1
Q
vital signs: how are vital signs obtained
A
via palpation of pulse, inspection of respiration, and obtaining blood pressure, oxygen saturation levels, temperature, and pain levels
2
Q
vital signs: why are vital signs obtained
A
it provides:
- info. of pt.’s health status
- baseline data
- monitoring of pt.’s condition
- identification of problems
- evaluation of pt.’s response to intervention
3
Q
vital signs: physiology of normal regulation of body temperature
A
regulated by:
- neural and vascular control
- heat production [post. hypothalamus], i.e.:
- by-product of BMR
- voluntary movements
- shivering
- non-shivering thermogenesis [brown fat in neonates]
- heat loss [ant. hypothalamus], i.e.:
- radiation: indirect loss from surface to surface
- conduction: direct loss from surface to surface
- convection: loss by air movement
- evaporation: heat/fluid loss by diaphoresis
4
Q
vital signs: physiology of normal regulation of pulse
A
it is affected by stroke volume (it is the amount of blood your heart pushes into the artery every time it contracts), cardiac output and compliance (how elastic an artery is which allows blood to flow more easily
5
Q
vital signs: physiology of normal regulation of respiration
A
involves three processes:
- ventilation: the mechanical movement of gases in and out of the lungs
- diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
- perfusion: the distribution of red blood cells to and from the pulmonary capillaries
6
Q
vital signs: physiology of normal regulation of blood pressure
A
regulated through:
- cardiac output: the amount of blood coming from heart
- peripheral vascular resistance: resistance of blood flow
- blood volume: circulating volume
- blood viscosity: thicker blood causes more pressure to be made which increases blood pressure
- artery elasticity or “compliance”
7
Q
vital signs: physiology of normal regulation of oxygen saturation
A
accuracy is dependent upon light transmission and adequate arterial pulsations
8
Q
vital signs: normal vital signs
A
temperature - 36-38 degree Celsius (96.8-100.4 degree Fahrenheit) pulse - 60-100 bpm respiration - 12-20 bpm blood pressure - <80 oxygen saturation - 95-100% pain - absence of pain
9
Q
vital signs: abnormal vital signs
A
temperature - hypothermia [mild, moderate, severe] - frostbite pulse - tachycardia - bradycardia - dysrhythmia respiration - bradypnea - tachypnea - hyperpnea - apnea - hyperventilation - hypoventilation - cheyne-strokes, kussmaul's [hyperventilation] blood pressure - hypotension - orthostatic hypotension - hypertension
10
Q
vital signs: abnormal vital signs interventions
A
- review, analyze, decide if further investigation is necessary/notify the physician
- proper functioning equipment
- equipment appropriate for pt.
- know the pt.’s baseline; educate pt. to know their baseline
- medical Hx and medications
- have a routine for taking vital signs
- frequency of measurement dependent on diagnosis
- indication for medication administration
- analyze and interpret significant changes
- communicate significant changes
11
Q
infection control: interventions to prevent the spread of infection
A
Hand hygiene before and after all pt. contact
- When to use hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a pt., after touching pt. surroundings
- Alcohol-based hand sanitizer: 20-30 seconds
- Soap and water: 40-60 seconds
Visibly soiled
Coming into contact with a pt. that has spore-forming microorganisms
Proper use of supplies
Proper disposal of certain supplies
Good technique of donning and removing PPE
Critical thinking
Artificial nails (don’t have, get them)
12
Q
infection control: types of isolation
A
Tier I
- Standard precautions: Don gloves when in contact with bodily fluids or mucous membranes
Tier II
- Contact precautions Ie. Rhino virus, c. diff., MRSA, VRE, MDRO (multi-drug resistant organisms); Don gown and gloves
- Droplet precautions Ie. Pneumonia, bacterial meningitis, shingles, influenza; Don gloves, gown, face mask
- Air-borne precautions Ie. Chicken-pox, tuberculosis; All PPE + N95 mask (Mask is specifically fitted to fit an individual’s face)
13
Q
infection control: donning and removing PPE
A
Donning - Gown - Mask - Goggles - Gloves Removing - Gloves - Cap - Goggles - Gown - Mask
14
Q
infection control: medical asepsis
A
- Clean technique
- Practices/procedures that assist in reducing the number of organisms present and prevent the transfer or organisms
- Used when coming into contact with mucous membranes or skin Ie. Bedpans, food utensils, blood pressure cuffs, endotracheal tubes
15
Q
infection control: surgical asepsis
A
- Sterile technique
- Procedures used to eliminate all microorganism (pathogens & spores) from an object or area
- Used when there will be intentional perforation of the pt.’s skin Ie. IV insertion, catheters
16
Q
mobility: purpose of body mechanics
A
to maintain coordinated efforts of the musculoskeletal and nervous system to maintain balance, posture, and body alignment
to facilitate activities of lifting, bending, moving, and performing ADL’S
to achieve balance via a relatively low center of gravity balanced over a wide base of support
17
Q
mobility: proper body mechanics
A
equilibrium maintained as long as center f gravity aligns with base of support
facing direction of movement prevents abnormal twisting of the spine
balanced use of arms and legs reduced risk of back injury
leverage, rolling, and turning and pivoting requires less work than lifting
less friction equals less force needed to move an object
alternating period of rest and activity helps to reduce fatigue and injury
18
Q
mobility: devices used for positioning
A
foot boots/splints trochanter rolls wedge pillow side rails trapeze bar hand rolls/splints pillow bed boards
19
Q
mobility: assessment of mobility
A
range of joint motion gait activity tolerance - exercise - activity body alignment pain associated with activity
20
Q
mobility: nursing interventions on musculoskeletal system mobility
A
perform ROM exercises to improve strength
skin integrity
perform skin assessment, turn patient q2h
21
Q
mobility: nursing intervention on elimination system mobility
A
keep pt. hydrated via either drinking or IV fluids
gastrointestinal
provide a high-fiber diet, it encourages digestive movement
22
Q
mobiity: nursing intervention on psychosocial system mobility
A
encourage social interactions, regulate sleep-wake cycles
developmental changes
maintain normal development (young)
prevent falls via strength build-up, encourage
23
Q
mobility: nursing interventions on respiratory system mobility
A
promote expansion of the chest and lungs
- use incentive spirometer
prevent stasis of pulmonary secretions
24
Q
mobility: nursing interventions on cardiovascular system mobility
A
monitor pulse, blood pressure (especially before performing movements)
encourage pt. to breath out during movement
- discourages valsalva maneuver which leads to syncope
25
mobility: nursing intervention on metabolic system mobility
increase intake of protein and vitamins
| consider tube-feeding for pt.'s with a lack of appetite
26
mobility: nursing interventions on prevention of blood clots
encourage movement
increase circulating fluids
administer blood-thinners
promote circulation with SED's or ted stockings
27
oxygenation: oxygen level of room air
21% O2 on room air
28
oxygenation: nasal cannula
```
1L = 24 O2 on nasal cannula
2L = 28
3L = 32
4L = 36
5L = 40
6L = 44
humidification may be added for comfort (prevents nares drying)
may only administer 6L or less
```
29
oxygenation: simple mask
5-6L = 40% O2 on simple mask
7-8L = 50
10L = 60
ranges exist because the pt. is breathing in room air as well as the prescribed oxygen
30
oxygenation: partial rebreather mask
6-10L = 40-70% O2 on partial rebreather
should not run below 5L
the reservoir bag should never be fully collapsed
31
oxygenation: non-rebreather mask
delivers 60-80% O2 on non rebreather
should not run below 10L
the reservoir bah should never be fully collapsed
32
oxygenation: venturi mask
delivers a specific amount of oxygen
33
oxygenation: airway maintenance techniques
```
hydration
- 1500-1600 mL/day (unless contraindicated)
humidification
- add sterile water to the O2 supply
nebulization
- adds medication to the humidification
chest physiotherapy
- removes secretions or mobilizes them through:
-- postural drainage
-- chest percussion
-- chest vibration
coughing techniques
artificial airways
- oropharyngeal
- nasopharyngeal
- endotracheal
- tracheostomy
suctioning techniques
- oropharyngeal
- nasophaaryngeal
- orotrahceal
- nasotracheal
- traccheostomy
ambulation
- ROM
positioning
- at a 45 degree semi-fowler's position
chest tubes
- removes air or fluid from pleural space
```
34
skin integrity and wound healing: inspection and palpation of skin
```
skin color distribution
skin turgor
presence of edema
characteristics of any skin lesions
particular attention paid to areas that are most likely to break down
hyperemia
- areas of redness
- perform blanching of that area
-- if it turns white then back to red, that is normal and indicates short-term injury
it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer
incontinence
skin around dressings
```
35
skin integrity and wound healing: untreated vs. treated wound assessment
untreated:
- skin color distribution
- skin turgor
- presence of edema
- characteristics of any skin lesions
- particular attention paid to areas that are most likely to break down
- hyperemia
-- areas of redness
-- perform blanching of that area
-- if it turns white then back to red, that is normal and indicates short-term injury
it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer
- incontinence
- skin around dressings
treated:
- appearance
- size
- drainage
- presence of swelling
- pain
- status of drains or tubes
- wound base
36
skin integrity and wound healing: pressure site assessment
inspect pressure areas for discoloration and capillary refill or blanch response
inspect pressure areas for abrasions or excoriations
palpate the surface temperature over the pressure area sites
palpate bony prominences and dependent body areas for presence of edema
37
skin integrity and wound healing: interventions to prevent skin breakdown
```
provide nutrition
maintain skin hygiene
for stage I ulcers to prevent further ulcerification
- reduce irritants
- reduce pain
avoiding skin trauma
- semi-fowler's position
- frequent weight shifts
- exercise and ambulation
providing supportive devices
prevent entry of microorganisms
prevent transmission of pathogens
minimize direct pressure over bony prominence's
improve circulation
schedule and record position changes
clean and dress the ulcer using medical asepsis
obtain C&S, if infected
teach the pt.
check for blanching
color guide for wound care
- if it is red, protect
- if it is yellow, cleanse
- if it is black, debride
```
38
skin integrity and wound healing: hemorrhage
an escape of blood through ruptured or unruptured vessel walls
39
skin integrity and wound healing: infection
invasion off the body by organisms that have the potential to cause disease
40
skin integrity and wound healing: dehiscence
a bursting open, splitting, or gaping long natural or sutured lines
41
skin integrity and wound healing: evisceration
protrusion of underlying content through a lesion caused by intentional ie. surgical incision) or unintentional trauma
42
nursing process: steps of the nursing process
assess
- gather information about the client's condition
diagnose
- identify the client's problem[s]
plan
- set goals of care and desired outcomes and identify appropriate nursing actions
implement
- perform the nursing action identified in planning
evaluate
- determine if goals were met and if outcomes were achieved
43
nursing process: interpreting and analyzing data collection
clustering information into groups using a logical sequence
comparing information to standards of care
identifying patterns that the information hold
make a conclusion about what the information means
44
nursing process: actual nursing diagnosis
regards a human response
| i.e. nutritional imbalance
45
nursing process: risk nursing diagnosis
a human response that may occur
| i.e. risk for fall
46
nursing process: health promotion diagnosis
pt. wants to improve their well-being
| i. e. smoke cessation
47
nursing process: the diagnostic process
analysis and interpretation
- data validation and clustering
- derived from assessment which includes subjective an objective data and risk factors
identification of pt. health problem
- based on defining characteristics [i.e. pain, ineffective breathing]
formulation of nursing diagnosis
48
nursing process: developing SMART goals
```
should be Specific for the pt.
should be Measurable
- i.e. pain rating from 0-10
should be Attainable
should be Realistic
should be Timely
- i.e. present a specific time frame
```
49
nursing process: discharge planning
thought of upon admission to the facility or institution
| it is part of the nursing care plan
50
nursing process: implementation
fourth step of thee nursing process
implements the interventions that have been agreed upon by the pt. and the nurse
implementation process:
- reassessing the pt.
-- interventions may have to change depending on the pt.'s status and response to interventions
- organizing resources and care delivery
- anticipating and preventing complications
- communicating nursing interventions
implementation skills
- cognitive, interpersonal, and psycho-motor skills
51
nursing process: evaluation
it is the final step of the nursing process
measures the pt.'s response to nursing actions and the pt.'s progress toward achieving the goals
it is an on-going process
it requires critical thinking
it requires evaluative thinking
- performing assessments throughout the whole period of care
interpretation and summation of findings occur
remember to document
52
electronic health records: EHR
electronic record of pt. health information generated whenever a pt. accesses medical care in any health care delivery setting
integrated all pertinent pt. information into one record
enables research and quality of care
provides continuity and quality of care
- pt.'s will not always just go to one facility so this keeps the information for each pt. at the ready
53
electronic health records: purpose of reccords
communication between different health care professionals and professions
legal documentation to serve a proof that care was given and interventions were done
financial billing which aids the process of reimbursement from insurance companies
education used for research purposes to aid in individual learning and team learning
aids in the navigation of the nursing process
provides readily available information for research
auditing and monitoring which confirms care was given to the pt.
54
electronic health record: methods of reccording
narrative documentation
- written expressively by the nurse
problem-oriented medical records
- uses a database to document assessment findings
- has a problem list, plan-of-care, and progress notes
source records
charting by exception
- only charting if there is a deviation from the norm
- charting anything that isn't within normal limits
cases management and critical pathways
55
electronic health record: legal responsibilities in documentation
standards of documentation are set by federal and state regulations, state statutes, standards of care and accrediting agencies
in the eyes of the law, "if you didn't document it, you didn't do it"
56
electronic health record: maintaining pt. confidentiality
it is the legal and ethical obligation of health care professionals to maintain pt. confidentiality
only staff who have direct involvement in a specific pt.'s care have legitimates access to records
health insurance portability and accountability act [HIPAA] governs all areas of pt. information and the management of their care
57
electronic health record: guidelines for effective documentation
factual
- describes what is going on, what is the objective, decreases judgment, avoids vague statements [i.e. the pt. seems upset], avoids subjective terms [i.e. the wound is healing "nicely"]
accurate
- requires information to be given verbatim, using appropriate and accepted abbreviations
complete
- requires relevant and specific information, as possible
current
organized
- performed by the nurse/health care professional that gave care and should not be done under the name of someone else and vice versa
58
electronic health record: change-of-shift report
"hand-off report"
provides continuity, individualized care
SBAR is a format type to giving half-off
- i.e. Situation [J.R. in 207b came in for___]' Background [had a productive]; Assessment [specific assessment done by the health members from facility]; Recommendations
normal findings and routine information does not need to be provided
changes to health status, medications delivered, lab results, etc. do need to be reported
59
electronic health records: telephone reports
read-backs are required if critical values are being reported
- this is a useful method to minimize errors
60
electronic health records: telephone or verbal orders
frequently cause medical errors
no verbal orders unless it is an emergency situation
document that the order is a verbal order
student nurses can never take a verbal order
61
electronic health records: transfer reports
pt. is going from one facility to another
medication reconciliation- accurate list of all pt. medications from admission through to discharge. with each transfer within the institution the list of medications must be reconciled for accuracy unless proper contraindication is given.
62
electronic health records: incident reports
important part of quality improvement
always contact HCP when an incident occurs
do not mention in pt.'s medical record because it may be used against the health care professional in court
document objective description of incident, follow-up actions
goal is to identify changes needed to prevent future occurrence
- goal is not to place blame or to save oneself from legal ramifications... although, it does help
- goal is to find error in current practice, prevent any errors from reoccurring in the future
analysis helps identify trends, changes in policy and procedure, staff education programs
63
medications: pharmokinetics
how medications affect the pt.
the study of how medications:
- enter the body [absorption] and all the processes that occur in the body
- reach their site of action [distribution]
- metabolism
- metabolize and absorbed and distributed into cells, tissues, or organs
- alter physiological functions
- exit the body [excretion]
64
medications: therapeutic effect
expected or predictable physiological response
| i.e. administration of analgesic for pain relief
65
medications: side effect
intended, secondary effect
| i.e. benadryl works as an anti-histamine with a side effect of drowsiness
66
medications: adverse effect
a severe response to a medication that is unintended, in which case administration should be stopped
i.e. medications which causes severe nausea and vomiting
67
medications: toxic effect
accumulation of medication in the bloodstream occurs either because the medication has been taken for a long time or its not being metabolized or excreted
68
medications: idosyncratic reaction
over- or under-reaction to a medication
| i.e. benadryl has a side effect of drowsiness, an idiosyncratic reaction is increased energy
69
medications: allergic reaction
unpredictable response to a medication due to antibodies reacting against the medication
may cause a mild or severe allergic reaction
70
medications: serum half-life
time for medication concentration to be halved, form time the medication is absorbed
this is important because at this point the effect of the medication decreases but we want to maintain the level of medication in the blood stream constant
71
medications: onset
time it takes for a medication to produce a response
| i.e. PO pain med.'s begin after 30 minutes
72
medications: peak
time at which a medication reaches its highest effective concentration
73
medications: trough
minimum blood serum concentration before next scheduled dose
74
medications: duration
time medication take to produce greatest result
75
medications: plateau
blood serum concentration is reached and maintained
76
medications: implementing nursing actions to prevent medications errors
be informed of medication name, purpose, action, and potential undesired effects
investigate further on refusal of medications
have qualified nurses or physicians assess a medication history
be properly advised of the experimental nature of medication
receive labeled medications safely without discomfort [same discomfort may occur]
receive appropriate supportive therapy
not receive unnecessary medications
informed of whether medications are part of research
77
medications: synergistic effect
occurs when the combined effect of two medications is greater than the effect of the medication given separately
these effect may be wanted
78
nutrition: types of diets
NPO
- nothing by mouth
- indicated for pt.'s being prepped for surgery or a procedure
- indicated for pt.'s with dysphagia
clear liquids
- indicated for pt.'s who have just undergone surgery or a procedure
full liquids
pureed
- indicated for pt.'s with extreme tooth loss or lack of chewing abilities
mechanical soft
soft/low residue
- indicated for pt.'s who are having GI complications
high fiber
- indicated for pt.'s who need improvement with their digestive system
low sodium
low cholesterol
diabetic
regular
79
nutrition: aspiration prevention
keep pt. in a sitting position during feedings and an hour after feedings
80
nutrition: parenteral therapy
```
indications
- pt. has a non-functioning GI system
- pt. has a highly stressed system [i.e. burn victim]
contents
- essential nutrients
route of administration
- via a central line through the jugular vein or sub-clavian vein
- via a PICC line [peripheral line]
monitor lab values consistently
use aseptic technique when giving TPN care
complications:
- hypo- or hyper-glycemia
- electrolyte imbalance
- misplacement of lumen
- air in the lumen
- occlusion in the lumen
```
81
safety: indicated use for restraints
pt. is pulling at lines/tubes
pt. is taking of oxygen administration device[s]
for emergency situations, may be placed without an order and call the physician to get an order
in all cases, used only after every possible means of ensuring safety unsuccessful and documented
82
safety: types of restraints
use of four side rails
mittens
soft-restraints
leather restraints
83
safety: alternative to restraints
- orient pt.'s and families to env't.; explain all procedures and treatments
- put an alarm on bed and chair
- provide companionship and supervision
- assign confused or disoriented pt.'s to rooms near the nurses station or even in the hallway
- de-escalation during an aggressive situation
- provide appropriate visual and auditory stimuli
- remove cues that promote leaving [i.e. street clothes]
- attend to basic needs: food, liquids, and toileting
- camouflage IV lines and tubes
- evaluate all medications to ensure effective pain management
84
safety: potential hazards for developing fetus'
improper pre-natal care
substance abuse by the mother
lack of education on care of child
85
safety: potential hazards for infants, toddlers, and preschoolers
accidents [many are preventable]
| lack of parent education on prevention of accidents
86
safety: potential hazards for school-age children
lack of education about safe play
| misuse or no use of protective safety equipment for sports
87
safety: potential hazards for adolescent's
drug abuse
MVA
drowning
alcohol abuse
88
safety: potential hazards for adults
unhealthy life-style habits:
| - i.e. alcohol and drug abuse, stress
89
safety: potential hazards for older adults:
```
age-related physiological changes
effect of medications
psychological factors
illness
accidents
- i.e. falls, environmental hazards, burns
```
90
safety: risk factors affecting pt. safety
```
lifestyle
impaired mobility
sensory impairments
cognitive impairments
cognitive impairments
safety awareness
pressure ulcers
falls
restraint use
pt. satisfaction
nosocomial infection
```
91
safety: safety concerns within the health care agency
```
falls
- accounts for 90% of reported incidents
restraints
accidents
- pt. centered: cuts, burns, ingestion, seizure
- procedure-related: medications, fluid, devices
- equipment-related: malfunction, misuse
side rails
```
92
safety: joint commission nat'l pt. safety goals
improve the accuracy of pt. identification
improve the effectiveness of communication among care-givers
improve the safety of using medications
reduce the harm associated with clinical alarm systems
reduce the risk of healthcare associated infections
the hospitals identifies safety risks inherent in their pt. pop.
93
safety: developing a nursing care plan for pt.'s at-risk for falls
use identification of pt.'s at-risk for falls
modify the pt.'s home/health car env't. to reduce risks
bed at the lowest position
telephone within reach
place the call light near the pt.
inspect walkers, canes, and crutches
1-2 hour rounding
94
urine elimination: factors that affect urine elimination
disease conditions
sociocultural
psychological
fluid balance
- dehydration effect urination by decreasing output
- diuretics effecct urination by increasing output
surgical procedures
medications
- plan voiding procedure before administering diuretics
- pyridium turns urine orange
diagnostic examination
95
urine elimination: urinary retention
accumulation or urine from inability of bladder to empty properly; bladder can hold 2-3 L or urine which causes distention
women who give birth, trauma pt.'s, and certain med.'s make individuals susceptible
S&S: bladder distention, incontinence
complications: UTI's
96
urine elimination: urinary tract infection
bateriuria- presence of bacteria in the urine
women are more susceptible b/c their urethra is shorter than men's and the urinary meatus is close to the vagina and rectum
catheterized pt.'s, the elderly, and non-hygienic individuals are always susceptible
S&S: hesitancy, painful urination, cloudy urine, hematuria, plank pain [infection has reached kidneys]
prevention: hydration, proper hygiene, void after sexual intercourse
complications: pyelonephritis, bacteremia
97
urine elimination: urinary incontinence
involuntary leakage of urine
may be continuous or intermittent and temporary or permanent depending n the cause
older adults are susceptible
- 5-% of nursing home pt.'s have incontinence
types: total, funcitonal [caused by env't. factors], stress, urge reflex [no urge felt], overflow, transient
98
urine elimination- urinary diversions
temp. or permanent changes in the normal pathway of urine
types: stoma, ileal conduit reservoir, nephrostomy, suprpubic tube
disadvantages: bag emptying, psycho-social considerations
used with those who have bladder cancer or an obstruction or the urine paathway
99
urine elimination: assessment of I&O's
monitor fluid and electrolyte balance
nurse's or physicians judgment
must include all oral fluids and semi-liquids [i.e. gelatin]
if urinary output falls below 30 mL/hr. assess for alterations in renal function
measure urine volume with bedpan, urine hat, urinal, catheter bag
100
urine elimination: characteristics of urine
```
color
- straw, amber, light-yellow
clarity
- clear
amount
odor
- foul scent indicates infection
- ammonia scent indicates urinary retention
fruity scent indicates change in blood glucose levels
```
101
urine elimination: urine testing
```
urine collection
- random
- clean voided or mid-stream
- sterile
common tests
- glucose levels
- protein levels
WBC
- presence of bacteria
- RBC
- specific gravity: shows how many particles are in urine which shows the function of the kidneys
urine culture
- done if infection is suspected
```
102
diagnostic tests of the urinary system
```
abdominal x-ray of "flat-plate"
IV pyelogram
- injection of dye to view inner function of the kidneys via a scan
computerized axial tomography
renal ultrasounds
invasive
- endoscopy/cystoscopic examination
-- viewing the bladder via catheter insertion
- arteriogram [angiogram]
-- cathter up the renal artery
nursing responsibilities
- ID of allergies
- hydration
```
103
urine elimination: nursing measure to promote normal micturition
stimulate micturition reflex: sitting [females] and standing [males and providing privacy
maintain elimination habits
maintain adequate fluid intake [2000 mL/day]
promote bladder emptying by increasing intra-abdominal pressure, pt. education, good hygiene
strengthen pelvic floor muscles: kegel exercises [women]
compress bladder manually [crede method]
drug therapy as an adjunct to treating incontinence/retention
104
urinary elimination: prevention of infection
good hand-washing
keep spigot away from contaminated areas
do not open drainage ; if system become disconnected, do not touch ends and wipe ends with antiseptic
use separate receptacles for pt.'s
prevent pooling an reflux of urine
no dependent loops
clamp tubing if bag must be raised
drain urine from tubing into bag before exercise or ambulation
avoid prolonged clamping or kinking of the tubing
empty bag at last every 8 hours of if over-filled
remove catheter as soon as possible
secure the catheter on pt.'s leg to avoid pulling of catheter
perform routine perineal hygiene
105
bowel elimination: factors that influence bowel elimination
```
age
- elderly have decreased blood flow to GI tract not allowing nutrients to get absorbed, mobility issues, decreased cognitive functions
diet
- bulk, high-fiber diets are recommended
fluid intake
- a decrease makes stool hard
physical activity
- immobility slows peristalsis -> constipation
psychological factors
- stress -> peristalsis
personal habits
- maintain privacy for the pt.
position during defecation
pain
- presence of hemorrhoids, abdominal surgery
pregnancy
- slows peristalsis in the 3rd trimester
surgery and anesthesia
- slows peristalsis
medications
- anesthesia, opoids slows peristalsis -> constipation
- antibiotics cause diarrhea by killing the normal flora in the GI tract
diagnostic tests
```
106
bowel elimination: peristalsis
movement of air, fluid and waste products through the GI tract
107
bowel elimination: constipation
caused by immobility [i.e. opoids]
straining causes a decrease in the heart rate
can cause dehiscence of wounds
108
bowel elimination: impaction
unrelieved constipation, hardened stool
primary symptom: liquid stool
other symptoms: diminished appetite, nausea
109
bowel elimination: diarrhea
decrease of stool; a liquid, un-formed stool
symptoms: fluid and electrolyte imbalance, skin breakdown
causes: antibiotics, food poisoning, C. diff. infection
110
bowel elimination: incontinence
cannot control passing stools
111
bowel elimination: flatulence
walls stretching from increase gas
112
bowel elimination: hemorrhoids
engorged veins surrounding the rectum caused by straining
113
bowel elimination: assessment of bowel elimination
```
nursing hx
physical assessment
lab examinations
- fecal specimens
- fecal occult blood test
-- upper GI bleeding -> dark brow/black stool
-- lower GI bleeding -> red stool
total bilirubin
- indicates liver or gallbladder disease
alkaline phosphatase
- indicates live or gallbladder disease
amylase
- indicates pancreatic disease
carcionoembryonic antigen
- indicates gall-baldder liver, or pancreatic cancer
cancer and sensitivity test for presence of c. diff.
```
114
bowel elimination: common diagnostic examinations of the GI tract
```
diagnostic examinations
- plain film of abdomen/kidneys, ureter, bladder
- upper GI/barium swallow
-- barium is a contrast material, gives more detail
- upper endoscopy
-- sedation/light anesthesia required
- barium enema
-- lower GI barium method
- ultrasound
colonoscopy
- biopsy available to screen for colon cancer starting at age 50 and after every 10 years
flexible sigmoidscopy
CAT scan
- gives more angles than an x-ray
MRI
enteroclysis
- contrast material inserted into the jejunum; views entire small intestine
```
115
bowel elimination: nursing interventions that promote normal elimnation
```
timing
- i.e. after a meal
privacy
sitting position
positioning on a bedpan
- position head of bed at a 30 degree angle
```
116
fluid-electrolyte, acid-base balance: volume
fluid amount
117
fluid-electrolyte, acid-base balance: osmolality
fluid concentration
118
fluid-electrolyte, acid-base balance: distribution
movement of fluid among its various compartments
- intracellular
- - fluid within cells
- - 42% of total body weight
- extracellular
- - 17% of total body weight
- - three compartments:
- -- interstitial: fluid surrounding the cells
- -- intravascular: fluid within the bloodstream of plasma
- -- transcellular: pleural fluid, cerebrospinal fluid
119
fluid-electrolyte, acid-base balance: elimination
occurs via the kidneys [primarily], skin, lungs, GI tract
insensible water loss is continuous and is not perceived by the person but can increase significantly with fever or burns
sensible water loss occurs through excess perspiration and can be perceived by the pt. or by the nurse through inspection
120
fluid-electrolyte, acid-base balance: fluid-electrolyte, acid-base balance: osmosis
involves the movement of a pure solvent such as water from an area of lesser concentration to an area of greater concentration
121
fluid-electrolyte, acid-base balance: diffusion
the movement of a solute in a solution across a semi-permeable membrane from an area of higher concentration to an area of lower concentration
122
fluid-electrolyte, acid-base balance: filtration
the process by which water and diffusible substances move together in response to fluid pressure
123
fluid-electrolyte, acid-base balance: active transport
requires metabolic activity and the expenditure of energy to move materials across cell membranes from low to high concentration
124
fluid-electrolyte, acid-base balance: volume or isotonic imbalances
fluid imbalance
disturbances of the amount of fluid in the extracellular compartment
water and electrolytes are gained or lost in equal proportions; there's either a deficit or excess of BOTH fluid and electrolytes
ECV imbalance
- hypovolemia: [deficit] decreased vascular volume
- hypervolemia: [excess] S&S: edema, pulmonary edema, crackles in lungs, increase in blood pressure
125
fluid-electrolyte, acid-base balance: osmolality or concentration imbalances
fluid imbalance
disturbances of the concentration of body fluids
loss or excess of only water so concentration of serum affected
body fluids become hypertonic [high concentration] or hypotonic [low concentration]
causes osmotic shifts of water across cell membranes to maintain equilibrium
126
fluid-electrolyte, acid-base balance: hypernatremia
fluid imbalance
water deficit
causes: loss of relatively more water than salt or gain of relatively more salt than water
water leaves the cells by osmosis and the cells shrive because of the loss of fluid
S&S: cerebral dysfunction--shriveling brain cells, lethargy, confusion, extreme thirst, restlessness, seizures
127
fluid-electrolyte, acid-base balance: hyponatremia
fluid imbalance
water intoxication
causes: gain of relatively more water than salt or loss of relatively more salt than water
the excessively diluted condition of interstitial fluid caused water to enter cells by osmosis, causing the cells to swell
S&S: cerebral dysfunction--swelling brain cells, apprehension, nausea and vomiting headache
128
fluid-electrolyte, acid-base balance: clinical dehydration
fluid imbalance
ECV deficit [loss of water and electrolytes] and hypernatremia combined
causes: gastroeneritis, severe vomiting and diarrhea
S&S: thirst, dry mucous membrane, sudden weight loss, tachycardia, thready pulse, postural hypotension, restlessness, confusion, agitation, oliguria [scanty urine production]
129
fluid-electrolyte, acid-base balance: potassium imbalance
electrolytes imbalance
causes pt. to have dysrhythmia by interfering with the electrical rhythm w/i the heart
- hypokalemia: decrease in serum potassium via diuretic, diarrhea, vomiting
hyperkalemia: increase in serum potassium
130
fluid-electrolyte, acid-base balance: calcium imbalance
electrolyte imbalance
hypocalcemia: decrease in serum calcium
hypercalemia: increase in serum calcium when it leaves and weakens the bones
131
fluid-electrolyte, acid-base balance: buffers
regulates acid-base balance
buffers: substances that can absorb or release hydrogen ions to correct an acid-base imbalance
- each buffer system consists of a weak acid which can release hydrogen ions when fluid is too alkaline and a base which can take up hydrogen ions when fluid is too acidic
- the largest chemical buffer in ECF is the carbonic acid [H2CO3] and bicarbonate [HCO3] buffer system
- - consists of 1 part carbonic acid and 20 parts bicarbonate
132
fluid-electrolyte, acid-base balance: respiratory system
regulates acid-base balance
when the concentration of hydrogen ionss is altered, the resp. system reacts to correct the imbalance by excreting H2CO3 [carbonic acid]
the lungs alter the rate and depth of respiration
excess H2CO3: rate and depth of respiration increases [hyperventilation], excess H2CO3 removed, pH returns to normal
deficit H2CO3: rate and depth of respiration decreases [hypoventilation], H2CO3 increases back to normal, pH returns to normal
133
fluid-electrolyte, acid-base balance: renal system
regulates acid-base balance
kidneys take from a few hours to several days to regulate acid-base imbalance
kidneys excrete metabolic acids
excess acid: kidneys excrete hydrogen ions and reabsorb bicarbonate, pH returns to normal
deficit acid: kidneys hold onto hydrogen ions, pH returns to normal
134
fluid-electrolyte, acid-base balance: types of acid-base imbalances
respiratory acidosis [acid env't. w/i the lungs]
respiratory alkalosis [basic env't. w/i the lungs]
metabolic acidosis [acidic env't. w/i the kidneys]
metabolic alkalosis [basic env't. w/i the kidneys
135
fluid-electrolyte, acid-base balance: pH [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
measure hydrogen ion concentration in the body fluid
an increase in concentration of hydrogen makes a solution more acidic, vice versa
normal pH range is 7.35 to 7.45
136
fluid-electrolyte, acid-base balance: PaCO2 [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
the partial pressure or carbon dioxide in arterial blood and is a reflection of the depth of pulmonary ventilation
normal range is 35 to 45 mmHg
137
fluid-electrolyte, acid-base balance: PaO2 [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
the partial pressure of oxygen in arterial blood which has no primary role in acid-base regulation if it is within normal limits
normal range is 80 to 110 mmHg
138
fluid-electrolyte, acid-base balance: oxygen saturation [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
the point at which hemoglobin i saturated by oxygen [O2]
when the PaO2 falls below 60 mmHg, there is a large drop in saturation
normal range is 95 to 100%
139
fluid-electrolyte, acid-base balance: base excess [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
the amount of blood buffer [hemoglobin and bicarbonate] that exists
normal range is -2 [too acidic] to +2 [too basic
140
fluid-electrolyte, acid-base balance: HCO3 [ABG]
one of six components analyzed to measure ABG's used to evaluate acid-base balance
the major renal compartment of acid-base balance and is excreted and reproduced by the kidneys to maintain a normal acid-base env't.
normal range is 22 [below is acidic] to 26 [above is basic]
141
fluid-electrolyte, acid-base balance: ABG summary
```
pH
- 7.35-7.45
PaCO2
- 35-45 mmHg
PaO2
- 80-100 mmHg
O2 saturation
- 95-100%
base excess
- -2-+2 mmol/L
HCO3
- 22-26 mep/L
```
142
fluid-electrolyte, acid-base balance: assessment of fluid and electrolytes imbalance
nursing hx
- factors: age, env't. dietary intake, lifestyle, medications
medical hx
- factors: recent surgery, Gi output, acute illness or trauma, chronic illness
daily weights
- indicator of fluid status
fluid intake and output
- 24 hours I&O: comparison of intake and output
- intake includes all liquids consumed and IV's
- output includes urine, diarrhea vomitus, gastric suction, wound drainage
143
fluid-electrolyte, acid-base balance: nursing intervention for fluid, electrolyte, acid-base imbalances
daily weight and I&O measurement
enteral replacement of fluid if pt. isn't tolerating oral fluids
restriction of fluids
parenteral replacment of fluids and electrolytes
total parenteral nutrition
IV therapy [crystalloids]
health promotion
- fluid replacement education
- teach pt.'s w/ chronic conditions about risk factors and S&S of imbalances
144
fluid-electrolyte, acid-base balance: types of IV solutions
hypertonic: moves fluid into the cells causing them to enlarge
isotonic: expands the body's fluid volume; it has the same osmolality as blood
hypotonic: pulls fluid from cells causing them to shrink
NURS200
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