688 terms

# JSCCFundamentalsExam

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Body mechanics
is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.
Today, nurses use information about body alignment, balance, gravity, and friction when?
When implementing nursing interventions such as positioning clients, determining the risk of client falls, and selecting the safest way to move or transfer clients.
The terms body alignment and posture are similar and refer to
the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
Body alignment
means that the individual's center of gravity is stable. Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Balance is enhanced by keeping the body's center of gravity low with a wide base of support and maintaining correct body posture. If the center of gravity is displaced it increases the risk of falls, which could lead to more problems.
Impaired balance is a major threat to what?
physical safety and contributes to a fear of falling and self-imposed restrictions on activity.
You need balance for maintaining a
static position (sitting) and for moving (walking).
The Surgeon General of the United States noted that falls represent the largest threat to what?
bone health and functional independence of older individuals.
Weight is what?
the force exerted on a body by gravity. Unbalanced things fall b/c gravity is always directed down (pushing down). To lift safely, the lifter has to overcome the weight of the object and know its center of gravity. In symmetrical inanimate objects the center of gravity is at the exact center of the object.
People, however, are not geometrically perfect; their centers of gravity are usually at _?_%
55% to 57% of standing height and are in the midline.
Friction
is a force that occurs in a direction to oppose movement. The greater the surface area of object, the greater the friction. Nurses use assistive devices like full body sling to assist moving patient.
Long bones contribute to what?
height and length.
Short bones occur in _______
and work with what to permit movement? Occur in clusters and work with ligaments and cartilage to permit movement of extremities.
Flat bones provide
structural contour.
Irregular bones make up
vertebral column and some bones in skull like mandible.
Bones are further characterized by what?
firmness, rigidity, and elasticity. Firmness results from inorganic salts, such as calcium and phosphate that are in the bone matrix.
Firmness is related to
the bone's rigidity, which is necessary to keep long bones straight, and enables bones to withstand weight bearing. bones have a degree of elasticity and skeletal flexibility that change with age.
pathological fractures
(fractures caused by weakened bone tissue).
the internal structure of long bones contains _____, participates in ______ and acts as a reservoir for what?
Contains bone marrow, participates in red blood cell (RBC) production, and acts as a reservoir for blood.
Clients with altered bone marrow function or diminished RBC production are usually
weakened and fatigue easily, which decreases their mobility and places them at risk of falling.
What are the four classifications of joints?:
synostotic, cartilaginous, fibrous, and synovial.
synostotic joint
refers to bones jointed by bones. (no movement) boney tissue forms between these bones provide strength and stability.
fibrous joint, or syndesmosis joint,
is a joint in which a ligament or membrane unites two bony surfaces. fibers of the ligaments are flexible and permit limited movement.
Ligaments
are white, shiny, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages. ligaments between the vertebral bodies and the ligamentum flavum prevent damage to the spinal cord during movement of the back.
Tendons
are white, glistening, fibrous bands of tissue that connect muscle to bone. The Achilles tendon (tendo calcaneus) is the thickest and strongest tendon in the body.
Cartilage
is nonvascular, supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear. Permanent cartilage is unossified (not hardened) except in advanced age and diseases such as osteoarthritis.
Muscles are made of fibers that do what?
contract when stimulated by an electrochemical impulse that travels from the nerve to the muscle across the neuromuscular junction. The electrochemical impulse causes the filaments (predominantly protein molecules of myosin and actin) within the fiber to slide past each other, with the filaments changing length.
Muscle contractions are categorized by one of three functional purposes:
moving, resisting, or stabilizing body parts.
concentric tension is what?
increased muscle contraction causes muscle shortening resulting in movement,
Eccentric tension helps control what?
the speed and direction of movement.
Concentric and eccentric muscle actions are necessary for active movement and are therefore referred to as what?
dynamic or isotonic contraction.
Isometric contraction (static contraction) causes what?
an increase in muscle tension or muscle work but no shortening or active movement of the muscle.
Voluntary movement is a combination of
isotonic and isometric contractions.
Leverage
is an inducing or compelling force and occurs when specific bones, Force is applied to one end of the bone to lift a weight as another point rotates the bone in the opposite direction.
Posture
(the position of the body in relation to the surrounding space).
Muscle tone, or tonus, is...
the normal state of balanced muscle tension. The body achieves tension by alternating contraction and relaxation without active movement of neighboring fibers of a specific muscle group.
the motor fibers from the right motor strip initiate what?
voluntary movement for the left side of the body,
motor fibers from the left motor strip initiate what?
voluntary movement for the right side of the body.
During voluntary movement, impulses descend from_______ to ________.
the motor strip to the spinal cord.
neurotransmitters, or chemicals such as acetylcholine, do what?
transfer electric impulses from the nerve across the neuromuscular junction to the muscle.
Parkinson's disease is example of what type of problem?
neurotransmitter problem
Clients with muscular dystrophy experience what?
progressive, symmetrical weakness and wasting of skeletal muscle groups, with increasing disability and deformity.
Damage to the cerebellum causes problems with what?
balance, and motor impairment directly related to the amount of destruction of the motor strip. Trauma to the spinal cord also impairs mobility.
muscle atrophy,
loss of muscle tone, and joint stiffness.
Comprehensive safe-client-handling programs include the following elements:
an ergonomics assessment protocol for health care environments, client assessment criteria, algorithms for client handling and movement, special equipment kept in convenient locations to help transfer clients, back injury resource nurses, an "after-action review" that allows the health care team to apply knowledge about safe client moving in different settings, and a no-lift policy.
Mobility refers to
a person's ability to move about freely,
immobility refers to
the inability to move about freely.
Bed rest is an intervention that restricts clients to
bed for therapeutic reasons.
NANDA International (NANDA-I) defines impaired physical mobility as
a limitation in independent, purposeful physical movement of the body or one or more extremities.
The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of (how long?)
days
An individual of average weight and height and without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of ______% a day
3% a day.
disuse atrophy describes
the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage.
The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as (5 things?)...
(1) response to stress and injury, (2) growth and development, (3) reproduction, (4) maintenance of the internal environment, and (5) energy production, utilization, and storage.
Tissues and cells live in an internal environment that the endocrine system helps regulate through maintenance of
sodium, potassium, water, and acid-base balance.
When the client is immobile, the client's body often excretes more
nitrogen (the end product of amino acid breakdown) than it ingests in proteins
Immobility and excess nitrogen excretion results in what?
negative nitrogen balance.
Another metabolic change associated with immobility is ________ from bones.
calcium resorption (loss) from bones.
Why does immobility cause calcium resoprtion from bones?
Immobility causes the release of calcium into the circulation. Pathological fractures occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile.
The most common respiratory complications are what?
Atelectasis and Hypostatic pneumonia.
atelectasis
(collapse of alveoli)
hypostatic pneumonia
(inflammation of the lung from stasis or pooling of secretions).
Hypostatic pneumonia frequently results because
mucus is an excellent place for bacteria to grow.
Orthostatic hypotension is
an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure, or a drop of 10 mm Hg or more in diastolic blood pressure when the client changes from the supine to standing position
As the workload of the heart increases, so does its
oxygen consumption.
As immobilization increases, cardiac output ______
falls, further decreasing cardiac efficiency and increasing workload.
Clients who are immobile are also at risk for __________formation.
thrombus formation.
A thrombus is
an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.
There are three factors that contribute to venous thrombus formation:
(1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity).
The three factors that contribute to venous thrombus formation are often referred to as
causes two skeletal changes:
impaired calcium metabolism and joint abnormalities.
Because immobilization results in bone resorption, the bone tissue is less dense or is atrophied, and_______results
disuse osteoporosis results.
When disuse osteoporosis occurs, the client is at risk for what type of fractures?
pathological fractures.
About 80% of people who have osteoporosis are
female
A joint contracture is
an abnormal and possibly permanent condition characterized by fixation of the joint.
Early prevention of contractures is key; they can begin to form after only
8 hours of immobility in the older adult client.
footdrop is when...
the foot is permanently fixed in plantar flexion.
The client with footdrop is unable to
lift the toes off the ground.
Who are especially at risk for foot drop?
Clients who have suffered CVAs or brain attacks with resulting right- or left-sided paralysis (hemiplegia).
When the client is recumbent or flat, the kidneys and the ureters move toward a more level plane. the renal pelvis fills before urine enters the ureters. This condition is called what?
urinary stasis.
Renal calculi
are calcium stones that lodge in the renal pelvis or pass through the ureters.
Immobilized clients are at risk for calculi because they frequently have what?
hypercalcemia.
A pressure ulcer is
an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues.
Ischemia develops when the pressure on the skin is
greater than the pressure inside the small peripheral blood vessels supplying blood to the skin.
The newborn infant's spine is flexed and lacks what?
the anteroposterior curves of the adult.
A big concern for adolescence who experience immobility is what?
Social isolation
For older adults with immobility, the nurse should automatically include what?
A nutritional assessment.
Sometimes nurses inadvertently contribute to a client's immobility by providing what?
unnecessary help with activities such as bathing and transferring.
Range of motion (ROM) is
the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse.
The sagittal plane is
a line that passes through the body from front to back, dividing the body into a left and a right side.
The frontal plane
passes through the body from side to side and divides the body into front and back.
The transverse plane is
a horizontal line that divides the body into upper and lower portions.
A flexion contracture of the neck is a serious disability because
the client's neck is permanently flexed with the chin close to or actually touching the chest.
One feature of the shoulder that sets it apart from other joints in the body is what?
that the strongest muscle controlling it, the deltoid, is in complete elongation in the normal position
Because the lower extremities are concerned chiefly with locomotion and weight bearing, _____of the hip joint is more important than its _____.
Stability/Mobility
Excessive abduction makes the affected leg appear _____, whereas excessive adduction makes the affected leg appear _____.
Too short/too long
Excessive flexion of the toes results in what?
clawing.
When this is a permanent deformity, the foot is unable to rest flat on the floor and the client is unable to walk properly
foot properly
The term gait describes
a particular manner or style of walking.
The gait cycle begins with
the heel strike of one leg and continues to the heel strike of the other leg.
The mechanics of human gait involve coordination of
the skeletal, neurological, and muscular systems of the human body.
anthropometric measurements
(measures of height, weight, and skinfold thickness)
Cardiovascular nursing assessment of the client who is immobilized includes
blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis (e.g., edema and delayed wound healing).
A third heart sound, heard at the apex, is an early indication of
congestive heart failure.
Monitoring peripheral pulses allows the nurse to evaluate what?
the heart's ability to pump blood.
A dislodged venous thrombus is called
an embolus
More than 90% of all pulmonary emboli begin in
the deep veins of the lower extremities.
Acute confusion in older adults is what? (normal or not normal)
not normal; a thorough nursing assessment is the priority.
The two diagnoses most directly related to mobility problems are
impaired physical mobility and risk for disuse syndrome.
The diagnosis of impaired physical mobility applies to
the client who has some limitation but is not completely immobile.
The diagnosis of risk for disuse syndrome applies to
the client who is immobile and at risk for multisystem problems because of inactivity.
Other possible nursing diagnosis are:
â€¢Ineffective airway clearance â€¢Ineffective individual coping â€¢Risk for injury â€¢Impaired skin integrity â€¢Insomnia â€¢Social isolation â€¢Impaired urinary elimination
Discharge planning begins when?
when a client enters the health care system.
Supplementation with vitamin C is necessary to replace
protein stores,
vitamin B complex is needed for
skin integrity and wound healing.
If the client needs to wear abdominal binders, remove them how often?
every 2 hours to allow the client to breathe deeply.
Ensure that clients who are immobile take in a minimum of _______ fluid a day
2000 ml of fluid a day, if not contraindicated, to help keep mucociliary clearance normal.
The most cost-effective way to address the deep vein thrombosis (DVT) problem is how?
through an aggressive program of prophylaxis. Heparin and low-molecular-weight heparin (LMWH) are the most widely used drugs in the prophylaxis of DVT.
antiembolic exercises are what?
Knee flexion and extension, doing the alphabet with their feet and they need to be done hourly while awake.
The major risk to the skin from restricted mobility is the formation of
pressure ulcers.
teach the mobile patients to shift weight every
15 minutes.
A trochanter roll prevents what?
external rotation of the hips when the client is in a supine position.
Do not use rolled washcloths as hand rolls, because why?
they do not keep the thumb well abducted, especially in clients who have a spastic paralysis.
Provide support at the waist using a
gait belt so the pt's center of gravity remains midline.
hemiplegia-
one sided paralysis;
hemiparesis-
one sided weakness. these pt's will need assistance w/walking. always stand on the affected side.
if pt falls lower them to floor, sliding down your_____ and supporting them under where?
leg and supporting them under their arms.
Chapter 25
Chapter25
Affective learning: deals with what?
expression of feelings and acceptance of attitudes, opinions, or values.
Values clarification is an example of
affective learning.
Affective learning includes:
receiving (being willing to attend to another person's words), responding (active participation through listening and reacting verbally and nonverbally), valuing (attaching worth to an object or behavior demonstrated by the learner's behavior), organizing (developing a value system by identifying and organizing values and resolving conflicts), and characterizing (acting and responding with a consistent value system). Pg 365
Analogies:
familiar images used to supplement verbal instruction that make complex information more real and understandable.
General principles to follow when using analogies include:
being familiar with the concept; knowing the client's background, experience, and culture; and keeping the analogy simple and clear. Pg 378
Cognitive learning:
learning which includes all intellectual behaviors and requires thinking.
Cognitive learning includes what 6 things?:
knowledge (learning new facts or information and being able to recall them), comprehension (the ability to understand the meaning of learned material), application (using abstract, newly learned ideas in a concrete situation), analysis (breaking down information into organized parts), synthesis (the ability to apply knowledge and skill to produce a new whole), and evaluation (a judgment of the worth of a body of information for a given purpose. Pg 365
Compliance:
a client's adherence to the prescribed course of therapy. Pg 366
Functional illiteracy:
the inability to read above a fifth-grade level and a major problem in America today.
Learning:
the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. Pg 362
Learning objective:
a description of what the learner will be able to do after successful instruction.
The learning objective arises from where?
the client's request for information or the nurse's perceived need for information because of a client's health restrictions or the recent diagnosis of an illness. Pg 362
Motivation:
a force that acts on or within a person (i.e., an idea, emotion, or a physical need) that causes the person to behave in a particular way. Motivation sometimes results from a social, task, or physical motive.
Social:
need for connection, social approval, or self-esteem,
need for achievement and competence,
Physical:
Psychomotor learning:
acquiring skills that require the integration of mental and muscular activity, such as the ability to walk or to use an eating utensil.
Psychomotor learning includes what 7 things?:
Perception, Set, Guided Response, Mechanism, Complex overt response, Adaption, Origination.
â€¢Perception:
Being aware of objects or qualities through the use of sense organs.
â€¢Set:
A readiness to take a particular action. There are three sets: mental, physical, and emotional.
â€¢Guided response:
The performance of an act under the guidance of an instructor involving imitation of a demonstrated act.
â€¢Mechanism:
A higher level of behavior by which a person gains confidence and skill in performing a behavior that is more complex or involves several more steps than a guided response.
â€¢Complex overt response:
Smoothly and accurately performing a motor skill that requires a complex movement pattern.
The ability to change a motor response when unexpected problems occur.
â€¢Origination:
Using existing psychomotor skills and abilities to perform a highly complex motor act that involves creating new movement patterns. Pg 366
Reinforcement:
using a stimulus, which increases the probability for a response.
Reinforcers can be positive or negative; although, people respond better to positive reinforcement and the effects are what for negative reinforcement?
less predictable and often undesirable when using negative reinforcement.
Reinforcers may be
social , material ,and activity (a walk outside).
A nurse primarily uses ______ reinforcers.
social
Return demonstrations:
when the learner, having first observed a teacher demonstrate a skill, then practices the skill themselves. Combine a demonstration with discussion to clarify concepts and feelings.
Self-efficacy:
a concept in social learning theory that refers to a person's perceived ability to successfully complete a task. When people believe they are able to execute a particular behavior, they are more likely to actually perform the behavior consistently and correctly.
Self-efficacy comes from four sources:
enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states.
Teaching:
an interactive process that promotes learning, which consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.
â€¢ All state Nurse Practice Acts recognize that WHAT falls within the scope of nursing practice.
client teaching
â€¢ Who sets standards for client and family education?
The Joint Commission (TJC)
â€¢ The goal of client education is to assist individuals, families, or communities in achieving optimal levels of health and includes what 3 purposes?
Health Maintenance, Restoration of Health, and Coping with Impaired Functions
Examples of Health Maintenance and Promotion and Illness Prevention?
first aid, stress management, nutrition, exercise, immunizations, and avoidance of risk
Example of Restoration of Health?
clients disease/condition, rational for treatment, medications, surgical interventions, expected duration of care.
Example of Coping With Impaired Functions?
home care, self help devices, physical or speech therapies, implications of noncompliance with therapy, enviromental alterations.
In 2007, The Joint Commission (TJC) launched its "Know Your Rights" campaign to help clients understand their rights when receiving medical care, such as?
-the right to be informed about the care they will receive -the right to receive information about care in their preferred language -the right to know the names of their caregivers -the right to receive treatment for pain -the right to receive an up-to-date list of current medications -the right to expect that they will be heard and treated with respect
The American Hospital Association (AHA) in "The Patient Care Partnership" (formerly known as "A Patient's Bill of Rights") indicates that clients have the right to do what?
make informed decisions about their care and that the information required to make informed decisions needs to be accurate, complete, and relevant to the client's needs.
Referent
Idea that initiates reason for communication(C)/Perceived need to provide person with information and learning objectives(T)
Sender
Person who conveys message to another(C)/Teacher who performs activities aimed at helping other person to learn(T)
Intrapersonal Variables (Sender)
Knowledge, values, emotions, and sociocultural influences that affect sender's thoughts(C)/Teacher's philosophy of education, knowledge of material, approach, teaching experiences, emotions and values.(T)
Message
Information expressed or transmitted by sender.(C)/Content or information taught.(T)
Channels
Methods used to transmit message (visual, auditory, touch).(C)/Methods used to present content (visual and auditory materials, touch, taste, smell).(t)
Person to whom the message is transmitted.(C)/Learner(T)
Knowledge, values, emotions, and sociocultural influences that affect receiver's thoughts.(C)/Willingness and ability to learn (physical and emotional health, education, experience, developmental level).(T)
Feedback
Information revealing that the true meaning of the message was received.(C)/Determination of whether the client achieved learning objectives.(T)
â€¢ Teaching methods (based on domains of learning) include:
Cognitive, Affective, Psychomotor
â€¢ Basic Learning Principles include:
Attention, Motivation, Use of Theories, Pyschosocial Adaption to Illness, Active Participation, Ability to Learn, Physical Capability, Learning Enviroment
â€¢ Five Stages of Adaptation to Illness, Grief, and Learning:
Denial, Anger, Bargaining, Resolution, Acceptance
Nursing tools to test for literacy:
-Wide Range Achievement Test (WRAT3) evaluates reading, spelling, and math skills, for clients from 5 to 74 years of age. -Rapid Estimate of Adult Literacy in Medicine (REALM) uses pronunciation of health â€‹care terms to determine approximate reading level. -Cloze Test for reading comprehension, asks clients to fill in blanks within a written.
4.â€‹The school nurse is about to teach a freshman-level health class about nutrition. To achieve the best learning outcomes, the nurse should; Provides information using a lecture, Uses simple words to promote understanding, Develops topics for discussion that require problem solving, Completes an extensive literature search focusing on eating disorders.
Develops topics for discussion that require problem solving
Telling approach
is for teaching limited information (preparing a client for an â€‹upcoming procedure). If a client is highly anxious but it is vital for â€‹information to be given, telling is effective.
Participating approach:
the nurse and client set objectives and become involved in â€‹the learning process together. The client helps decide content, and the nurse â€‹guides and counsels the client with pertinent information.
Entrusting approach
provides the client the opportunity to manage self-care. The â€‹client accepts responsibilities and performs tasks correctly and consistently.
Reinforcing approach
(see key terms for reinforcement).
â€‹-Simulation
â€‹Clients attempt to solve a pertinent problem or situation, which a nurse has â€‹presented to them individually or as part
â€¢ Teaching illiterate or learning disabled clients, do what first?
Establish Trust
Teach the most important portions when?
At the very begining and then reiterate at the end.
Speak in a ____tone of voice
Lower
1.â€‹A client needs to learn to use a walker. Acquisition of this skill will require learning in the:?Affective domain,Cognitive domain,Attentional domain,Psychomotor domain?
Psychomotor
2.â€‹The nurse plans to teach a client about the importance of exercise:? When there are visitors in the room,When the client's pain medications are working,Just before lunch, when the client is most awake and alert,When the client is talking about current stressors in his or her life
When Pain Med Are Working
3.â€‹A client newly diagnosed with cervical cancer is going home. The client is avoiding discussion of her illness and postoperative orders. In teaching the client about discharge instructions, the nurse does what? Teaches the client's spouse, Provides only the information the client needs to go home, Focuses on knowledge the client will need in a few weeks, Convinces the client that learning about her health is necessary
Provides only the information the client needs to go home
5.A nurse is going to teach a client how to perform a breast self-examination. The behavioral objective that best measures the client's ability to perform the examination is: The client will verbalize the steps involved in breast self-examination within 1 week, The nurse will explain the importance of performing breast self-examination once a â€‹month, The client will perform breast self-examination correctly on herself before the end of the â€‹teaching session, The nurse will demonstrate breast self-examination on a breast model provided by the â€‹American Cancer Society
The client will perform breast self-examination correctly on herself before the end of the â€‹teaching session
6.A client who is having chest pain is going for an emergency cardiac catheterization. The most appropriate teaching approach in this situation is the: Telling approach, Selling approach, Entrusting approach, Participating approach
Telling Approach
7.The nurse is teaching a parenting class to a group of pregnant adolescents and has given the adolescents baby dolls to bathe and talk to. This is an example of what?
Role Play
9.â€‹A client needs to learn how to administer a subcutaneous injection. The nurse knows the client is ready to learn when the client... Has walked 400 feet, Expresses the importance of learning the skill, Can see and understand the markings on the syringe, Has the dexterity needed to prepare and inject the medication.
Expresses the importance of learning the skill
10.â€‹A client who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. The best teaching method would be what?
Simulation
â€¢ Air pollution:
the contamination of the atmosphere with a harmful chemical. Prolonged exposure to air pollution increases risk of pulmonary disease.
â€¢ Ambularm:
a device worn on the leg that signals when the leg is in a dependent position such as over the side rail or on the floor.
â€¢ Aura:
a bright light, smell, or taste. Some clients report an aura before a conclusive episode of seizures.
â€¢ Bed-Check:
weight-sensitive sensor mats placed under the client's mattress or chair that sounds an audible alarm at the bedside when pressure is released off the mat.
â€¢ Bioterrorism:
the use of biological agents to create fear and threat; most likely form of terrorism to occur; anthrax, smallpox, pneumonic plague, botulism.
â€¢ Carbon Monoxide:
colorless, odorless, poisonous gas produced by the combustion of carbon and organic fuels; binds strongly with hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of oxygen delivered to tissues.
â€¢ Environment:
Client's environment includes all of the many physical and psychosocial factors that influence of affect the life and survival of that client. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution.
â€¢ Food and Drug Administration (FDA):
a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances.
â€¢ Food Poisoning:
staphylococcal and clostridial bacteria are the most common types.
â€¢ Hypothermia:
occurs when the core body temperature 35'C or below
â€¢ Immunization:
the process by which resistance to an infectious disease is produced or augmented. Active immunity: injection Passive Immunity: antibodies passed from one person to another
â€¢ Land Pollution
: improper disposal of radioactive and bioactive waste products can lead to land pollution.
â€¢ Noise Pollution:
occurs when the noise level in an environment becomes uncomfortable to the inhabitants of the environment.
â€¢ Pathogen:
any microorganism capable of producing an illness. Limit by aseptic practice and hand washing.
â€¢ Poison:
any substance that impairs health or destroys life when ingested, inhaled, or otherwise absorbed by the body.
â€¢ Pollutant:
a harmful chemical or waste material discharged into the water, soil, or air.
â€¢ Relative Humidity:
the amount of water vapor in the air compared with the maximum amount of water vapor that the air could contain at the same temperature. Most comfortable humidity to most people is 70%.
â€¢ Restraint:
a human, mechanical, and/or physical device that is used with or without the client's permission to restrict his or her freedom of movement or normal access to a person's body.
â€¢ Safety:
freedom from psychological and physical injury.
â€¢ Seizure:
involves a hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic. Clients who have had a neurological injury or metabolic disturbance are at risk.
â€¢ Seizure Precautions:
encompass all nursing interventions to protect the client from traumatic injury, position for adequate ventilation and drainage of oral secretions, and providing privacy and support following the seizure.
â€¢ Status Epilepticus:
medical emergency whereby a person has continual seizures without interruption.
â€¢ Water Pollution:
contamination of lakes, rivers, and streams, usually by industrial pollutants.
A safe environment includes what 5 things?
Meeting basic needs, Reducing physical hazards, Reducing the transmission of pathogens, Maintaining sanitation, Controlling Pollution
Basic Needs:
Physiological needs, including the need for sufficient oxygen, nutrition, and optimum temperature and humidity, influence a patient's safety.
Low concentrations of oxygen include what symptoms?
Food Poisoning Preventative measures include:
hand washing before handling food, adequate cooking, and proper storage and refrigeration of perishable foods.
Comfort zone varies, but usual comfort zone is
65-75'F.
Hypothermia occurs when?
When a patient is exposed to cold for a prolonged period of time.
Exposure to extreme heat raises the core temperature resulting in
heatstroke or heat exhaustion.
You can minimize many physical hazards how?
through reduction of obstacles, control of bathroom hazards, adequate lighting, and security measures.
Terrorism:
a potential environmental health threat is the possibility of a bioterrorist attack.
What is the leading cause of death in children over age 1 and cause more death and disabilities than do all diseases combined?
Injuries
School-Age Child have a high risk of what?
At risk of injury from strangers. A child needs to be warned repeatedly not to accept anything from a stranger.
Adolescent are in danger of what?.
Risk-taking behavior
Adult: threats to safety usually are related to what?
life style habits. Drinking and driving, smoking, and a person under a high level of stress is more likely to have an accident.
Older Adult: physiological changes that occur during the aging process increase the client's risk for
falls and other types of accidents such as burns and car accidents.
Risks in the Health Care Agency Include;
Med errors, falls, client inherent accidents, procedure related accidents, equipment related
â€¢ 3 types of medical errors accounted for almost 60% of client safety incidents:
infection following surgery, bed sores, failure to diagnose and treat in time
â€¢ Medication errors can occur: during
â€¢ Nursing History: includes
data about the client's level of wellness to determine in any underlying conditions exist that pose threats to safety.
â€¢ Environmental Interventions: nursing interventions directed at eliminating environmental threats include
general preventative measures such as meeting basic needs, reducing physical hazards, and reducing pathogen transmission.
THE SIX RIGHTS OF PATIENT MEDICATION SAFTEY:
right patient, right route, right medication, right dose, right time, right documentation.
NINE LIFE SAVING PATIENT SAFTEY SOLUTIONS:
1. Be aware of look-alike, sound -alike meds.2. Use two forms of patient id (arm band, medical record number)3. Communicate critical info. (during patient handover)4. Correct procedure/correct body site -take a "time out" to verify and mark correct body part.5. Ensure med accuracy at transitions in care- compare all pt meds against medical order and home med list during ADMISSION,TRANSFER, AND DISCHARGE.6. Control concentrated electrolyte solutions ( be sure to use 6 rights of med safety and follow agency protocol for these solutions)7. Avoid catheter/tubing misconnections-label tubing and catheters to avoid mix up with multiple catheters.8. NEVER re use single use injection devices.9. Hand hygiene to prevent health care associated infections- before/after each encounter and after contact with contaminated objects ( even when wearing gloves)
The critical thinking nurse uses what four things in her assessment data for safety?
knowledge , experience , standards and attitudes
Home hazard assessment is necessary for in home care to a client. Key areas are...
bathroom, kitchen and stairs. Refer to pg.819 for specific examples.
Fall Assessment tool used to help assess risk for falls gives a score of ______ or higher to indicate high risk for falls
15 and higher.
Infants should sleep how?
on back-reduce the risk of SIDS
Snug fitting sheets, no ______
pillows- reduce suffocation
Pacifiers where?
attached to string shouldn't be placed around neck
Formula prepared how?
as directed-prevent contamination
Crib slats should be less than
2 3/8 inches apart
No small
parts/toys or plastic bags-choking/suffocation hazard
Children less than 80lbs or under 8 yrs should always
be in car seat. Children under 12 should ride in back seat of cars with air bags.
Care givers should know what?
cpr
How to swim, cross the street, and not to play in cars or trunks.
Teach your school age children what?
Bike safety, proper safety gear use and that firearms should stay locked up.
injuries related to car accidents, drug/alcohol effects, sex ed safety
Anthrax-acute infectious disease caused by_____ and infected through what? Death how quickly?
Bacillus anthracis. Infected through skin contact, ingestion or inhalation. Death within 24-36 hours.
Botulism-caused by __________. Most common form? Food born how quickly and Inhalation how quickly?
Clostridium botulinum. Food borne botulism is the most common form. Inborne form also exists.Food born-12-36 hrs after intake. Inhalation-24-72hrs after inhalation
A single case of __________ is a public health emergency
small pox
4. Smallpox-acute viral illness is especially deadly when?
when airborn
Options to try before restraints?
Diversions activities, placing close to nurse station, calm demeanor, time out techniques for aggressive behaviors, visual/auditory stimuli, remove cues that promote leaving (stairs, car keys, etc), Attend to toileting, food needs, camouflage IV with clothing, ensure good pain managment, review labs.APPLYING RESTRAINTS:
What does RACE stand for?
Rescue, Activate Alarm, Confine fire, Exstinguish
What does PASS stand for?
Pull pin, Aim, Squeeze and Sweep
Can siezure assessment precautions be delegated?
NO
Cathartics do what? They're stronger than __________ and stimulate what?
Cathartics and Laxatives empty the bowel and assists with constipation. Cathartics are stronger than laxatives. Cathartic Suppositories stimulate the rectal mucosa.
Anti-diarrheal opiate agents: treat diarrhea how?
by decreasing intestinal muscle tone, inhibiting peristaltic waves and increasing segmental contractions.
Enema is what?:
instillation of a solution into the rectum and sigmoid colon. Stimulates peristalsis, breaks up fecal mass, stretches rectal wall and initiates defecation reflex.
When giving an enema, position the client how?
In left side-lying sim w/ right knee flexed.
Using cold water with an enema can cause what?
cramps
Insert an enema how far?
7.5 to 10cm (3-4in) in adult's rectum.
Tap water is __(hypertonic/hypotonic)__ and has lower ______ than interstitial fluid
Hypotonic, lower osmotic pressure.
Can you repeat water enemas if they don't work?
NO, due to water toxicity/circulatory overload.
What is the safest solution to use for enemas and why?
Normal Saline, because it exerts the same OP as interstitial fluid.
Hypotonic solutions do what? Benefits who? Most common type?
exerts OP that pulls fluid out of interstitial spaces. Benefits clients unable to receive large volumes of water. 120-180ML (4-6oz) is effective. Fleet Enema most common.
Soapsuds enemas use what type of soap?
Pure Castile soap
High enema refers to what?
to height at which fluid is delivered. Cleanses entire colon. Raise solution to 30-45cm
Low enema cleanses only what?
the rectum and sigmoid. Raise 7.5cm (3in) above anus.
Oil-retention does what?
lubricates rectum and colon. Feces absorb oil and become softer. Is held for several hours.
Digital Removal is tried when? It means what?
Its a last resort, use fingers to break up stool and remove in sections. Excess rectal manipulation causes irritation.
Digital Removal stimulates what and can cause what?
stimulates vagus nerve which causes reflex lowering of Heart Rate.
What type of technique is placing of Nasogastric tubes?
Clean technique
When placing a NG tube put patient in what position?
High Fowlers
Levin Tube is common for? and is a?
decompression. Single-lumen tube w/ holes near top. Connect to drainage bag or suction.
Salem sump is a preferable and common method of?
decompression.
Ostomy Pouch Opening should be no more than ______ larger than the stoma
1/16th larger than stoma.
Diet Therapy provides what type of relief?
long term relief, not short term.
Aphasia
A speech disorder marked by a loss or defect in the ability to speak, write, or comprehend spoken or written language.
Conductive hearing loss
Hearing loss resulting from damage to or malformation of the middle or outer ear.
Delusions
Persistent belief in a untruth or a provably inaccurate misperception despite clear evidence to the contrary.
Expressive aphasia
inability to name common objects or to express simple ideas in words or writing
Hyperesthesia
An abnormal condition of increased sensitivity, particularly a painful reaction to normally painless touch stimuli.
Illusions-
Inaccurate sensory perception based on a real stimulus; examples include mirages or interpreting music or wind as voices.
Otolaryngologist-
concerned with the diagnosis and treatment of disorders of the head and the neck, including the ears, nose, and throat.
Ototoxic-
is damage to the ear (oto-), specifically the cochlea or auditory nerve and sometimes the vestibular system, by a toxin. This can result in sensorineural hearing loss, dysequilibrium, or both. Ex. Antibiotic Steptomycin can cause ototoxic effects
9. Proprioceptive-
changes that occur after age 60 that include difficulty with balance, spatial orientation, and coordination.
10. Receptive aphasia-
inability to understand written or spoken language
11. Sensory deficit-
a deficit in normal functions of sensory reception and perception
12. Sensory deprivation-
inadequate quality/quantity of stimulation a person experiences
when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli: excessive stimulation
14. Stereognosis-
a sense that allows a person to recognize an objects size, shape, and texture
15. Strabismus-
Abnormal condition of squint or crossed-eyes caused by the visual axes not meeting at the same point.
16. Reception-
response of a nerve cell to stimulation
17. Perception-
awareness to a sensation reaction
1. Presbyopia-
unable to see objects clearly
2. Cataract-
cause problems with glare and blurred vision
3. Glaucoma-
peripheral visual loss
4. Diabetic retinopathy-
decreased vision or vision loss
5. Macular degeneration-
blurring of reading matter, distortion of central vision, distortion of vertical lines
6. Prebycusis-
7. Cerumen accumulation-
causes a conduction deafness
9. Xerostomia-
decrease in salivary production, interferes with the ability to eat and leads to appetite problems
10. Peripheral Neuropathy-
symptoms numbness, tingling , and stumbling gait
11. Stroke-
disrupts blood flow to the brain
â€¢ Who has a higher incidence of hearing impairment and macular degeneration than African Americans or Asians?
White Americans
â€¢ What is almost 3 times as common in African Americans as in Whites?
Glaucoma
â€¢ Hispanic Americans have increase in what?
diabetic retinopathy
â€¢ To prevent sensory deprivation: help client do what?
move around, provide visual stimulation, listen to client as you speak to them and even a PET for companionship..
â€¢ Childhood ___________ are important prevention methods of hearing loss.
immunizations
â€¢ Always dress the infected side first of a patient who has diminished what?
tactile(touch) sensation
â€¢ Any factors that lower the consciousness impair what?
sensory perception
â€¢ Symptoms of sensory overload include:
racing thoughts, scattered attention, restlessness, and anxiety
â€¢ Temperature setting of a hot water heater should be no higher than _______to avoid accidental burns...yeah this seemed important
49 C
â€¢ ______ is a common cause of blindness in children.
Trauma
â€¢ Older adults with a deficit are sometimes diagnosed with _____.
dementia.
â€¢ Gustatory and olfactory changes begin around age____and include a decrease in taste buds.
age 50
â€¢ Hearing changes begin at age ______.
30
â€¢ Hearing Handicap Inventory for the Elderly (HHIE-S)-
five minute, ten item questionnaire developed to assess how individual perceives social and emotional effects of hearing loss
â€¢ Mini-Mental State Examination (MMSE)
a tool used to measure disorientation, altered conceptualization, and abstract thinking
â€¢ HHIE-S -
Hearing Handicap Inventory for the Elderly - is a 5-minute, 10-item questionnaire developed to assess how the patient perceives the social & emotional effects of hearing loss
â€¢ For the HHIE-S score, the higher the score
the greater the handicapping effect of a hearing impairment
â€¢ Welch-Allyn audioscope
- instrument is highly sensitive to detecting hearing loss
â€¢providing a patient with ________ for their home is an essential part of discharging
resources
â€¢ ____ becomes almost a primary sense for the hearing impaired
Vision
â€¢Visually impaired - rely on _____________to determine emotional tone
voice tones and inflections
â€¢Aphasia
(difficulty speaking) - unable to produce or understand language
â€¢Expressive aphasia
(motor type of aphasia) - inability to name common objects or to express simple ideas in words or writing
â€¢Sensory/receptive aphasia -
inability to understand written or spoken language
Global aphasia -
inability to understand language or communicate orally
Other Factors Affecting Perception
- prescribed or OTC medication or herbal products, â€¢ some antibiotics are ototoxic and permanently damage the auditory nerve, â€¢ opioid analgesics, sedatives, and antidepressant , edications often alter the perception of stimuli, â€¢ pain can also cause perceptual problems
examples of nursing diagnoses that apply to clients with sensory alterations include the following:
â€¢ risk-prone health behavior, â€¢ impaired verbal communication, â€¢ risk for injury, â€¢ impaired physical mobility, â€¢ self-care deficit: bathing/hygiene, dressing/grooming, toileting, â€¢ situational low self-esteem, â€¢ disturbed sensory , erception, â€¢ social isolation, â€¢ disturbed thought processes
________ is always a top priority; client also help prioritize aspect of care
safety
The most effective interventions enable the client w/sensory alterations to
function safely w/existing deficits & to continue a normal lifestyle
Good sensory function begins with
prevention ; educate patient about interventions
Three recommended vision screening interventions are:
-screening for rubella or syphilis in women who are considering pregnancy, -advocationg adequate prenatal care , -periodic screening of all children, for congenital blindness & vision impairments caused by refractive errors and strabismus (disorder where the eyes do not line up in the same direction),
nurses role is___,__ and ___
detection, education and referral
Children at risk for hearing impairments include;
-Family history of childhood hearing problems, -Perinatal infection (rubella, herpes or cytomegalovirus) , -Low birth weight , -Chronic ear infection, -Down syndrome
If undetected glaucoma leads to permanent visual loss exams need to occur every 1-2 years if:
-There is a family history of glaucoma, -If client is of African decent, -Had a serious eye injury,Taking steroid medications, -Over 65, -Clients over 40 should have a routine hearing assessment as part of their annual exam
Federal regulations ________________before an individual can purchase a hearing aid
require medical clearance from a physician
Hearing aids are contraindicated for the following conditions:
-Visible congenital or traumatic deformity of the ear, -Active drainage in last 90 days, -Sudden/progressive hearing loss in last 90 days, -Acute/chronic dizziness, -Unilateral sudden hearing loss w/in last 90 days, -Visible cerumen or foreign body in ear canal, -Pain/discomfort in ear, -Audiometer air-bone gap of 15 decibels or greater
______often are very sensitive to glare
With aging color perception changes,-_________ colors' perception usually declines
Blue, violet and green
__________are easier to see
Red, orange and yellow
Excessive ______ occluding the ear causes conductive heading loss
cerumen
Good _________increases taste perception and appetite
oral hygeine
Improve smell by strengthening ____________
pleasant olfactory stimulation
Bedridden patients require routine stimulation through
ROM exercises, positioning, and participation in self care activities
Patient with recent sensory impairment requires a complete orientation to the immediate environment which includes;
Knowing boundaries to room and Knowing where objects are located
Most common language disorder following a stroke is
aphasia (impairment of language ability)
Initially you need to establish very basic communication and recognize that aphasia does not indicate what?
intellectual impairment or degeneration of personalities
Combining activities such as dressing changes, bathing, and vital sign measurement in one visit prevents client from becoming
overly fatigued - schedule times for rest and quiet
Documentation is defined as
anything written or printed that you rely on as record or proof for authorized personal.
Documentation is NOT to be shared with persons who are not
involved in the patients care.
Documentation can be shared with the family only with what?
WITH the patient's permission. (Verbal permission, written permission, Power of Attorney)
Nursing documentation must be what 3 things?
Accurate, comprehensive and fexible
The Joint Commission (TJC) is an agency
accreditation
Prospective payment system is a system developed by __________and reimburses the hospitals how?
Medicare, reimburses a set dollar amount for each DRG
What is a DRG?
Drug related diagnosis
When does discharge planning start?
As soon as a patient is admitted to the hospital
What causes discharge planning to start as soon as a patient is admitted?
DRG's
In order for a healthcare facility to recover its costs from Medicare, everything that is done for a client while in the hospital (medications administered, labs, x-rays, procedures, etc) must be
DOCUMENTED!
HIPPA regulations require that any disclosure or requests regarding a patient's health information are limited to
MINUMUM necessary.
TJC standards require that ALL patients admitted to a health care institution must undergo the following:
-Physical Assessment, -Psychosocial (Mental) Assessment, -Environmental Assessment, -Self-Care Assessment, -Client Education, -Discharge Planning (starts as soon as patient is admitted to healthcare facility...VERY IMPORTANT!!!)
-Record is defined as a
confidential, permanent legal documentation of information relevant to a client's health care.
Record information about the client's health care when??
after EACH client contact.
Records are available to ALL members of what?
the client's personal healthcare team (only the client's nurses, doctors, surgeons, PT, OT, etc can view client's records if that patient is THEIR patient)
Reports are defined as
an oral, written, or audio-taped exchange of info between caregivers.
Common reports given by RN's are:
-Change-of-shift reports, -Telephone reports, -Transfer reports, -Incident reports
Incident reports are NEVER to be what?
documented or added to the client's chart/medical record. Incident reports are documented separately. VERY IMPORTANT!!!
One of the best defenses for legal claims (lawsuits) associated with nursing care is
DOCUMENTATION!
Common charting mistakes that can result in malpractice according to the Nurses Service Organization are:
-failing to record pertinent health or drug information (Ex: failing to record that a medication was given or failure to record a patient's VS that led to the patient's death), -failing to record nursing actions (Ex: failing to record that you did not give a patient his meds because the patient refused.), -failure to record that medications have been given (Ex: this could lead to over-medication. If you fail to record that you gave a patient a strong pain med and the next shift nurse comes back and re-administers that same medication because they thought that you didn't because you failed to document and the patient goes into cardiac arrest and die...it's your ass!), -failing to record drug reactions or changes in client's condition (Ex: failing to report that a certain med elevated patients BP out-of-control. If patients experience an adverse/idiosyncratic reaction to a drug and it is not discontinued because you failed to notify MD and document, the patient could receive the same med and next time it just might elevate their BP enough to kill them.), -writing illegible or incomplete records (leads to medication errors mostly....self explanatory), -failing to document a discontinued medication (already explained this)
DO NOT ______,_____ or_______errors while recording.
ERASE, WHITE-OUT, or SCRATCH OUT
DO NOT write what kind of comments about a client or other healthcare providers?
Correct all errors when?
promptly (avoid rushing)
Record all FACTS and avoid what?
OPINIONS
How much space should you put between nursing notes?
NONE
Record using what type of writing utensil?
Black Ink ONLY (no felt tip or erasable pen)
If order is questioned, record what?
that clarification was sought
TRUE or FALSE; Vague phrases are a super great idea and our nursing professors love them -
(if you even have to ask) FALSE
Begin each entry with what 3 things?
with date, time, and YOUR signature
TRUE or FALSE? Doctors are allowed to use your computer under your name to check orders because they're on your team with the same patient so it's not a HIPPA violation.
FALSE- Doctors (nor anyone else) can ever use your username/password for any reason ever. If you're signed on and they put an order in, the computer will say that you did!
Factual recording contains what type of information?
descriptive, OBJECTIVE information about what nurses SEE, HEARS, FEELS, SMELL.
When recording SUBJECTIVE DATE....document the patient's opinions how?
Their EXACT WORDS in quotation marks whenever possible (Ex: Client states " I see dead people")
When carrying out patient's treatments, procedures, or administering medications, ALWAYS document what 4 things?
-Time administered/performed, -Equipment used/medication given, -Client's response (objective and subjective. pain level. VS), -Your signature
Narrative documentation is the _____________ method for recording nursing care.
Narrative Documentation is what?
It is simply a story-like format to document information specific to the clients conditions and nursing care.
Problem-oriented medical record-
a method of documentation that emphasizes the client's problems.
Progress notes
are written notes in which RN's and MD's monitor and record the progress of a client's problems. They come in various formats and structures (Review Box 26-2 for the list of different formats....too much to write and hard to condense)
Source records
is a method in which the client's chart has a separate section for each discipline (Ex: a client's chart has sections for the RN's, MD's, Medication, Social Work, PT, etc)
caregivers are able to easily locate the proper section of the chart to record in
details about a specific problem are scattered throughout the chart in the different disciplinary sections.
Charting by exception-
charting that focuses on the documentation of deviations from the established norm or abnormal findings.
Charting by exception reduces____________ and highlights _________in the patients condition.
documentation time and highlights trends or changes
Critical pathway is a multidisciplinary care plan that includes:
-Clients problems, -Key interventions, -Expected outcomes, -All within an established TIME FRAME!
Advantage of critical pathway care plans?
eliminate nurses' notes, flow sheets, and nursing care plans.
Variances in critical pathways occur when?
unexpected outcomes, unmet goals, and interventions are not met within the set TIME FRAME! (Although some variances can be POSITIVE)
What's a positive variance from critical pathway goals that were set?
When a Pt progresses faster than expected
What is a Kardex
a portable "flip-over" file or notebook with an activity and treatment section and a nursing care plan section that organize information for quick reference as nurses give change-of-shift reports or make walking rounds.
Kardex's are kept where?
at the nurses' station
The client care summary or Kardex includes the following information:
-â€¢Basic demographic data (e.g., age, religion), â€¢HIPAA code word, â€¢Physician's or health care provider's name, â€¢Primary medical diagnosis, â€¢Medical and surgical history, â€¢Current treatment orders from health care provider to be carried out by the nurse (e.g., dressing changes, ambulation, glucose monitoring), â€¢Nursing care plan, â€¢Nursing orders (e.g., education sessions, symptom relief measures, counseling), â€¢Scheduled tests and procedures, â€¢Safety precautions to be used in the client's care, â€¢Factors related to activities of daily living, â€¢Nearest relative/guardian or person to contact in an emergency, â€¢Emergency code status, â€¢Allergies
Acuity records
offer a way to determine the hours of care and staff required for a given group of clients.
A client's acuity level is based on
the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period. The acuity level rates clients in comparison with one another.
Acuity system might be rated on a scale of
1-5 (1 is totally dependent, and 5 is independent).
Accurate acuity ratings justify
overtime and the number and qualifications of staff needed to safely care for clients.
Standardized care plans
based on the institution's standards of nursing practice, are preprinted, established guidelines that are used to care for clients who have similar health problems.
Most standardized care plans also allow the nurse to write in what?
specific goals or desired outcomes of care and the dates by which these outcomes should be achieved.
One advantage of standardized care plans is establishment of clinically sound what?
standards of care for similar groups of clients. These standards are useful when conducting quality improvement audits. Another advantage is education.
The standardized care plans can also improve _____of care among professional nurses.
continuity
The use of standardized care plans is controversial. Why?
the risk that the standardized plans inhibit nurses' identification of unique, individualized therapies for clients.
Standardized care plans cannot replace what?
the nurse's professional judgment and decision making and need to be updated on a regular basis to ensure content is current and appropriate.
The earlier a client is discharged, the more likely it is that a hospital will be
fully reimbursed.
TJC (2007) has standards for client education necessary for effective discharge planning including instruction in__________, ______ techniques to support adaption, Access to ______, how/when to obtain __________, ________responsibility to patient care, and ______instructions.
instruction in potential food-drug interactions, rehabilitation techniques to support adaption, Access to available community resources, how/when to obtain further treatment/follow up care, Patient and Family responsibility to patient care, and Medication instructions.
Documentation in the ________ system has different implications than in other areas of nursing because the client and family witness the majority of care rather than the nurse.
Home Care
Who decides is someone is qualified for home care and the amount they receive?
Medicare
The Omnibus Budget Reconciliation Act of 1987 includes what?
extremely significant Medicare and Medicaid legislation for long-term care documentation.
For long term care each resident is viewed holistically by using the _______ ______ _____.
Resident Assessment Instrument (RAI).
The fiscal support for long-term care residents hinges on what?
The justification of nursing care as demonstrated in documentation of the services rendered.
Nurses make four types of reports, including
change-of-shift reports, telephone reports, transfer reports, and incident reports.
This type of report provides continuity of care among nurses who are caring for a client...
change of shift reports
An advantage of oral reports is that they allow
staff members to ask questions or clarify explanations.
Taped reports improve efficiency by taping report before the end of the shift when time is available and by avoiding
social conversations between peers.
True or False? A change-of-shift report should not simply be the reading of documented information.
TRUE!
To prepare for a change of shift report, gather what?
information from work sheets, the client's records, and the client's care plan.
Avoid using what type of language when giving report?
judgmental language such as uncooperative, difficult, or bad when describing such behavior
To document a phone call, the nurse includes what in her documentation?
when the call was made, who made it (if other than the writer of the information), who was called, to whom information was given, what information was given, and what information was received.
A telephone order (TO)
involves a physician's or health care provider's stating a prescribed therapy over the phone to a registered nurse.
A verbal order (VO) may be accepted when?
when there is no opportunity for a physician or health care provider to write the order, as in emergency situations.
True or False? In report you should share significant information about family members as it relates to client's problems.
TRUE
True or False? In report you should review all routine care procedures and tasks, such as bathing.
FALSE
True or False? In Transfer Reports it is NOT necessary to include the Pt's emergency code status(ie;DNR/DNI).
False! They could code while being transferred.
True or False: In Transfer Reports it is a good idea to get info on what the Pt will need done after he's moved to the floor, even though it's in the computer, as well as if the Pt is on isolation precautions.
True!
An incident is
any event that is not consistent with the routine operation of a health care unit or routine care of a client.
Examples of incidents include what?
client falls, needle-stick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that led to injury or a risk for client injury.
Incident (or occurrence) reports are an important part of a unit's ______ ____ _____
quality improvement program.
Three important purposes of medical records are
communication, education, and research.
The Institute of Medicine recognized that the only way to use data and information to improve care delivery, as well as quality improvement, research, and education, is through what?
information technology.
Information technology (IT) refers to
the management and processing of information, generally with the assistance of computers.
Health care information system (HIS)
is a group of systems used within a health care enterprise that support and enhance health care (Hebda and others, 2005).
A HIS consists of two majors types of information systems:
clinical information systems (CIS) and administrative information systems.
Nursing information system (NIS),
an order entry system, and laboratory, radiology, and pharmacy systems to coordinate their core client care services.
Nursing informatics is defined by the American Nurses Association (2001) as
a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.
An effective nursing information system meets two goals.
First, it supports the way that nurses function and work by providing nurses the flexibility to use the system to view data and collect information, provide client care, and document the client's condition and care provided. Secondly, it supports and enhances nursing practice through improved access to information and clinical decision-making tools
Nursing information systems basically have two designs. The ___________design is the most traditional.
nursing process
In the more advanced nursing information systems, standardized nursing languages such as the ________, __________ and ______ are incorporated into the software programs.
NANDA International nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC)
One of the challenges of computerized documentation is inclusion of the what?
nursing process
The second design model for a nursing information system is the
protocol or critical pathway design
Which information system allows a user to select one or more appropriate protocols for a client then merging multiple protocols so that a master protocol or path is used to direct client care activities?
protocol or critical pathway design
Some specific advantages of nursing information systems:
â€¢Increased time to spend with clients, â€¢Better access to information, â€¢Enhanced quality of documentation, â€¢Reduced errors of omission, â€¢Reduced hospital costs, â€¢Increased nurse job satisfaction, â€¢Compliance with TJC and other accrediting agencies, â€¢Development of a common clinical database
A barrier to the successful implementation of a clinical information system is the reluctance on the part of some nurses and other clinical staff to accept what?
What was the first federal legislation to protect automated client records and to provide uniform protection nationwide?
HIPPA
PHI includes what?
individually identifiable health information such as demographic data; facts that relate to an individual's past, present, or future physical or mental health condition; provision of care; and payment for the provision of care that identifies the individual.
The _________and_________of information from a client's record is a primary source for the unauthorized release of information.
printing and faxing
What are some steps to take to enhance fax security?
Confirm fax#, Use cover sheet, Authenticate at both ends of transmission, Use speed dial when available, place fax machine in secure area, log fax transmissions, and work in 2011, not 1985 where fax machines should be nearly irrelevant. Wait, where is the part about securely sending a telegraph via pony express? Does the horse have to sign the HIPPA waiver?
Order entry systems allow nurses to
order supplies and services from another department.
The computerized physician order entry (CPOE) is
CPOE is a process by which the physician or an advanced practice nurse directly enters orders for client care into the hospital information system.
CPOE allows direct entry of what?
orders to eliminate issues related to illegible handwriting and transcription errors.
CPOE system speeds up what?
the implementation of ordered diagnostic tests and treatments, which improves staff productivity and saves money .
The electronic health record (EHR) is what?
a longitudinal electronic record of client health information generated by one or more encounters in any care delivery setting (HIMSS, 2007).
A unique feature of an EHR is its ability to integrate
all pertinent client information into one record, regardless of the number of times a client enters a health care system.
True or False? EHR captures and manages episodic and longitudinal EHR information on a pt.
TRUE
Pathogen-
Infectious agent
Colonization-
If microorganism is present or invades host, grows and/or multiplies but does not cause infection.
Communicable disease-
if infectious disease can be transmitted from one person to another
-Symptomatic-
if pathogens multiply and cause clinical signs/symptoms.
-Asymptomatic-
if no s/s are present
*CHAIN OF INFECTION:
1. An infectious agent or pathogen, 2. A reservoir or source for pathogen growth, 3. A portal of exit from the reservoir, 4. A mode of transmission, 5. A portal of entry to a host, 6. A susceptible host
Virulence-
Ability to survive in the host or outside the body.
Dose-
sufficient number of organisms
Reservoir-
A place where a pathogen can survive but may or may not multiply. A variety of microorganisms live on the skin and within the body cavities, fluids, and discharges
Most bacteria require/prefer what 4 environmental factors??
Water, Temp of 20-43 degree C, pH 5-7, dark areas. (remember this is MOST bacteria, definitely not all!)
-Bacteriostasis-
cold temp prevent growth & reproduction of bacteria
-Bactericidal-
a temp or chemical that destroys bacteria
Transplacental means what?
Transferred mother to fetus
Portal of exits-
Where the bacteria exits the body, ie: Blood, skin, and mucous membranes, respiratory tract, genitourinary tract, GI tract, and transplacental (mother to fetus).
Susceptibility-
degree of resistance to a pathogen
Pathogenicity-
extent of infection depends on the dose of the organism, and the susceptibility of the host.
Inflammatory response-
protective reaction that serves to neutralize pathogens and repair body cells *NON SPECIFIC
Superinfection-
when a broad-spectrum antibiotic eliminates a wide range of normal flora organisms, not just the infection.
Inflammation-
body's cellular response to injury, infection, or irritation.
Inflammatory Exudates are what (and the 3 kinds are what?)-
fluid & cells that are discharged from cells or blood vessels. 3 kinds; Serous, Sanguineous, Purulent
Serous looks like-
clear, like plasma
Sanguineous contains-
contains RBCs
Purulent is what?-
WBC's & bacteria
What are the 4 stages of the Course Of Infection?
Incubation, Prodromal, Illness, Convalescence
Incubation period-
interval b/t entrance & appearance of 1st symptoms
Prodromal stage-
onset of non-specific S/S- onset of more specific symptoms
Illness stage-
interval when client manifests S/S specific to type of infection
Convalescence-
interval when acute symptoms or infection disappear
Granulation tissue-
scar tissue
HAIS is also known as what? And means? An example?
(nosocomial infections)-health care associated infections *sites: urinary tract, surgical or traumatic wounds, Respiratory tract, bloodstream
*HAIS can start from what two places?
exogenous ( present outside the body) or endogenous (part of normal flora or virulent organisms residing that could cause infection).
Exogenous
( present outside the body)
Endogenous
(part of normal flora or virulent organisms residing that could cause infection).
Latrogenic infection-
type of HAI from a diagnostic or therapeutic procedure.
Client susceptibility-
Many factors influence susceptibility; age, nutritional status, stress, disease process, medical therapy.
________ infections are most common areas of skin or mucous membrane breakdown
Localized
Examples of localized infections include
surgical or traumatic wounds, pressure ulcers, oral lesions, and abscesses.
To identify causative organisms, nurse do what?
collects specimens of body fluid such as sputum or drainage from infected body sites for cultures.
Rinse contaminated objects with ______________to remove organic material.
COLD WATER Hot water causes the protein in organic material to coagulate & stick to objects.
Suppurative-
pus forming infection
Asepsis-
absence of pathogenic (disease-producing) microorganisms
Medical asespsis-
clean technique, lowers # of organisms present & prevents the transfer of organisms.
Disenfection-
process that eliminates many or all microorganisms with the exception of bacterial spores
Sterilization-
complete elimination or destruction of ALL microorganisms, including spores.
Direct Contact transmission:
- care & handling or contaminated body fluids (blood or body fluid from infected to workers direct skin.)
Indirect Contact transmission
-transfer of an infectious agent through a contaminated intermediate object (contaminated instruments of hands).
Droplet precautions:
diseases that are transmitted by large droplets & expelled in the air 3-6 feet.
Airborne Precautions:
diseases transmitted by smaller droplets and remain in the air for a long period of time * requires a negative air flow room
Protective environment:
requires a positive airflow room (when airflow is set at >12 air exchanges per hour, and all air is filtered through a HEPA filter), very limited client population.
Epidemiology-
cause and effect of health care associated infections.
Sterile Field-
An area free of microorganisms & prepared to receive sterile items.
In a Sterile Field only ________ touched sterile, only _____ touches clean, sterile objects become contaminated when?
Sterile touches sterile, clean touches clean and it becomes contaminated when out of sight or exposed to air for prolonged periods.
There's (how many inches?) around the peripheral edge of the sterile paper that is considered contaminated.
1 inch
Surgical scrub-
scrub from fingers to elbows for 5 MINUTES
What 3 things can significantly reduce the risk of MSD's?
-Knowledge of proper body mechanics coupled with -engineering solutions (e.g. mechanical lifts or friction reducing devices) and -ergonomics.
MSD stands for what?
Musculoskeletal disorders
A lift team consists of
2 physically fit people, competent in lifting techniques, who use client handling equipment to perform high-risk transfers.
Use balance to maintain proper body alignment and posture with 2 techniques:
-Widen the base of support by separating the feet to a comfortable distance. -Increase balance by bringing the center of gravity closer to the base of support.
Clients who do not maintain ________________are unsteady, which places them at fall risk.
a balance with their center of gravity
Ways to reduce friction during client movement include;
Decrease the surface area of the client who is unable to assist in moving up in the bed by placing the client's arms across the chest. -If able, get the client to bend his or her knees as you assist in moving them up in the bed. -Use an air-assisted device. -Use the common lift sheet.
The three categories of exercise are:
Isotonic, Isometric and Resistive Isomentric
Isotonic-
cause muscle contraction and change muscle length: walking, swimming, dancing, aerobics, jogging, bicycling, and moving arms and legs with light resistance.
Isometric-
tightening or tensing of muscles without moving body parts: quadriceps set exercises, contraction of gluteal muscles (ideal for an immobilized patient)
Resistive Isometric-
help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity: pushups, hip lifts, footboards for client to push off of in bed.
The assessment of mobility has 3 components:
ROM/Limited ROM, Gait and Exercise
Active ROM is when
the client is able to move his or her joints independently.
Passive ROM is when
the nurse must move each joint because the client is unable to do so themselves.
CPM machines are used to
place the client's joints through a selective repetitive range of motion.
ROM should be initiated when?
as soon as the client loses the ability to move the extremity or joint.
Proprioception is
the awareness of the position of the body and its parts.
Balance is controlled by
the cerebellum and inner ear.
A client with a right-sided cerebral hemorrhage and damage to the right motor strip may have
left-sided hemiplegia.
Clients that have been on bed rest, immobilized clients, clients with diabetes mellitus and cardiovascular disease are at a high risk for
orthostatic hypotension
Orthostatic hypotension is what? Examples?
a drop in blood pressure when the client changes position from horizontal to vertical. Signs and symptoms include: dizziness, light-headedness, nausea, tachychardia, pallor, and fainting.
What do you do if a client begins to fall while you're assisting them with walking?
assume wide base of support with one foot in front of the other, thus supporting the client's body weight, extend one leg and let the client slide against the leg, and gently lower the client to the floor, protecting the client's head.
Nephron-
functional unit of the kidney; forms the urine
Proteinuria-
presence of large proteins in the urine (a sign of glomerular injury)
Erythroprotein-
functions within bone marrow to stimulate RBCs production & maturation & prolongs the life of mature RBCs
Peritoneal Dialysis-
indirect method of cleansing the blood of waste products using osmosis & diffusion with the peritoneum functioning as a semi permeable membrane
Hemodialysis-
uses a machine equipped with semipermeable filtering membrane (artificial kidney) removes accumulated waste products &excess fluids rom the blood
Dysuria-
paiful or difficult urination; often due to bladder inflammation
Nocturia-
awakening to void one or more times at night; client may have renal disease, prostate enlargement, or cardiac disease; to minimize, avoid fluids 2 hrs before bedtime
Polyuria-
excessive output of urine; (diabetes mellitus or insipidus)
Oliguria-
diminished urinary output relative to intake (usually 400mL/24hr); (dehydration, renal failure, UTI)
Diuresis-
increased urine formation
Cystitis-
irritated bladder; causes frequent or urgent sensation to void
Hematuria-
blood-tinged urine
Urinary Retention-
bladder is unable to respond to the micturition reflex & thus is unable to empty
Urinary Incontinence-
involuntary leakage of urine that is sufficient to be a problem
Residual urine-
volume of urine remaining after voiding (>100mL)
Bacteriuria-
bacteria in the urine
Bacteremia/urosepsis-
bacteria in the bloodstream
1500 to 1600 mL/day (pg. 1130)
Clients with chronic alterations in kidney function do not make sufficient amounts of
active vitamin D
Bladder normally holds as much as ______mL
600mL of urine
Adults usually feel the need to urinate by _mL
150/200 mL
Children usually feel need to urinate by ____mL
50 to 100 mL
___________&__________cause changes in nerve functions that can lead to loss of bladder tone, reduced sensation of bladder fullness, or inability to inhibit bladder contractions
Diabetes mellitus & multiple sclerosis
_________&_________are 2 examples of conditions that make it difficult to reach & use toilet facilities.
Degenerative joint disease & Parkinsonism
Volume of urine formed at night is about Â½ of the volume during the day because why?
both intake and metabolism decline
Diuretics increase urine output while the use of _______or______often causes urinary retention
anticholinergics or antihistamines
What determines whether it is proper for a male to care for the urinary needs of a female or if gender-congruent care is needed?
Cultural Needs
Most people void an average of _____times a day.
5 or more
__________often interferes with normal urine elimination.
Constipation
Bleeding from the kidney= what kind of urine?
dark red urine
Bleeding from the bladder or urethra= what kind of urine?
bright red urine
Dark amber urine is a result of high concentrations of _______ by ______dysfuntion
bilirubin caused by liver dysfunction
Urine voided from clients with renal disease will appear ________or_____ because why?
cloudy or foamy because of high protein concentration
A sweet or fruity odor from urine occurs from ____or_____ seen with what two conditions?
acetone or accetoacetic acid, seen with diabetes mellitus or starvation
acetone or accetoacetic acid are by products of what?
by products of incomplete fat metabolism
Label all specimens collected with what 3 things?
client's name, date, and time of collection.
Random (routine urinalysis) is collected when?-
collected during normal voiding (urinary catheter or urinary diversion bad)
Clean-voided or midstream is collected when? How much?
Collect after patient initiates a stream (collect 30 to 60 mL)
Specific gravity is what?
the weight or degree of concentration of a substance compared with an equal volume of water;
__________test is more accurate than a specific gravity test because it measures the total number of particles in a solution
osmolality
Urine culture take approx. _____ hours before lab findings can be reported
24-48
Urine Cultures are what technique?
Sterile or Clean
pH of urine will indicate what?
acid base balance
______is normally not present in urine, but is common in renal disease
protein
______may often be found in the urine of clients with diabetes mellitus
glucose
_____are the end products of fat metabolism, clients whose diabetes mellitus is poorly controlled experience breakdown of fatty acids
ketones
blood- a positive test for occult blood occurs when?
when intact erythrocytes, hemoglobin or myoglobin is present
specific gravity-
measures concentration of particles in urine
damage to _______or_________allows RBCs to enter the urine
glomeruli or tubules
WBCs in urine- greater numbers indicate what?
urinary tract infection
Bacteria in urine indicates
UTI
Crystals- is a result of
food metabolism
Uric acid or calcium phosphate buildup can result in
renal stone formation
Transport specimen from urinalysis to lab within _________minutes, or refrigerate immediately, but do not refrigerate over_____ hours;
15 to 30, over 2 hours
Prior responsibilities of a diagnostic examination includes what?:
Asses client for history of shellfish (iodine) allergy, also ensure that clients receive appropriate pretest diet (clear liquids or nothing by mouth [NPO])
Shellfish allergies predict what type of medical allergy?
(iodine) allergy, which is used in specific studies (intravenous pyelogram [IVP] and renal arteriogram);
Abdominal roentgenogram-
determine the size, shape, symmetry, and location of the kidneys
Computerized axial tomography (CT) scan-
obtain detailed images of structures within a selected plane of the body; allows the viewing of tumors and obstructions
Intravenous pyelogram (IVP)-
iodine-based injection that allow the healthcare provider to view the collecting ducts and renal pelvis and outline the ureters, bladder and urethra
Endoscopy-cytoscopy-
direct visualization, specimen collection, and/or treatment of the interior of the bladder and urethra
Urinary retention following surgery requires what?
a short-term goal to void within 24 hours
Kegel-
pelvic muscle strengthening exercises
Collaborative activities-
prescribed by the health care provider and carried out by the nurse, such as medication administration (pg. 1149)
To stimulate micturition reflex, do what?
assist client in assuming the normal position for voiding and use sensory stimuli if clients requires (running water, stroking inner aspect of the thigh, pouring warm water over client's perineum)
The micturition reflex is what?
The impulses traveling from the urinary bladder to the sacral region of the SC, back to the bladder, the brain can influence the this by sending signals to inhibit or influence urination.
A client with normal renal function and who does not have heart or kidney disease needs to drink
2000 to 2500 mL of fluid daily. This dilutes urine, promotes regular micturition, and flushes the urethra of microorganisms.
Peristalsis-
propels food through the length of the GI tract
Cardiac & lower esophageal sphincter-
lies between esophagus & upper end of the stomach; prevents reflux of stomach contents back into the esophagus
Masticate-
the mouth breaks down food into a size suitable for swallowing
Valsalva maneuver-
pressure exerted to expel feces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway;
Arteriosclerosis cause what?-
causes decreased mesenteric blood flow, thus decreasing absorption from the small intestine; also causes a decrease in peristalsis & esophageal emptying slows (pg. 1177)
Fiber-
the non-digestible residue in the diet, provides the bulk of fecal material;
when there is no fiber to transport waste matter through the colon, it increases the risk for
polyps
Polyps-
small growth, typically benign & with a stalk protruding from a mucous membrane; more likely to form when there is no fiber to transport waste matter
Lactose intolerant-
client lacks the enzyme needed to digest milk sugar lactose
Paralytic ileus-
a temporary stop of peristalsis; usually is seen in clients that have any surgery that involve direct manipulation of the bowel; usually last 24 to 48 hrs
Constipation-
symptom, not a disease; infrequent bowl movements (less than every 3 days), hard feces; caused by improper diet, reduced fluid intake, lack of exercise & certain meds
Impaction-
results from unrelieved constipation; a collection of hardened feces, wedged in the rectum, that a person cannot expel; continuous oozing of diarrhea stool, abdominal distention, & cramping
Incontinence-
inability to control passage of feces & gas from the anus
Flatulence-
gas accumulated in the lumen of the intestines, causes the bowl wall to stretch and distend
Hemorrhoids-
dilated, engorged veins in the lining of the rectum
External hemorrhoids-
clearly visible; hardened underlying vein causes purple coloration (thrombosis)
Internal hemorrhoids-
have an outer mucous membrane & is caused by increased venous pressure resulting from defecation, pregnancy, heart failure, & chronic liver disease
Clostridium difficile (C. difficile)-
common causative agent of diarrhea; symptoms range from mild diarrhea to severe colitis; acquired by factors that cause an overgrowth of C. diff and by contact with the C. diff organism; most common diagnostic test is enzyme-linked immunosorbent assay (ELISA)
Stoma-
temporary or permanent artificial opening in the abdominal wall
Colostomy-
surgical opening created in the colon with the ends of the intestine brought through the abdominal wall to create the stoma
Fecal occult blood testing (FOBT, guaiac test) and the 3 types?-
measures microscopic amounts of blood in feces; diagnostic screening tool for colon cancer; 3 types: guaiac (gFOBT), immunochemical (iFOBT), & stool deoxyribonucleic acid (DNA) test
Purpose of the GI tract is to
absorb fluid & nutrients, prepare food for absorption & use by the body cells, and provide temporary storage of feces (pg. 1175)
6 to 8 glasses (1500 to 2000 mL) of un-caffeinated fluid daily (pg. 1178)
Three functions of the colon:
1. Absorption (water, sodium, chloride) 2. Secretion 3. Elimination
Rectum-
bacteria converts fecal matter to final form; normally empty until just before defecation (pg. 1176)
Food passes quickly through an infant's intestinal tract because of
rapid peristalsis.
The usual age for control of defecation is
2-3 yrs old
Poor fluid intake increase risk of constipation due to
reabsorption of fluid in the colon resulting in hard dry stool (pg. 1178)
Physical activity promotes
peristalsis (pg. 1178)
During stress, ____ is increased, can cause ______. Related issues to excessive stress are?
peristalsis increased; can cause diarrhea or gaseous distention; related diseases; ulcerative colitis, irritable bowel syndrome, Crohn's disease (pg. 1178)
___________ decreases peristalsis
Depression
Frequent straining in defecation & delivery can result in
permanent hemorrhoids (pg. 1178)
Clients who receive ___________or______anesthesia is less at risk for elimination alterations because it affects bowl activity minimally or not at all
local or regional
Chronic use of cathartics causes
large intestine to lose muscle tone & become less responsive to stimulation by laxatives; laxative, if used too frequently, causes serious diarrhea that leads to dehydration & electrolyte depletion (pg. 1178)
Ileostomy bypasses what and results in?
the entire large intestine and result in stools that are frequent and liquid (pg. 1181)
Colostomy of transvers colon results in
more solid, formed stool; sigmoid colostomy releases near-normal stool (pg. 1181)
3 types of colostomies are;
Loop, End, and Double-Barrel
Loop colostomy-
performed in a medical emergency when health care providers anticipate closure of the colostomy; usually temporary large stomas in the transvers colon; catheter temporarily placed under bowel loop [moved within 7 to 10 days]; has two opening through one stoma [proximal end drains stool, distal end drains mucus])
End colostomy-
one stoma, proximal end of the bowl with the distal portion of the GI tract either removed or sewn closed (Hartmann's pouch) and left in the abdominal caviry; surgical treatment of colorectal cancer; clients with diverticulitis treated surgically often have a temporary end colostomy
Double- Barrel Colostomy-
consists of two distinct stomas: proximal functioning stoma and the distal nonfunctioning stoma
Observable peristalsis is often a sign of
intestinal obstruction (pg. 1186)
Abdominal distention causes an increase in ________sounds when auscultated
pitch or tinkling
Hypoactive sounds (less than five sounds per minute) occur with
paralytic ileus; High- pitched and
Hyperactive bowel sounds (35 or more sounds per minute) occur with
small intestine obstruction and inflammatory disorders (pg. 1187)
Gas or flatulence creates a _______note on percussion, while masses, tumors, and fluid create _____ sounds (pg. 1187)
tympanic, dull
Use medical aseptic technique during collection of stool specimens because
25% of the solid portion of a stool is bacteria from the colon (pg. 1187)
When collecting a fecal specimen, collect how much?
an inch of formed stool or 15 to 30 mL of liquid diarrhea stool (pg. 1187)
Fecal incontinence in older people is most commonly caused by
overflow leakage as a result of constipation
Warning signs of colon cancer include;
change in bowel habits, rectal bleeding, and sensation of incomplete bowel evacuation.
Beginning regular colon screenings at what age?
at age 50
Noxious change-
abnormal fecal smell
Upper Endoscopy-
exam of the upper GI tract allowing more direct visualization through a lighted fiber-optic tube
Ultrasound-
technique that uses high-frequency sound waves to echo off body organs, creating a picture
Colonoscopy-
endoscopic exam of the entire colon with the use of colonoscope inserted into the rectum
Who have the highest incidence of colon cancer among US racial and ethnic groups
African Americans
Torticollis-
inkling of head to affected side (sternocleidomastoid is contracted). Acquired or congenital condition. Poss. Treatments: surgery, heat, support, etc.
Lordosis-
exaggeration of anterior convex curve of lumbar spine. Temp. condition (ex. Pregnancy) Poss. Treatments: spine-stretching exercise
Kyphosis-
increased convexity in curvature of thoracic spine. Congenital condition, ass. w/rickets, osteoporosis, tuberculosis of spine. Poss. Treatments: spine-stretching exercise, sleep w/o pillows, bed board, bracing, and poss spinal fusion (based on severity)
Congenital Hip Dysplasia-
hip instability, limited abduction of hips, & sometimes adduction contractures (head of femur does not articulate w/acetabulum b/c of shallowness of acetabulum) Congenital (hereditary), common w/breech deliveries. Poss. Treatments: maintenance of continuous abduction of thigh, abduction splints, casting & surgery
Knock-knee-
legs curved inward---knees come together as person walks. Congenital cond., ass. w/rickets. Poss. Treatments: knee braces surgery if not corrected by growth
Bowlegs-
1 or both legs bent outward @ knee (normal until 2-3 yrs of age) Congenital cond., ass. w/rickets. Slowing rate of curving if not corrected by growth
Clubfoot-
95% medial deviation & plantar flexion of foot. Congenital cond. Poss. Treatments: casts, splints (ex. Denis Browne splint), surgery (based on degree of deformity)
Pigeon toes-
internal rotation of forefoot or entire foot, common in infants. Congenital cond., habit. Poss. Treatments: growth, wearing reversed shoes.
Patients with mobility- ask questions such as:
1. Describe any changes you have noticed in your ability to walk & take care of yourself on a daily basis. 2. Have you experienced any stiffness, swelling, pain, or difficulty w/moving?
Patients with immobility- ask questions such as:
1. How have your appetite & diet changed since you have been having probs. moving around? 2. Have you noticed any places on your skin that are reddened or have any open sores?
Metabolic-
Inspection for slowed wound healing, abnormal lab data, & muscle atrophy. Anthropometric measurements (mid-upper arm circumference & triceps skinfold measurements) for decreased amounts of subcut fat.
Respiratory-
Palpation for generalized edema. Inspection for Asymmetrical chest wall movement, dyspnea, increased respiratory rate. Auscultation for crackles or wheezes.
Cardiovascular
- Auscultation for orthostatic hypotension. Auscultation & palpation for increased heart rate, 3rd heart sound, weak peripheral pulses, & peripheral edema.
Musculoskeletal-
Inspection & palpation for decreased ROM, erythema, &increased diameter in calf or thigh. Palpation for joint contracture. Inspection for activity intolerance, muscle atrophy, & joint contracture.
Skin-
Inspection & palpation for break in skin integrity.
Elimination-
decreased urine output, cloudy or concentrated urine, & decreased frequency in bowel movements. Palpation for distended bladder & abdomen. Auscultation for decreases bowel sounds.
TED Hose-
compression stockings
A foot cradle may be used for
patients w/poor peripheral circulation as a means of reducing pressure on tips of toes
Fowler's-
head of patient up 45-60 degrees,
Supine-
patient lying flat on back w/ pillows for support,
Prone-
patient lying flat on stomach (pillows can be place under clients feet & abdomen),
Lateral-
patient lying on side with supporting pillows,
Sims'-
client lying partially on abdomen.
If client is overweight & transfer belt is not safe, move client from bed to chair using
powered standing-assist.
What represent the largest threat to bone health & functional ability of olderaults?
Falls