NUR 231 Test 2 Notes Bundle
NUR 231 Test 2 Notes Bundle NUR 231
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This 80 page Bundle was uploaded by Issy Notetaker on Sunday October 4, 2015. The Bundle belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 166 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.
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Date Created: 10/04/15
Chapter 31 0 Medication is used in diagnosis treatment cure relief and prevention 0 Every HC facility plays a role in the safe administration of medication and the evaluation of the effects 0 Nurses are responsible in all settings for the evaluation of the effects teaching about medications and effects adherence to dosage schedule and evaluating ability to selfadminister Scienti c Knowledge Base 0 To administer drugs safely nurse must have an understanding of the legal aspects of HC Pharmacology pharmacokinetics life sciences pathophysiology anatomy and math Allows use to why we are giving it what it will do to the body therefore we know it was the right decisions to administer 0 Medication in Legislation and Standards Federal Regulates pharmaceutical industry to protect people Ensures medications are safe and effective 1St law was Pure Food and Drug Act Sets standards for safety potency and ef cacy FDA enforces laws 0 Ensures all medications have gone under rigorous testing To be in pure and controlled form for pt Re nes and controls distribution testing naming and labeling regulation of controlled substances USP set standards for strength purity quality packaging safety labeling dose form Medwatch was implemented to encourage HC staff to report when a medication is improperly labeled o If a medication I found to have an adverse effect physician lls out a form and turns it in Medication then goes under more testing State and Local must conform to federal Additional controls control of substances that are not regulated by federal 0 Alcohol and tobacco Health Care Institutions and Medication Laws 0 Meet federal state and local 0 Size of agency determines services provided 0 More restrictive than governmental Medication Regulations and Nursing Practice 0 Nurse Practice Acts have large in uence over nursing 0 Protect pt from nurses 0 De ne scope of practice 0 Broad 0 HC agencies are not able to modify expand or restrict to intent of the act 0 Main purpose is to protect people from those uanensed Controlled Substance Acts are to be followed strictly o If not followed nes imprisonment or loss of license can occur 0 PharmacologicalConcepts Medication Names 0 Chemical Name exact description of composition and molecular structure 0 Generic Name Given by manufacturer 0 Becomes official name listed in US pharmacopeia 0 Ex Acetaminophen Trade namebrand name name medication is marketed under 0 Ex Tylenol Be sure to obtain exact spelling of medications Classi cation 0 Indicates effect of medication on the body symptoms relieved desired effects 0 More than one medication can be in a classi cation 0 One medication can be in more than one classi cation 0 A medication can have more than one desired effect Medication Forms 0 Form determines route of administration 0 Composition of medication determines absorption and metabolism 0 Tablets Capsules elixirs suppositories 0 Solid liquid oral topical parenteral instillation o Pharmacokinetics as the basis of Medication Actions Study of how medications enter the body are absorbed reach action site alter function metabolize and then leave the body Used when timing administration selecting route considering risks for alterations to actions evaluating pt response Absorption Passage of molecules into the blood from site of administration and has many in uencing factors 0 Route of Administration 0 Each routedifferent absorption rate Skin Slow Mucus membranes and Respiratory system Fast Oral Slow IV most rapid Ability of medication to dissolve o Depends on preparation form 0 Body absorbs solutions and suspensions in liquid state faster than tablets and capsules 0 Acidic will pass through mucosa quickly Blood Flow to Administration Site 0 Richer suppyquicker absorption Body SA 0 LargerQuicker absorption 0 Reason why more are absorbed in small intestine instead of stomach Lipid Solubility o Lipid soluble cross cell membranes easily and absorb quickly 0 Some are absorbed quickly when food is in stomach Food changes medication structure 0 Also why sometimes food should not be taken w medication Time administration to have meds before during or after feeding 0 Some medications interfere w each other Make sure they are not given at the same time 0 Know medication medication or medicationfood interactions before administering the medication Distribution Moved to site of action Rate and extent are dependent upon factors Physical and chemical properties of the medication and physiology of person taking medication Circulation 0 Medication enter blood and are passed through system 0 More circulation to sitequicker effect 0 Impaired circulationslows distribution Membrane Permeability 0 Ability of medications to pass through tissues and membranes 0 Some membranes are barriers BBB or placental membrane Protein Binding 0 Degree to which medications bind to serum proteins 0 Protein levels will affect binding ability Older have less albumin Metabolism After reaching site of action it is metabolized into a lessinactive form to excretion Biotransformation Enzymes detoxify breakdown remove biologically active chemicals 0 Occurs in liver lungs kidneys blood intestines Liver oxidizes and transforms toxic substances 0 O Excretion Degrades harmful chemicals Function decreases with age or liver disease Decrease in rate of metabolism and excretion Increased risk for toxicity 0 Exit body from kidneys liver bowel lungs exocrine glands Chemical makeup of medication determines exit route 0 O O Lungs Gaseous and Volatile Exocrine Lipid soluble Good hygiene is needed GI Medication that enter hepatic circulation and are excreted into bile Kidneys Main route Renal function decrease increase in risk for toxicity 0 Types of Medication Action Va ry Every pt will respond differently Don39t always respond in same way to repeated doses Therapeutic Effects Expected or predicted effect Desired effect Some medications have multiple Know this in order to provide pt education and evaluate accurately Side EffectsAdverse Effects 0 Side Predicable and unavoidable secondary effects 0 O O Harmless or can cause injury If more serious than therapeutic effect drug will be stopped Major cause of pt stopping medication use Adverse Unintended and undesirable unpredictable severe responses 0 O O 0 If these occur a Medwatch form is led Immediate or delayed Recognize early for discontinuation of medication HCP must report to FDA Toxic Effects 0 0 Develop after prolonged intake or when there is an accumulation in the blood Can have lethal effects 0 Some antidotes are available Idiosyncratic Reactions unpredictable overunder reaction or has a different reaction to the medication that is not normal Allergic Reactions Unpredictable immunoglobulin reactions 0 Common w antibiotics 0 1st dose causes sensitization and every dose after elicits and antibody attacking response 0 Medication allergy symptom may vary 0 Can be life threatening o If known history of allergies it should be documented and pt should wear a bracelet 0 Medication Interactions When one medication modi es the action of another medication Common Can increase or diminish effects Synergistic When the effect of the medications together is greater than the effect of the medications alone Can be desired when the effect is bene cial 0 Timing of Medication Dose Responses lV administration act immediately Other routes take time for effect to begin Quantity and distribution are constantly changing MEC minimum effective concentration is plasma level concentration that is too low to give off an effect Toxic Concentration level of concentration when toxicity occurs Therapeutic Range Between MEC and toxic Highest level is the peak and lowest is the trough concentration 0 Peak Time when medication reaches highest effective concentration 0 Trough Minimum blood serum concentration level before the next dose 0 Onset Time taken for medication to create a response 0 Time is takes for medication to produce greatest result 0 Plateau Where blood serum concentration is maintained 0 IV infusion peaks are reached quickly and levels fall quickly Trough levels are drawn 30 minutes before administering the next dose and peak 30 minutes after Biological 12 life time taken for a the concentration to be lowered to 12 by the excretion process 0 Half every interval until is it completely excreted To maintain a therapeutic plateau then the drug must be administered at regular intervals around the clock 0 One dose is given and then another when the rst reaches 12 life Some facilities have drug schedules that can be altered by the nurse and their knowledge about the medication A hospital needs to identify 0 Time critical medications Must be given w 30 minutes before or after schedule 0 Non time critical medications must be give 60120 minutes before or after schedule 0 Teach pt about time schedules in words that they are able to understand 0 Routes of Administration Depends on properties and desired effect of medications and pt mental and physical condition Oral routes Easiest and most commonly used 0 Given by mouth and swallowed w food generally more preferred Slower onset prolonged effect Sublingual Administration Placed under tongue and dissolved not swallowed 0 Don t eat or drink anything until drug is completely dissolved Buccal Administration Place medication in mucus membrane of the cheek until it dissolves 0 Alternate cheeks with each dose 0 Don t chew swallow or drink w tablet Parenteral Routes Injection of medication into tissues 0 Four sites 0 Intradermal into dermis o Subcutaneous into subcutaneous tissue 0 Intramuscular Into mm o Intravenous Into vein 0 The other ways listed are not normally done by a nurse but they are responsible for monitoring the medication delivery system understanding the medication given and evaluation of the pt response Epidural into epidural space through a catheter 0 Regional analgesia 0 Nurses w advanced education can place and administer medication via epidural IntrathecaI Catheter placed in subarachnoid space or in a ventricle in the brain 0 Medication is delivered by Physicians and specially educated nurses 0 Usually long term medication lntraosseous lnfusing medication into the bone marrow o Commonly used in children lntraperitoneal Administered into peritoneal cavity to be absorbed o Chemotherapeutic agents insulin antibiotics lntrapleural administered in pleural space 0 Chemotherapeutic agents 0 Medications to relieve pleural effusion promoting adhesion lntraarterial Medication into arteries 0 Common w arterial clots lntracardiac into the heart and lntraarticular into joint are also used TopicalAdministration Direct or in the body cavity Applied to skin and mucus membranes Local effects Apply by 0 Spreading over area 0 Applying moist dressings o Soaking body parts 0 Giving medical baths Thins or breaks down skins Transdermal disks or patches have more systemic effects 0 Fixed to skin and left in place for 12 hours to 7 days Mucus membrane administration 0 Liquid or ointment direct application Inserting medication into body cavity lnstilling medication into a body cavity lrrigating body cavity Spraying medication onto body cavity OOOO Inhalation Through nasal and oral passages Endotracheal or tracheostomy tubes are also used if inserted Absorbed quickly into the rich vascularized lungs Local or systemic effects lntraocular Inserting medication into eye on a contact like lens Can remain for up to a week 0 Systems of Medication Measurement Proper administration depends on ability to correctly calculate and measure dosages Errors can be fatal 0 Nursing Knowledge 0 O 0 Clinical calculations must be held wout error Most facilities use the metric system Apothecary system is hardly used Metric System Most logically set up Decimal system Easily convertible Basic units 0 Length Meters m 0 Weight Grams g 0 Volume Liters L Convert fractions to decimals Leading zero is always placed in front of a decimal but there is NO trailing zero Household Measurements Most familiar to people Inaccurate Usually used for dischrage Items used in measurement often vary in size Scales are not well calibrated Include o Drops teaspoons Tablespoons cups pints quarts Convenient when accuracy is not critical Solutions Various concentrations Used for o Injections irrigations and infusions A given mass of a solid substance that is dissolved in a speci c volume of liquid Concentration when dissolved is known as gL or mgmL ect or as a percentage 98000 people die a year form medical errors 35 billion dollars in costs annually Some medications heparin require more than one nurse to verify correct calculation Veri cation on calculations from a another nurse is critical Clinical Calculations Need to understand basic mathematics skills To calculate doses mix solutions perform other activities Conversions Within One System Simple dividing or multiplying Conversion Between Systems Equivalent tables are used Compare order w medication system used Dosage Calculations 0 Before using a system make a reasonable estimate in your head and then calculate Recheck calculation before administering Have another nurse check to calculation also 0 Always do this when you are unsure or calculations seem unreasonable Ratio Proportion Method 0 O 0 Relationship between two numbers shown by First and last numbers are called extremes and secondthird are means Always label the answer Steps Estimate the Answer Set up the Proportion Cross Multiply the Means and Extremes Divide both sides by the number before Compare to estimate 0 Formula Method 0 0 First memorize the formula dose ordereddose on handX Amount on hand Amount to Administer Amount to Administer will be the same unit as the amount on hand Estimate the answer Label all parts Step Estimate Answer Set up Formula Calculate Answer Compare to Estimate 0 Dimensional Analysis 0 Factorlabel or unit factor method 0 More accurate 0 Steps Identify unit of measure needed to administer Estimate answer Place appropriate abbreviation for x on the left Place available information from problem in fraction format 0 Place so canceling units is an option Cancelun s Reduce to lowest terms Solve for x and label answer Compare to estimate Pediatric Doses 0 Children are at 3x higher risk for having a medication errors 0 Common reasons 0 O O O O O Confusion in formulations Availability of pediatric concentrations Inaccurate prep of medication that need to be diluted Similar packaging and medication names Unknowledgeable parents Errors in cacuation an use of inaccurate measuring devices Calculations require caution bc small errors can create big problems 0 Child weight height and maturity of body systems affect metabolism and excretion Dif cult to evaluation nonverbal or verbal children 0 Guidelines 0 O 0 Make sure pt weight is in kg Convert to kg before calculating medication dose Doses are much smaller mcg rather than mg or g Use smaller syringes IM doses don39t exceed 1mL for a child or 5 ml for an infant UsuaHy Subcutaneous usually don39t exceed 5 mL Medications aren39t round off to nearest tenth Less than 1 mL measure in syringe with 110 markings Tuberculin is used when 11000 doses are needed Estimate does before beginning Compare and Evaluate amount ordered over 24 hour to dose about to give 0 Common method of calculation is based on weight 0 o Prescriber s Role BSA is used rarely Can be physician NP or PA Written or verbal or telephone order 0 Telephone requires a read back and verify Abbreviations are often used to indicate Dosage Frequency Routes 0 Special instructions Medication errors often occur bc of abbreviations 0 Check agency policy for list they use Each order must include pt name order date medication name dosage route time of administration drug interaction signature of prescriber NS cannot take telephone orders 0 Types and Orders in Acute Care Agencies Must have order before administration of medication Orders are commonly based on FrequencyUrgency of administration 0 Change in status Standing orders or Routine Medication Orders Carried out until prescriber cancels or a certain amount of days go by Often indicate a termination date prn Orders 0 Medication is to be given when pt requires it 0 Objective and Subjective assessment should be used to determine need 0 Document assessment ndings for why the medication was needed time of administration evaluation of effectiveness of medication Single OneTime Orders 0 Given once at a speci ed time STAT Orders 0 Single dose given immediately Often used for emergencies or sudden change in condition Now Orders 0 More speci c than one time 0 Medication is need quickly but not STAT or right away 0 Up to 90 minutes to administer the medication 0 Only administered one time Prescriptions Prescriber writes a prescription for pt to take outside to HC facility 0 More detailed to help pt to understand how to take the medications and when re ll is needed 0 Pharmacist39s Role Prepares and distributes medication Work w all members of HC team Fill prescriptions accurately must know is prescription is valid Rarely mix solutions most come pre mixed from manufacturer Dispensing correct medication in correct dosage with correct label is the main job Provides information on side effects toxicity interactions incompatibilities 0 Distribution Systems AMDS Systems for storage and distribution of medications Special medication rooms portable locked carts computerized medication cabinets individual storage units Locked when unattended Unit Dose 0 Uses carts w a 24 hr supply of medication for each pt 0 Each drawer is labeled for each pt 0 Cart is re lled at a certain time each day 0 Limited amounts of pm and stock meds are kept here but NO controlled substances 0 Reduced medication errors saves steps Automated Medication Dispensing System 0 Control dispensing of all medications You select the patient medication dose and route 0 A drawer will open record it in the chart and charge the patient 0 Connected to medical record and the nurses name in the record Some require bio identi cation some require bar code scanning Reduce incidence of medication errors 0 Nurse39s Role Assess medication ordered to make sure it is the correct medication Assess pt ability to selfadminister Determine time to give medication administer the medications correctly evaluate pt response to medication Pt and family education 0 Medication Errors There is room for administration of medication one hour before or after time Federal regulations are in place to enforce correct administration times o If these are broken severe punishment can result Inaccurate prescribing administration of the wrong medication giving medication at wrong time or route giving extra doses or failing to give a dose Prevention is essential When occurred 0 Pt safety and wellbeing should be rst to be assessed Document Notify HC provider When stable report to supervisor Create incident win 24 hours of incident 0 Must be accurate and factual description of what occurred Report all errors even if there were no adverse effects Medication Reconciliation is important and nurse play essential role 0 Compare current medication orders to the medications that were given before a transfer or admittance Done on admission and discharge 0 Always clarify information 0 Consulting may be needed Critical Thinking 0 Knowledge Use from many disciplines Understand why the medication is prescribed what will the medication will alter physiology to have therapeutic effect Consult experts when a medication is not known to you 0 Experience How to skills Gaining experience will make the process easier 0 Attitudes Discipline for taking time for methods of veri cation and to look up medications that are unknown Responsibility and Accountability for safe administration Medication right on time correct dose If normal dose is unknown notify HCP All action you preform or don39t you are responsible Responsible for information you give pt and family Responsible for safe administration and assessing ability to selfadminister medication 0 Standards Actions to ensure the care given is safe Set by HC facilities and nursing profession Check nurse procedure manuals Avoid distractions or interruptions when preparing and administering medication Focus on medications only until you have nished gathering and deHve ng The ANA Scope and Standards of practice apply to medication Six rights of medication administration Right Medication Order is required for every medication administered 0 Written CPOE verbal telephone 0 Compare to written orders w MAR when it is ordered to verify 0 Once MAR is veri ed and correct use it verify medication 0 Done at every new medication order 0 Compare label on medication wo MAR 3 times 0 Before removal from container drawer self 0 Amount ordered is removed from container 0 At pt bedside before administration Never prepare unmarked or illegible medication Only administer medication that is personally prepared Listen to questions and concerns from the pt 0 May notice if the medication being given is different from one that has been previously given If pt is refusing medication discard it 0 Unit doses can be saved if unopened o If refusing narcotic have a second person verify the disposal Use clinical judgement wen giving prn medications 0 Give pain meds to the pt before starting assessment If a mistake is made speak up Right Dose Unitdose reduces errors When medication is prescribed in a dose that is different from what I supplied errors occur Have another nurse check calculations Prepare using standard measurement devices Errors often occur in splitting pills Assess pt ability to split pills if not able avoid ordering medications that are to be split Crushing devices need to be completely cleaned between uses 0 Mix crushed with food that is not their favorite food bc altered taste may occur 0 Some forms of medications can t be crushed Right Patient Use 2 identi ers before administering a medication 0 Pt name identi cation number telephone number Compare identi ers to MAR to bracelet while at bedside Barcodes may be used to scan to nurses ID badge pt wrist band and medication package 0 Help to eliminate errors Right Route Consult if order doesn39t have assigned route o If given route isn39t recommended notify HC provider 0 Label syringes after adding medication 0 Use different colored syringes for enteral and parenteral medication Right Time Know why the medication is ordered for certain times and if schedule can be altered HC provider should write this information in order 0 Can be On ca PC STAT prn requires nurses judgement Priority is given to timecritical medication Document when HC provider was contacted for clari cation Evaluate need for home care and ability to selfadminister 0 Help plan schedules for medication administration at home Right Documentation Many errors are result of inaccurate documentation Ensure MAR is re ecting pt full name ordered medication written in full time medication is to be administered dosage route frequency If there is a question contact the HC provider Nurse is responsible to start the chain of command in the situation where HCP are unable to make clearly written orders Document preassessment data After administration 0 Indicate medication was given as ordered in MAR 0 Immediately after administration 0 Name of medication dose route time site of injection pt response positive or negative Notify HCP is there was a negative effect and document time date and name of HCP contacted Never document that a medication was given until it has been given Never place medication in the room and then leave Check mouth to ensure is were swallowed After giving medication wash hands and don39t touch pis unless you are applying topical solution Maintain Patient39s Rights To be informed of name purpose action and potential undesired effects of a medication To refuse medication 0 Don39t become defensive To have quali ed nurses or physicians assess a medication history To be properly advised of the experimental nature of medication therapy and give written consent 0 Nursing Process 0 Assessment To received labeled medications wout discomfort in accordance w 6 rights To receive supportive therapy w medication To not receive unneeded medications To be informed if the medication is part of a study Handle all questions the pt and family have Through Patient Eyes Use professional knowledge skills and attitudes Compassionate coordinated care As pt values beliefs preferences and needs when determining responses to medication therapy Begin assessment by asking questions 0 Medication management 0 Routine 0 Ability to afford medications o Beliefs and expectations attached to medication History Review medical history 0 Provides contradictions to medications o Risks for adverse effects Illnesses diseases and longterm health related problems Allergies 0 Inform team members of all food or medication allergies Food products are sometimes used in medications Cross check 0 Note reactions to allergen in medical record admission notes history Medications 0 About each medication Length of use Current dose Sideadverse effects experienced Action Purpose Normal Dose Route Side effects Nursing Implications for administration and monitoring 0 Consult texts and professionals 0000 Diet History 0 Normal eating patterns 0 Food Preferences 0 Dosage schedule should be planned around them 0 Teach to avoid foods that can interact w medication Note Say which interact positively and negatively Pt Perceptual or Coordination Problems 0 Dif culty selfadministering 0 Assess ability to prepare and take medications If unable assess family Pt Current Condition Ongoing physical or mental assessment needs to occur in order to determine whether or not to continue medication 0 A careful assessment should be done before any medication is given HCP should be noti ed if pt is unable to take the medication 0 Assessment ndings are a baseline Pt Attitude About Medication Use Reveals level of medication dependence or avoidance Observe pt behavior 0 Be aware of culture beliefs that can interfere Pt Understanding of and Adherence to Medication Therapy In uences willingness or ability to follow regimen If poor adherence investigate why 0 Determine understanding of importance of regular doses purpose proper administration methods and side effects Pt Learning Needs 0 Assess health literacy Determine instruction needs Diagnosis Anxiety Ineffective health Maintenance Readiness for enhanced immunization status De cient Knowledge medications Noncompliance medications Impaired swallowing Effective therapeutic regimen management Planning Organize so there is no rushing and ensure safe administration Rushing makes error Minimize distractions and interruptions during preparation and administration Goals and Outcomes Contribute goals to safety 0 Contribute to patient understanding 0 Provide most important information about the medication rst 0 At discharge ensure pt is able to receive medications Setting Priorities Prioritize which medications need to be given rst Note if it is appropriate to give prn medications is an op on Provide pain medication rst if patient is in pain Provide most pressing education about medication rst in the teaching process Teamwork and Collaboration Family and friends will help to reinforce practices Collaborate w pharmacist prescriber and case mangers 0 Ability to afford medication Obtaining medications Health literacy Basic dosage calculations Community resources 0000 0 Implementation Health Promotion Identify WB diminishing factors Everything about pt will in uence adherence to medication Teach bene ts and knowledge needed about the mediation Create a treatment plan and schedule to t pt routine Make referrals and arraignment of resources Pt and Family Teaching 0 Bene ts of medication how to make the medication correctly symptoms and side effects use and storage Help to establish a routine 0 Provide information on Purpose Actionseffects Proper administration and risks of improper administration Accurately measure Symptoms of side effect and toxicity 0 Change in behavior is rst sign Basic safety guidelines for medication administration 0 Use and storing properly 0 Special teaching should be applied to those w daily 0 injections Teach prep and administration to pt and family Acute Care 0 Receiving Transcribing and Communicating Medication Orders 0 Order is required to administer all medication 0 CPOE are used for direct entrance for orders Help reduce errors and mortality rates o If handwritten be sure these are legible Medication names Doses Symbols If not legible order MUST be rewritten o Verifying of orders varies from agency 0 NS cannot take verbal or telephone orders Read backs are required Follow institutional policy 0 Must include Pt Full name Date and Time order is written Medication name Dose Route Time and frequency of administration Signature of HCP 0 Check all orders for accuracy at least 3 times before administration and always when medication is ordered 0 Always determine if medication is compatible with condition and other medications 0 Once medication is deemed safe it is place on the MAR or eMAR Includes all information about medication order AND room an bed number medical record numbers medical or food allergies other patients 0 Verify accuracy of medications before each administration If there is missing information or non corresponding information DO NOT give the medication until the HCP is noti ed and xes the order 0 Follow 6 rights of medication administration Accurate Dose Calculation and Measurement 0 O O 0 Use standard measuring containers for liquids Calculate each dose when preparing the medication Ask for another nurse to double check calculations If you are ever in doubt have someone double check the calculation 0 Correct Administration 0000 0 Follow 6 rights Verify identify using 2 identi ers Compare pt armband to MAR Aseptic technique and proper procedures assessment before administration Monitor the response carefully Recording Medication Administration 0 O O 0 Follow agency policy of documentation Record name of medication dose route and exact time of administration Record site of injection Explain why if a dose is refused or missed and notify HCP Restorative Care 0 Administration activities will vary bw facilities 0 Nurse is responsible for correct instruction of action administration side effects monitoring compliance and determining effectiveness Special Consideration for Administering Medications to Speci c AgeGroups Infants and Children 0 CO 000 O Vary in age weight height SA metabolism and excretion of medication Doses are lower Special caution is needed for preparation Require psychological prep before medication administration Supportive are is needed Explain at appropriate level Involve in choices when possible Praise after taking the medication 0 Older Adults 0 Physiological economical and behavioral factors in uence Polypharmacy O A pt takes 2 medications to treat same illness 2 medications in same chemical class uses 2 medications for similar actions or mixes herbals and nutritional substances OTC medication use lack of knowledge incorrect beliefs and visiting more than one HCP are all factors More common before computer systems Older adults are more likely bc often suffer from chronic health problems Can be unavoidable o Frequent communication is needed to minimize risks 0 Evaluation Essential Gather data and create a holistic evaluation Goal safe and effective response to therapeutic treatment and ability to selfadminister Be alter for restrictions in pts on more than one medication Physiological measures behavioral responses rating scales and pt statements Through Pt Eyes 0 More effective w pt cooperation Do they understand how to safely administer medication 0 Are they able to understand the schedule 0 Do they understand why they are taking the medications they are taking Can they describe the effectiveness of the medication 0 Include pt to enable them to feel more empowered about their care Pt Outcomes Clinical condition changes on a minute by minute basis 0 Compare desired with actual outcome 0 Be alert for reactions 0 Measure HR BPP behavior change what pt states 0 Medication Administration 0 Oral Administration By Mouth Easiest and most desirable way Food may decrease the effect More are able to selfadminister and ingest these Best if given 30 minutes before meals or w food depends on medication 0 Know medication interactions t determine best time to give the medication Protect pt from aspiration Assess ability to swallow 90 degree angle for meds admin unless contradicted Use multiple disciplines if needed Special care needs to be given to those with a feeding tube 0 Risk for tube obstruction reduced medication effects increased risk for toxicity 0 Veri cation is necessary for tube placement and if placement is compatible w medication absorption 0 Use liquids when possible 0 Can crush simple tablets open gel capsules 0 Dilute in sterile water NOT tap water Flush w AT LEAST 15 mL of sterile water bf and after each medication One medication at a time do not mix medications If given on empty stomach allow 30 minutes before or after eating Determine compatibility w enteral feeding 0 Verify w drug reference or consult pharmacist Monitor closely for adverse reactions Higher risk of drug interaction 0 Topical Medication Application Use gloves Medication goes through the skin Applied locally to usually intact skin or mucus membranes Skin Applications Local applications Systemic or local effects Wear gloves and applicators Use sterile technique w open wound Clean skin thoroughly bf administering medication Apply according to medication instructions Cover well but not overly thick layer 0 Apply gauze cover if indicated in order 0 Lightly spread creams and lotions 0 Apply liniment by a gentle but rm rub 0 Dust powder Some are given through a transdermal patch 0 Remove old patch before applying a new one if not an OD can occur 0 Carefully assess skin where patch was 0 Guidelines Document location on pt body where medication was placed Ask pt if there is an existing patch During history ask if they are taking medications via patch or any route other than oral Apply noticeable label on the patch Document removal and application in MAR Nasal lnstillation Sprays Drops Tampons Different positions will reach different sinuses Decongestant is most common 0 Can become quotaddictedquot o If swallowed serious systemic effects occur Saline drops are the safest Easier for pt to selfadminister If used often assess for irritation Nose bleeds are treated w epinephrine infused tampons EyelnsUHann Eye drops and ointments Ophthalmic medications are for eye conditions Age reated problems impair selfadministration ability lnclude family in instruction and determine ability to administer 0 Have family demo Guidelines 0 Avoid instilling directly on cornea 0 Avoid touching eyelids or structure w tip of applicator 0 Use medication only for the affected eye 0 Use different medication for each pt Do all other activities before administration because vision can be blurred lntraocular Administration 0 Contact lens like delivery vessel 0 Can remain for week 0 Teach about monitoring for the adverse effects of the lens insertions and removal Ear lnstillation Internal ear structures are sensitive Use sterile solutions Drainage may indicate eardrum rupture Don t force in medication Drops should be at room temperature Sterile solutions are used when eardrum is ruptured Nonsterile solutions into the middle ear can result in infection Vaginal lnstillation Suppositories foam jellies creams Sometime stored in refrigerators Give w gloved hands Some can selfadminister provide privacy Discharge is foul smelling Teach proper pericare Rectal lnstillation Suppos ones Local effects for promoting defecation Systemic effects reduction of Nausea Stored in refrigerator Enema might be needed before administration 0 Administering Medications by Inhalation Aerosol Spray mist powder penetrating lungs Used for maintenance or rescue Rapid absorption Pressurized MeteredDose lnhalers Breath Actuated Metered Dose and Dry Powder Inhalers Mainly local effects Serious systemic side effects can occur pMDl chemical propellant Doesn39t require a lot of pressure to press down canister in order to administer medication but does need some hand strength 0 Gets medication further in lungs Children and Elderly Spacers break up medication for a faster acting response BAls Medication is released upon raising a lever and inhaling Release is dependent on breath DPls Aerosol is created upon inhaling through reservoir 0 Medication is activated by pt breath Unit singled dosed or month long doses 0 Powder Clumps w humidity To fast inhalation will not get all of dose Different Respiratory problems require different medications Rescues are used for fast action situations Maintenance medications have a schedule Slower actions Need to learn selfadministration Safe and Effective use is key Education on when medication is empty and needs replacing Counting down numbers occur 0 Divide number of dose by the number a patient uses per day Re ll 710 days before suspected emptying Administering Medications by lrrigations Wash out body cavity or consistent stream of solution Sterile water saline antiseptic solutions in eyes ears throat vagina urinary tract Aseptic if a tear in mucus membrane or skin 0 Clean otherwise Parenteral Administration of Medications Injection into body tissues lnvasive Aseptic techniques Risk of infection after piercing the skin Action of medication is quick Closely observe pt response Equipment 0 Variety of sizes and types for the different volumes of medications and tissue type Synnges O O O LuerLok Needles are twisted onto tip and lock themselves into place preventing accidental removal NonLuer Lok needles slip onto tip w safety devices to prevent needlestick injury Number of sizes 560 mL Hardly use gt5mL for medication injection Large volumediscomfort Prepacked w needle Needle can be changed and removed Tuberculin calibrated into 116 of a minim and 1100 mm 1mL max Small precise doses lnsulin are small and calibrated Don t let an unsterile object to the inside of the syringe tip Needles O O 0 Some are packaged in individual sheaths for ability to change needles Usually stainless steel Disposable Parts Hub ts on syringe Shaft Connects to hub Bevel Slanted tip 14 3 inches Size is chosen based on size weight and tissue of pt IM 115 inches Subcut 38 58 Smaller gauge Larger diameter Gauge depends on viscosity of concentration Disposal lnjection Units 0 000 There are pre lled syringes and needles Safely dispose of needle and all glass used Check medication concentration Don39t prepare medication dose but expel unneeded portions Preparing and lnjection From an Ampule Contain single dose of medication Several sizes Glass w constricted neck that is snapped off for access to the medication Aspirate medication into syringe using and lter needle 0 Replace w real needle before use Preparing and Injection From a Vial Single or multidose vial w a rubber seal Liquid or dry forms of medication 0 O Unstable meds are dry Vial notes if it is dilution or solvent it needed and amount Closed system 0 Air must be injected for easy removal After mixing multidose note date and time of mixing concentration and refrigerate rest of solution Mixing Medications Minimizes injections received at a time Mixing Medication From and Vial and an Ampule 0 Prepare medication from vial rst using same syringe and needle then ampule Mixing Medication from 2 Vials O 0 Principles Don t contaminate one medication with another Ensure nal dose is accurate Maintain aseptic technique Use only one syringe and needleneedless device Aspirate amount of air equal to dose in vial A Inject air into vial A make sure needle doesn39t touch solution Aspirate amount of air equivalent to dose B lnject air into vial B Withdrawal medication immediately lnsert needle back into vial A and withdraw medication Don t press on plunger to reinsert B medication into A Withdrawal needle and apply a new safety needle needless device lnsulin Preparation Prescribed in concentrations of 100 mL of solution or 500mL more rare Classi ed by rate of action Know onset peak and duration of each pt ordered dose lmitate normal insulin release in body Insulin pen give multiple doses in on pen Correction insulin is provided upon Blood Glucose Levels to correct elevated levels 0 Temporary 0 Before injection gently roll insulin vital in hands to suspendinsan 0 Don39t shake You can mix insulins IF they are compatible 0 Rules Maintain individual routine to those on mixed insulin Don39t mix w any other medications or dilutions Never mix insulin glargine or insulin detemir Inject rapid acting insulins mixed w NPH insulin w 15 minutes of meal Verify insulin dose w another nurse while preparing them 0 Administering Injections Injection route varies based on tissue Tissue characteristics in uence rate of absorption Before injection 0 Know Volume injecting Characteristics of viscosity 0 Location of anatomical structures Nerve and bone damage can occur when a medication is wrongly administered 0 Tissue damage and extreme pain can also occur Minimize discomfort Use sharpbeveled needle in smaIIest Iength suitable Position comfortably Elect proper injection site Apply vapocooIant spray Divert pt attention Insert needle quickly and smoothly Hold syringe steady while needle is in tissue Inject medication slowly and smoothly Subcut Into Ioose connective tissue under dermis Slower absorption than IM Slight Discomfort Best Sites 0 Outer posterior of upper arms 0 Abdomen o Anterior thighs Alternative sites 0 ScapuIar areas 0 Upper ventral or dorsal quteaI areas 0 Site must be free of lesions boney prom and large mm or nerves Abdomen is quickest absorption for insulin 0 Site should be alternated w each injection Only small volume water soluble medications are given subcut Size of needle is based on person weight 0 25 Gauge 58 needles is inserted at a 45 degree angle or 12 at 90 degrees Norma pt 0 If you can grasp 2 inches of tissue needle goes in at a 90 degree angle 1 inches is 45 degree angle Faster absorption More risks 1St verify that injection is justi ed Use longer and heavier needle Weight and adipose tissue determine length 90 degree angle insertion 25 mL of medication is normal Assess mm before giving the injection Site should be free of tenderness lesions relaxed Change position to reduce the strain on the mm Distract and apply pressure Sites 0 Ventrogluteal Glutues medius is deep and far away from major nerves and blood vessels Safest for all 0 Especially if larger amounts of medications Place pt supin or lateral w knee exed and hip to relax mm Place palm over greater trochanter w thumb pointing to groin index toward anterior superior iliac crest an middle along back of iliac crest to form a V o L hip R hand lnjection site is in middle of the V o Vastus Lateralis Anterior Lateral aspect of thigh Good site Middle third of mm is used for injection Lie at w knee exed or in sitting position 0 Deltoid Not as well developed and more injury risk Use for small V of medications or when other sites are not accessible Relax are and ex elbow Lower edge of acromion process forms the base and midpoint of lateral aspect forms tip Inject in middle Three nger widths from acromion process Use of ZTrack Method in IM injections 0000 CO Minimize local skin irritation Depress skin just below site of injection Clean skin w swab Insert needle and depress syringe at a rate of 1 mL per 1 seconds Leave needle in for 10 seconds Pull out needle release skin This leaves a separation bw where the needle entered and where the medication was administered Used for skin testing Potent medications Absorption is slow Requires a clear view of the injection site Inner forearm or upper back Use tuberculin or small hypodermic 515 degree angle of insertion Bevel of needle is pointed up Injections will cause the skin to bubble up Safety in Administering Medications by Injection Needless Devices 0 Needle sticks are common and occur when HC workers recap needles Mishandling of IV lines and needles Leaving needles at the pt bedside Exposure to blood borne pathogens is a deadly hazard to nurses Most are preventable w needle safety devices Safety syringes have a sheath to cover needle upon withdrawal Always dispose of needle and sharps in appropriate containers Puncture and leak proof Never force a needle in a full container Methods 0 Mixtures in large V IV uids 0 0 Injection of bolus or small V through existing IV quotPiggybackquot infusion 0 Existing IV line is running or there is an existing IV site placed 0 IV Fluid is primary way of uid replacement in pt unable to have oral uids 0 Means of electrolyte and nutrients Observe closely for adverse effects 0 Immediate action 0 Errors can be deadly o 6 rights 0 Double check calculations 0 Know desired action and side effects 0 Asses vitals before after and during 0 Advantages 0 Fast acting o Constant therapy blood levels 0 Less discomfort Serve adverse reactions occur if administered to quickly 0 Large Voume Infusions 0 Mix medications w large volumes of uids 0 Safest and easiest 0 Risk of fatal side effects are minimal 0 Disadvantage If too quickly risk of OD and circulatory uid ove oad 0 Nurses only mix in IV uids in emergency situations 0 Nurse never prepare high alert medications o If you have to mix a medication verify w pharmacist and have another check calculations and watch mixing 0 Steps Check medication compatibility Prepare medication in syringe w aseptic technique Clean injections port and stick in needle Mix by turning bag gently Attach medication label 0 DON T add medication to hanging bags ONLY NEW bags 0 Regulate rate 0 Frequently check site Intravenous Bolus quotPUSHquot o Concentrated dose into systemic circulation o Advantage when there is a uid restriction on the pt 0 Most dangerous method No correction time o Bf administration check IV line and site 0 Never give if the line is in amed or edemas Improper blood ow Volume Controlled Infusions 0 Small amounts of compatible IV uids Secondary connects to primary line or to a separate tube that is inserted into the primary line 0 Advantage Reduces rapid dose risks Diluted and longer diffusion rate Allow for administration of medications that are stable Control of IV intake 0 Piggyback Small bagbottle connected to short tubing connecting to upper Y port of primary Label Micro or Macro drip The smaller is higher than the primary Main line doesn39t infuse when piggy is Once piggy is empty primary will begin again 0 VolumeControl Administration Small containers attached below to primary Used w regular IV ow 0 MiniInfusion Pump Battery operated Allows small amounts of medications to be given w controlled infusion rates Intermittent Venous Access IV catheter capped off at one end w a small chamber covered by a rubber diaphragm or special design cap Advantages 0 Saves costs 0 Effectiveness of time is enhanced 0 Increased Mobility safety and control Assess IV site before administering Flush after administration Administration of IV Therapy in the Home Central venous catheter inserted before discharge Assess ability to manage therapy at home Begin instruction when pt is in hospital Teach to recognize problems signs of infections complications and to notify HCP when these occur Give information regarding maintenance of equipment Chapter 38 0 Regular exercise enhances all aspects of life 0 Scienti c Knowledge 0 Regular activity and exercise contribute to physical and emotional WB 0 Overview of Exercise and Activity MM and Nervous system maintain balance posture and proper alignment lfl proper reduction in injury risk Body Alignment Relationship of body part to part on a vertical and horizontal plane 0 No excess strain is present Adequate mm tone and balance Balance 0 Low center of gravity Widen base to support CoG Bring CoG closer to base C06 in human is 55 up from standing 0 Unsteady greater risk for falls Coordinated Body movement 0 Weight C06 and balance combined Friction Force in direction of opposition of movement Decrease when moving by place pt arms on chest and having them bend knees Use air assisted devices when you can Exercise and Activity 0 Condition body improve health maintain tness Depends on pt activity tolerance 0 Many factors affect Regular activity increase function of all body systems 0 Combination of o isotonic Mm contraction change in length aerobic and light weights enhance cardiopulmonary increase mm mass tone and strength and bone building 0 isometric tightening and tensing mm increase mm mass tone strength increased circulation and bone building 0 resistive isometric Contract mm while pushing against stationary object push up hip lifting mm strength and bone building 0 Regulation of Movement Skeletal System 0 Support protection movement mineral storage hematopoiesis Framework for shape alignment positioning Lever action Joints 0 Connection bw bones o Fibrous Fixed 0 Cartilaginous Little movement 0 Synovial Moveable Ligaments Tendons and Cartilage o Lig Flexible bands connecting bones to cartilage o Tendons Connect mm to bone 0 Cartilage Firm exible plastic like material Skeletal MM Contraction allow mm 600 in body Origin stays put insertion moves MM w Movement 0 Near skeletal region 0 Lever system MM w Posture 0 Low level of continuous contraction MM Groups 0 Antagonistic MM Movement ofjoint Active contracts while antagonistic relaxes o Synergistic MM Contract for same movement Two MM doing same action 0 Antigravity MM Stabilize Joints Oppose gravity affects Nervous System Regulates movement and posture Voluntary motor area Cerebral Cortex precentral gyrus Motor strip 0 Fibers cross over Impulses are neurotransmitters Proprioception 0 Awareness of body and parts position 0 Receptors on feet signal for posture and balance changes 0 Balance 0 Needed to do really anything 0 Cerebrum and inner ear are in charge 0 Principle of transfer and Positioning Safe pt transfer and positioning for techniques Decrease effort and strain Pathological In uences Congenital defects Affect ef ciency of muscuoskeeta 0 Balance alignment appearance 0 Nursing Knowledge Base 0 In uencing Factors 0 Scoliosis o Osteogenisis imperfecta Disorder of Bones Joints MM Osteoporosis Decrease in bone density Osteomalacia Delayed mineralization replacing rigid bone w soft bone Nonin ammatory joint disease Articular Disruption tear sprain dislocation If damage to voluntary movement centerD impaired alignment ad immobility Musculoskeletal trauma 0 Bruises Contusions sprains fractures Developmental Changes Appearance and functioning of body changes throughout life Infant through school age 0 O O O O O 0 Infant spine is exible and only in C shape Toddler has protruding abdomen walks w feet far apart 0 3 year slimmer taller better balance les protrusion narrower base more coordinated this point on mm and bones grow and develop Adolescent 0 Growth spurt uneven o Awkward and uncoordinated 0 Female hips widen more fat deposits Male Lone bone growth increase mm mass Young to Middle Adult Correct alignment and posture selfcon dent coordinate Pregnant Sway back bc of fetus back pain Older Adults Progressive bone mass loss Inactivity changes in hormones increased osteoclastic activity Behavioral Aspects More likely to exercise is support system is in place Assess knowledge barriers and current status Stage of readiness is the stage where person is most likely to engage in an exercise program Environmental Issues 0 Work Site Lack of time 0 Some works offer reminders and incentives to exercise 0 Schools 0 Facilitate exercise an activity 0 Community 0 Providing public bike trails or events Cultural and Ethnic What will motivate people from different backgrounds Know wat diseases affect different ethnic backgrounds more frequently diabetes in African Americans and Native Americans Family and Social Support Motivational tool 0 Critical Thinking 0 Include activities that t the ability of the pt Consider ROM and mobility Nursing Process 0 Assessment Note changes in growth and development deviations from the norm and learning needs First assess alignment Through Pt Eyes 0 Assess expectations 0 Determine perceptions Standing 0 Head Erect midline Symmetrical Straight Spine w normal curves Abdomen tucked Knees straight C06 is midline Sitting Head Erect Neck and column are straight Weight on thighs and butt Thighs parallel Feet on floor and arms on arm rest Proper reduces Mskeletal damage Recumbent Position Vertebra are straight Check extremities 0 Don39t want them to be crossed Mobility Determine coordination and balance ability to perform ADL ROM determines degree of damageinjury Shows stiffness swelling pain Increased mobiIity might be connective tissue disorder tears or fracture Style of walking Rhythm cadence speed Balance posture and ability to walk Smooth Exercise 0 Conditions improves health maintains tness provides therapy Activity Tolerance Kindamount of exerciseactivity a person can do Provides baseline for future activities 0 Diagnosis Often focuses on ability to move 0 Planning Info from many sources Goals and Outcomes Consider risks injuries and preexisting Improve OR maintain mobility Setting Priorities Prevent complications and injury Teamwork and Collaboration Understand pt needs 0 Implementation Health Promotion Encourage to engage in a regular program Holistic approach should be taken Teach calculation of max HR Discuss recommendations Include warm ups and cool downs O Stretching and exibility are good Integrate in ADLs Body Mechanics O O O O Acute Care Stretching and isometric exercises Active ROM exercises 0 When unable maintain joint mobility 0 Back Injury is common Before lifting assess weight need for assistance and available resources Use Lift teams and safe avaiabe equipment Use manual lifting only as last resort Medicate before if needed Low intensity walking Musculoskeletal OOOO Stretching and isometric Review chart for contradictions Design for speci c pt Contract and relax repeat w gradual increase in sets and reps Joint Mobility O 0 Maintain and improve Systemically assess each joint mobility o If not moved joint can become xed 0 Initiate passive ROM as soon as voluntary control is lost 0 Walking 0 Increases joint mobility 0 Measure in feet and yards 0 Note use of aids 0 Helping pt walk Require prep Assess tolerance strength coordination baselines and balance Sit w feet dangling for 12 minutes Assistance methods Gait belts for CoG Restorative Care 0 Implementing exercise and activity after acute care Aids Walkers O O O Canes O O O 0 Light and movable Waist high metal tubing Requires lifting to move Light weight movable metal or wood Less support than walker and less stable Cane on stronger side of body and moe cane weaker le then stronger leg Quad cane is most support Crutches O O 0 Temporary use Need to be measure for appropriate length and use Teach how to walk ascend and descend stairs and rise from sitting Measuring Aillary is commonly used Ht elbow exion distance bw pad and axilla 34 nger widths from axilla to 15cm to lat heel Handgrips are supporting wt NOT axilla Elbow at 30 degree position hand grips Gait Bear wt on 1 legs and on crutch alternatively Assess physical and functional abilities 3 Point Each crutch is 15 cm from lateral heel Axilla bears NO wt 4 Point Bear wt on both legs each is moved alternatively w opposing crutch 2 Point Partial t bearing on each foot move crutch at same time as opposing foot Swing through Plant and swing 0 Walking on Stairs Modi ed 3 pint Ascending Transfer wt to crutches unaffected leg moves up stair shift wt and move crutches Descending Wt to unaffected leg move crutches down move leg down 0 Sitting Position at center front of chair Crutches in hand opposing affected leg Supports wt on unaffected leg grasp arm of chair and slowly lower in Opposite for standing Restoration and Chronic lllness CHD Exercise and activity are secondary prevention 0 Cardia rehabilitation is important 0 Reduces mortality and morbidity Hypertension Exercise reduces BP 0 Low to moderate intensity are most effective COPD Progressive treatment 0 Diabetes Important component to care 0 lmproves glucose control 0 Lower blood sugar levels 0 Evaluation Pt Eyes 0 Pt knows effectiveness and bene ts Chapter 45 Elimination 0 Basic function o If fails all organs are affected 0 Psychological alterations can occur Embarrassment Scienti c Knowledge Base 0 All parts need to be intact and functional Efferent and afferent nerves from spinal cord included Good to know the reasons behind problem 0 Kidneys Remove wastes from blood Retroperitoneal L is higher than R Filter wastes from renal artery o 14 of blood per minute Nephron is functional unit 0 Forms urine Cluster of vessels in glomerulus are 1St site for ltration can39t lter large proteins and blood cells and if urine suggest injury to glomerulus and items are ltered into capsule Filter rate of 125mLminute Only 11 of ltrate is excreted in urine Fluid and electrolyte balance Output 12001500 mLday Produce erythropoietin renin Vasoconstriction complex w angiotensin aldosterone water retention prostaglandin and prostacyclin substance to convert Vit D into active form 0 Urete rs Transport form kidneys to bladder Tubes that are usually sterile Peristaltic waves Ends connecting to bladder and compressed during micturition to prevent re ux o Bladder Holds until urge to urinate Hollow Distensible Trigone is triangle of smooth mm and 3 openings ureters and urethra Pressure when full 0 Pregnancy has fetus pushing on bladder making it smaller 6001000 mL capacity 0 Urethra Exit from body Urethral Meatus Forceful ow clears area of bacteria Lined w mucus membranes Shorter in women 152 inches 0 Increased risk for infection Men 0 Also passage for semen 8inches 0 Sections Prostatic Membranous Penile Voluntary mm contraction o Urination All aspects of system must be working properly Cerebral Cortex Hypothalamus Thalamus and Brainstem Inhibit or allow urge to void Contraction of balder relaxation of urethra 24 hrs 24 months neurological function is developed to potty train V increases initiates stretch re ex send signals to spinal cord respond to or ignore External sphincter is relaxed stimulates detrusor mm to contract elimination Re exinconUnence Damage to spinal cord above sacrum No voluntary urination Urination wout warning Over ow Incontinence Bladder is overly full and this pressure exceeds external sphincter involuntary leakage Caused by head injury spinal injury MS ect Factors In uencing Pathophysiological acute and reversible or chronic and irreversible sociocultural psychological uid balance diagnostic procedures medications Disease affects 0 Renal function V or quality micturition act or both Decreased blood ow to and from kidney prerenal Renal tissue renal Obstruction in lower urinary tract preventing ow from kidneys postrenal Narrowing of urethra altered intervention weaken mm 0 Diabetes and NM disease change nerve functions Loss of bladder tone reduced sensation not able to contract bladder 0 Renal Tissue damage End Stage Renal Disease Uremic syndrome sets in Treatment is renal replacement therapy Dialysis Peritoneal or Hemo and organ transplant are replacements Needed when body can no longer control Sociocultural 0 Privacy varies o Expectations breaks affect times for urination Psychological 0 Anxiety and stress increase frequency and urgency 0 Timing and place Fluid Balance 0 Varies w food intake o 12 as much produced at night than during day Nocturia is sign of renal alteration 0 Input should output Polyuria Increased output Oliguria decreased output Anuria No urine is produced 0 Caffeine and alcohol promote urine formation diuresis o Fever makes highly concentrated low volume urine 0 Surgical Procedures 0 Stress triggers GAS ADH released water reabsorption 0 Pre Op orders affect what is consumed o Meds slow renal process Medications 0 Contribute to dysfunction 0 Cause change in color 0 Diagnostic Exam 0 In uences micturition 0 Limit uids before tests restriction diet 0 Dif culty voiding after test bc structure was affected in test Alterations in Elimination Unable to store empty fully permanent or temporary changes 0 Urinary Retention 0 Bladder is unable to drain properly so urine builds UP Usually obstruction 0 Doesn39t response to micturition signal 0 Pressure tenderness discomfort diaphoresis o Over ow develops small V escapes Void small amounts 23 times a day 0 Severe cases bladder holds 20003000 mL o If present pt must be catheterized 0 Measure residual urine left in bladder 1015 minutes after void Measure twice 0 Normal void should completely clear bladder 0 Post void residual regular catheter beating down increase uid intake UTI CO 0000 Most common health care infection Mainly from catheter Each day in place increase in risk Persons own ora is most common cause Bacteriuria spreads to bacteremiaurosepis infection in blood Women are more susceptible Travel up mucus lining Retention increases risk Stages Lower UTI is burning when urinating Infection worsens fever chills nausea vomiting Cystitis irritation to bladder causes frequent voiding Cystitis and irritation to mucosa leads to blood n urine hematuria Upper UTI Pyelonephritis ank pain fever Chill Urinary Incontinence O O O O O O O O Involuntary urine leakage Temporary or permanent Continuous or intermittent When relate to urinary causes stress or urge to urinate Urge more in younger bc UTI Stress more in older bc urethra mm become weak HyperOveractive bladder more likely to cause incontinence in older Urge incontinence is created Underreported and undertreated Place pt at risk for impaired kin integrity FuncUonal Factors outside tract are causing Urge and loss of urine before getting to bathroom Schedule toileting and environment alterations Stress Involuntary leak when abdominal pressure is increased Urge involuntary release right after void Mixed Urge and Stress combined Over ow involuntary loss at intervals Urinary Diversions o Bladder cancer radiation to bladder chronic urinary infections may need Drain urine from bladder o Reservoir are created One from iliem and colon Cateterized 46 times a day Orthotopic neobladder replace bladder w ileal pouch normal voiding o Urine drains continuously ostomy pouch o Nephrostomy Ostomy directly on kidney Fluid Balance 0 Nocturia peeing in the night 0 Polyuria Increased frequency and dilute o Oliguria Decreased output 400mL or less 0 Anuria No output 0 Nursing Knowledge Base 0 Infection Control and Hygiene Tract is sterile Medical and surgical asepsis when providing care Invasive procedure gets sterile technique 0 In uencing factors Age environment medication psychological factors mm tone uid balance surgical procedures disease Assess bowel elimination Growth and Development 0 Infants and children light yellowclear urine large amount excreted can39t concentrate go often bc no external control Toddlers control external sphincter nighttime voiding wout control is common 0 Pregnancy increase in frequency UTI risk increases multiple pregnancies can lead to stress or urge inconUnence Age afftects micturition often impairing kidney and bladder function increased frequency retains urine after voiding MM Tone Poor controlincontinence causes mm wasting Abdominal and pelvic mm are used 0 Nursing Process 0 Assessment Through Pt eyes 0 Frame of reference of experience Understand status and selfcare ability Cognitive ability to understand 55 What do they expect from the care 0 0 Personal gender social habits 0 Place in comfort position 0 P vacy Know own attitudes Culturally congruent care is important Identifying Urinary Alterations Assess history physical assessment and tests 0 Be aware of culture and language History 0 Review of elimination patterns and symptoms 0 Pattern 0 normal V and recent changes 0 Frequency note common times ie waking up before bed average 5 times a day 0 Symptoms 0 Conditions or factors that aggravate symptoms 0 Fluid balance vs intake 0 Urgency frequency nocturia Dribbling Retention ect o lndwelling catheter presence Physical Assessment 0 Data for presence and severity of alteration Skin and Mucosal Membranes o Hydration status shows o Is breakdown present 0 Rashes or blisters present Kidneys o Palpation Position shape size 0 Tenderness o Bruit sound Bladder o Distended can be palpated in lower abdomen 0 Percussion is a dull sound Urethral Meatus 0 Discharge in ammation and lesions 0 Normal Pink small slit like opening o If yeast is present check the vagina Assessment of Urine o IntakeOutput Daily average intake Change in output V shows alterations in kidney function Measure output For precise measurements use urimeter Report large increases or decreases 0 Concentration of Urine Color Diagnostic Examinations O O O O Clarity O O O O Odor PaIe straw amber based on concentration Dark Red Bleeding from kidneys Bright Red Bleeding from bladder Food can change color Dark Amber Liver problems Normal Transparent Standing Cloudy Renal Disease Cloudy Bacteria Thick More concentrated means more odor Stagnant Ammonia Diabetes Fruity or sweet Infection Foul Urine Testing LabeI w name date time Timely transport CoHchon 0 Random cIean voidedmidstream sterile timed o Varies based on developmental level and type Collection in children 0 Often dif cult 0 Offer uid 30 minutes before coHchon Common Test 0 Urinalysis First voided specimen Use special strips 0 Speci c Gravity Weight of concentration compared to V of water 0 Culture Sterile cIean voided sample Radiographic Techniques Direct Indirect Invasive Noninvasive Obtain specimen Assess history Administer bowel cleaning Give pretest diet FoIIowing day Assess I and O observe urine encourage uids 0 Diagnosis Focus on urinary elimination alteration or associated factors 0 Planning Building trust is important Goals and Outcomes Realistic and Individualized Collaborate w pt Setting Priorities 0 Personal and intimate Relationship needs to allow discussion and intervention 0 Give attention to pt perceived needs Reinforce good habits Teamwork and Collaboration 0 Consider home environment Specialists in Continence for pelvic oor mm 0 Physical therapist for overall strength to go to bathroom on own 0 Implementation Health Promotion 0 Understanding and participation in selfcare Pt Education 0 Teach about elimination problems 0 Learn symptoms and meanings Promoting normal 0 Prevents problems 0 Stimulating Micturition Re ex Control of sphincter Uses squatting or sitting position for women and standing for men Run water stroke inner thighs pour warm water over perineum Maintaining habits 0 Try to follow normal routine as much as possible Fluid Intake 0 Maintain optimal intake 22002700mL a day 0 Increasing helps to ush Complete Bladder emptying 0 Wait till stop in ow void again if needed 0 Schedule toilet times and care 0 Compress downward on bladder Preventing Infection 0 Perineal hygiene Cleaning meatus after voiding Optimal uid intake Void after intercourse Don39t take excessive bubble baths Cotton underwear OOOOO o Acute Care Drink high acid ash drinks cranberry juice Maintaining habit O O 0 Give 30 minutes to provide specimen Provide as much privacy as possible Have water running Medications O O 0 Drug therapy or other therapy can help Watch medication side effects constipation diarrhea dry mouth Block muscarinic receptor and suppress contractions VESIcare and Ditropan Cholinergic Drugs increase contraction Bethanechol AlphalAdrenergic blocker for men w prostate enlargement related incontinence Flomax Catheterization 0 Tube up urethra into bladder 0 Continuous ow of urine 0 Types Intermittent straight single use to drain in 5 10 minutes then remove Used for spinal cord or neurologic disorders 0 Straight or curved tip Men w prostate enlargement lndwelling remains in place until voiding on own is able short or long term 0 Small in atable balloon 23 lumens Insertion Requires order Aseptic technique is important Closed Drainage Minimizes risk of infection after insertion Large bag or leg bag that is held BELOW the bladder Watch for tube kinks and cut offs from positioning Perineal Hygiene 3 times daily Use soap and Water Don39t advance catheter into bladder increase infection risk Extra care reduces discomfort and infection Fluid lntake Should remain the same O Avoid citrus juice creates environment for growth Preventing Infection Keep system closed break means infection risk Drainage bag site of insertion spigot tube junction junction of tube and bag are all high risk areas Bacteria grow in pools of urine prevent back ow into the bladder Irrigations and nstiations O O O Flushing w sterile solution Irrigation can ush pus or blockage back into bladder Best to change tubing Antibiotic or antiseptic irrigations can be used w bladder infections Maintenance of closed system w irrigation is recommended 0 Removal of Indwelling Cath O 0000 Promote normal function prevent trauma Clean disposable towel trash sterile syringe De ate balloon completely Burning sensation is felt when pulling out Assess function by dating measuring and timing the voiding for 24 hours 0 Alternatives to Cath O O O Suprapubic Cath Surgical insertion of cath Anchored w sutures or ring seal Maintenance is same as indwelling Remains in all the time land 0 must be monitored Asses for 55 of infection Condom Cath Incontinent or comatose MEN At night or continuously worn Make sure blood supply to penis isn39t cut off Change daily Others Pads need to be changed frequently Restorative Care 0 Strengthening Pelvic Floor mm 0 O O Kegel exercises Continued use to maintain Noninvasive and low risk Bladder Retaining 0 Evaluation Pt Eyes Chapter 47 Reduce frequency Retaining normal bladder function Urological consultation is helpful Never refuse to toilet a pt Suppress voiding for 15 minutes and increase by 15 each week 0 Void every 34 hours Habit Training 0 Improve voluntary control 0 Establish pattern 0 Positive reinforcement promoted voiding Selfcath 0 Teach structure of system aseptic tech adequate uid intake frequency 0 56 times a day Skin Integrity 0 Acid urine irritates skin 0 Wash w soap and warm water Comfort 0 Clean dry clothing 0 Protective pads o Analgesics o Stimulating urination may be the only relief OOOOO Pt is best source of information Remember not just physiological but also psychological Pt Outcomes Make take weeks Mobility is used for many purposes Effects physical and emotional WB Not just for tness For expressions defense ADL Physical Therapy helps to maintain strength Scienti c Knowledge 0 Nature of Movement Complex Coordination bw musculoskeletal and Nervous system Body Mechanics Coordinated Efforts Need to mechanics around lifting Know balance alignment gravity and friction Alignment and Balance Position ofjoints tendons ligaments and mm C06 is stable Correct reduces stress aids in mm tone promotes comfort conserves energy Wout balance C06 is off increasing fall risk Balance is increased by keeping CoG low and base wide Impaired balance is a major risk factor Gravity and Friction Wt exerted on body gravity To lift lft must overcome wt of object and its CoG Using only principles of body mechanics in lifting pt leads to injury Friction greater surface area men greater friction Shear occurs when the head of the bed is lifted causing bones to move down and skin to be pulled up 0 Damages underlying structures 0 Use ergonomic assistive devices 0 Physiology and Regulation Skeletal System Attachments for mm and ligaments Leverage Bones 0 Long Ht and length 0 Flat Contour Short Occur in clusters and permit extremity movement Irregular Vertebra and mandible Firmness inorganic salts Rigidity Keep bones straight and wt bearing Elasticity Bone exibility Changes w age cartilage amount Aids in Ca2 regulation Bone marrow creates blood cells Ligaments Some are protective spinal cord Cartilage Infants have more 0 Permanent Unossi ed O 0000 Skeletal MM Contract and Relax Working element Functional Purpose 0 Moving o Resisting o Stabilizing Concentric tension increased contract mm shortening movement Isometric increases energy expenditure 0 Increase RR and HR are associated Eccentric Tension controls speed and direction mm lengthen Isotonic 0 Voluntary movement is isometric and isotonic contractions MM Movement and Posture o Leverage is created 0 MM in posture maintenance are short and featherlike MM of lower extremities trunk neck and back 0 Stabilize MM Regulation of Posture and Movement 0 Depend on shape development of skeletal mm 0 MM tone is the state of balance mm tension Nervous System 0 Movement and posture regulation Precentral gyrus and motor strip 0 Pathological In uences on Mobility Postural Abnormalities Congenital or acquired Affect balance posture alignment and ROM Cause pain impair alignmentmobility Maintain max ROM in unaffected joints Strengthen affected MM nd joints improve posture and use all mm groups MM Abnormalities Dystrophies Most prevalent in childhood diseases 0 Progressive and symmetrical weaknesswasting Damage to CNS 0 See Chapter 38 Direct Trauma to Musculoskeletal System Fractures most commonly come from external force 0 Nursing Knowledge Base 0 Safe Pt Handling Manually lifting increases risk for injury EB intervention reduce risk Laws mandate safe handling Eronomics assessment protocol for HC environments pt assessment criteria algorithms for pt handling an movement special equipment action after review and no lift policies 0 Factors in uencing Mobilitylmmobility Assess ability to move freely Broad spectrum bw mobile and immobile Some move back and forth Bedrest restricts pt to bed for therapeutic reasons 0 Duration is dependent on injuryillness and prior health state Hazards of Immobility are the cluster of MM deconditioning Systemic Effects mobility and immobility effect entire body All systems work better w movement Metabolic Changes 0 Alter endocrine metabolism Ca2 reabsorption and GI function 0 Endocrine system initiates series of responses aimed at maintaining BP and saving life Homeostasis function Thyroid alters BMR o Immobilized pt w infection have increased BMR o Immobilization results in negative nitrogen balance hypercalcemia occurs constipation pseudodiarrhea Fecal impaction o Endocrine Ca2 and GI Respiratory Changes 0 Aerobic enhances function 0 Lack of movement increases complications Atelectasis aveoar collapse Hypostatic pneumonia in ammation of lung or pooling of secretions Decreased oxygenation and increased stays Mucus accumulates Cardiovascular Changes 0 Orthostatic Hypotension increase in HR 15 decrease in BP 15mmHg S and 10mmHg D when supine to standing PooIing occur in immobile and decrease ANS response 0 Thrombus accumulation of platelets brin clotting and cellular elements Damage to cellular wall alterations in blood ow alterations in blood constitutes Virchow39s Triad of clotting factors 0 Increased Cardia Workload 02 consumption increases heart works harder decreases ef ciency output faIIs Musculoskeletal Changes 0 Permanent or temporary disability 0 Loss in endurance strength and mm mass 0 Impaired joint mobility 0 MM Effects Loses Iean mm Mass cycIe Iess mobility more Ioss more fatigued Iess mobility more loss 0 Mm atrophy decreased strength joint instability o Skeletal Effects Impaired Ca2 metabolism Disuse osteoporosis Risk for pathological fractures Joint abnormalities 0 Joint Contracture is abnormal and can be permanent Fixation ofjoint Early prevention is key Footdrop occurs when foot is permanently in plantar exion Urinary Elimination o Kidney move on level plane instead of w gravity 0 Renal pelvis ll w urine bf entering ureters urinary stasis increasing risk for UTI 0 Renal Calculi are calcium stones bc hypercacemia o Fluid intake diminishes urine becomes concentrated increasing caIcuIi stone risk Integumentary 0 Pressure on skinD Pressure Ulcers 0 Break in integrity is dif cult to heal 0 Pressure Ulcer resulted of decreased blood supply In ammation over boney prom Older adult is especially at risk Psychological Effects 0 Altered sleep patterns increased anxiety hostility depression emotional behavioral sensory and coping alterations Changes in ADLs sit and worry withdrawn 0 Developmental Changes Infants Toddlers Preschoolers As babdy grow muscquskeIetaI development occurs aow wt support Posture is awkward Prolonger immobility delays motor skills intellectual development and muscquskeIetaI development Adolescents Increase in growth 0 Growth is uneven Social isolation occurs when immobile Adults 0 Have necessary development and coordination Older Adults 0 Progressive bone mass loss occurs Nursing Process 0 Assessment Progressive or sudden immobilization can occur Encourage to do as many selfcare activities as possible Assess mobility and immobility Through Pt Eye Assess and ask questions about degree Mobility ROM Max amount of movement a joint can go in sagittal transverse and frontal plane 0 CPM machines 0 Important baseline assessment 0 Passive or active both assessed 0 Neck Reveals altered alignment changes in vision eld decreased independent function 0 Elbow best at 90 degrees xed extended impairs func on o Forearm xed in supination is a serious impairment 0 Wrist Weakened Grasp o Knee Stability Gait heel strike of one leg and heel strike of anther 0 Shows balance posture safety walking ability 0 Requires coordination of systems Tolerance type and amount of exercise pt is able to perform 0 Needed fr planning of interventions 0 Physiological emotional and developmental domains for assessment 0 Exercise cause physiological changes 0 Monitor for dyspnea fatigue pain vital sign change 0 Worried depressed or anxious have lower tolerance o Tolerance changes w age More in childhood less in adolescent pregnancy can cause lack of motivation Older adult has less activity and less tolerance Alignment o Siting Standing Laying down 0 Determine Normal based on growth and development Deviations and cause Opportunities to observe own posture Note learning needs Identify trauma mm damage nerve dysfunction Obtain concerning information 0 Put pt at ease 0 Turning at least every hours if not every hour 0 Aids Pillows blankets Immobility Metabolic System 0 Anthropometric Measurements to note mm atrophy 0 Note uid intake and output 0 Assess wound healing 0 Note nutrition intake and screen for malnutrition Respiratory System 0 Once every 2 hours 0 Inspect wall and full inspiratory and expiratory o Auscultate lung sounds Cardiovascular System 0 BP Pulses peripheral and apical signs of venous stasis 0 Monitor for orthostatic hypotension longer immobility greater risk 0 Listen for third heart sound indication of heart failure 0 Edema sometimes develops DVT embolus often in lower extermities MusculoskeletalSystem o Decreases tone and strength loss of mass contractures 0 ROM lntegumentary o CONTINUOUSLY assess for breakdown and color changes 0 Use Braden scale 0 Occurs every 2 hours Elimination 0 Evaluate each shift intake and output every 24 hours 0 Dehydration increases complications 0 Includes dietary choices bowel sounds frequency and consistency of movements PsychosocialAssessment 0 Changes in personality Confusion boredom isolation depression anger Emotional status change Assess for coping Identify correct and unexplained changes in sleeping 0 Observe on daily basis DevelopmentalAssessment OOOO O 0 Diagnosis Determine if progressing normally implement interventions to assist normal development Assess family and child coping Determine ability to meet needs Assess home and community for resources and risks Impaired physical mobility Risk for disuse syndrome Immobility can lead to many addition complications so be alert and try to prevent 0 Planning Communicate w respiratory nurses wound care nurses and others Goals and Outcomes Individualized Assist in achieving highest level of mobility and reduction in immobility hazards Setting Priorities 0 Effect on mental and physical status help the determine 0 Immediate needs are met rst 0 Plan according to severity of risks 0 Don t overlook potential complications Teamwork and Collaboration care 0 Implementation Team approach Encourage NAP to help w exercises Determine mobility needs an abilities Dietitian for nutritional Referrals for discharge Keep in mind home environment when planning home Health Promotion 0 Education Prevention and early detection 0 Prevention of Work Related 0 O O O 0 Increased injuries in workplace Most occur from overexertion Back injury from lifting and bending Strain in lumbar Pt care is best w health staff NoIift policies are instituted and lift teams must be used Know individual capacity and ability Consider pt ability to assist 0 Keep wt close to body bend at knees Tighten abdominal mm maintain trunk erect and knees bent don39t twist trunk Exercise enhance WB and improve health 0 O O Reduces risks Encourage the beginning of managed exercise programs Culture should be taken into consideration 0 Bone Health in Osteoporosis Pt 0 O 0 Acute Care Increased risk should be screened diet assessment for adequate Ca2 intake and Vitamin D intake Early evaluate and referral is the best Use aids main goal is to maintain ADLs independence Hazards of Respiratory status orthostatic hypotension impaired skin integrity 0 Reduce impact of immobility Metabolic System 0 0 High protein high caloric diet is needed w Vitamin C and B supplements Enteral or Parenteral nutrition might be indicated 0 Respiratory O O Reexpand Iungs dislodge and mobilize stagnant secretions cear Iungs Assess sputum cough pain wheezing Deep breath every 12 hours 3 deep breaths and cough on last one Chest physiotherapy drain by coughing identi es speci c areas Adequate uid intake is key to keep ciiary clearance Cardiovascular 0 Reducing Orthostatic Hypotension Increase Pulse rate Decreased pulse pressure drop in BP Fainting can occur To prevent Mobilize as soon as possible Dangle feet over bed Isometric exercises improve activity tolerance Assess getting up using safe handling algorithm 0 Reducing Cardiac Workload Discourage from using VaIsaIva Maneuver 0 Pressure changes decrease produce bradycardia Can result in sudden cardiac death 0 Preventing Thrombus Formation Identi cation of risk Leg foot and Ankle exercises Fluids Position Changes pt teaching Heparin therapy Continually assess for signs of bleeding SCDs and lPC use to decrease venous stasis Elastic stockings also antiembolic and keeps blood moving 0 Assess circulation in toes to make sure not too tight Proper positioning 0 Avoid crossing legs sitting for long periods wearing constricting clothing massaging legs Report suspicion immediately elevate leg but avoid pressure ROM reduces risk of contractures Antiembolic exercises done every hour while awake Musculoskeletal 0 Exercise prevent large atrophy and contractures 0 Active ROM is needed in daily schedules and passive is needed 0 CPM use continuous passive motion lntegumentary 0 Pressure ulcer formation 0 Turn every 12 hours 0 Teach to shift weight every 15 minutes Elimination Keep hydrated Prevent stasis calculi and infections Don39t cause distension Record frequency and consistency Fruits Veges and ber diet Stool softeners toileting aids ad hygiene may need to be provided Psychological Changes 0 Check history to determine at risk 0 Note coping ability 0 Incorporate social workers spiritual workers and others 0 Place in room w other person for interaction OOOOOO 0000 If private have staff go in and talk to pt regularly Books anf TV should be provide Involve in own care Encourage use of hygiene make up shaving hair do 0 Developmental O O O O 0 Continue w normal Mental and physical stimulation is needed Incorporate play Maintain calendar and clock in room Encourage to perform own ADL Positioning 0 00000000 Pillows folded sheets blankets towels are great aids Positioning boots to prevent foot drop Trochanter roll prevents hip rotation Trapeze bar allows pt to pullassist in transfer Unsupported jointsimpaired alignment Slightly exed is better Use bed to help as much as possible Low Fowlers 15 degrees SemiFowlers 30 degrees lower than this increases risk for respiratory problems minimum for feeding and if respiratory issues comfortable less pressure less risk for pressure ulcers Fowlers 45 degrees oral care bating more pressure and ucer risk less time is spent here Supported Fowler39s Position 4560 degree elevation Knee sighty elevates Eating if can t be moved to chair increased pressure on coccyx Supine Good alignment Pillows and rolls for arms and hands Prone Face or chest down Head turned to side Pace piows under knees and ankle Bene ts in acute respiratory distress Not common Trendelenburg Head down and feet up for shock faint feeling increases blood flow to head DO NOT use if heart problems or head injury are present Entire bed is tilted and no abdomen bending 0 Reverse Trendelenburg Opposite of normal re ux hernias back surgery and pregnancies Mush check of sli ng o SideLying Position Most weight on hip or shoulder 30 degree lat Position Trunk alignment is same as standing Maintain curves of spine Neck must be supported 0 Sim s Position Weight on anterior ileum humerus clavicle Enema and Suppository Transfer Techniques 0 Assess every situation 0 Use algorithm 0 Use pt strength 0 Moving Pt Safety is rst Various levels of assistance are needed Does the pt know what is expected of them Do they know the procedure What is the comfort level lf pt too heavy or immobile to move alone Non slip shoes aids assistance gait belt Stand on stronger side unless use of aid Remove obsticles o Transferring Bed to Chair Move obstacles Ensure there is help Explain procedure place chair next to bed Can pt bear weight 0 Bed to Stretcher ls pt able to assist gt200 pounds use friction reducing and 3 caregivers Restorative and Continuing Care 0 Max functional mobility and independence 0 Reduce de cits Functional for ADLs and lADLs functional beyond self care 0 ROM 0 Ensure joint mobility 0 Provide passive when needed 0 Should NOT cause pain 0 Walking 0 Asses activity tolerance strength pain balance coordination 0 Explain where to who when and why 0 How much independence can they assume 0 Gait belt provides support at the waste to keep CoG midline o Hemiplegia and hemiparesis Stand on affected side and support w gait belt 0 Evaluation Pt Eyes 0 Goals met New ones to be planned Pt Outcomes Evaluate understanding of teacher and proper use of techniques Chapter 48 Skin and Wounds Skin is 5 of body weight Protective barrier Injury triggers a healing complex Nurse needs to monitor integrity note problems planning implementing evaluating problems Know process of wound healing to identify appropriate interventions Scienti c Knowledge Base 0 Skin Two layers separated by dermalepidermal junction Epidermis Layers Stratum corneum dead keratinized cells 0 Protect underlying layers 0 Protect from dehydration 0 Permit absorption of topical medications Basal Layer Origin of cells Dermis Tensile strength mechanic support protection 0 Mostly connective tissue Collagen blood vessels nerves Fibroblasts are cells If injured epi will resurface the wound and restore the barrier and dermis will restores the structure and physical properties Aging makes skin more vulnerable 0 Pressure Ulcers Bedsores Goal is prevention Found more in long term care Preventable by good nursing Localized injury to skin and underlying structures usually over boney prominence Compression prevents proper blood flow 0 Can kill tissue Shear and friction force Factors Decreased mobility decreased sensory perception incontinence poor nutrition Pressure interferes w blood ow which interferes w cellular metabolism Pathogenesis Pressure intensity 0 Pressure applied of capillary that closes the cap 1532mm Hg for a prolonged time induces tissue ischemia 0 Tissue ischemia can result in tissue death 0 When an area that was on pressure is elevated If it turns red vasodilationD hyperemia If it blanche when pressedljBlanching hyperemia and is overcoming ischemic epEode If it does not blanch deep tissue damage is likely o Blanching will not show in those with dark pigmented skin Temperature will increase History of pressure ulcers Edema or change in skin color from normal 0 Duration 0 Low pressure over a long time and high pressure over a short time are both concerns 0 Can cause irreversible tissue damage in 90 minutes Turn person every 2 hours and high risk every 6090 minutes 0 Tissue Tolerance 0 Ability for tissue to handle the pressure 0 Depends on integrity of tissues and supporting structures 0 Extrinsic Shear Friction Moisture 0 Systemic Nutrition Age Hydration BP Risk Factors for Development Impaired Sensory Perception o Alter perception increases risk 0 Can39t feel the pressure or development Impaired Mobility 0 Unable to independently change position Alteration in Level of Consciousness 0 Unable to protect themselves 0 Confused Feel pressure but don39t know how to alleviate o Coma Can39t feel or communicate that it is happening Shear o Sliding movement of skin and tissue while underlying mm and bone are stationary 0 Skin is stuck to the bed and slide one way while underlying structures don39t 0 Capillaries are stretched causing necrosis win deep tissue layers and tissue damage occurs 0 Tension stretches the skin 0 Friction 0 Force of two surfaces moving across each other 0 Affect epidermis o Rug burn happens 0 When ski is dragged Moisture 0 Presence and duration increases risk 0 Reduces resistance and softens skin 0 Immobile pt are at a higher risk 0 Moisture from wound drainage perspiration inconUnence 0 Classi cation Assess at regular intervals Systemic parameters are used to evaluate Staging system Describes depth Stage I Nonblanching Redness of lntact Skin Discoloration edema warmth hardness pain Painful rm soft warmer or cooler Measure in cm Stage II Partial Skin Loss or Blister Shallow open ulcer or a blister o Shiny or dry Redpink wound No slough or bruising Feel for warmth and coolness Measure longest and widest parts e lll Full thickness skin loss Fat is visible Bone Tendon and MM is NOT shown 0 All layers of the skin 0 Some slough Can be shallow and will vary look based on area malleolus has no fat tissue 0 Red beefy color Stage IV FullThickness Tissue Loss MM and Bone visible Slough or Eschar present Undermining and Tunneling Varies by location 0 Increase risk of Osteomyelitis or Osteitis UnstageableUnclassified FullThickness Skin or Tissue Loss Sta OLQOOOO Unknown depth Depth is obscured by slough or eschar Usually stage III or IV Stable eschar should not be removed if on heels Dead tissue must be removed for proper healing Suspected Deep Tissue Injury 0 Depth Unknown 0 Purple or maroon localized area Painful rm boggy mushy warmer or cooler skin may come before 0 Rapid evolution Assess tissue at wound base 0 Amount percent Color of viable vs nonviable o Granulation is red and moist made of new blood vessels showing healing o Slough is soft yellow or white tissue that must be removed 0 Eschar is brown or black necrosis and must be removed for heling to occur 0 Measurement 0 Shows size changes and indicates healing 0 Length width depth Exudate 0 Amount color consistency odor o Excessiveinfection 0 Assess condition of skin surrounding Redness swelling edema warmth maceration When 0 Acute are admission and change is status 0 LTC Once weekly for 4 weeks and then 3 times a year 0 Classi cation of Wounds Wound integrity of the skin is disrupted and prevent it from functioning properly All wounds are not the same Classi ed by status of skin integrity cause severity cleanliness descriptions Process of Healing Grated physiological processes 0 Loss of tissue 0 BurnPressure Ulcer Secondary intention Left open and lls w scar tissue Longer healing high risk of infection Loss of tissue function Slow process OOOOO 0 Without loss of tissue 0 00000 0 Surgical incision Primary intention Skin edges are approximated Low risk of infection Quick healing and minimal scar Cells regenerate Cap walls stretch across and under suture line Tertiary Intention O O 0 Delay primary intention Surgical wounds that are left open for several days and then closed Minimal scarring Wound repair Partialthickness O O O 0 Shallow Loss of epidermis Heal by regeneration Components of healing In ammatory response Redness and Swelling 0 Moderate serous exudate First 24 hours of wound Epithelial reproduction New epithelial cells are created Migration Epithelial cell migrate to across wound grow towards other end 0 Only across moist surface 0 Kept moistquicker healing Reestablishment of epithelial layer occurs FullThickness Wound Repair 0 Four Phases Hemostasis Blood vessel constrict Platelets gather to stop the bleeding Clots form brin as a scaffoldlayout In ammatory Phase Damaged tissue secretes histamine D Vasodilation D Exudates serum and WBCs to wound Redness edema warmth throbbing WBC Neutrophil is main acting cell 0 Phagocytosis Macrophage Cleans the wound Makes a clean wound bed appear Proliferative Phase 0 New blood vessels appear 0 324 days long 0 Fill wound w granulation tissue contraction of the wound and resurfacing Collagen is the strength component Remodeling 0 Can take a year or more Scar tissue reorganizes and gains strength Scar tissue is usually lighter than normal skin Complications of Wound Healing o Hemorrhage Bleeding from the wound site Normal after trauma After hemostasis means a problem Internal or external Indicates Distension or swelling of a body part change in drainage type hypovolemic shock Hematoma is localized collection of blood 0 Dangerous when near a major vessel 0 Infection Second most common HAI Purulent material drain from it 0 Yellow green brown Odor Positive cultures don39t always indicate infection Bacterial infection prevents healing Can take several days for an infection to develop Fever tenderness pain elevated WBC count Edges of wound are in amed o Dehiscence When wound doesn39t heal right Tissue separate Partial or total separation of wound layers If at risk for poor wound healing at risk for this Obese have a higher risk 0 Nursing knowledge Common in abdominal wounds Increase in serosanguinous drainage 0 Evisceration Total separation of wound layers Emergency requiring surgery 0 Prediction and Prevention of Pressure ulcers Maintain skin integrity Risk assessment Identify those at risk Use consistent methods Braden scale is the most widely used 0 6 subscales Sensory perception moisture activity mobility nutrition friction and shear Lower scorehigher risk At risk lt16 High risk for multiple areas lt9 Prevention Priority 0 Economic Consequences 1018 of people acquire on upon admission Length of stay increases Cost of care increases Hospitals no longer receive reimbursement 0 Factors In uencing Formation and Healing Nutrition Normal healing requires good nutrition Wound healing is dependent upon proteins vitamins and trace minerals o Collagen A and C Zinc and Copper Calories provide energy Balanced intake is needed Malnutrition is indicated by serum proteins Tissue Profusion Oxygen is important in tissue repair PVD or poor circulation can prevent proper healing Infection Prolong in ammatory phase Delays synthesis of collagen Prevents epithelization Increases cytokine production Older decrease in macrophage functioning delayed in ammatory response delayed collagen synthesis and slower epithelialization Psychosocial Impact 0 Unknown Pt response to wound is for nurse to assess Changed body image selfconcept sexuality Note social and personal resources Scars drains odors and prosthetic devices can change perception Diabetes Mellitus Corticosteroid Therapy Chemo an Radiation Stress Slows healing lmmunosuppression Systematic Conditions affecting health 0 Cancer Renal disease Hematopoietic blood disorders 0 Nursing Process 0 Assessment Create a baseline Identify pressure ulcer risk development Focus on level of sensation movement continence status Pt eyes lnvolve pt and family 0 Know pt expectations 0 Keep informed about length of time for wound healing o More likely to comply w interventions Assess perception of wound healing Understand perception of wound assessment interventions and supportive interventions Skin Continual assess for ulcer formation Visual and tactile inspection Determine baseline and individualize care Accurately assess a dark skinned person Pay close attention to boney prominence areas or under casts Document 0 Location size and color 0 Reassess in one hour 0 Mark w marker to determine growth and palpate to determine damage to skin 0 Observe for blanching Pressure Ulcers Predictive Measures 0 Use Braden Scale 0 Early detection for risks prevent further development 0 Once pt is identi ed initiate interventions to maintain skin integrity and prevention strategies Mobility 0 Level of pt mobility Assess mm tone and strength Note activity level Part of baseline data Repositioning frequency depends on risk assessment 0 Be meticulous Nutritional Status 0 Malnutrition is a risk for skin breakdown Body Fluids 0 Prolonged exposure increases risks for skin breakdown and pressure ulcer formation 0 Prevent and reduce pt exposure to uids 0000 0 Assessment and management 0 Management increases comfort and willingness to be mobile Wounds Assess under two conditions 0 Time of before injury 0 After treatment 0 Obtain information about cause and history of wound Emergency Setting 0 Type determines criteria for inspection 0 Pt is stable is Spontaneous breathing clear airway strong carotid Then inspect wound for bleeding 0 Abrasion Super cial w itte bleeding Partialthickness o Laceration Bleeds more profusely Greater than 5 cm long or 25 cm deep 0 Puncture bleed in relation to depth and size Infection and internal bleeding are main concerns 0 Inspect for foreign bodies Soi glass cloth 0 Size is inspected next Deep requires sutures Bone or tissue that is exposed that needs to be protected 0 Determine tetanus shot status 0 Stable Setting O 0 Assess wound and determine progress of healing lf covered w a dressing and PO doesn39t state a need for change don39t remove dressing to inspect unless serious complication lnspect dressing and external drainage Assess wound during dressing change Wound Appearance O 0000 Observe closed edges Look for complications In ammation should disappear after 23 days 710 days edges begin to close Infection will be indicated by brightly in amed and swollen surrounding areas 0 Character of Drainage 0 O O O Drains O 0 Amount Depends on location and extent of wound 1 gram of weight 1 mL of drainage Color Varies depending on components Serous Sanguineous Serosanguinous Purulent Odor Strong odor may indicate infection Consistency Varies depending on components Be careful when changing dressing to ensure no movement of drain Penrose leis under dressing Assess of drains Placement Character of drainage Condition of collection equipment Drain and location Note if on pressure that correct pressure is being applied lf uid collects this inhibits healing and increases infection risk Wound Closures O Staple Strength Less irritation Suture Early removal reduces defect formation and minimizes chance of scar Wound closures o Dermabond tissue adhesive Palpitation Allows for normal healing 0 Observe for swelling or separation of edges 0 Note character of drains that is expelled when pressure is applied Cultures o If you detect purulent drainage take a sample when needed Fresh drainage should be used Clean wound w saine the collect Then gram stain is performed 0 A tissue biopsy may be needed but this is taken by a specialized nurse or the Physician 0 Planning Those w chronic or infected wounds have multiple needs Establish goals and interventions based on risk or presence of pressure ulcers type and severity of wound and if complications are present Usual goal is to see wound improvement over a 2week period Priorities are set based on assessment 0 Acute Immediate intervention 0 Chronic and stable Hygiene is priority Eliminating friction and shear forces 0 Promotion of wound healing 0 Implementation Health Promotion Most important 0 Prevention of pressure Ulcers 0 Assess risk factors Reduce and eliminate 0 Skin care and management of incontinence Perform frequent assessments Clean and dry skin 0 Avoid soap and hot water Apply moisturizer Control contain and correct incontinence perspiration and drainage 0 Timed voiding Moisturizer barriers Absorbent pads 0 Mechanical loading and supportive devices Positioning Reduce pressure and shear force Have bed at 30 degrees or less Reposition ever 15 to 2 hours Use positioning devices to protect boney prominences O Acute care Use transfer device to reposition rather than quotdraggingquot Limit chair sitting to 2 hours Assess skin after every repositioning Select support systems based on pt needs Educann Teach mobile person risk for skin breakdown Teach about shifting weight every 15 minutes 0 Management of Pressure Ulcers O O O O 0 Holistic approach Multidisciplinary work Reassess for location stage size tissue type and amount exudate surrounding skin Close monitoring is required Chronic is monitored less frequently Systematic documentation 0 Pressure Ulcer treatment 0 0000000 0 Relieve factors Correct bed or chair Turing and reposition at appropriate times Assess frequently Proper Nutrition Clean and debris the wound Use transparent lms Use a wound vac to suck out drainage Changed every 57 days Document Drainage Infection location size comfort healing Wound Management 0 O O 0 Maintain local wound environment Prevent and manage infection Clean wound Viable tissue is redpink moist and granulation Ussue Remove nonviable tissue Debridement method 0 Mechanical Wet to dry saline gauze nonselective Autolytic Use synthetic dressings to allow eschar to be selfdigested Chemical Topical enzyme preparation to break down a loosens dead tissue SharpSurgical removal by scalpel scissors or sharp instrument Rids of infection enables visualization provides clean base for healing O O O O Assess and try to prevent pain Nonviable tissue is black brown or tan Eschar Maintain moist environment Facilitates wound healing Protect wound Irrigation is a common wound cleaning method Educann Teach to prevent pressure ulcers and care for wounds Individualize Know pt experience Pan education to meet needs of pt and famil Nutritional Status Protein Status Increased intake aids in the healing process Hemoglobin Maintian at 12 g100mL First Aid for Wounds O O O O Stabilize Cardiopulmonary system Hemostasis Control bleeding w direct pressure Elevate area Pressure dressings are used in the rst 2448 hours of a serious injury Allow puncture wound to bleed Don39t remove penetrating object Cleaning Gentle Removes contaminates Vigorous can cause bleeding or more injury For minor just rinse w normal saline and cover Protection Protect wound from further injury Apply dressing and immobilize Dressings O 0000 More extensivelarger Towels and diapers are good secondary dressings Use requires knowledge of healing process Correct dressing will promote healing Purposes Protection Reduces exposure 0 When no drainage ten brin takes over Hemostasis promotion from pressure 0 Assess for disruption of underlying circulation Assess color changes pulses comfort and changes in sensation Not removed routinely Supports wound site Protect pt from seeing wound Thermal insulation of wound Moist environment Absorbs drainage 0 Layers O Contact primary layer Covers incision Fibrin blood products debris Can stick to suture line Absorbent layer 0 Holds other secretions Wicking action Outer protectivesecondary layer Prevents entrance back into the wound Thicker materal Type of dressing applied will depend on the purpose and wound Changing frequency will also depend on the dressing wound and purpose Keep surrounding skin clean and dry Remove tape slowly Types of Dressings 0 Easy to apply comfortable materials promote heaHng Dressing to treat pressure ulcers can39t be too moist in order to prevent skin breakdown Pressure ulcer dressing depends on stage Gauze sponges are common Absorbent Wick away exudate Can be saturate and used to cleanpack wounds Provides moisture and drainage Nonadherant Gauze Telfa Wounds w little or no drainage Little irritation to wound Selfadhesive transparent lm Traps moisture Super cial and partial wounds Adheres to skin Barrier allowing for wound to breathe Can be removed wout damaging tissue See through No secondary dressing required 0 Hydrocolloid dressings Adhesive and Occlusive Contact layer forms gel to be absorbed and provide the moist environment Support healing Absorbs drainage Lique es necrotic debris Impermeable and selfadhesive Preventative dressing on friction common area 35 life span Shallow to moderate ulcers Granules Paste Wafer o Hydrogel Water or glycerin based gel Hydrates the wound and absorbs small amounts of exudate Partial and full thickness wounds deep wounds necrotic wounds burns and radiation damage skin Good for painful areas Soothing Don39t adhere to the wound bed Require secondary dressing 0 Foam are used around drainage tubes Absorb moderate to heavy exudate 0 Calcium alginate form a gel and are highly absorbent Don39t use in dry wounds Shape around wound Require secondary dressing 0 Moist to Dry Fullthickness wounds Used when debridement is required Dries and adheres to wound lsotonic solutions moisten 0 Pressure Control bleeding ConUnuous 0 Synthetic Moist environment is maintained Autolytic debriding Protects from friction and contamination Provides absorption 0 Changing Dressings O O 0 Know type of dressing presence of underlying drainstubes and supplies for wound care Clean technique I only appropriate in some cases Sterile is usually used PO for changing will indicate the type frequency and solutionsointments PRN change is common Guidelines Asses skin under tape Hand hygiene before and after Sterile gloves before directly touching wound Removing or changing dressings when they become wet or 55 of infection and as ordered Evaluate pain and give meds Describe procedure Gather all supplies Know normal signs of healing Answer question Teach pt about changing dressing or wound care Demo and provide opportunity to practice Sterile Technique 0 Packing a Wound O 0000 Assess size shape and depth Dressing should be exible ln contact w entire wound Don t pack to tightly Negative Wound Therapy vaccum Suctions drainage and facilitates healing Draws wound edges together Reduces edema Acute and chronic wounds 24 hours 5 days Airtight seal must be maintained 0 Secure Dressings O 0000 O O Tapes Eyeball length and tear Ties Secondary dressings Cloth binders Type depends on dressing and placement drainage frequency of dressing changes Assess skin at every dressing change Don t place tape over irritated skin 0 Comfort 0 Be careful when removing tape o Gently clean edges of the wound o Careful turning and repositioning 0 Pain meds 30 minutes before 0 Cleaning skin a debris 0 Hand hygiene and aseptic techniques 0 Basic skin cleaning 0 Noncytotoxic solutions added to gauze or irrigation Principles Direction Least contaminated to most Gentle friction Flow of solution should be from least to most If drain clean from incision to drain Irrigation Flush w low pressure Cleans exudate and debris Sterile when on open wound 35 mL syringe w 19 gauge needle Suture Care 0 000000 0 Threads or metal sewn into the body Suture depends on injury and placement Many type of suture material Can cause local in ammation Staples are sometimes used PO is required to remove To remove Check type used Manner in which suture crosses skin determines how removal works Pull out every other suturestaple and the 0 back and pull out rest NEVER PULL AREA OF SUTURE THAT IS EXPOSED TO THE AIR INTO THE WOUND Drainage Evaluation 0 0 Remove drainage w tube or device with continuous or no suction Specil skin barriers are applied Drainage Evacuators Portable drains exerting a low pressure sucUon Bandage and Binders 0 Extra protection Create pressure Immobilize Support wound Reducesprevents Edema Secures splints and dressings o Gauze bandages are lightweight and permit circulation Elastic exert pressure 0 Principles for Application Don39t cause injury to underlying tissue lnspect wound for abrasions or discoloration Cover exposed wounds Assess underlying tissue condition Assess skin distal to wound circulation o Binder Application Abdominal is common 0 Support large abdominal incisions Secured in a variety of ways 0 o Slings Support arms Fits under arm and over chest 0 Bandage Application Secure and support dressing 0 Heat and Cold Therapy 0 Assessment of Tolerance Signs of intolerance Area being treated should be free of alterations in skin integrity and integrity of extremities Sensann Mental Status Don39t cover bleeding area w warmlj bleeding will continue Edema areas should not be covered w codinhibits circulation Level of conscious Condition of equipment Fraying of wires Evenness of temperature distribution 0 Body responses to heat and cold Systemic Heatloos mechanisms 0 Sweating and vasodilation Heat Promotion 0 Vasoconstriction and Piloerection o Shivering Local 0 Maintenance of normal body temperature HeatBurning sensation ColdNumbness 0 Local Effects Heat 0 1 hour of application reduction in blood flow 0 Damages epithelial cells Cold Diminishes swelling and pain Vasodilation re ex Skin reddens and then numbs and burns Tissue can freeze 0 Factors 0 Applic Short exposure is better tolerated Some areas are more sensitive Body can respond to minor changes Less tolerance when larger area is exposed Tolerance depends on age and physical condition ation PO will state Site type treatment frequency duration Moist vs Dry Depends on wound and site Warm Moist compress lmprove circulation Reduce edema Promote consolidation Must change often Warm Soaks Soak area in warm warmed solution 0 Dry part thoroughly after Sitz baths Sit on chair that keeps feet out of water and immerses peri area Temperature depends on reason Lasts 20 minutes Hot Packs Cold Moist Compress 20 minutes at 15 C Relieves in ammation and swelling Cold Soaks Same as warm but cold lce BagsCollars Prevents edema formation controls bleeding anesthetize body part 0 Looks like rubber bladder but lled w ice and water 0 Evaluation Does pt know about skin integrity
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