note mobility and turgor Note skin integrity any lesions and the condition of any dressings and drains Complete any standardized scales used to quantify risk of skin breakdown Verify that any air loss or pressure loss surfaces being used are properly applied and operating at correct settings Any protection of bony prominences and high risk areas for skin breakdown Huge when pt is first admitted to the hospitalif not documented insurance won39t pay for a dime Abdomen Assess contour of abdomen flat rounded Listen to bowel sounds in all four quadrants minimum of 5 minutes Check any tube placement for drainage and insertion site integrity Note color and amount of drainage Type of tube and location lnquire whether passing flatus or stool Stool noted for color consistency and amount Ask patient if they are passing gas Last time they had a BM color etc Keep in mind that if you have a post operative surgical patient for the first Sunday April 19 2015 2448 hours they may experience a paralytic ileus from undergoing general anesthesia until all the anesthesia has gotten out of their system Genitourinary lnquire whether voiding regularly Check urine for color clarity amount Normal is 3040mLhr 8002000 mLday Note any drainage devices foleysuprapubic catheter or ostomy bag Record output a minimum of every shift lf urine output is below expected value perform a bladder scan according to agency protocol s problem in production of urine or its retention KNOW FORMULAAND BRING CALCULATOR Activity Activity level Dependence Ad lib assist total care Tolerance of activity do they tire after 5 minutes Use of ambulatory aid or equipment Complete any standardized scales used to quantify the patient s risk for falling Safety Check Siderail position brake used bed position location of call light phone waterice chairs bedside commode urinal etc Charting Paper charting Eectronic charting Charting in most hospitals is at least partially computerized Important lab values to commit to memory Hemoglobin Men 1418 Women 12 16 Hematocrit Men 4252 Women 3747 Sodium Na 136145 mEqL Potassium K 3550 mEqL PT 11125 seconds Go with INR Stands for Pro Time How long it takes blood to clot lnr 076127 Bleeding times People on blood thinners Serum Creatinine Men 0612 mgmL Women 0511 mgmL BUN 1020 mgmL Blood uria nitrogen Glucose values Normal Person Minimum fasting 70 Maximum fasting 100 Post Prandial less than 140 Pre Diabetic Minimum fasting 101 Maximum fasting 126 Post Prandial 140200 Diabetic Minimum fasting more than 126 Maximum fasting more than 126 Post Prandial more than 200 Sunday April 19 2015 Sunday April 19 2015
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