Holy moly found on other blog
INDIANAPOLIS (AP) -- Lena Nelson had looked forward to buying dolls and other presents for her first granddaughter, who was born prematurely last week. Instead, she was planning Monday for the girl's funeral.D'myia Sabrina Nelson and another premature baby girl, Emmery Miller, died Saturday after they received an adult dose of a blood thinner at Methodist Hospital.Four other babies also were affected. Three were in stable condition Monday at Methodist, while the fourth was in critical condition at Riley Hospital for Children.Hospital officials said that the overdoses were the result of human and procedural error and that their hearts go out to the families, but Nelson said that doesn't ease her pain."They couldn't give me enough apologies for what they have done," Nelson said. "They just took her away. It's like murder. She was just taken away from us."Heparin, which is often used in premature children to prevent blood clots that could clog intravenous drug tubes, arrives at the hospital in premeasured vials. The vials are placed in a computerized drug cabinet by pharmacy technicians.When nurses need to administer the drug, they retrieve it from a specific drawer, which then locks again.Sam Odle, chief executive of Methodist and Indiana University Hospitals, said a pharmacy technician with more than 25 years' experience accidentally took the wrong dosage from inventory and stocked it in the drug cabinet in the Newborn Intensive Care Unit. Nurses, who are accustomed to only one dosage of heparin being available, then administered the wrong dose.The adult and infant doses have similar packaging, officials have said.Odle said Monday that the three hospitals that make up Clarian Health Partners -- Methodist, Riley and Indiana University -- would no longer keep certain doses of heparin in inventory. All newborn and pediatric critical care units will require a minimum of two nurses to validate any dose of heparin. And nursing units will receive an alert when a change in packaging or dose is entered in the drug cabinet.In addition, all employees will be required to sign a document about the importance of correct drug administration by Sept. 23.Odle stressed that the hospital is "among our nation's safest" and said Methodist would learn from the mistake.The deaths came just days before the state was to approve a rule that would require hospitals to report errors.
Saturday, September 30, 2006
Friday, September 29, 2006
did she post the grades yet!!???
anyone heard about our grades!!!
whats going on ... i cant take it anymore!!!LOL
whats going on ... i cant take it anymore!!!LOL
A Card For Mr. Sevilla, Re: Loss of His Grandma!
I am Gonig To Bring A Condolence Card, For Mr. Sevilla and His Family. We can all sign it on Thursday!
May The Lord Give Him and His Family
The Strength They Need In This Time Of Grief.
May The Lord Give Him and His Family
The Strength They Need In This Time Of Grief.
no pharm on oct. 2nd
to all you pharm students this is from Mr. Sevilla... just in case!!
Hello Everyone,As you know, my grandmother was very ill last Monday. She actually passed away 1 hour after I dismissed the class. Since the funeral is on Monday, October 2nd, there will be no class. I will post the items we spoke of (Calculation Exam, Table, and Lecture Outline) by next Tuesday.Please don't worry about getting all of the material for the course, I already have some creative solutions in mind to catch up. Thank all of you for your understanding during this time. Richard
Hello Everyone,As you know, my grandmother was very ill last Monday. She actually passed away 1 hour after I dismissed the class. Since the funeral is on Monday, October 2nd, there will be no class. I will post the items we spoke of (Calculation Exam, Table, and Lecture Outline) by next Tuesday.Please don't worry about getting all of the material for the course, I already have some creative solutions in mind to catch up. Thank all of you for your understanding during this time. Richard
med info
In case anyone doesn't know if you go under Fern Sisons docushare it has documents of her notes for Medication and Pharm..its really helpful:)
Thursday, September 28, 2006
Wednesday, September 27, 2006
Question of the week 09.25.06
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
1. Ask client to cough sputum into container
2. Have the client take several deep breaths
3. Provide a appropriate specimen container
4. Assist with oral hygiene
1. Ask client to cough sputum into container
2. Have the client take several deep breaths
3. Provide a appropriate specimen container
4. Assist with oral hygiene
Good Luck Ladies and Gentlemen!
Tomorrow is our test and we have all hung in there, to this point! I beleive in us all and for what it us worth, I am so proud of us. I will see you all tomorrow, some will be more nervous than others. In that, remember the more nervous you are, the "Cloudier" your thoughts get. Get some rest, eat breakfast, and wear bright colors ( not too bright to were I can't see anything but your loud outfit). Adios Amigos!!!
Iron Deficiency Anemia
There is a good explanation of Iron Deficiency Anemia, with interventions for and complications on Mrs. Sison's docushare page. Hope it helps.....
Monday, September 25, 2006
Clear, concise info
from our own Caralee Bromme's docushare site. I could kick myself for not finding this sooner!
Her slides reflect the organized nursing process way of thinking that should make studying so much easier for me.
Caralee Bromme's slides/study guides for electrolyte, ABG and acid base balance
Her slides reflect the organized nursing process way of thinking that should make studying so much easier for me.
Caralee Bromme's slides/study guides for electrolyte, ABG and acid base balance
Thanks Daneille!!!
I just wanted to say "Thank You" Danielle! You have been so great at keeping our Blog informative and entertaining. I really appreciate all that you have done!
More Videos
Hi all,
In reviewing for the upcoming exam I was looking at the disc that came with the Fundamentals book and along with the NCLEX review questions, there are some animated videos of the procedures we have been working on lately that I think may be helpful. It helps visualize what is going on in the inside of the patient. There is an NG Tube insertion, Administering an Enema, Catheterization, and others.....
In reviewing for the upcoming exam I was looking at the disc that came with the Fundamentals book and along with the NCLEX review questions, there are some animated videos of the procedures we have been working on lately that I think may be helpful. It helps visualize what is going on in the inside of the patient. There is an NG Tube insertion, Administering an Enema, Catheterization, and others.....
N1 Message from Fernisa
Nursing 1 Review Shima 402
Hi everyone! A test review for Nursing 1 will be done tomorrow at 2:30PM in Shima 402. I really believe this review will help everyone so please come. It will be given by me (Fernisa Sison) and Caralee Bromme.Thanks,
Fernisa
This was posted on the 4th sem. blog
Tracy Study Group hours
Okay folk, for those wanting to join the Tracy Study Group, here are available hours.
Tue/Wed may not begin until mid-October based on what you folks want to do.
Monday 11-1 (PHARM?)
Tue 1-3
Wed 1-3
Thur none
Fri 10-2 or 4-6
Sat as needed 10-2
Sun as needed 10-2
Please let me know which time/dates you are interested in and if we should make Monday a Pharm (N3) study day.
kdaniellem@yahoo.com
Tue/Wed may not begin until mid-October based on what you folks want to do.
Monday 11-1 (PHARM?)
Tue 1-3
Wed 1-3
Thur none
Fri 10-2 or 4-6
Sat as needed 10-2
Sun as needed 10-2
Please let me know which time/dates you are interested in and if we should make Monday a Pharm (N3) study day.
kdaniellem@yahoo.com
Sunday, September 24, 2006
testing strategies
I FOUND THIS ON ANOTHER BLOG AND THOUGHT THAT IT MIGHT BE HELPFUL FOR OUR UPCOMING TEST.
Test Strategies
1.If the question asks what you should do in a situation, use the nursing process to determine which step in the process would be next.
2.If the question asks what the client needs, use Maslow's hierarchy to determine which need to address first.
3.If the question indicates that the client doesn't have an urgent physiologic need, focus on his safety.
4.If the question involves communicating with a patient, use the principles of therapeutic communication.
Source: Nursing Student Success Made Incredibly Easy!, Lippincott Williams & Wilkins, 2005.
Test Strategies
1.If the question asks what you should do in a situation, use the nursing process to determine which step in the process would be next.
2.If the question asks what the client needs, use Maslow's hierarchy to determine which need to address first.
3.If the question indicates that the client doesn't have an urgent physiologic need, focus on his safety.
4.If the question involves communicating with a patient, use the principles of therapeutic communication.
Source: Nursing Student Success Made Incredibly Easy!, Lippincott Williams & Wilkins, 2005.
Virtual Cooperation
I commend your class on the best class participation to date on sharing your thoughts and virtually studying together.
Saturday, September 23, 2006
All Questions have been "touched"
I did combine some duplicates, so look for and add additional info in the "comments".
I have pulled together another compilation, but will wait until tomorrow evening to send it out to contributors so we can include some addt'l comments.
It is a very large document at this time, I'll see if I can't edit it down a bit.
If you contributed and you do not have a public email on the blog, you will need to email me a request to receive it. I will reply to the email address you send me.
goshblogit@gmail.com
Congrats to all.... this was a BIG JOB and you all stepped up and knocked it out!
I have pulled together another compilation, but will wait until tomorrow evening to send it out to contributors so we can include some addt'l comments.
It is a very large document at this time, I'll see if I can't edit it down a bit.
If you contributed and you do not have a public email on the blog, you will need to email me a request to receive it. I will reply to the email address you send me.
goshblogit@gmail.com
Congrats to all.... this was a BIG JOB and you all stepped up and knocked it out!
# 45
Discuss nursing care of the client who has a colostomy
- empty ostomy frequently to keep free of odors.
-keep stoma site clean and dry. for ileostomies, special care must be taken to prevent skin breakdown.
-apply a barrier such as karaya gum over skin around the stoma to prevent contact with any excretions.
-assess the pouch for correct fit if there is any skin irritation or leakage around the stoma.
-measure clients intake and output while hospitalized.
-disposable appliances can be kept on for up to seven days. they must be changed when they begin to leak.
-if feces leak onto the peristomal skin, the appliance should be removed and good asking care given to the peristomal area before applying a new appliance
-if irritation persists at the stoma or on the surrounding skin, the appliance should be replaced every 24-48 hrs. good skin care and any prescribed treatments are priorities until the irritation subsides.
-control odors because odor control is essential to clients self-esteem.
-teach clients to include dark green vegetables in the diet ( chlorophyll helps deordorize feces) . Bismuth subgallates also help lessen fecal odor. A deodorizer can be placed in the pouck and some appliances have a charcoal filter disk.
-teach self-care dietary considerations. initallly clients should avoid high fiber foods and gas producing foods
-teach client to avoid heavy lifting and contact sports.
-address self-esteem and sexuality issues.
-instruct client to avoid laxatives and enemas because they may cause severe fluid and electrolyte imbalances.
- empty ostomy frequently to keep free of odors.
-keep stoma site clean and dry. for ileostomies, special care must be taken to prevent skin breakdown.
-apply a barrier such as karaya gum over skin around the stoma to prevent contact with any excretions.
-assess the pouch for correct fit if there is any skin irritation or leakage around the stoma.
-measure clients intake and output while hospitalized.
-disposable appliances can be kept on for up to seven days. they must be changed when they begin to leak.
-if feces leak onto the peristomal skin, the appliance should be removed and good asking care given to the peristomal area before applying a new appliance
-if irritation persists at the stoma or on the surrounding skin, the appliance should be replaced every 24-48 hrs. good skin care and any prescribed treatments are priorities until the irritation subsides.
-control odors because odor control is essential to clients self-esteem.
-teach clients to include dark green vegetables in the diet ( chlorophyll helps deordorize feces) . Bismuth subgallates also help lessen fecal odor. A deodorizer can be placed in the pouck and some appliances have a charcoal filter disk.
-teach self-care dietary considerations. initallly clients should avoid high fiber foods and gas producing foods
-teach client to avoid heavy lifting and contact sports.
-address self-esteem and sexuality issues.
-instruct client to avoid laxatives and enemas because they may cause severe fluid and electrolyte imbalances.
# 27
27. DISCUSS THE PATIENT EDUCATION NEEDED FOR THE CLIENT WHO HAS AN INFECTION:
- emphasize necessity of taking antibiotics as directed (dosage and length of therapy) premature discontinuation of treatment when cleint begins to feel well may result in return of infection.
-discuss the importance of not taking antibiotics/using leftover drugs unless specifically instructed by healthcare provider. Inappropriate use can lean do development of drug-resistant strains/secondary infections (MRSA VRE)
-discuss the role of smoking in respiratory infections
-include info in preoperative teaching about ways to reduce potential for postoperative infection( respiratory measures to prevent pneumonia, wound/dressing care, avoidance of others with infection)
-involve in appropriate community education programs to increase awareness of spread/preventon of communicatble diseases
-promote safer-sex practices and report sxual contacts of infected individuals to prevent the spread of sexually transmitted diseases.
- emphasize necessity of taking antibiotics as directed (dosage and length of therapy) premature discontinuation of treatment when cleint begins to feel well may result in return of infection.
-discuss the importance of not taking antibiotics/using leftover drugs unless specifically instructed by healthcare provider. Inappropriate use can lean do development of drug-resistant strains/secondary infections (MRSA VRE)
-discuss the role of smoking in respiratory infections
-include info in preoperative teaching about ways to reduce potential for postoperative infection( respiratory measures to prevent pneumonia, wound/dressing care, avoidance of others with infection)
-involve in appropriate community education programs to increase awareness of spread/preventon of communicatble diseases
-promote safer-sex practices and report sxual contacts of infected individuals to prevent the spread of sexually transmitted diseases.
# 35
35. DISCUSS THE PATIENT EDUCATION NEEDED FOR THE CLIENT TAKING IRON SUPPLEMENTS: DIET EDUCATION
Oral preparations are most effectively absorbed if administered 1 hr before or 2 hr after meals. If gastric irritation occurs, administer with meals. Take tablets and capsules with a full glass of water or juice. Do not crush or chew enteric-coated tablets and do not open capsules .
Avoid using antacids, coffee, tea, dairy products, eggs, or whole-grain breads with or within 1 hr after administration of ferrous salts. Iron absorption is decreased by 33% if iron and calcium are given with meals. If calcium supplementation is needed, calcium carbonate does not decrease absorption of iron salts if supplements are administered between meals.
Oral preparations are most effectively absorbed if administered 1 hr before or 2 hr after meals. If gastric irritation occurs, administer with meals. Take tablets and capsules with a full glass of water or juice. Do not crush or chew enteric-coated tablets and do not open capsules .
Avoid using antacids, coffee, tea, dairy products, eggs, or whole-grain breads with or within 1 hr after administration of ferrous salts. Iron absorption is decreased by 33% if iron and calcium are given with meals. If calcium supplementation is needed, calcium carbonate does not decrease absorption of iron salts if supplements are administered between meals.
#41 Discuss the assessment needed for the client who is going to have a diagnostic study using radiopaque media.
Radiopaque agents are drugs used to help diagnose certain medical problems. They contain iodine, which absorbs x-rays. Depending on how they are given, radiopaque agents build up in a particular area of the body. The resulting high level of iodine allows the x-rays to make a ``picture'' of the area.
Before Using This Medicine
In deciding to use a diagnostic test, any risks of the test must be weighed against the good it will do. This is a decision you and your doctor will make. Also, test results may be affected by other things. For radiopaque agents, the following should be considered:
Allergies—Tell your doctor if you have ever had any unusual or allergic reaction to iodine, to products containing iodine (for example, iodine-containing foods such as seafood, cabbage, kale, rape [turnip-like vegetable], turnips, or iodized salt), or to any radiopaque agent. Also tell your doctor if you are allergic to any other substance, such as sulfites or other preservatives.
Pregnancy—Studies have not been done in humans with most of the radiopaque agents. However, iohexol, iopamidol, iothalamate, ioversol, ioxaglate, and metrizamide have not been shown to cause birth defects or other problems in animal studies. Some of the radiopaque agents, such as diatrizoates have, on rare occasions, caused hypothyroidism (underactive thyroid) in the baby when they were taken late in the pregnancy. Also, x-rays of the abdomen are usually not recommended during pregnancy. This is to avoid exposing the fetus to radiation. Be sure you have discussed this with your doctor.
Breast-feeding—Although some of these radiopaque agents pass into the breast milk, they have not been shown to cause problems in nursing babies. However, it may be necessary for you to stop breast-feeding temporarily after receiving a radiopaque agent. Be sure you have discussed this with your doctor.
Children—Children, especially those with other medical problems, may be especially sensitive to the effects of radiopaque agents. This may increase the chance of side effects.
Older adults—Elderly people are especially sensitive to the effects of radiopaque agents. This may increase the chance of side effects.
Other medical problems—The presence of other medical problems may affect the use of radiopaque agents. Make sure you tell your doctor if you have any other medical problems, especially:
Asthma, hay fever, or other allergies (history of)—If you have a history of these conditions, the risk of having a reaction, such as an allergic reaction to the radiopaque agent, is greater
Type 2 diabetes mellitus—There is a greater risk of having kidney problems
High blood pressure (severe) or
Pheochromocytoma (PCC)—Injection of the radiopaque agent may cause a dangerous rise in blood pressure
Kidney disease (severe)—More serious kidney problems may develop; also, the radiopaque agent may build up in the body and cause side effects
Liver disease—The radiopaque agent may build up in the body and cause side effects
Multiple myeloma (bone cancer)—Serious kidney problems may develop in patients with this condition
Overactive thyroid—A sudden increase in symptoms, such as fast heartbeat or palpitations, unusual tiredness or weakness, nervousness, excessive sweating, or muscle weakness may occur
Sickle cell disease—The radiopaque agent may promote the formation of abnormal blood cells
Radiopaque agents are taken by mouth or given by enema or injection. X-rays are then used to check if there are any problems with the stomach, intestines, kidneys, or other parts of the body.
Some radiopaque agents, such as iohexol, iopamidol, and metrizamide are given by injection into the spinal canal. X-rays are then used to help diagnose problems or diseases in the head, spinal canal, and nervous system.
The doses of radiopaque agents will be different for different patients and depend on the type of test. The strength of the solution is determined by how much iodine it contains. Different tests will require a different strength and amount of solution depending on the age of the patient, the contrast needed, and the x-ray equipment used.
Found on Medline Plus
I think most important part is Allergies to iodine and or shellfish and
past and current medical history
Before Using This Medicine
In deciding to use a diagnostic test, any risks of the test must be weighed against the good it will do. This is a decision you and your doctor will make. Also, test results may be affected by other things. For radiopaque agents, the following should be considered:
Allergies—Tell your doctor if you have ever had any unusual or allergic reaction to iodine, to products containing iodine (for example, iodine-containing foods such as seafood, cabbage, kale, rape [turnip-like vegetable], turnips, or iodized salt), or to any radiopaque agent. Also tell your doctor if you are allergic to any other substance, such as sulfites or other preservatives.
Pregnancy—Studies have not been done in humans with most of the radiopaque agents. However, iohexol, iopamidol, iothalamate, ioversol, ioxaglate, and metrizamide have not been shown to cause birth defects or other problems in animal studies. Some of the radiopaque agents, such as diatrizoates have, on rare occasions, caused hypothyroidism (underactive thyroid) in the baby when they were taken late in the pregnancy. Also, x-rays of the abdomen are usually not recommended during pregnancy. This is to avoid exposing the fetus to radiation. Be sure you have discussed this with your doctor.
Breast-feeding—Although some of these radiopaque agents pass into the breast milk, they have not been shown to cause problems in nursing babies. However, it may be necessary for you to stop breast-feeding temporarily after receiving a radiopaque agent. Be sure you have discussed this with your doctor.
Children—Children, especially those with other medical problems, may be especially sensitive to the effects of radiopaque agents. This may increase the chance of side effects.
Older adults—Elderly people are especially sensitive to the effects of radiopaque agents. This may increase the chance of side effects.
Other medical problems—The presence of other medical problems may affect the use of radiopaque agents. Make sure you tell your doctor if you have any other medical problems, especially:
Asthma, hay fever, or other allergies (history of)—If you have a history of these conditions, the risk of having a reaction, such as an allergic reaction to the radiopaque agent, is greater
Type 2 diabetes mellitus—There is a greater risk of having kidney problems
High blood pressure (severe) or
Pheochromocytoma (PCC)—Injection of the radiopaque agent may cause a dangerous rise in blood pressure
Kidney disease (severe)—More serious kidney problems may develop; also, the radiopaque agent may build up in the body and cause side effects
Liver disease—The radiopaque agent may build up in the body and cause side effects
Multiple myeloma (bone cancer)—Serious kidney problems may develop in patients with this condition
Overactive thyroid—A sudden increase in symptoms, such as fast heartbeat or palpitations, unusual tiredness or weakness, nervousness, excessive sweating, or muscle weakness may occur
Sickle cell disease—The radiopaque agent may promote the formation of abnormal blood cells
Radiopaque agents are taken by mouth or given by enema or injection. X-rays are then used to check if there are any problems with the stomach, intestines, kidneys, or other parts of the body.
Some radiopaque agents, such as iohexol, iopamidol, and metrizamide are given by injection into the spinal canal. X-rays are then used to help diagnose problems or diseases in the head, spinal canal, and nervous system.
The doses of radiopaque agents will be different for different patients and depend on the type of test. The strength of the solution is determined by how much iodine it contains. Different tests will require a different strength and amount of solution depending on the age of the patient, the contrast needed, and the x-ray equipment used.
Found on Medline Plus
I think most important part is Allergies to iodine and or shellfish and
past and current medical history
#25
25. Discuss the outcomes for the client who has the nursing diagnosis Ineffective Breathing Pattern.
Client Will (Specify Time Frame):
-Demonstrate a breathing pattern that supports blood gas results within the client's normal parameters
-Report ability to breathe comfortably
-Demonstrate ability to perform pursed-lip breathing and controlled breathing and use relaxation techniques effectively
-Identify and avoid specific factors that exacerbate episodes of ineffective breathing patterns
From Evolve website
Client Will (Specify Time Frame):
-Demonstrate a breathing pattern that supports blood gas results within the client's normal parameters
-Report ability to breathe comfortably
-Demonstrate ability to perform pursed-lip breathing and controlled breathing and use relaxation techniques effectively
-Identify and avoid specific factors that exacerbate episodes of ineffective breathing patterns
From Evolve website
#18
18. Discuss how a nurse would assess a client’s self care abilities.
Assessment based on Orem’s model, review objective and subjective data related to (USCR) Universal Self Care Requisites - the category of self-care requites that are basic and common to all humans and are constantly present; these needs must be met to achieve optimal health and well-being.
There are eight universal self-care requisites:
(1) AIR
(2) FOOD
(3) WATER
(4) ELIMINATION
(5) ACTIVITY AND REST
(6) SOLITUDE AND SOCIAL INTERACTION
(7) PREVENTION OF HAZARDS
(8) NORMALCY
Assess Self-Care Agency (SCA) - assets or abilities of an individual to perform self-care, also are there friends/family members participating in care.
Identify Self-Care Deficit (SCD) - deficit relationship that exists when the demand for self-care exceeds the person's ability to perform self-care.
Couldn’t locate more definitive info, please feel free to add your comments.
Assessment based on Orem’s model, review objective and subjective data related to (USCR) Universal Self Care Requisites - the category of self-care requites that are basic and common to all humans and are constantly present; these needs must be met to achieve optimal health and well-being.
There are eight universal self-care requisites:
(1) AIR
(2) FOOD
(3) WATER
(4) ELIMINATION
(5) ACTIVITY AND REST
(6) SOLITUDE AND SOCIAL INTERACTION
(7) PREVENTION OF HAZARDS
(8) NORMALCY
Assess Self-Care Agency (SCA) - assets or abilities of an individual to perform self-care, also are there friends/family members participating in care.
Identify Self-Care Deficit (SCD) - deficit relationship that exists when the demand for self-care exceeds the person's ability to perform self-care.
Couldn’t locate more definitive info, please feel free to add your comments.
#24
#24 Discuss the nursing interventions for the client who is experiencing orthostatic hypotension.
When the cause of orthostatic hypotension is related to medication, it is often possible to treat it by reducing dosage or changing the prescription. If it is caused by low blood volume, an increase in fluid intake and retention will solve the problem.Medications designed to keep blood pressure from falling can be used when they will not interfere with other medical problems.When orthostatic hypotension cannot be treated, the symptoms can be significantly reduced by remembering to stand up slowly or by wearing elastic stockings.
** Advise and assist clients to rise from chair/bed slowly, promote safety if dizziness is present. pg 131- ATI
When the cause of orthostatic hypotension is related to medication, it is often possible to treat it by reducing dosage or changing the prescription. If it is caused by low blood volume, an increase in fluid intake and retention will solve the problem.Medications designed to keep blood pressure from falling can be used when they will not interfere with other medical problems.When orthostatic hypotension cannot be treated, the symptoms can be significantly reduced by remembering to stand up slowly or by wearing elastic stockings.
** Advise and assist clients to rise from chair/bed slowly, promote safety if dizziness is present. pg 131- ATI
#15 Discuss the documentation needed for the client with a chest tube.
The puropose of the chest tube is to remove the air and fluid form the pleural space and to restore normal intrapleural pressure so the the lungs can expand.
**First document assessment from pre-insertion of the chest tube:document: breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm, and O2 (oxygen) saturation; allergies; also document that O2 and suction are available at bedside; also doument any client teaching that took place.
** Then document post-insertion, maintenance, and post-removal:
--Immediately after isertion and q 4 hrs. document: insertion site, location, tube size; document fluctuations in the air leak indicator, air bubbles in the air leak indicator, and that the suction is set at the ordered level in the drainage collection system.
--Immediately after insertion, q 4 hrs while chest tube is in place, and immediately after removal of the chest tube document: comfort level, breath sounds, heart rate, B/P, temp., respiratory rate and rhythm, O2 saturation; drainage for amont. color, and consistency; the dressing for occlusiveness and drainage from the insertion site; the chest wall at insertion site for subcutaneous emphysema (?)
--While chest tube is in place and drainiage collection system is in use document the volume of drainage (date,time, and initials)I couldn't find this anywhere in the book but after some research on the internet gathered this info.
The puropose of the chest tube is to remove the air and fluid form the pleural space and to restore normal intrapleural pressure so the the lungs can expand.
**First document assessment from pre-insertion of the chest tube:document: breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm, and O2 (oxygen) saturation; allergies; also document that O2 and suction are available at bedside; also doument any client teaching that took place.
** Then document post-insertion, maintenance, and post-removal:
--Immediately after isertion and q 4 hrs. document: insertion site, location, tube size; document fluctuations in the air leak indicator, air bubbles in the air leak indicator, and that the suction is set at the ordered level in the drainage collection system.
--Immediately after insertion, q 4 hrs while chest tube is in place, and immediately after removal of the chest tube document: comfort level, breath sounds, heart rate, B/P, temp., respiratory rate and rhythm, O2 saturation; drainage for amont. color, and consistency; the dressing for occlusiveness and drainage from the insertion site; the chest wall at insertion site for subcutaneous emphysema (?)
--While chest tube is in place and drainiage collection system is in use document the volume of drainage (date,time, and initials)I couldn't find this anywhere in the book but after some research on the internet gathered this info.
#22
#22
Nusing Interventions for the client who is hyperventilating:
*Monitor rate, rhythm, depthm and effort of respirations.
*Monitor vital signs and cardiac rhythm.
*Evaluate pulse oximetry to determine oxygenation.
*Elevate head of bed/position client appropriately, provide airway adjuncts and suction as indicated to maintain airway.
*Encourage frequent position changes and deep breathing/coughing exercises.
*Provide supplemental oxygen at lowest concentration indicated by lab results and client symptoms/situations.
*Encourage adequate rest and limit activities to within client tolerance.
*Keep environment allergen/pollutant free to reduce irritant effect on airways.
Nurse's Pocket Guide 266-268
Nusing Interventions for the client who is hyperventilating:
*Monitor rate, rhythm, depthm and effort of respirations.
*Monitor vital signs and cardiac rhythm.
*Evaluate pulse oximetry to determine oxygenation.
*Elevate head of bed/position client appropriately, provide airway adjuncts and suction as indicated to maintain airway.
*Encourage frequent position changes and deep breathing/coughing exercises.
*Provide supplemental oxygen at lowest concentration indicated by lab results and client symptoms/situations.
*Encourage adequate rest and limit activities to within client tolerance.
*Keep environment allergen/pollutant free to reduce irritant effect on airways.
Nurse's Pocket Guide 266-268
Study Session
There will be a study session for Exam 2 on Tuesday from 2:30-3:30 in Shima 402 held by Ms. Sison and Ms. Bromme.
# 49
Discuss the nursing interventions for the client who is experiencing shortness of breath and dypnea. Fundamentals 1302
Position in semi-Fowlers or high-Fowlers allowing for maximum chest expansion in bed-confined clients, particular dyspneic clients. Encourage client to turn from side to side frequently, so alternate sides of chest are permitted maximum expansion. Dyspneic clients often sit in bed and lean over their overhead table advantage abdominal organs are not pressing on diaphagm, also lower part of chest on table helps in exhaling. Breathing exercises for clients with restricted chest expansion (I'm thinking this is shortness of breath part of the question) people with COPD or clients recovering from thoracic surgery, breathing exercise is abdominal diaphragmatic and pursed-lip breathing; abdominal breathing permits deep full breaths with liffle effort; pursed-lip breathing helps the client develop control over breathing.
Position in semi-Fowlers or high-Fowlers allowing for maximum chest expansion in bed-confined clients, particular dyspneic clients. Encourage client to turn from side to side frequently, so alternate sides of chest are permitted maximum expansion. Dyspneic clients often sit in bed and lean over their overhead table advantage abdominal organs are not pressing on diaphagm, also lower part of chest on table helps in exhaling. Breathing exercises for clients with restricted chest expansion (I'm thinking this is shortness of breath part of the question) people with COPD or clients recovering from thoracic surgery, breathing exercise is abdominal diaphragmatic and pursed-lip breathing; abdominal breathing permits deep full breaths with liffle effort; pursed-lip breathing helps the client develop control over breathing.
#29, #42
Hello ladies and some gents, this is my first post and I just wanted to say that everyone's collaboration has been very helpful to me, so in order to keep the mood going I have posted two of my answers. I didn't find them word for word in the text but I did try to use some of my "critical thinking skills' and this is what I came up with. Please feel free to add more or to correct anything you may find wrong.
29.)pp. 1068-1076
Nursing Interventions for immobile client:
Muscoloskeletal: ROM to prevent contractures, milk to prevent osteo
CV system: leg devices to increase venous return, food less in sodium to prevent edema, teaching not to use Valsalve maneuver, do not massage calves to prevent emboli.
Respiratory system: encourage deep breating and coughing exercises, change postions frequently to prevent pooling of secretions
Metabolic Systems: change positions frequently to avoid decresing metabolic rate and to avoid interrupting the balance between catabolism and anabolism; Encourage eating and drinking continuously to counteract the effects of anorexia as much as possible.
Urinary system: change position frequently to prevent urinary stasis and to prevent calculi from from finding an adequate location in which to form; encourage urination as much as possible (assuring that the client is comfortable) to prevent urinary retention and to prevent bacteria from growning(causing urinary infection)
GI system: Change position frequently; encourage ambulation to prevent constipation; encourage constant bowel elimination to prevent the weakening of the defecation reflex.
Psychoneurologic System: provide support and engage in active communication with client.
42.) pp 1369-1375; pp 1262-1265
Describe and discuss the assessment needed for client with:
Fluid and electrolyte imbalance:
i. Nursing hx: attention to chronic lung diseases or DM that can disrupt normal balances; find out food/fluid intak, fluid output and s/sx of altered fluid and electrolyte imbalance.
ii. Asses skin, oral cavity, mucous membrane, and eyes and CV, respiratory, neurologic, and muscular status.
iii. Check daily weights, vital signs, and I&O
iv. Lab test: electrolytes, CBC, osmolality, Urine Ph, specific gravity, ABG.
Urinary Elimination Dysfunction:
i. Nursing Hx: clients normal voiding pattern, frequenc, and appearance of urine, any recent changes, any past or current problems with urination, presence of ostomy, and any factors influencing the elimination pattern
ii. Asses skin for color, texture,and tissue turgor and presence of edema
iii. Percussion of kidneys, palpation and percussion of bladder
iv. Asses urine for organic and inorganic solutes to evaluat normal or abnormal urine function
v. Measure urine output (normal should be 60mL hr or 1500 mL/day)
vi. Measure residual urine: (should not be present, if is could indicate urinary stasis or UTI)
vii. Diagnostic test: BUN-for urea; creatinine clearance-to determine glomeluar filtration rate.
29.)pp. 1068-1076
Nursing Interventions for immobile client:
Muscoloskeletal: ROM to prevent contractures, milk to prevent osteo
CV system: leg devices to increase venous return, food less in sodium to prevent edema, teaching not to use Valsalve maneuver, do not massage calves to prevent emboli.
Respiratory system: encourage deep breating and coughing exercises, change postions frequently to prevent pooling of secretions
Metabolic Systems: change positions frequently to avoid decresing metabolic rate and to avoid interrupting the balance between catabolism and anabolism; Encourage eating and drinking continuously to counteract the effects of anorexia as much as possible.
Urinary system: change position frequently to prevent urinary stasis and to prevent calculi from from finding an adequate location in which to form; encourage urination as much as possible (assuring that the client is comfortable) to prevent urinary retention and to prevent bacteria from growning(causing urinary infection)
GI system: Change position frequently; encourage ambulation to prevent constipation; encourage constant bowel elimination to prevent the weakening of the defecation reflex.
Psychoneurologic System: provide support and engage in active communication with client.
42.) pp 1369-1375; pp 1262-1265
Describe and discuss the assessment needed for client with:
Fluid and electrolyte imbalance:
i. Nursing hx: attention to chronic lung diseases or DM that can disrupt normal balances; find out food/fluid intak, fluid output and s/sx of altered fluid and electrolyte imbalance.
ii. Asses skin, oral cavity, mucous membrane, and eyes and CV, respiratory, neurologic, and muscular status.
iii. Check daily weights, vital signs, and I&O
iv. Lab test: electrolytes, CBC, osmolality, Urine Ph, specific gravity, ABG.
Urinary Elimination Dysfunction:
i. Nursing Hx: clients normal voiding pattern, frequenc, and appearance of urine, any recent changes, any past or current problems with urination, presence of ostomy, and any factors influencing the elimination pattern
ii. Asses skin for color, texture,and tissue turgor and presence of edema
iii. Percussion of kidneys, palpation and percussion of bladder
iv. Asses urine for organic and inorganic solutes to evaluat normal or abnormal urine function
v. Measure urine output (normal should be 60mL hr or 1500 mL/day)
vi. Measure residual urine: (should not be present, if is could indicate urinary stasis or UTI)
vii. Diagnostic test: BUN-for urea; creatinine clearance-to determine glomeluar filtration rate.
# 40
40) Discuss the nursing interventions for clients who are at risk for aspiration.(pg. 93 Nurses pocket guide)
Priority #1: assess causative/contributing factors:
-Note level of consciousness/awareness of surroundings cognitive impairment.
-Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment and whether they are of an acute or progressive nature ( ALS).
-Assess amount and consistency of respiratory secretions and strength of gag/cough reflexes.
-Observe for neck and facial edema, or example, client with head/neck surgery, tracheal/bronchial injury.
-Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
-Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS -suppressant drugs; can affect awareness and muscles of gag/swallow.
Nursing priority #2 : to assist in correcting factors that can lead to aspiration:
-Monitor use of oxygen masks in clients ast risk for vomiting. Refrain from using oxygen masks for comatose individuals.
-Keep wire cutters/scissors with client at all times when jaws are wired/banded to facilitate clearing airway in emergency situations
-Maintain operational suction equipment at bedside/chair side.
-Suction ( oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
_Assist with postural drainage to mobilize thickened secretions that may interfere with swallowing.
-Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed) to determine presence of secretions/silent aspiration.
-Elevate client to highest or best possible position for eating and drinking and during tube feedings.
-Feed slowly, instruct client to chew slowly and thoroughly.
-Give semisolid foods; avoid pureed foods(increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g. casseroles, puddings, stews) to aid swallowing effort.
-Provide very arm or very cold liquids (activates temperature receptors in the mouth that help to simulate swallowing). Add thickening agent to liquids as appropriate.
-Avoid washing solids down with liquids.
-Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
-Determine best position for infant/child(e.g. with the head of bed elevated 30 degrees and infant propped on right side after feeding because upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea).
-Provide oral medications in elixir form to crush, if appropriate.
-Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.
Nursing Priority #3: To promote wellness (teaching/discharge considerations):
-Review individual risk/potentiating factors.
-Provide information about the effects of aspiration on the lungs. -Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
-Train client to suction self or train family members in suction techniques(especially if client has constant or copious oral secretions) to enhance safety/self -sufficiency.
-Instruct individual/family member to avoid/limit activities that increase intra-abdominal ressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.
Just a quick tip, when answering a question that asks something like which is the best nursing intervention for a client at risk for aspiration, use one of the options from nursing priority # 1 because more than likely there will be an intervention from each of the three priorities.
Priority #1: assess causative/contributing factors:
-Note level of consciousness/awareness of surroundings cognitive impairment.
-Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment and whether they are of an acute or progressive nature ( ALS).
-Assess amount and consistency of respiratory secretions and strength of gag/cough reflexes.
-Observe for neck and facial edema, or example, client with head/neck surgery, tracheal/bronchial injury.
-Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
-Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS -suppressant drugs; can affect awareness and muscles of gag/swallow.
Nursing priority #2 : to assist in correcting factors that can lead to aspiration:
-Monitor use of oxygen masks in clients ast risk for vomiting. Refrain from using oxygen masks for comatose individuals.
-Keep wire cutters/scissors with client at all times when jaws are wired/banded to facilitate clearing airway in emergency situations
-Maintain operational suction equipment at bedside/chair side.
-Suction ( oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
_Assist with postural drainage to mobilize thickened secretions that may interfere with swallowing.
-Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed) to determine presence of secretions/silent aspiration.
-Elevate client to highest or best possible position for eating and drinking and during tube feedings.
-Feed slowly, instruct client to chew slowly and thoroughly.
-Give semisolid foods; avoid pureed foods(increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g. casseroles, puddings, stews) to aid swallowing effort.
-Provide very arm or very cold liquids (activates temperature receptors in the mouth that help to simulate swallowing). Add thickening agent to liquids as appropriate.
-Avoid washing solids down with liquids.
-Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
-Determine best position for infant/child(e.g. with the head of bed elevated 30 degrees and infant propped on right side after feeding because upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea).
-Provide oral medications in elixir form to crush, if appropriate.
-Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.
Nursing Priority #3: To promote wellness (teaching/discharge considerations):
-Review individual risk/potentiating factors.
-Provide information about the effects of aspiration on the lungs. -Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
-Train client to suction self or train family members in suction techniques(especially if client has constant or copious oral secretions) to enhance safety/self -sufficiency.
-Instruct individual/family member to avoid/limit activities that increase intra-abdominal ressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.
Just a quick tip, when answering a question that asks something like which is the best nursing intervention for a client at risk for aspiration, use one of the options from nursing priority # 1 because more than likely there will be an intervention from each of the three priorities.
#9 from Cassie
Discuss the procedure for suctioning:
a) oral
b) nasopharygeal
c) orophayngeal
d) trachel/trachesotomy
pg. 1318-1324 fundamentals & pg.396-398 ATI
Oropharyngeal and nasopharyngeal suctioning are done to remove secretions form the upper respiratort tract when client can cough effectively, but is unable to expectorate or swallow them; to facilitate ventilation; obtain secretions for testing, to prevent infection.
1. Assess the need for suctioning: bubbling or rattling breath sounds, decreased breath sounds, dyspnea, restelesness, gurgling sounds during respiration, adventitious breath sounds when chest is ausculatated, change in mental status, skin color, pulse rate and rhythm
2. Delegate: oropharnygeal suctioning with a Yankauer suction tube can be done by UAP or client family b/c it is not a sterile procedure, but sterile oropharnygeal or nasopharyngeal suctioning must be performed by the nurse.
3. gather equpiment pg. 1319
wash hands and appropriate infection control procedure
4. provide for privacy
5. provide client safety and comfort:
- explain procedure and what client should expect to feel
- Oral: postion client in semi-fowler with head turned to one side, if conscious with functional gag reflex.
- Nasal: postion client in semi-fowler with neck hyperextended, if conscious with functional gag reflex.
- if unconscious, place in side-lying posistion facing the nurse
- place towel on pillow or under chin
- select proper suction pressure (for wall units, usually 110-150mm/Hg for adults)
- measure distance between client's ear lobe and tip of nose (about 5 in)
- test the pressure of the suction and patency of catheter by applying a sterile gloved finger to the port to create suction.
- Oral: mositen catheter tip with water; gently insert catheter into one side of mouth (reduces gag reflex) and glide into oropharynx, without applying suction (prevents damage to pharyngeal mucosa)
- Nasal: lubricate the catheter tip with water-soluble lubricant; gently insert catheter into one nostril and guide it along floor of the nasal cavity. Do not force; if one nostril isnot patent try the other.
- after catheter is posistioned, use nondominant hand to occlude the suction port and apply suction. gently rotate and withdraw catheter. suction intermittently as catheter is withdrawn.this should take no longer than 15 seconds.
- clear catheter by suctioning sterile water through it before reinserting it.
- ask client to breathe deep and cough between catheter insertions (help break up sputum/mucous)
- after suction is complete, suction secretions in mouth and under tongue.
-allow client to rest 20-30 seconds before reinserting catheter. replace nasal canula, if applicable during this time.
-evaluate effectiveness of suctiong by assessing and documenting pre and post suctioning respiratort status (skin color, lung sounds, dyspnea, anxiety); document amount, consistency, color, odor of sputum.
Suctioning a traceostomy is done to maintain a patent airway, prevent airway obstructions, to promote respiratory function (optimal gas exchange), to prevent pneumonia.
1.assess client for presence of congestion of the thorax by ausculataion.
2. delegate sterile, invasive procedure to nurse or respiratory therapist
3. gather equpiment.
4. explain procedure will make breathing easiert and that it will cause couhging.
- wash hand, gloves
- administer analgesia if necessary ( coughing causes pain for clients who have had thoracic surgery)
- place in semi-fowler unless contraindicated
- select proper suction pressure (for wall units usually 110-120 mm/Hg for adults)
- place catheter tip in sterile saline solution, occlude the thumb and suction a small amount of the sterile solution through the catheter.
- quickly and gently insert the catheter without applying suction
- insert catheter about 5 in. for adults or untill the client coughs or resistance is felt
- clear cather by suctiong sterile water through it before reinserting it
- ask client to breathe deep and cough between catheter insertion.
- after each withdrawl of the suction catheter, flush the catheter by suctiong sterile water through it.
- after suctioning is complete suction secretions in mouth, and under tongue.
evaluate effectiveness of suctioning (same as above) and also document amount of sterile solution instilled.
Key Procedure Points of All Suctioning:
- use sterile technique
- determine proper lenght of tube to insert
- hyperventilate or oxygentate the client before suctioning
-DONOT APPLY SUCTION WHILE INSERTING THE TUBE
- apply suction while rotating and withdrwaing the catheter.
- restrict suction time to 5-15 seconds to minimize oxygen loss.
- encourage client to cough and breather deep between suctions
-hyperventilate or oxygentate between suctions
-let client rest between scutions
- evaluate respiratory status before and after suctioning.
-protect against expousre to body fluids.
a) oral
b) nasopharygeal
c) orophayngeal
d) trachel/trachesotomy
pg. 1318-1324 fundamentals & pg.396-398 ATI
Oropharyngeal and nasopharyngeal suctioning are done to remove secretions form the upper respiratort tract when client can cough effectively, but is unable to expectorate or swallow them; to facilitate ventilation; obtain secretions for testing, to prevent infection.
1. Assess the need for suctioning: bubbling or rattling breath sounds, decreased breath sounds, dyspnea, restelesness, gurgling sounds during respiration, adventitious breath sounds when chest is ausculatated, change in mental status, skin color, pulse rate and rhythm
2. Delegate: oropharnygeal suctioning with a Yankauer suction tube can be done by UAP or client family b/c it is not a sterile procedure, but sterile oropharnygeal or nasopharyngeal suctioning must be performed by the nurse.
3. gather equpiment pg. 1319
wash hands and appropriate infection control procedure
4. provide for privacy
5. provide client safety and comfort:
- explain procedure and what client should expect to feel
- Oral: postion client in semi-fowler with head turned to one side, if conscious with functional gag reflex.
- Nasal: postion client in semi-fowler with neck hyperextended, if conscious with functional gag reflex.
- if unconscious, place in side-lying posistion facing the nurse
- place towel on pillow or under chin
- select proper suction pressure (for wall units, usually 110-150mm/Hg for adults)
- measure distance between client's ear lobe and tip of nose (about 5 in)
- test the pressure of the suction and patency of catheter by applying a sterile gloved finger to the port to create suction.
- Oral: mositen catheter tip with water; gently insert catheter into one side of mouth (reduces gag reflex) and glide into oropharynx, without applying suction (prevents damage to pharyngeal mucosa)
- Nasal: lubricate the catheter tip with water-soluble lubricant; gently insert catheter into one nostril and guide it along floor of the nasal cavity. Do not force; if one nostril isnot patent try the other.
- after catheter is posistioned, use nondominant hand to occlude the suction port and apply suction. gently rotate and withdraw catheter. suction intermittently as catheter is withdrawn.this should take no longer than 15 seconds.
- clear catheter by suctioning sterile water through it before reinserting it.
- ask client to breathe deep and cough between catheter insertions (help break up sputum/mucous)
- after suction is complete, suction secretions in mouth and under tongue.
-allow client to rest 20-30 seconds before reinserting catheter. replace nasal canula, if applicable during this time.
-evaluate effectiveness of suctiong by assessing and documenting pre and post suctioning respiratort status (skin color, lung sounds, dyspnea, anxiety); document amount, consistency, color, odor of sputum.
Suctioning a traceostomy is done to maintain a patent airway, prevent airway obstructions, to promote respiratory function (optimal gas exchange), to prevent pneumonia.
1.assess client for presence of congestion of the thorax by ausculataion.
2. delegate sterile, invasive procedure to nurse or respiratory therapist
3. gather equpiment.
4. explain procedure will make breathing easiert and that it will cause couhging.
- wash hand, gloves
- administer analgesia if necessary ( coughing causes pain for clients who have had thoracic surgery)
- place in semi-fowler unless contraindicated
- select proper suction pressure (for wall units usually 110-120 mm/Hg for adults)
- place catheter tip in sterile saline solution, occlude the thumb and suction a small amount of the sterile solution through the catheter.
- quickly and gently insert the catheter without applying suction
- insert catheter about 5 in. for adults or untill the client coughs or resistance is felt
- clear cather by suctiong sterile water through it before reinserting it
- ask client to breathe deep and cough between catheter insertion.
- after each withdrawl of the suction catheter, flush the catheter by suctiong sterile water through it.
- after suctioning is complete suction secretions in mouth, and under tongue.
evaluate effectiveness of suctioning (same as above) and also document amount of sterile solution instilled.
Key Procedure Points of All Suctioning:
- use sterile technique
- determine proper lenght of tube to insert
- hyperventilate or oxygentate the client before suctioning
-DONOT APPLY SUCTION WHILE INSERTING THE TUBE
- apply suction while rotating and withdrwaing the catheter.
- restrict suction time to 5-15 seconds to minimize oxygen loss.
- encourage client to cough and breather deep between suctions
-hyperventilate or oxygentate between suctions
-let client rest between scutions
- evaluate respiratory status before and after suctioning.
-protect against expousre to body fluids.
#48 from Amie
48. Discuss the assessment needed for the client who is at risk for hyponatremia.
Those at risk for hyponatremia include patients who have experienced:
Burns
Vomiting and diarrhea
Use of diuretics ("water pills"), especially of the type known as thiazide diuretics
Certain kidney diseases
Liver cirrhosis
Congestive heart failure
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Assess clinical manifestations including lethargy, confusion, apprehension, muscle twitching, abdominal cramps, anorexia, nausea, vomiting, headache, seizures, coma. View Lab findings: serum sodium below 135 mEq/L and serum osmolality below 280 mOsm/kg
Hyponatremia is associated with numerous medications. The patient's medication list should be examined for drugs known to cause hyponatremia.
Hyponatremia has been noted in patients with poor dietary intake who consume large amounts of beer (called beer potomania) and after use of the recreational drug N-methyl-3,4-methylenedioxyamphetamine (ie, MDMA or ecstasy).
from Amie
Those at risk for hyponatremia include patients who have experienced:
Burns
Vomiting and diarrhea
Use of diuretics ("water pills"), especially of the type known as thiazide diuretics
Certain kidney diseases
Liver cirrhosis
Congestive heart failure
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Assess clinical manifestations including lethargy, confusion, apprehension, muscle twitching, abdominal cramps, anorexia, nausea, vomiting, headache, seizures, coma. View Lab findings: serum sodium below 135 mEq/L and serum osmolality below 280 mOsm/kg
Hyponatremia is associated with numerous medications. The patient's medication list should be examined for drugs known to cause hyponatremia.
Hyponatremia has been noted in patients with poor dietary intake who consume large amounts of beer (called beer potomania) and after use of the recreational drug N-methyl-3,4-methylenedioxyamphetamine (ie, MDMA or ecstasy).
from Amie
#30
NURSING INTERVENTIONS FOR CLIENT WITH A NURSING DIAGNOSIS OF ACTIVITY INTOLERANCE:
(I KNOW IT'S LONG BUT IT INCLUDES RATIONALES FOR THE INTERVENTIONS)
Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions.
Assess the client daily for appropriateness of activity and bed rest orders. Inappropriate prolonged bed rest orders may contribute to activity intolerance (Kasper, Braunwald, & Fauci, 2005). EB: A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen et al, 1999).
If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998; Fletcher, 2005; Kasper, Braunwald, & Fauci, 2005).
If client is mostly immobile, consider use of a transfer chair, a chair that becomes a stretcher. Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Nelson et al, 2003).
When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Watch the client closely for dizziness during increased activity (Fried & Fried, 2001). Postural hypotension can be detected in up to 30% of elderly clients. These methods can help prevent falls (Tinetti, 2003).
When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. When an adult rises to the standing position, 300 to 800 mL of blood pools in the lower extremities. Maintenance of blood pressure during position change is quite complex; many sensitive cardiac, vascular, neurologic, muscular, and neurohumoral responses must occur quickly. If any of these responses are abnormal, blood pressure and organ perfusion can be reduced. As a result, symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, neck ache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition (Bradley & Davis, 2003).
If a client experiences syncope with activity, refer for evaluation by a physician. Syncope has many causes, including benign vasovagal, but can also be due to serious cardiac disease, resulting in death (Hauer, 2003).
Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Fried & Fried, 2001).
Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (Wenger, 2001):
Onset of chest discomfort
Dyspnea
Palpitations
Excessive fatigue
Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced intraventricular conduction defect, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
Exercise hypotension (drop in systolic blood pressure of 10 mm Hg from baseline blood pressure despite an increase in workload)
Excessive rise in blood pressure (systolic >180 mm Hg or diastolic >110 mm Hg) Note: These are upper limits; activity may be stopped before reaching these values
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Instruct the client to stop the activity immediately and report to the physician if the client is experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician. The client should be evaluated before resuming activity.
Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998; Kasper, Braunwald, & Fauci, 2005).
Assess for constipation. If present, refer to care plan for Constipation. Impaired mobility is associated with increased risk of constipation.
Refer the client to physical therapy to help increase activity levels and strength.
Consider dietitian referral to assess nutritional needs related to activity intolerance. Recognize that undernutrition causes significant morbidity due to the loss of lean body mass. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis and pressure sores. Respiratory muscle weakness causes difficulty in expectorating, increasing susceptibility to chest infection. Immunocompetence declines, increasing the risk of infection, which in turn reduces nutritional status (Holmes, 2003).
Identify the factors that contribute to undernutrition in hospital patients. There are two main ways in which undernutrition develops. The first, protein-energy malnutrition arises during acute injury or illness when increased nutrient requirements and loss of body protein are common. The second is inadequate nutrient intake during a time of increased nutritional demand or over a prolonged period of reduced dietary consumption. This is particularly common in older people and those with disabilities and chronic or mental illness (Holmes, 2003).
Provide emotional support and encouragement to the client to gradually increase activity. Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can increase mobility by helping the client overcome limitations.
Use a gait walking belt when ambulating the client. Gait belts help improve the caregiver's grasp, reducing the incidence of injuries (Nelson, 2003).
Work with the client to set mutual goals that increase activity levels.
If the client is scheduled for a surgical intervention that will result in bed rest in intensive care, consider referring to physical therapy for a prehabilitation program including warm-up, aerobic conditioning, strength building, and flexibility enhancement. EBN: Increasing a client's functional capacity before hospitalization can be a helpful means of modifying the predictable deconditioning that happens with intensive care unit (ICU) admission (Topp et al, 2002).I GOT THE INFO FROM EVOLVE
(I KNOW IT'S LONG BUT IT INCLUDES RATIONALES FOR THE INTERVENTIONS)
Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a disease can help direct appropriate interventions.
Assess the client daily for appropriateness of activity and bed rest orders. Inappropriate prolonged bed rest orders may contribute to activity intolerance (Kasper, Braunwald, & Fauci, 2005). EB: A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen et al, 1999).
If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998; Fletcher, 2005; Kasper, Braunwald, & Fauci, 2005).
If client is mostly immobile, consider use of a transfer chair, a chair that becomes a stretcher. Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Nelson et al, 2003).
When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Watch the client closely for dizziness during increased activity (Fried & Fried, 2001). Postural hypotension can be detected in up to 30% of elderly clients. These methods can help prevent falls (Tinetti, 2003).
When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. When an adult rises to the standing position, 300 to 800 mL of blood pools in the lower extremities. Maintenance of blood pressure during position change is quite complex; many sensitive cardiac, vascular, neurologic, muscular, and neurohumoral responses must occur quickly. If any of these responses are abnormal, blood pressure and organ perfusion can be reduced. As a result, symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, neck ache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition (Bradley & Davis, 2003).
If a client experiences syncope with activity, refer for evaluation by a physician. Syncope has many causes, including benign vasovagal, but can also be due to serious cardiac disease, resulting in death (Hauer, 2003).
Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Fried & Fried, 2001).
Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (Wenger, 2001):
Onset of chest discomfort
Dyspnea
Palpitations
Excessive fatigue
Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced intraventricular conduction defect, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
Exercise hypotension (drop in systolic blood pressure of 10 mm Hg from baseline blood pressure despite an increase in workload)
Excessive rise in blood pressure (systolic >180 mm Hg or diastolic >110 mm Hg) Note: These are upper limits; activity may be stopped before reaching these values
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Inappropriate bradycardia (drop in heart rate >10 beats/min or < 50 beats/min)
Increased heart rate above 100 beats/min
Instruct the client to stop the activity immediately and report to the physician if the client is experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician. The client should be evaluated before resuming activity.
Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998; Kasper, Braunwald, & Fauci, 2005).
Assess for constipation. If present, refer to care plan for Constipation. Impaired mobility is associated with increased risk of constipation.
Refer the client to physical therapy to help increase activity levels and strength.
Consider dietitian referral to assess nutritional needs related to activity intolerance. Recognize that undernutrition causes significant morbidity due to the loss of lean body mass. The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis and pressure sores. Respiratory muscle weakness causes difficulty in expectorating, increasing susceptibility to chest infection. Immunocompetence declines, increasing the risk of infection, which in turn reduces nutritional status (Holmes, 2003).
Identify the factors that contribute to undernutrition in hospital patients. There are two main ways in which undernutrition develops. The first, protein-energy malnutrition arises during acute injury or illness when increased nutrient requirements and loss of body protein are common. The second is inadequate nutrient intake during a time of increased nutritional demand or over a prolonged period of reduced dietary consumption. This is particularly common in older people and those with disabilities and chronic or mental illness (Holmes, 2003).
Provide emotional support and encouragement to the client to gradually increase activity. Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can increase mobility by helping the client overcome limitations.
Use a gait walking belt when ambulating the client. Gait belts help improve the caregiver's grasp, reducing the incidence of injuries (Nelson, 2003).
Work with the client to set mutual goals that increase activity levels.
If the client is scheduled for a surgical intervention that will result in bed rest in intensive care, consider referring to physical therapy for a prehabilitation program including warm-up, aerobic conditioning, strength building, and flexibility enhancement. EBN: Increasing a client's functional capacity before hospitalization can be a helpful means of modifying the predictable deconditioning that happens with intensive care unit (ICU) admission (Topp et al, 2002).I GOT THE INFO FROM EVOLVE
#4
4. Describe the acid/base status of the client with
a) NG TUBE – METABOLIC ALKALOSIS (bicarb exceeds 20:1 ratio)
Causes
GI losses - vomiting, gastric suctioning, pyloric stenosis
Hypokalemia - potassium-losing diuretics, kidneys excrete H+ ,try to conserve K
Hyperaldosteronism, Cushing's syndrome
Excessive antacid intake
Diuretics
Placing patient with COPD on mechanical ventilation, relief of chronic respiratory acidosis
Clinical picture
Depressed respirations
Hypocalcemia - decreased ionized Ca - dizziness, tingling of fingers & toes, c ircumoral paraesthesia, carpopedal spasm, hypertonic muscles
Hypokalemia often present
Compensation
Hypoventilation - retain CO2
Kidneys excrete more HCO3
Treatment
Treat underlying cause
Give NS for kidney to absorb Na and Cl allowing excretion of HCO3
Nursing considerations
Replace GI losses with isotonic fluids, flush NG tube with NS
Teach patient not to use baking soda as antacid
Monitor K levels
http://classes.kumc.edu/son/nurs466/lecture%20notes/ABG.htm
b) client with diagnosis of COPD – RESPIRATORY ACIDOSIS (excess CO2)
Causes
Lung diseases - COPD, ARDS
Neuromuscular diseases affecting respirations - Guillian-Barre, multiple sclerosis
Anesthesia
Pneumonia
Clinical picture
Acute
Feeling of fullness in head - cerebral vasodilation
Confusion, dizziness, lethargy, restlessness, decreased attention span
Decreased respirations
Dysrhythmias
Chronic
Weakness, dull headache
Barrel chest, use of accessory muscles to breathe
Compensation
Kidneys retain HCO3
Treatment
Administer oxygen - low concentration if chronic
Keep airway clear, postural drainage & vibration, humidified air
Force fluids
Promote lung expansion - incentive spirometer, blowing up balloons.
Nursing considerations
Assess respiratory status frequently- effort, accessory muscle use, lung sounds, skin color, mental status
Monitor serial ABGs
Assist patient into comfortable positions that facilitate lung expansion - Semi- or high Fowlers
Be prepared to intubate
Teach exercises to enhance expiration - pursed lip breathing
http://classes.kumc.edu/son/nurs466/lecture%20notes/ABG.htm
c) Ileostomy - METABOLIC ACIDOSIS (low bicarb:carbonic acid ratio cause ph to fall)
· Gastrointestinal HCO3- loss. HCO3- is lost as a result diarrhea, external pancreatic drainage (transplant or pancreatitis) or small bowel drainage (ileostomy).
http://umed.med.utah.edu/ms2/renal/Word%20files/i)%20Acid_Base%20Disorders.htm
a) NG TUBE – METABOLIC ALKALOSIS (bicarb exceeds 20:1 ratio)
Causes
GI losses - vomiting, gastric suctioning, pyloric stenosis
Hypokalemia - potassium-losing diuretics, kidneys excrete H+ ,try to conserve K
Hyperaldosteronism, Cushing's syndrome
Excessive antacid intake
Diuretics
Placing patient with COPD on mechanical ventilation, relief of chronic respiratory acidosis
Clinical picture
Depressed respirations
Hypocalcemia - decreased ionized Ca - dizziness, tingling of fingers & toes, c ircumoral paraesthesia, carpopedal spasm, hypertonic muscles
Hypokalemia often present
Compensation
Hypoventilation - retain CO2
Kidneys excrete more HCO3
Treatment
Treat underlying cause
Give NS for kidney to absorb Na and Cl allowing excretion of HCO3
Nursing considerations
Replace GI losses with isotonic fluids, flush NG tube with NS
Teach patient not to use baking soda as antacid
Monitor K levels
http://classes.kumc.edu/son/nurs466/lecture%20notes/ABG.htm
b) client with diagnosis of COPD – RESPIRATORY ACIDOSIS (excess CO2)
Causes
Lung diseases - COPD, ARDS
Neuromuscular diseases affecting respirations - Guillian-Barre, multiple sclerosis
Anesthesia
Pneumonia
Clinical picture
Acute
Feeling of fullness in head - cerebral vasodilation
Confusion, dizziness, lethargy, restlessness, decreased attention span
Decreased respirations
Dysrhythmias
Chronic
Weakness, dull headache
Barrel chest, use of accessory muscles to breathe
Compensation
Kidneys retain HCO3
Treatment
Administer oxygen - low concentration if chronic
Keep airway clear, postural drainage & vibration, humidified air
Force fluids
Promote lung expansion - incentive spirometer, blowing up balloons.
Nursing considerations
Assess respiratory status frequently- effort, accessory muscle use, lung sounds, skin color, mental status
Monitor serial ABGs
Assist patient into comfortable positions that facilitate lung expansion - Semi- or high Fowlers
Be prepared to intubate
Teach exercises to enhance expiration - pursed lip breathing
http://classes.kumc.edu/son/nurs466/lecture%20notes/ABG.htm
c) Ileostomy - METABOLIC ACIDOSIS (low bicarb:carbonic acid ratio cause ph to fall)
· Gastrointestinal HCO3- loss. HCO3- is lost as a result diarrhea, external pancreatic drainage (transplant or pancreatitis) or small bowel drainage (ileostomy).
http://umed.med.utah.edu/ms2/renal/Word%20files/i)%20Acid_Base%20Disorders.htm
#43
43. P. 1365-1366
Hypernatremia:
Def: excess sodium in the ECF, or a serum sodium of greater than 145 mEq/L. Because of the osmotic pressure of extracellular fluid is increased, fluid moves out of the cells into the ECF. As a result, the cells become dehydrated.
Patient education regarding nutrition for hypernatremia:
teach client to avoid the intake of salt and foods high in sodium.
that is all I could find in the book..more info anyone?
Hypernatremia:
Def: excess sodium in the ECF, or a serum sodium of greater than 145 mEq/L. Because of the osmotic pressure of extracellular fluid is increased, fluid moves out of the cells into the ECF. As a result, the cells become dehydrated.
Patient education regarding nutrition for hypernatremia:
teach client to avoid the intake of salt and foods high in sodium.
that is all I could find in the book..more info anyone?
# 33
# 33 discuss the stages of wound healing:
There are four stages of wound healing.
Stage 1—Inflammatory process occurs; blood vessels constrict, providing a clot; vasodilatation brings more nutrients and WBC’s to wound; blood flow is re-established after epithelial cells begin to grow. A slight fever is normal.
Stage 2—Collagen and granulation tissue forms in the wound.
Stage 3-- Collagen fibers strengthen the wound; scar is pink and raised.
Stage 4—Scar becomes smaller, flatter and white
I also found the following; I am not sure just which info. Semillo is looking for here, so I will post both.
Wounds heal by one of three processes: primary, secondary or tertiary intention.
Primary Healing—wound with little tissue loss, edges approximated (close together), heals rapidly with minimal scarring, low risk of infection (i.e.: surgical incisions), healing in the Primary intention takes place in three ways:
Inflammatory phase (reaction)—begins within minutes and lasts about three days. Reparative processes control bleeding, deliver blood and cells (leukocytes) to the area, and form epithelial cells at the site of the wound.
Proliferative Phase (regeneration)—begins with the appearance of new blood vessels, lasts from 3 to 24 days. The wound fills in with connective or granulation tissue and the top is closed by epithelization. Fibroblasts synthesize collagen, which closes the wound defect.
Maturation (Remodeling)-- The collagen scar continues to gain strength. The collagen fibers undergo remodeling (reorganization) before assuming their normal appearance. This process may take more than a year, depending on the extent of the wound.
Secondary Healing--- Wounds involving loss of tissue; wound edges widely separated; wound appears pink to dark red; healing occurs by granulation resulting in a large scar, increased likelihood of infection, healing time is longer (i.e.-burns, pressure ulcers).
Tertiary Healing-- Occurs when a widely separated wound is later brought together with some type of closure material. This type of wound usually is fairly deep and likely to contain extensive drainage, and tissue debris. These wounds have a high risk of infection (i.e.-wound dehiscence).
ATI Fundamentals book. pg 233
There are four stages of wound healing.
Stage 1—Inflammatory process occurs; blood vessels constrict, providing a clot; vasodilatation brings more nutrients and WBC’s to wound; blood flow is re-established after epithelial cells begin to grow. A slight fever is normal.
Stage 2—Collagen and granulation tissue forms in the wound.
Stage 3-- Collagen fibers strengthen the wound; scar is pink and raised.
Stage 4—Scar becomes smaller, flatter and white
I also found the following; I am not sure just which info. Semillo is looking for here, so I will post both.
Wounds heal by one of three processes: primary, secondary or tertiary intention.
Primary Healing—wound with little tissue loss, edges approximated (close together), heals rapidly with minimal scarring, low risk of infection (i.e.: surgical incisions), healing in the Primary intention takes place in three ways:
Inflammatory phase (reaction)—begins within minutes and lasts about three days. Reparative processes control bleeding, deliver blood and cells (leukocytes) to the area, and form epithelial cells at the site of the wound.
Proliferative Phase (regeneration)—begins with the appearance of new blood vessels, lasts from 3 to 24 days. The wound fills in with connective or granulation tissue and the top is closed by epithelization. Fibroblasts synthesize collagen, which closes the wound defect.
Maturation (Remodeling)-- The collagen scar continues to gain strength. The collagen fibers undergo remodeling (reorganization) before assuming their normal appearance. This process may take more than a year, depending on the extent of the wound.
Secondary Healing--- Wounds involving loss of tissue; wound edges widely separated; wound appears pink to dark red; healing occurs by granulation resulting in a large scar, increased likelihood of infection, healing time is longer (i.e.-burns, pressure ulcers).
Tertiary Healing-- Occurs when a widely separated wound is later brought together with some type of closure material. This type of wound usually is fairly deep and likely to contain extensive drainage, and tissue debris. These wounds have a high risk of infection (i.e.-wound dehiscence).
ATI Fundamentals book. pg 233
#16
16. P. 1380
With FVE, you want to restrict dietary sodium as ordered.
1. Explain the reason for the restricted intake and how much and what type of fluids are permitted orally. Many clients need to be informed that ice chips, gelatin, and ice cream are considered fluids.
2. Help the client decide the amt of fluid to be taken with each meal, between meals, before bedtime, and with medication.
3. Identify fluids or fluidlike substances the client likes and makesure that these are provided.
4. Set short term goals that make the fluid restrictions more tolerable.
5. Place allowed fluids in a small container.
6. provide frequent mouth care and rinses to reduce thirst sensation.
7. Avoid ingesting salty or sweet foods b/c these foods produce thirst.
8. Encourage in participating in maintaining fluid intake record
With FVE, you want to restrict dietary sodium as ordered.
1. Explain the reason for the restricted intake and how much and what type of fluids are permitted orally. Many clients need to be informed that ice chips, gelatin, and ice cream are considered fluids.
2. Help the client decide the amt of fluid to be taken with each meal, between meals, before bedtime, and with medication.
3. Identify fluids or fluidlike substances the client likes and makesure that these are provided.
4. Set short term goals that make the fluid restrictions more tolerable.
5. Place allowed fluids in a small container.
6. provide frequent mouth care and rinses to reduce thirst sensation.
7. Avoid ingesting salty or sweet foods b/c these foods produce thirst.
8. Encourage in participating in maintaining fluid intake record
#23
EFFECTS OF SMOKING ON THE RESPIRATORY SYSTEM:
Damage to the respiratory system from cigarette smoking is slow, progressive, and deadly. A healthy respiratory system is continuously cleansed. The mucus produced by the respiratory tubules traps dirt and disease-causing organisms, which cilia sweep toward the mouth, where it can be eliminated. Smoking greatly impairs this housekeeping. With the very first inhalation of smoke, the beating of the cilia slows. With time, the cilia become paralyzed and, eventually, disappear altogether. The loss of cilia leads to the development of smoker's cough. The cilia no longer effectively remove mucus, so the individual must cough it up. Coughing is usually worse in the morning because mucus has accumulated during sleep.
To make matters worse, excess mucus is produced and accumulates, clogging the air passageways. Pathogenic organisms that are normally removed now have easier access to the respiratory surfaces and the resulting lung congestion favors their growth. This is why smokers are sick more often than nonsmokers. In addition, a lethal chain reaction begins. Smoker's cough leads to chronic bronchitis, caused by destroyed respiratory cilia. Mucus production increases and the lining of the bronchioles thickens, making breathing difficult. The bronchioles lose elasticity and are no longer able to absorb the pressure within the alveoli (microscopic air sacs) enough to rupture the delicate alveolar walls; this condition is the hallmark of smoking-induced emphysema. The burst alveoli cause worsening of the cough, fatigue, wheezing, and impaired breathing. Emphysema is fifteen times more common among individuals who smoke a pack of cigarettes a day than among nonsmokers.
Simultaneous with the structural changes progressing to emphysema may be cellular changes leading to lung cancer. First, cells in the outer border of the bronchial lining begin to divide more rapidly than usual. Eventually, these displace the ciliated cells. Their nuclei begin to resemble those of cancerous cells--large and distorted with abnormal numbers of chromosomes. Up to this point, the damage can be repaired if smoking ceases. However, if smoking continues, these cells may eventually break through the basement membrane and begin dividing within the lung tissue, forming a tumor with the potential of spreading throughout lung tissue. Eighty percent of lung cancer cases are due to cigarette smoking. Only 13% of lung cancer patients live as long as 5 years after the initial diagnosis.
FOUND ON THE INTERNET...I'LL TRY TO FIND MORE INFO
Damage to the respiratory system from cigarette smoking is slow, progressive, and deadly. A healthy respiratory system is continuously cleansed. The mucus produced by the respiratory tubules traps dirt and disease-causing organisms, which cilia sweep toward the mouth, where it can be eliminated. Smoking greatly impairs this housekeeping. With the very first inhalation of smoke, the beating of the cilia slows. With time, the cilia become paralyzed and, eventually, disappear altogether. The loss of cilia leads to the development of smoker's cough. The cilia no longer effectively remove mucus, so the individual must cough it up. Coughing is usually worse in the morning because mucus has accumulated during sleep.
To make matters worse, excess mucus is produced and accumulates, clogging the air passageways. Pathogenic organisms that are normally removed now have easier access to the respiratory surfaces and the resulting lung congestion favors their growth. This is why smokers are sick more often than nonsmokers. In addition, a lethal chain reaction begins. Smoker's cough leads to chronic bronchitis, caused by destroyed respiratory cilia. Mucus production increases and the lining of the bronchioles thickens, making breathing difficult. The bronchioles lose elasticity and are no longer able to absorb the pressure within the alveoli (microscopic air sacs) enough to rupture the delicate alveolar walls; this condition is the hallmark of smoking-induced emphysema. The burst alveoli cause worsening of the cough, fatigue, wheezing, and impaired breathing. Emphysema is fifteen times more common among individuals who smoke a pack of cigarettes a day than among nonsmokers.
Simultaneous with the structural changes progressing to emphysema may be cellular changes leading to lung cancer. First, cells in the outer border of the bronchial lining begin to divide more rapidly than usual. Eventually, these displace the ciliated cells. Their nuclei begin to resemble those of cancerous cells--large and distorted with abnormal numbers of chromosomes. Up to this point, the damage can be repaired if smoking ceases. However, if smoking continues, these cells may eventually break through the basement membrane and begin dividing within the lung tissue, forming a tumor with the potential of spreading throughout lung tissue. Eighty percent of lung cancer cases are due to cigarette smoking. Only 13% of lung cancer patients live as long as 5 years after the initial diagnosis.
FOUND ON THE INTERNET...I'LL TRY TO FIND MORE INFO
# 20
Discuss the strategies used when weighing a client with fluid imbalance to ensure accuracy. Fundamentals p 1371
To ensure accurate weight measurements, nurse should: balance scale before each use and weigh the patient at (1) at the same time everyday e.g. before breakfast and after the first void, (2) wearing the same or similar clothing, (3) on the same scale (document type of scale used)
To ensure accurate weight measurements, nurse should: balance scale before each use and weigh the patient at (1) at the same time everyday e.g. before breakfast and after the first void, (2) wearing the same or similar clothing, (3) on the same scale (document type of scale used)
#13
13.P1076
Nursing strategies to maintain and promote body alignment and mobility involve postitioning clients appropriately, moving and turning clients in bed, transferring clients, providing ROM exercises, ambulating clients w/ or w/o mechanical aids, and strategies to prevent complications of immobility. Whenever postioning, moving, lifting, and ambulating clients, nurses must use proper body mechanics to avoid musculoskeletal strain and injury.
Nursing strategies to maintain and promote body alignment and mobility involve postitioning clients appropriately, moving and turning clients in bed, transferring clients, providing ROM exercises, ambulating clients w/ or w/o mechanical aids, and strategies to prevent complications of immobility. Whenever postioning, moving, lifting, and ambulating clients, nurses must use proper body mechanics to avoid musculoskeletal strain and injury.
#36
OUTCOME STATEMENT FOR CLIENT WITH NURSING DIAGNOSIS OF INEFFECTIVE AIRWAY CLEARANCE
Client Will (Specify Time Frame):
-Demonstrate effective coughing and clear breath sounds; is free of cyanosis and dyspnea
-Maintain a patent airway at all times
-Relate methods to enhance secretion removal
-Relate the significance of changes in sputum to include color, character, amount, and odor
-Identify and avoid specific factors that inhibit effective airway clearance
I GOT THIS FROM EVOLVE
Client Will (Specify Time Frame):
-Demonstrate effective coughing and clear breath sounds; is free of cyanosis and dyspnea
-Maintain a patent airway at all times
-Relate methods to enhance secretion removal
-Relate the significance of changes in sputum to include color, character, amount, and odor
-Identify and avoid specific factors that inhibit effective airway clearance
I GOT THIS FROM EVOLVE
#6
NON-CARDIAC VS. CARDIAC PAIN
-non-cardiac pain is chest pain that is not caused by a heart problem. cardiac pain is chest pain that is caused by a heart problem.
-CARDIAC PAIN INCLUDES:
-Heart attack. A heart attack — a blood clot that's blocking blood flow to your heart muscle can cause pressure, fullness or a crushing pain in your chest that lasts more than a few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms, especially your left arm. Other signs and symptoms may include shortness of breath, sweating, dizziness and nausea. All, some or none of these may accompany your chest pain.
-Angina. Fatty deposits can build up in the arteries that carry blood to your heart, narrowing them and temporarily restricting blood flow to your heart, especially during times of exertion. Restricted blood flow to your heart can cause recurrent episodes of chest pain — angina pectoris, or angina. Angina (an-JI-nuh or AN-juh-nuh) is often described as a pressure or tightness in the chest. It's usually brought on by physical or emotional stress. The pain usually goes away within minutes after you stop the stressful activity.
-Other cardiac causes. Other problems that can cause chest pain include inflammation of the sac surrounding your heart (pericarditis), a short-lived condition often related to a viral infection. Pericarditis causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick. A rare, life-threatening cause of chest pain called aortic dissection involves the main artery leading from your heart — your aorta. If the inner layers of this blood vessel separate, forcing blood flow between them, the result is sudden and tearing chest and back pain. Aortic dissection can result from a sharp blow to your chest or develop as a complication of uncontrolled high blood pressure. Coronary spasm, also known as Prinzmetal's angina, can cause varying degrees of chest discomfort. In coronary spasm, coronary arteries — arteries that supply blood to the heart — go into spasm, temporarily closing down blood flow to the heart. Spasm of the coronary arteries may occur spontaneously or be triggered by a stimulant, such as nicotine or caffeine. Coronary artery spasm, which tends to cause episodes of chest pain, can occur with activity or at rest. A spasm may even wake you from sleep. The condition may coexist with coronary artery disease — a buildup of fatty deposits in the coronary arteries. Other possible heart-related conditions that can cause chest pain are metabolic syndrome and endothelial dysfunction.
-NON-CARDIAC PAIN INCLUDES:
-Heartburn. Stomach acid that washes up from your stomach into the tube (esophagus) that runs from your mouth to your stomach can cause heartburn — a painful, burning sensation behind your breastbone (sternum). Often this feeling is accompanied by a sour taste and the sensation of food re-entering your mouth (regurgitation). Heartburn-related chest pain usually follows a meal and may last for hours. Signs and symptoms occur more frequently when you bend forward at the waist or lie down.
-Panic attack. If you experience periods of intense fear accompanied by chest pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath, you may be experiencing a panic attack — a form of anxiety.
-Pleurisy. Sharp, localized chest pain that's made worse when you inhale or cough may be caused by pleurisy. This condition occurs when the membrane that lines your chest cavity and covers your lungs becomes inflamed. Pleurisy may result from a wide variety of underlying conditions, including pneumonia and, rarely, autoimmune conditions such as lupus. An autoimmune disease is one in which your body's immune system mistakenly attacks healthy tissue.
-Costochondritis. In this condition — also known as Tietze's syndrome — the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed. The pain from costochondritis (kos-toe-KHON-dri-tis) may occur suddenly and be intense, leading you to assume you're having a heart attack. Yet the location of the pain is different. Costochondritis causes your chest to hurt when you push on your sternum or on the ribs near your sternum. Heart attack pain is usually more widespread, and the chest wall usually isn't tender.
-Pulmonary embolism. This condition occurs when a blood clot becomes lodged in a lung artery, blocking blood flow to lung tissue. Symptoms of this life-threatening condition can include sudden, sharp chest pain that begins or worsens with a deep breath or cough. Other signs and symptoms can include shortness of breath, rapid heartbeat, anxiety and faintness. It's rare for pulmonary embolism to occur without preceding risk factors, such as recent surgery or immobilization.
-Other lung conditions. A collapsed lung (pneumothorax), high blood pressure in the arteries carrying blood to the lungs (pulmonary hypertension) and asthma also can produce chest pain.
-Sore muscles. Muscle-related chest pain tends to come on when you twist side to side or when you raise your arms. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
-Injured ribs or pinched nerves. A bruised or broken rib, as well as a pinched nerve, can cause chest pain that tends to be localized and sharp.
-Swallowing disorders. Several disorders of the esophagus, the tube that runs from your mouth to your stomach, can make swallowing difficult and even painful. One type is esophageal spasm, a condition that affects a small group of people with chest pain. When people with this condition swallow, the muscles that normally move food down the esophagus are uncoordinated. This results in painful muscle spasms. Because esophageal spasms can be calmed with the medication nitroglycerin — which also rapidly relieves some heart-related pain — this condition is sometimes mistaken for a heart problem. Another swallowing disorder, which also affects a small group of people with chest pain, is achalasia (ak-uh-LA-zhuh). In this condition, the valve in the lower esophagus doesn't open properly to allow food to enter your stomach. Instead, food backs up into the esophagus, causing pain. Pain with swallowing also can accompany heartburn.
-Shingles. This infection of nerves caused by the chickenpox virus can produce pain and a band of blisters on your back around to your chest wall. This sharp, burning pain may begin several hours to a day or so before blisters appear.
-Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder (cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.
-Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of the body can cause chest pain.
NOT IN BOOK...FOUND ON INTERNET
-non-cardiac pain is chest pain that is not caused by a heart problem. cardiac pain is chest pain that is caused by a heart problem.
-CARDIAC PAIN INCLUDES:
-Heart attack. A heart attack — a blood clot that's blocking blood flow to your heart muscle can cause pressure, fullness or a crushing pain in your chest that lasts more than a few minutes. The pain may radiate to your back, neck, jaw, shoulders and arms, especially your left arm. Other signs and symptoms may include shortness of breath, sweating, dizziness and nausea. All, some or none of these may accompany your chest pain.
-Angina. Fatty deposits can build up in the arteries that carry blood to your heart, narrowing them and temporarily restricting blood flow to your heart, especially during times of exertion. Restricted blood flow to your heart can cause recurrent episodes of chest pain — angina pectoris, or angina. Angina (an-JI-nuh or AN-juh-nuh) is often described as a pressure or tightness in the chest. It's usually brought on by physical or emotional stress. The pain usually goes away within minutes after you stop the stressful activity.
-Other cardiac causes. Other problems that can cause chest pain include inflammation of the sac surrounding your heart (pericarditis), a short-lived condition often related to a viral infection. Pericarditis causes sharp, piercing and centralized chest pain. You may also have a fever and feel sick. A rare, life-threatening cause of chest pain called aortic dissection involves the main artery leading from your heart — your aorta. If the inner layers of this blood vessel separate, forcing blood flow between them, the result is sudden and tearing chest and back pain. Aortic dissection can result from a sharp blow to your chest or develop as a complication of uncontrolled high blood pressure. Coronary spasm, also known as Prinzmetal's angina, can cause varying degrees of chest discomfort. In coronary spasm, coronary arteries — arteries that supply blood to the heart — go into spasm, temporarily closing down blood flow to the heart. Spasm of the coronary arteries may occur spontaneously or be triggered by a stimulant, such as nicotine or caffeine. Coronary artery spasm, which tends to cause episodes of chest pain, can occur with activity or at rest. A spasm may even wake you from sleep. The condition may coexist with coronary artery disease — a buildup of fatty deposits in the coronary arteries. Other possible heart-related conditions that can cause chest pain are metabolic syndrome and endothelial dysfunction.
-NON-CARDIAC PAIN INCLUDES:
-Heartburn. Stomach acid that washes up from your stomach into the tube (esophagus) that runs from your mouth to your stomach can cause heartburn — a painful, burning sensation behind your breastbone (sternum). Often this feeling is accompanied by a sour taste and the sensation of food re-entering your mouth (regurgitation). Heartburn-related chest pain usually follows a meal and may last for hours. Signs and symptoms occur more frequently when you bend forward at the waist or lie down.
-Panic attack. If you experience periods of intense fear accompanied by chest pain, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating and shortness of breath, you may be experiencing a panic attack — a form of anxiety.
-Pleurisy. Sharp, localized chest pain that's made worse when you inhale or cough may be caused by pleurisy. This condition occurs when the membrane that lines your chest cavity and covers your lungs becomes inflamed. Pleurisy may result from a wide variety of underlying conditions, including pneumonia and, rarely, autoimmune conditions such as lupus. An autoimmune disease is one in which your body's immune system mistakenly attacks healthy tissue.
-Costochondritis. In this condition — also known as Tietze's syndrome — the cartilage of your rib cage, particularly the cartilage that joins your ribs to your breastbone, becomes inflamed. The pain from costochondritis (kos-toe-KHON-dri-tis) may occur suddenly and be intense, leading you to assume you're having a heart attack. Yet the location of the pain is different. Costochondritis causes your chest to hurt when you push on your sternum or on the ribs near your sternum. Heart attack pain is usually more widespread, and the chest wall usually isn't tender.
-Pulmonary embolism. This condition occurs when a blood clot becomes lodged in a lung artery, blocking blood flow to lung tissue. Symptoms of this life-threatening condition can include sudden, sharp chest pain that begins or worsens with a deep breath or cough. Other signs and symptoms can include shortness of breath, rapid heartbeat, anxiety and faintness. It's rare for pulmonary embolism to occur without preceding risk factors, such as recent surgery or immobilization.
-Other lung conditions. A collapsed lung (pneumothorax), high blood pressure in the arteries carrying blood to the lungs (pulmonary hypertension) and asthma also can produce chest pain.
-Sore muscles. Muscle-related chest pain tends to come on when you twist side to side or when you raise your arms. Chronic pain syndromes, such as fibromyalgia, can produce persistent muscle-related chest pain.
-Injured ribs or pinched nerves. A bruised or broken rib, as well as a pinched nerve, can cause chest pain that tends to be localized and sharp.
-Swallowing disorders. Several disorders of the esophagus, the tube that runs from your mouth to your stomach, can make swallowing difficult and even painful. One type is esophageal spasm, a condition that affects a small group of people with chest pain. When people with this condition swallow, the muscles that normally move food down the esophagus are uncoordinated. This results in painful muscle spasms. Because esophageal spasms can be calmed with the medication nitroglycerin — which also rapidly relieves some heart-related pain — this condition is sometimes mistaken for a heart problem. Another swallowing disorder, which also affects a small group of people with chest pain, is achalasia (ak-uh-LA-zhuh). In this condition, the valve in the lower esophagus doesn't open properly to allow food to enter your stomach. Instead, food backs up into the esophagus, causing pain. Pain with swallowing also can accompany heartburn.
-Shingles. This infection of nerves caused by the chickenpox virus can produce pain and a band of blisters on your back around to your chest wall. This sharp, burning pain may begin several hours to a day or so before blisters appear.
-Gallbladder or pancreas problems. Gallstones or inflammation of your gallbladder (cholecystitis) or pancreas can cause acute abdominal pain that radiates to your chest.
-Cancer. Rarely, cancer involving the chest or cancer that has spread from another part of the body can cause chest pain.
NOT IN BOOK...FOUND ON INTERNET
#37
#37
37) Discuss the nursing care of the client with a chest tube.Pg. 1325-1326
- Chest tubes inserted into pleural cavity to restore negative pressure and drain collected fluid or blood
- Insertion and removal require sterile technique and must be done without introducing air or microorganisms into the pleural cavity.
- monitor and maintain the patency and integrity of the drainage system
- Assess the clients vital signs, O2 Sat, cardiovascular status, and resp. status
- Keep rubber tipped clamps and sterile occlusive dressing near the client. If tube becomes disconnected from the collection system, submerge the end in 1 in. of sterile saline or water to maintain the seal. If the chest tube is inadvertently pulled out, the wound should be immediately covered with a dry sterile dressing. If you can hear air leaking out the site, ensure that the dressing is not occlusive. If the air cannot escape, this would lead to pneumothorax.
- Use standard precautions and personal protective equipment while manipulating the system and assisting w/insertion or removal.
- Observe the dressing site at least every 4 hrs. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing site for a crackling sound indicative of subcutaneous emphysema which can result from poor seal at the chest tube insertion site
- Determine level of discomfort with and w/out activity and medicate client for pain if indicated.
- Encourage deep breathing and coughing exercises every 2 hrs (may be contraindicated in clients who have had lung removed). Have client sit upright to perform excercises, and splint the chest around the tube insertion site with a pillow or hand to minimize discormfort.
- Rerposition client every 2 hrs. When the client is lying on the affected side, placed rolled towels beside the tubing. Frequent position changes promote drainage, prevent complications, and provide comfort. Rolled towels prevent occlusion of the chest tube by the clients weight.
- Assist the client w/ ROM exercises of the affected shoulder 3 times a day to maintain joint mobility
- When transporting and ambulating the client:
b. Keep water sealed unit below chest level and upright
c. Disconnect the drainage system from the suction apparatus before moving the client
and make sure the air vent is open
#38
IRON DEFICIENCY ANEMIA
The following are the most common symptoms of iron-deficiency anemia. However, each individual may experience symptoms differently. Symptoms may include:
abnormal paleness or lack of color of the skin
irritability
lack of energy or tiring easily (fatigue)
increased heart rate (tachycardia)
sore or swollen tongue
enlarged spleen
a desire to eat peculiar substances such as dirt or ice (a condition called pica)
What are the physical findings of iron deficiency anemia?
The answer
ability to detect early anemia by inspection of conjunctiva is poor
pallor
smooth tongue
brittle nails
koilonychias-DYSTROPHY OF THE NAILS
high output state
tachycardia
bounding water hammer pulse
venous hum flow murmurs
FOUND ON INTERNET
The following are the most common symptoms of iron-deficiency anemia. However, each individual may experience symptoms differently. Symptoms may include:
abnormal paleness or lack of color of the skin
irritability
lack of energy or tiring easily (fatigue)
increased heart rate (tachycardia)
sore or swollen tongue
enlarged spleen
a desire to eat peculiar substances such as dirt or ice (a condition called pica)
What are the physical findings of iron deficiency anemia?
The answer
ability to detect early anemia by inspection of conjunctiva is poor
pallor
smooth tongue
brittle nails
koilonychias-DYSTROPHY OF THE NAILS
high output state
tachycardia
bounding water hammer pulse
venous hum flow murmurs
FOUND ON INTERNET
#47
SIGNS OF LUNG CANCER
Chronic coughing - a common early symptom
Coughing up blood
Worsening cough
Chronic chest pain
Fever
Shortness of breath
Wheezing
Hoarseness
Chest pain
Recurrent pneumonia
Recurrent bronchitis
Swollen neck
Swollen face
Loss of appetite
Weight loss
Tiredness
Weakness
Fatigue
Chronic coughing - a common early symptom
Coughing up blood
Worsening cough
Chronic chest pain
Fever
Shortness of breath
Wheezing
Hoarseness
Chest pain
Recurrent pneumonia
Recurrent bronchitis
Swollen neck
Swollen face
Loss of appetite
Weight loss
Tiredness
Weakness
Fatigue
Some possible symptoms of spread of lung cancer:
Diaphragm paralysis
Breathing difficulty
Fluid retention in upper body
Facial swelling
Neck swelling
Upper body swelling
Pleural effusion
Diaphragm paralysis
Breathing difficulty
Fluid retention in upper body
Facial swelling
Neck swelling
Upper body swelling
Pleural effusion
Other symptoms that can be related to late-stage lung cancer can include:
Fatigue.
Loss of appetite.
Headache, bone pain, aching joints.
Bone fractures not related to accidental injury.
Neurologic symptoms, such as unsteady gait and/or episodic memory loss.
Neck and facial swelling.
Unexplained weight loss.
Fatigue.
Loss of appetite.
Headache, bone pain, aching joints.
Bone fractures not related to accidental injury.
Neurologic symptoms, such as unsteady gait and/or episodic memory loss.
Neck and facial swelling.
Unexplained weight loss.
FOUND ON THE INTERNET
#2..ALL DONE!
P. 1068-1071
2. Discuss the effects of immobility on each system:
-musculoskeletal system
-Disuse osteoporosis: w/o the stress of weight bearing acivities, the bones demineralize. With osteoporosis the bones are depleted of calcium which gives the bones strength and density.
- Disuse atrophy: unused muscles atrophy(decrease in size) losing most of their strength and function.
-Contractures: permant shortening of the muscles, limiting joint mobility. Eventually involves tendons, ligaments, and joint capsules and is irreversible except by surgery.
-Stiffness and pain in joints: the collagen(connective) tissues at the joint become ankylosed (permanently immobile). Also the bones demineralize and excess calcium may deposit in the joints contributing to stiffness and pain.
-Cardiovascular System:
-Diminished cardiac reserve: imbalance in the autonomic nervous system, resulting in a preponderance of sympathetic activity over cholinergic activity that increases HR. Rapid HR reduces diastolic pressure, coronary blood flow, and the capacity of the heart to respond to any metabolic demands above the basal levels. Experience tachycardia w/ minimal exertion.
- Increased use of valsalva maneuver: holding the breath and straining against a closed glottis. Tachycardia and arrythmias can result if the client has cardiac disease.
-Orthostatic (postural) hypotension: vasoconstriction prevents pooling of the blood in the legs and effectively maintains central BP to ensure adequate blood perfusion of the heart and brain. During prolonged immobility thid reflex becomes dormant. When the immobile person tries to sit or stand, this reconstricting mechanism fails to function properly inspite of increased adrenalin output. Blood pulls in the lower extremities and central BP drops. Cerebral perfusion is compromised and the person feels dizzy or lightheaded and may faint. This is usually accompanied with an increased HR.
-Venous vasodilation and stasis: the skeletal muscles do not contract sufficiently, and the muscles atrophy. The skeletal muscles can no longer assist in pumping blood back to the heart against gravity. Blood pools in the leg veins, causing vasodilation and engorgement. Known as incompetent valves.
-Dependent edema: When the venous pressure is suficiently great, some of the serous part of the blood is forced out of the Blood vessel into the interstitial spaces surrounding the blood vessel, causing edema. Most common in parts of the body below the heart. Most likely to occur in sacrum of the heels and the lower legs.
-Thrombus formation: thrombophlebitis(a clot that is loosely attached to an inflamed vein wall): impaired venous return to the heart, hypercoagulability of the blood, and injury to vessel wall. nA theombus is particularly dangerous if it breaks loosse fromt the vein wall and enters circulation as an embolus.
-Respiratory System:
-decreased respiratory movement: The body presses against the rigid bed and curtails chest movement. The abdominal organs push against the diaphragm, restricting lung movement and making it difficult to fully expand the lungs. B/C an immobile person rarely sighs there is no stretching movements and thge cartilaginous intercostal joints may become fixed in an expiratory phase of respiration. These changes produce shallow respirations and reduce vital capacity.
-Pooling of respiratory secretions:Inactivity allows secretions to pool by gravity interfering w/ the normal difusion of oxygen and CO2 in the alveoli.
- Atelectasis:Bed rest reduces the amount of surfactant produced. The combo of decreased surfactant and blockage of a bronchiole with mucus can cause atelectasis (collapse of a lobe or an entire lung).
-Hypostatic pneumonia: Pooled secretions allow for bacterial growth. Under these conditions, a minor upper respiratory infection can evolve rapidly into a severe infection of the lower respiratory tract. Pneumonia caused by static respiratory secretions can severely impair oxygen-carbon dioxide exchange in the alveoli and cause death.
-Metabolic System:
-Decreased metabolic rate: basal metabolic rate and gastrointestinal motility and secretionsof various digestive glands decrease as the energy requirements of the body decrease.
- Negative Nitrogen balance: catabolic processes(protein breakdown) exceed the anabolic processes(protein synthesis). Catabolized muscle mass realease nitrogen. Over time, more nitrogen is excreted than ingested. The negetave nitrogen balance represents a depletion of protein stores that are essential for building mudcle tissue and for wound healing.
-Anorexia: Loss of appetite b/c of the decreased metabolic rate and the increased catabolism that accompany immobility.caloric intake is decreased.
-Negative Calcium balance: direct result of immobility. Greater amts. of Ca are extracted from the bone than replaced. Bones need weight bearing and stress for Ca to be replaced.
-Urinary System:
-Urinary stasis: when a person remains in a horizontal position, gravity impedes the emptying of urine from the kidneys and the urinary bladder. The renal pelvis may fill w/ urine before before it is pushed into the ureters, and empyting is not as complete. Also, muscle tone is decreased in immobility, including the detrusor muscle and bladder emptying is also compromised.
-Renal calculi: The urine becomes more alkaline and the calcium salts precipitate out as crystals to form renal calcculi (stones). As the stones pass along the long narrow ureters they cause extreme pain and bleeding and can sometimes obstruct the urinary tract.
-Urinary retention: (accumulation of urine in the bladder). bladder distention, and urinary incontinence(unvoluntary urination). This is caused by decreased muscle tone and the immobolized person is unable to relax the perineal muscles sufficiently to urinate. The bladder may stretch excessively, eventually inhibiting the urge to void.
-Urinary infection: static urine provides an excellent medium for bacteria to grow.urinary distention often causes minute tears in bladder mucosa, allowing infectious organisms to enter. The increased alkalinity caused by hypercalcuria supports bacterial growth.E. coli causes the most infections.
-Gastrointestinal System
-Constipation is a frequent problem b/c of decreased perstalsis and colon motility. Repeated postponement eventually suppresses the urge and weakens the defecation reflex. Some excessively use the Valsalva manuever and this effort increases the intra-abdominal and intrathoracic pressures and places undue stress on the heart and circulatory system.
-Integumentary System
- Reduced skin turgor: skin can atrophy. Shifts in body fluids between the fluid compartments can affect the consistency and health of the dermis and subq tissues, eventually causing a gradual loss of skin elasticity.
-skin breakdown: normal blood circulation relies on muscle activity. skin breakdown and pressure ulcers can occur.
-Psysconeurologic System
-Immobility can lower self-esteem. Frustration and decreased self esteem can provoke emotional reactions. Persons perception of time intervals deteriorates as a result of lack of intellectual stimulation and the stress of the illness and immobility. Immobility can impair social and motor development of young children.
2. Discuss the effects of immobility on each system:
-musculoskeletal system
-Disuse osteoporosis: w/o the stress of weight bearing acivities, the bones demineralize. With osteoporosis the bones are depleted of calcium which gives the bones strength and density.
- Disuse atrophy: unused muscles atrophy(decrease in size) losing most of their strength and function.
-Contractures: permant shortening of the muscles, limiting joint mobility. Eventually involves tendons, ligaments, and joint capsules and is irreversible except by surgery.
-Stiffness and pain in joints: the collagen(connective) tissues at the joint become ankylosed (permanently immobile). Also the bones demineralize and excess calcium may deposit in the joints contributing to stiffness and pain.
-Cardiovascular System:
-Diminished cardiac reserve: imbalance in the autonomic nervous system, resulting in a preponderance of sympathetic activity over cholinergic activity that increases HR. Rapid HR reduces diastolic pressure, coronary blood flow, and the capacity of the heart to respond to any metabolic demands above the basal levels. Experience tachycardia w/ minimal exertion.
- Increased use of valsalva maneuver: holding the breath and straining against a closed glottis. Tachycardia and arrythmias can result if the client has cardiac disease.
-Orthostatic (postural) hypotension: vasoconstriction prevents pooling of the blood in the legs and effectively maintains central BP to ensure adequate blood perfusion of the heart and brain. During prolonged immobility thid reflex becomes dormant. When the immobile person tries to sit or stand, this reconstricting mechanism fails to function properly inspite of increased adrenalin output. Blood pulls in the lower extremities and central BP drops. Cerebral perfusion is compromised and the person feels dizzy or lightheaded and may faint. This is usually accompanied with an increased HR.
-Venous vasodilation and stasis: the skeletal muscles do not contract sufficiently, and the muscles atrophy. The skeletal muscles can no longer assist in pumping blood back to the heart against gravity. Blood pools in the leg veins, causing vasodilation and engorgement. Known as incompetent valves.
-Dependent edema: When the venous pressure is suficiently great, some of the serous part of the blood is forced out of the Blood vessel into the interstitial spaces surrounding the blood vessel, causing edema. Most common in parts of the body below the heart. Most likely to occur in sacrum of the heels and the lower legs.
-Thrombus formation: thrombophlebitis(a clot that is loosely attached to an inflamed vein wall): impaired venous return to the heart, hypercoagulability of the blood, and injury to vessel wall. nA theombus is particularly dangerous if it breaks loosse fromt the vein wall and enters circulation as an embolus.
-Respiratory System:
-decreased respiratory movement: The body presses against the rigid bed and curtails chest movement. The abdominal organs push against the diaphragm, restricting lung movement and making it difficult to fully expand the lungs. B/C an immobile person rarely sighs there is no stretching movements and thge cartilaginous intercostal joints may become fixed in an expiratory phase of respiration. These changes produce shallow respirations and reduce vital capacity.
-Pooling of respiratory secretions:Inactivity allows secretions to pool by gravity interfering w/ the normal difusion of oxygen and CO2 in the alveoli.
- Atelectasis:Bed rest reduces the amount of surfactant produced. The combo of decreased surfactant and blockage of a bronchiole with mucus can cause atelectasis (collapse of a lobe or an entire lung).
-Hypostatic pneumonia: Pooled secretions allow for bacterial growth. Under these conditions, a minor upper respiratory infection can evolve rapidly into a severe infection of the lower respiratory tract. Pneumonia caused by static respiratory secretions can severely impair oxygen-carbon dioxide exchange in the alveoli and cause death.
-Metabolic System:
-Decreased metabolic rate: basal metabolic rate and gastrointestinal motility and secretionsof various digestive glands decrease as the energy requirements of the body decrease.
- Negative Nitrogen balance: catabolic processes(protein breakdown) exceed the anabolic processes(protein synthesis). Catabolized muscle mass realease nitrogen. Over time, more nitrogen is excreted than ingested. The negetave nitrogen balance represents a depletion of protein stores that are essential for building mudcle tissue and for wound healing.
-Anorexia: Loss of appetite b/c of the decreased metabolic rate and the increased catabolism that accompany immobility.caloric intake is decreased.
-Negative Calcium balance: direct result of immobility. Greater amts. of Ca are extracted from the bone than replaced. Bones need weight bearing and stress for Ca to be replaced.
-Urinary System:
-Urinary stasis: when a person remains in a horizontal position, gravity impedes the emptying of urine from the kidneys and the urinary bladder. The renal pelvis may fill w/ urine before before it is pushed into the ureters, and empyting is not as complete. Also, muscle tone is decreased in immobility, including the detrusor muscle and bladder emptying is also compromised.
-Renal calculi: The urine becomes more alkaline and the calcium salts precipitate out as crystals to form renal calcculi (stones). As the stones pass along the long narrow ureters they cause extreme pain and bleeding and can sometimes obstruct the urinary tract.
-Urinary retention: (accumulation of urine in the bladder). bladder distention, and urinary incontinence(unvoluntary urination). This is caused by decreased muscle tone and the immobolized person is unable to relax the perineal muscles sufficiently to urinate. The bladder may stretch excessively, eventually inhibiting the urge to void.
-Urinary infection: static urine provides an excellent medium for bacteria to grow.urinary distention often causes minute tears in bladder mucosa, allowing infectious organisms to enter. The increased alkalinity caused by hypercalcuria supports bacterial growth.E. coli causes the most infections.
-Gastrointestinal System
-Constipation is a frequent problem b/c of decreased perstalsis and colon motility. Repeated postponement eventually suppresses the urge and weakens the defecation reflex. Some excessively use the Valsalva manuever and this effort increases the intra-abdominal and intrathoracic pressures and places undue stress on the heart and circulatory system.
-Integumentary System
- Reduced skin turgor: skin can atrophy. Shifts in body fluids between the fluid compartments can affect the consistency and health of the dermis and subq tissues, eventually causing a gradual loss of skin elasticity.
-skin breakdown: normal blood circulation relies on muscle activity. skin breakdown and pressure ulcers can occur.
-Psysconeurologic System
-Immobility can lower self-esteem. Frustration and decreased self esteem can provoke emotional reactions. Persons perception of time intervals deteriorates as a result of lack of intellectual stimulation and the stress of the illness and immobility. Immobility can impair social and motor development of young children.
Friday, September 22, 2006
Question # 26
26. Discuss the nursing interventions for the client who has the nursing diagnoses "Risk for infection".
Pg. 640, 642(table-6) 643(table 29-6)
-Proper handwashing
-maintain the integrity of the clients skin and mucous membranes.
-ensure that the client receives a balanced diet.
-Educate the public about immunization.
-Ensure the client has adequate sleep and rest.
-Break the chain of infection by:
Ensure articles are correctly cleaned and disinfected or sterilized before use.
Educate clients and support persons about appropriate methods of cleaning,
disinfecting, and sterilizing articles.
Change dressings and bandages when they are wet or soiled.
Assist clients to carry out appropriate skin and oral hygiene.
Dispose of damp,soiled linens appropriately.
Dispose of feces and urine in appropriate receptacles.
Ensure that all fluid containers, such as bedside water jugs and suction and
drainage bottles are covered or capped.
Empty suction and drainage bottles at the end of each shift.
Avoid talking,coughing, or sneezing over open wounds or sterile fields and cover the
mouth and nose when coughing or sneezing.
Wash hands between contact, after touching body substances, and before performing
invasive procedures or touching open wounds.
Instruct clients and support persons to wash hands before handling food or eating,
after eliminating, and after touching infectious material.
Wear gloves if handing excretions and secretions.
Wear gowns if there is a danger of soiling clothing with body substances.
Place discarded soiled materials in moisture-proof refuse bags.
Hold used bedpans steadily to prevent spillage.
Initiate and implement aseptic precautions for all clients.
Wear masks and eye protection when in close contact with client who have infections
transmitted by droplets from the respiratory tract.
Wear masks during irrigation procedures.
Use sterile technique when exposing open wounds or handling dressings.
Place used and disposable needles and syringes in puncture resistant containers for
disposable.
Provide clients with their own personal care items.
Pg. 640, 642(table-6) 643(table 29-6)
-Proper handwashing
-maintain the integrity of the clients skin and mucous membranes.
-ensure that the client receives a balanced diet.
-Educate the public about immunization.
-Ensure the client has adequate sleep and rest.
-Break the chain of infection by:
Ensure articles are correctly cleaned and disinfected or sterilized before use.
Educate clients and support persons about appropriate methods of cleaning,
disinfecting, and sterilizing articles.
Change dressings and bandages when they are wet or soiled.
Assist clients to carry out appropriate skin and oral hygiene.
Dispose of damp,soiled linens appropriately.
Dispose of feces and urine in appropriate receptacles.
Ensure that all fluid containers, such as bedside water jugs and suction and
drainage bottles are covered or capped.
Empty suction and drainage bottles at the end of each shift.
Avoid talking,coughing, or sneezing over open wounds or sterile fields and cover the
mouth and nose when coughing or sneezing.
Wash hands between contact, after touching body substances, and before performing
invasive procedures or touching open wounds.
Instruct clients and support persons to wash hands before handling food or eating,
after eliminating, and after touching infectious material.
Wear gloves if handing excretions and secretions.
Wear gowns if there is a danger of soiling clothing with body substances.
Place discarded soiled materials in moisture-proof refuse bags.
Hold used bedpans steadily to prevent spillage.
Initiate and implement aseptic precautions for all clients.
Wear masks and eye protection when in close contact with client who have infections
transmitted by droplets from the respiratory tract.
Wear masks during irrigation procedures.
Use sterile technique when exposing open wounds or handling dressings.
Place used and disposable needles and syringes in puncture resistant containers for
disposable.
Provide clients with their own personal care items.
INFO ON QUIZ #4-POSTED ON COURSE COMPASS
Fri, Sep 22, 2006 -- Quiz #4
After much deliberation, the I have decided to have Quiz #4 online for those who have found it to be beneficial to their learning. However the following changes have been made so please reorganize your time. 1) It will open up Sunday, 10/08/06 at 12mn and will close at 10/10/06 at 12mn which is a 3 day window period. If you do not take this quiz during this time frame, you will not be able to make it up. 2) time to take the test will be now 20 minutes. 3) If you take longer that the requiered 20 minutes, you will get a zero. This quiz should be taken alone and on your honor. No group testing, no taking pictures of the screen of the test and no sacrificial lambs.
After much deliberation, the I have decided to have Quiz #4 online for those who have found it to be beneficial to their learning. However the following changes have been made so please reorganize your time. 1) It will open up Sunday, 10/08/06 at 12mn and will close at 10/10/06 at 12mn which is a 3 day window period. If you do not take this quiz during this time frame, you will not be able to make it up. 2) time to take the test will be now 20 minutes. 3) If you take longer that the requiered 20 minutes, you will get a zero. This quiz should be taken alone and on your honor. No group testing, no taking pictures of the screen of the test and no sacrificial lambs.
question #12
Discuss the physiology of "third-spacing" & who are more @ risk for developing this? Fundamentals 1363 and ATI 408
Fluid shifts from vascular space into an area where it is not readily accessible as extracelluar fluid. This fluid remains in the body but is essentially unavailable for use, causing an isotonic fluid volume deficit.
@ Risk patients: those with edema,(I thought Mrs. Semillo said this affected Alcoholics can anyone confirm that and add to whom else this would affect)
Body cavities affected are the peritoneal space and pleural cavity
Fluid shifts from vascular space into an area where it is not readily accessible as extracelluar fluid. This fluid remains in the body but is essentially unavailable for use, causing an isotonic fluid volume deficit.
@ Risk patients: those with edema,(I thought Mrs. Semillo said this affected Alcoholics can anyone confirm that and add to whom else this would affect)
Body cavities affected are the peritoneal space and pleural cavity
question #3
Discuss the nursing care of the client with an indwelling foley catheter. Fundamentals pp.1279
Directed at preventing infection and encouraging urinary flow through drainage system, encourage large amount of fluid intake(3000 ml/day), accurately record fluid I&O, changeing the retention catheter and tubing, maintaining patency of the drainage system, preventing contamination of drainage system, teaching the above to the patient.
Directed at preventing infection and encouraging urinary flow through drainage system, encourage large amount of fluid intake(3000 ml/day), accurately record fluid I&O, changeing the retention catheter and tubing, maintaining patency of the drainage system, preventing contamination of drainage system, teaching the above to the patient.
QUESTIONS 34 AND 46
34. SIDE EFFECTS OF IRON SUPPLEMENTS
PDA, DRUG GUIDE
-CNS: IM, IV: SEIZURES, DIZZINESS, HEADACHE, SYNCOPE
(FAINTING)
-CV: IM, IV: HYPOTENSION, TACHYCARDIA
-GI: NAUSEA
-PO: CONSTIPATION, DARK STOOLS, DIARRHEA, EPIGASTRIC
PAIN, GI BLEEDING
-IM, IV: TASTE DISORDER, VOMITING
-DERM: IM, IV: FLUSHING, URTICARIA (MULTIPLE SWOLLEN RAISED
AREAS ON THE SKIN THAT ARE INTENSELY ITCHY,
LAST UP TO 24 HOURS, ON CHEST, BACK, SCALP, FACE
AND EXTREMITIES. AKA: HIVES)
-LOCAL: PAIN AT IM SITE (IRON DEXTRAN), PHLEBITIS AT IV SITE,
SKIN STAINING AT IM SITE (IRON DEXTRAN)
-MS: IM, IV: ARTHRALGIA, MYALGIA
-MISC: PO: STAINING OF TEETH (LIQUID PREP)
IM, IV: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS,
FEVER, LYMPHADENOPATHY
46. PURPOSE OF ANTIEMBOLYTIC STOCKINGS
MOSBYS, FUND. PGS 908-909
-ELASTICIZED STOCKINGS WORN TO PREVENT THE FORMATION OF
EMBOLI AND THROMBI, ESPECIALLY IN PATIENTS WHO HAVE HAD
SURGERY OR WHO HAVE BEEN RESTRICTED TO BED. RETURN
FLOW OF VENOUS CIRCULATION IS PROMOTED, PREVENTING
VENOUS STASIS AND DILATION OF THE VEINS, CONDITIONS THAT
PREDISPOSE A PERSON TO VARISCOSITIES AND THROMBOEMBOLIC
DISORDERS.
-COMPRESS THE VEINS IN THE LEGS AND FACILITATE RETURN OF
VENOUS BLOOD BACK TO THE HEART. ALSO IMPROVES ARTERIAL
CIRCULATION TO THE FEET AND PREVENT EDEMA OF THE LEGS
AND FEET. USED BOTH PRE AND POST OPERTIVELY.
PDA, DRUG GUIDE
-CNS: IM, IV: SEIZURES, DIZZINESS, HEADACHE, SYNCOPE
(FAINTING)
-CV: IM, IV: HYPOTENSION, TACHYCARDIA
-GI: NAUSEA
-PO: CONSTIPATION, DARK STOOLS, DIARRHEA, EPIGASTRIC
PAIN, GI BLEEDING
-IM, IV: TASTE DISORDER, VOMITING
-DERM: IM, IV: FLUSHING, URTICARIA (MULTIPLE SWOLLEN RAISED
AREAS ON THE SKIN THAT ARE INTENSELY ITCHY,
LAST UP TO 24 HOURS, ON CHEST, BACK, SCALP, FACE
AND EXTREMITIES. AKA: HIVES)
-LOCAL: PAIN AT IM SITE (IRON DEXTRAN), PHLEBITIS AT IV SITE,
SKIN STAINING AT IM SITE (IRON DEXTRAN)
-MS: IM, IV: ARTHRALGIA, MYALGIA
-MISC: PO: STAINING OF TEETH (LIQUID PREP)
IM, IV: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS,
FEVER, LYMPHADENOPATHY
46. PURPOSE OF ANTIEMBOLYTIC STOCKINGS
MOSBYS, FUND. PGS 908-909
-ELASTICIZED STOCKINGS WORN TO PREVENT THE FORMATION OF
EMBOLI AND THROMBI, ESPECIALLY IN PATIENTS WHO HAVE HAD
SURGERY OR WHO HAVE BEEN RESTRICTED TO BED. RETURN
FLOW OF VENOUS CIRCULATION IS PROMOTED, PREVENTING
VENOUS STASIS AND DILATION OF THE VEINS, CONDITIONS THAT
PREDISPOSE A PERSON TO VARISCOSITIES AND THROMBOEMBOLIC
DISORDERS.
-COMPRESS THE VEINS IN THE LEGS AND FACILITATE RETURN OF
VENOUS BLOOD BACK TO THE HEART. ALSO IMPROVES ARTERIAL
CIRCULATION TO THE FEET AND PREVENT EDEMA OF THE LEGS
AND FEET. USED BOTH PRE AND POST OPERTIVELY.
Nursing Diagnosis Resource
This is a real find! The Evolve website is also the resource for the N2 med-surg text. If you add this course you will have access to some fabulous Nursing Diagnosis aids.
Go to Evolve website http://evolve.elsevier.com/staticPages/s_index.html
log in then add Content for Ackley: Nursing Diagnosis Handbook, 7th Edition
There is a tremendously helpful ND Constructor.
Go to Evolve website http://evolve.elsevier.com/staticPages/s_index.html
log in then add Content for Ackley: Nursing Diagnosis Handbook, 7th Edition
There is a tremendously helpful ND Constructor.
Thursday, September 21, 2006
#7
7. P.1279-1280
Nursing care of the indwelling catheter is largely directed toward preventing infection of the urinary tract and encouraging urinary flow through the drainage system. It includes encouraging large amounts of fluid intake, accurately recording I and O, changing the retention catheter and tubing, maintaining the patency of the drainage system, and teaching these measures to the client.
-Fluids: up to 3,000mL/day- keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection.
-Dietary measures: acidifying the urine may decrease urinay tract infections. Eating acidific foods help: eggs, cheese, meat, plums, prunes, whole garins, poultry, etc.
-Perineal care: no special cleaning other than the routine care.
-Changing catheter and tubing: routine changing is not recommended.
Nursing care of the indwelling catheter is largely directed toward preventing infection of the urinary tract and encouraging urinary flow through the drainage system. It includes encouraging large amounts of fluid intake, accurately recording I and O, changing the retention catheter and tubing, maintaining the patency of the drainage system, and teaching these measures to the client.
-Fluids: up to 3,000mL/day- keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection.
-Dietary measures: acidifying the urine may decrease urinay tract infections. Eating acidific foods help: eggs, cheese, meat, plums, prunes, whole garins, poultry, etc.
-Perineal care: no special cleaning other than the routine care.
-Changing catheter and tubing: routine changing is not recommended.
Questions 11 and 39
11. Pallor: result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. It may be difficult to determine in clients with dark skin. It is usually characterized by the absence of underlying red tones in the skin and maybe most readily seen in the buccal mucosa. In brown-skinned clients, pallor may appear a yellowish brown tinge; in black clients, the skin may appear ashen gray. Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucosa membranes, nail beds, palms of the hands, and soles of the feet.
39. Purpose of the condom catheter:
Prescribed for incontinent males, so as to not soil themselves. Preferable to insertion of a retemtion catheter b/c the risk for urinary tract infection is minimal. With the condom catheter you do need to be aware of the RF for skin breakdown.
39. Purpose of the condom catheter:
Prescribed for incontinent males, so as to not soil themselves. Preferable to insertion of a retemtion catheter b/c the risk for urinary tract infection is minimal. With the condom catheter you do need to be aware of the RF for skin breakdown.
Study Guide Answer #8
8. Discuss the age related changes of the urinary and bowel eliminations.
BOOK- pg. 405, 1228-29, 1258
Urinary- excretory fxn of kidney diminishes, but not significantly below norm unless a disease process intervenes.
- Reduced filtering ability of kidney and impaired renal function (less # functioning nephrons and arteriosclerotic changes in blood flow)
- Less effective concentration of urine (decreased tubular function)
- Urinary urgency and urinary frequency (Enlarged prostate gland in men; weakened muscles supporting bladder or weakness of urinary sphincter in women)
- Tendency for nocturnal frequency and retention of residual urine (Decreased bladder capacity and tone)
- Decrease kidney fxn also places elder at higher risk for toxicity from meds if excretion rates longer
Bowel-
- Increased tendency for constipation (decreased muscle tone of intestines, peristalsis, inadequate fluid/fiber intake, decreased activity levels)
- Laxatives: inhibit natural defecation reflexes, decrease absorption of certain volumes,
BOOK- pg. 405, 1228-29, 1258
Urinary- excretory fxn of kidney diminishes, but not significantly below norm unless a disease process intervenes.
- Reduced filtering ability of kidney and impaired renal function (less # functioning nephrons and arteriosclerotic changes in blood flow)
- Less effective concentration of urine (decreased tubular function)
- Urinary urgency and urinary frequency (Enlarged prostate gland in men; weakened muscles supporting bladder or weakness of urinary sphincter in women)
- Tendency for nocturnal frequency and retention of residual urine (Decreased bladder capacity and tone)
- Decrease kidney fxn also places elder at higher risk for toxicity from meds if excretion rates longer
Bowel-
- Increased tendency for constipation (decreased muscle tone of intestines, peristalsis, inadequate fluid/fiber intake, decreased activity levels)
- Laxatives: inhibit natural defecation reflexes, decrease absorption of certain volumes,
Wednesday, September 20, 2006
Question #17 - Medications and Urinary Elimination
#17 - List medications that would affect urinary elimination.
Ch.47, Pg 1259
Diuretics that increase urine formation such as chlorothiazide and furosemide.
Ch.47, Pg 1260, Box 47-1
Medications that may cause urinary retention:
- Anticholinergic and antispasmodic medications such as atropine and papaverine
- Antidepressant and antipsychotic agents, such as phenothiazines and MAO inhibitors
- Antihistamine preparations, such as pseudoephedrine (Actifed and Sudafed)
- Antihypertensives, such hydralazine (Apresoline) and methyldopate (Aldomet)
- Antiparkinsonism drugs, such as levodopa, trihexyphenidyl (Artane), and benztropine mesylate (Cogentin)
- Beta-adrenergic blockers, such as propranolol (Inderal)
- Opioids, such as hydrocodone (Vicodin)
Chapter also mentions that some meds may alter color urine, but didn't list any.
Feel free to add to this . . .
Ch.47, Pg 1259
Diuretics that increase urine formation such as chlorothiazide and furosemide.
Ch.47, Pg 1260, Box 47-1
Medications that may cause urinary retention:
- Anticholinergic and antispasmodic medications such as atropine and papaverine
- Antidepressant and antipsychotic agents, such as phenothiazines and MAO inhibitors
- Antihistamine preparations, such as pseudoephedrine (Actifed and Sudafed)
- Antihypertensives, such hydralazine (Apresoline) and methyldopate (Aldomet)
- Antiparkinsonism drugs, such as levodopa, trihexyphenidyl (Artane), and benztropine mesylate (Cogentin)
- Beta-adrenergic blockers, such as propranolol (Inderal)
- Opioids, such as hydrocodone (Vicodin)
Chapter also mentions that some meds may alter color urine, but didn't list any.
Feel free to add to this . . .
Question #44 - 24 Hr Urine Specimen
#44 - Describe the procedure for collecting a 24 hour urine specimen.
Ch. 32, Pg 769
1. Obtain specimen container with preservative (if indicated) from the laboratory. Label the container with identifying information for the client, the test to be performed, time started, and time of completion.
2. Provide a clean receptacle to collect urine (bedpan, commode, or toilet collection device).
3. Post signs in the client's chart, Kardex, room, and bathroom alerting personnel to save all urine during the specified time.
4. At the start of the collection period, have the client void and discard this urine. (Again, this is the start of the timed urine specimen, and should be written on container, for example, 9/21/06, 0700).
5. Save all urine produced during the timed collection period in the container, refrigerating or placing the container on ice as indicated. Avoid contamination the urine with toilet paper or feces.
6. At the end of the collection period, instruct the client to completely empty the bladder and save this voiding as part of the specimen. Take the entire amount of urine collected to the laboratory with the completed requisition.
7. Record collection of the specimen, time started and completed, and any pertinent observations of the urine on appropriate records.
*Remember, ALL urine (except for the first voiding) in a 24 hour period must be collected for accurate results
Ch. 32, Pg 769
1. Obtain specimen container with preservative (if indicated) from the laboratory. Label the container with identifying information for the client, the test to be performed, time started, and time of completion.
2. Provide a clean receptacle to collect urine (bedpan, commode, or toilet collection device).
3. Post signs in the client's chart, Kardex, room, and bathroom alerting personnel to save all urine during the specified time.
4. At the start of the collection period, have the client void and discard this urine. (Again, this is the start of the timed urine specimen, and should be written on container, for example, 9/21/06, 0700).
5. Save all urine produced during the timed collection period in the container, refrigerating or placing the container on ice as indicated. Avoid contamination the urine with toilet paper or feces.
6. At the end of the collection period, instruct the client to completely empty the bladder and save this voiding as part of the specimen. Take the entire amount of urine collected to the laboratory with the completed requisition.
7. Record collection of the specimen, time started and completed, and any pertinent observations of the urine on appropriate records.
*Remember, ALL urine (except for the first voiding) in a 24 hour period must be collected for accurate results
Exam2 study question - #14
Nursing care for the client with a urinary diversion...p1284
-The nurse must accurately assess intake and output, note any changes in urine color, odor or clarity, and frequently assess the condition of the stoma and surrounding skin. Clients who must wear a urine collection appliance are at risk for impaired skin integrity because of irritation by urine.Well-fitting appliances are vital. The nurse should consult with an enterostomal therapist/wound, ostomy, continence nurse to identify the most appropriate appliance for the client's needs.
-The nurse must accurately assess intake and output, note any changes in urine color, odor or clarity, and frequently assess the condition of the stoma and surrounding skin. Clients who must wear a urine collection appliance are at risk for impaired skin integrity because of irritation by urine.Well-fitting appliances are vital. The nurse should consult with an enterostomal therapist/wound, ostomy, continence nurse to identify the most appropriate appliance for the client's needs.
Exam#2 study question - #19
Purpose(s) of catheterizing a client (p1275-Box 47-2)
- To relieve discomfort due to bladder distention or to provide gradual decompression of a distended bladder.
- To assess the amount of residual urine if the bladder empties incompletely.
- To obtain a urine specimen.
- To empty the bladder completely prior to surgery.
- To facilitate accurate measurement of urinary output for critically ill clients whose output needs to be monitored hourly.
- To provide for intermittent or continuous bladder drainage and irrigation.
- To prevent urine from contracting an incision after perineal surgery.
- To manage incontinence when other measures have failed.
- To relieve discomfort due to bladder distention or to provide gradual decompression of a distended bladder.
- To assess the amount of residual urine if the bladder empties incompletely.
- To obtain a urine specimen.
- To empty the bladder completely prior to surgery.
- To facilitate accurate measurement of urinary output for critically ill clients whose output needs to be monitored hourly.
- To provide for intermittent or continuous bladder drainage and irrigation.
- To prevent urine from contracting an incision after perineal surgery.
- To manage incontinence when other measures have failed.
Question of the Week 09.18.06
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify his understanding?
1. "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed."
2. "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy."
3. "If I have cancer at stage 3 it means I have less involvement of the cancer."
4. "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle."
1. "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed."
2. "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy."
3. "If I have cancer at stage 3 it means I have less involvement of the cancer."
4. "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle."
Tuesday, September 19, 2006
Exam # 2 Study question - number 5
5. Discuss the patient education needed for the client with obtaining a midstream clean catch urine specimen.
P. 156, 160 in Tech.
Care is taken to ensure that the specimen is as free as possible from contamination by microorganism around the urinary meatus.
Use each towelettes only once.
Clean perineal area from front (area of least contamination) to back (greatest area of contamination) and discard it.
Instruct the client to start voiding: bacteria in the distal urethra and at the urinary meatus are cleared by the first milliliters of urine expelled.
Place specimen container into the stream of urine and collect specimen, taking care not to touch the container: avoid contaminating the interior of the specimen container and the specimen itself.
Collect 30 to 60 ml of urine
Cap the container tightly, touching only the outside to prevent contaminating and spilling of the specimen.
If necessary, clean outside of the container with a disinfectant to prevent transfer of microorganism to others.
P. 156, 160 in Tech.
Care is taken to ensure that the specimen is as free as possible from contamination by microorganism around the urinary meatus.
Use each towelettes only once.
Clean perineal area from front (area of least contamination) to back (greatest area of contamination) and discard it.
Instruct the client to start voiding: bacteria in the distal urethra and at the urinary meatus are cleared by the first milliliters of urine expelled.
Place specimen container into the stream of urine and collect specimen, taking care not to touch the container: avoid contaminating the interior of the specimen container and the specimen itself.
Collect 30 to 60 ml of urine
Cap the container tightly, touching only the outside to prevent contaminating and spilling of the specimen.
If necessary, clean outside of the container with a disinfectant to prevent transfer of microorganism to others.
test study questions
I guess i will start the questions for the next exam. There are a lot of questions this time around.
1. Discuss the indicators needed to assess the fluid status of clients.
P. 1371
Current and Past Medical History
Seeing a health care provider for treatment of any chronic diseases or disorders
Experiencing any acute conditions such as severe trauma, head injury, thyroid or parathyroid disorders.
Medications and Treatments
Currently taking medications on a regular basis, or undergone any treatments such as dialysis, tube feedings, etc.
Food and Fluid Intake
How much and what type of fluids do you drink a day.
Describe diet on a typical day
Recent changes in diet or fluid intake.
On restrictive diet?
Has food and fluid intake been affected by changes in appetite, nausea, pain, difficulty breathing.
Fluid Output
Recent changes in frequency and amount of urine output
Problems with vomiting or constipation.
Any unusual fluid losses such as excessive sweating.
Fluid, Electrolyte, and Acid-Bases Imbalances
Gained or loss weight
Symptoms of excessive thirst, dry skin or mucous membranes, dark or concentrated urine, or low urine output.
Problems with swelling of hands or feet, difficulty breathing, how many pillows you sleep with.
Experience any of the following symptoms: difficulty concentration or confusion, dizziness or feeling faint, muscle weakness, twitching, cramping, excessive fatigue, muscle weakness, numbness, tingling, burning, abdominal cramping, heart palpations.
Measurements P.1369
Daily weights
signs
Fluid intake and output
Review of Laboratory test results p. 1375
Serum electrolytes
Complete blood count
Osmolality
Urine ph
Urine specific gravity
Arterial blood gases
1. Discuss the indicators needed to assess the fluid status of clients.
P. 1371
Current and Past Medical History
Seeing a health care provider for treatment of any chronic diseases or disorders
Experiencing any acute conditions such as severe trauma, head injury, thyroid or parathyroid disorders.
Medications and Treatments
Currently taking medications on a regular basis, or undergone any treatments such as dialysis, tube feedings, etc.
Food and Fluid Intake
How much and what type of fluids do you drink a day.
Describe diet on a typical day
Recent changes in diet or fluid intake.
On restrictive diet?
Has food and fluid intake been affected by changes in appetite, nausea, pain, difficulty breathing.
Fluid Output
Recent changes in frequency and amount of urine output
Problems with vomiting or constipation.
Any unusual fluid losses such as excessive sweating.
Fluid, Electrolyte, and Acid-Bases Imbalances
Gained or loss weight
Symptoms of excessive thirst, dry skin or mucous membranes, dark or concentrated urine, or low urine output.
Problems with swelling of hands or feet, difficulty breathing, how many pillows you sleep with.
Experience any of the following symptoms: difficulty concentration or confusion, dizziness or feeling faint, muscle weakness, twitching, cramping, excessive fatigue, muscle weakness, numbness, tingling, burning, abdominal cramping, heart palpations.
Measurements P.1369
Daily weights
signs
Fluid intake and output
Review of Laboratory test results p. 1375
Serum electrolytes
Complete blood count
Osmolality
Urine ph
Urine specific gravity
Arterial blood gases
Monday, September 18, 2006
Pharmacology Practice
OK, y'all. Whether you have taken Pharm before or are just starting, see if you can find the answers to these Qs. Post your answers in the comments. We can all compare answers. These are good practice from the N101 Folder.
a. effectiveness.
b. predictability.
c. safety.
d. selectivity.
2. Use of drugs to diagnose, prevent, or treat disease or to prevent pregnancy is known as:
a. clinical pharmacology.
b. pharmacology.
c. pharmacotherapeutics.
d. experimental pharmacology.
3. Goals of the preadministration assessment of the patient include:
a. determining the action of the drug.
b. managing toxicity from the drug.
c. identifying patients at risk for adverse effects from the drug.
d. evaluating the expected outcome of the drug.
4. Which of the following patients would be identified as most predisposed to adverse reactions:
a. a 30-year-old man with a fracture.
b. A 75-year-old woman with liver disease.
c. A 50-year-old man with a upper respiratory tract infection.
d. A 7-year-old with an ear infection.
5. Which of the following is a PRN medication order?
a. a hypnotic if the patient cannot sleep
b. an antacid after each meal
c. a glucocorticoid taper
d. any drug not requiring a prescription
6. The first legislation to regulate drug safety was the:
a. Federal Pure Food and Drug Act of 1906.
b. Food, Drug, and Cosmetic Act.
c. Kefauver-Harris Amendment.
d. Controlled Substances Act.
7. After which phase of a clincial trial may a manufacturer apply for FDA approval?
a. I
b. II
c. III
d. IV
8. Which of the following is the most common method by which drugs can cross the cell membrane to exert an effect?
a. Passage through channels or pores
b. Passage with the aid of a transport system
c. Direct penetration of the membrane
d. Transmission along a sodium channel
9. Which of the following is a true statement in regards to pH dependent ionization?
a. An acid is a proton donor while a base is a proton acceptor.
b. Acids will ionize best in an acidic media.
c. For bases to ionize, the media must be alkaline.
d. When acids give up positively charged ions, the acid will become more basic.
10. A patient is in severe pain. Which of the following routes of administration would be the most expeditious?
a. Oral
b. Intramuscular
c. Intravenous
d. Transdermal
11. A drug that produces its effects by preventing the activation of a receptor would be classified as:
a. an agonist.
b. an antagonist.
c. a partial agonist.
d. intrinsic.
12. The ED50 indicates the dose required to produce a:
a. minimal response in half of the population.
b. toxic response in half of the population.
c. therapeutic response in half of the population.
d. sustained response in half of the patients.
13. If drugs A and B are taken together and drug B augments the effects of drug A, the interaction would be classified as:
a. inhibitory.
b. beneficial.
c. antagonistic.
d. potentiative.
14. A patient who has taking an antidepressant develops signs of Parkinson’s disease. This syndrome would be classified as
a(an):
a. allergic reaction.
b. idiosyncratic effect.
c. iatrogenic disease.
d. teratogenic effect.
15. When discussing the concept of pharmacodynamic tolerance, the nurse should include the fact that:
a. the phenomenon only occurs with opioids.
b. this means that the patient will require more drug to achieve the same effect.
c. the patient requires a stable dose of medication until the drug is discontinued.
d. addiction is likely to develop if the drug is not tapered.
16. The nurse of an elderly patient would monitor renal excretion
of drugs by assessing:
a. creatinine clearance.
b. serum creatinine levels.
c. white blood counts.
d. blood urea nitrogen.
17. At what age does the hepatic metabolizing ability the child become similar to that of the adult?
a. 3 months
b. 6 months
c. One year
d. Three years
18.The period during which thee is the highest risk of teratogeninduced gross malformations is:
a. immediately pre-conception.
b. 2-3 weeks after conception.
c. 3-8 weeks after conception.
d. 20-24 weeks after conception.
19. Match:
1. Levodopa
2. Tacrine (Cognex)
3. Phenytoin (Dilantin)
4. Baclofen (Lioresal)
A. Alzheimer’s disease
B. Perkinson’s disease
C. Muscle Spesticity
D. Epilepsy
20. Match:
1. Atropine
2. Bethanacol
3. Neostigmine
4. Tubocurarine
A. Neuromuscular blocking agent
B. Muscarinic Antagonist
C. Muscarinic agonist
D. Cholinestarase inhibitor
True/False:
21. Dopaminergic agents promote activation of dopamine receptors
Multiple Choice:
26. When caring for patients receiving dantrolene, the nurse should monitor:
a. liver enzymes.
b. renal function studies.
c. the complete blood count.
d. serum electrolytes.
27. Most Antiepileptic drugs treat a specific form(s) of epilepsy. Which of the following is effective for almost all forms?
a. Phenytoin
b. Ethosuximide
c. Valproic acid
d. Phenobarbital
28. The only two known risk factors for AD are:
a. obesity and illicit drug use.
b. high socioeconomic status and
Caucasian race.
c. advancing age and family history.
d. alcoholism and hypertension.
29. Centrally acting anticholinergics used in the treatment of Parkinson’s disease control
symptoms by:
a. blocking cholinergic receptors.
b. activating dopamine receptors.
c. preventing destruction of dopamine in
the central nervous system.
d. increasing synthesis of dopamine.
30. Activation of which of the following receptor subtypes causes contraction of skeletal muscle?
a. Alpha1
b. Muscarinic
c. Nicotinic
d. Beta2
31. The only reason that a patient would be taking an irreversible cholinesterase inhibitor
would be for the treatment of:
a. glaucoma.
b. myasthenia.
c. muscular dystrophy.
d. hypertension.
32. In recovery the patient who had received a neuromuscular blocker must be monitored until:
a. they are fully conscious.
b. they can breathe spontaneously.
c. all muscle function has fully recovered.
d. vital signs are normal.
33. Which of the following nondepolarizing neuromuscular blockers has the shortest duration of action?
a. pancuronium
b. rocuronium
c. vecuronium
d. mivacurium
34. Which of the following agents is termed the prototype of the amide agents?
a. Procaine
b. Cocaine
c. Bupivacaine
d. Lidocaine
35. Anesthetic agents with a high minimum alveolar concentration (MAC):
a. have low anesthetic potency.
b. require less drug to achieve immobility.
c. can be used alone to achieve surgical anesthesia.
d. characterize most anesthetic agents in use today.
36. Which of the following descriptors relates to physical dependence?
a. A state in which larger doses are required to produce the same response that could formerly be elicited by a smaller dose.
b. A state in which an individual will seek and use the drug despite physical, psychological or social harm.
c. The state in which pain is undertreated and the patient appears to be drug seeking.
d. A state in which an abstinence syndrome will occur if the drug use is abruptly continued.
37. A patient with a history of migraines is asking for a medication to take in effort to prevent attacks. Which of the following drugs will this patient likely be given?
a. Propranolol
b. Sumatriptan
c. Ergotamine
d. Dihydroergotamine
38. Haloperidol is classified as a(n):
a. low-potency antipsychotic drug.
b. medium-potency antipsychotic drug.
c. high-potency antipsychotic drug.
d. atypical antipsychotic drug.
39. The nurse is caring for a patient on antipsychotics who develops acute dystonia. This will likely be treated with:
a. 5HT3 blockers.
b. anticholinergics.
c. neuroleptics.
d. tricyclics.
40. Which of the above is considered a serious side effect of the TCAs?
a. Headache
b. Dry mouth
c. Nasal stuffiness
d. Orthostatic hypotension
41. Monoamine oxidase inhibitors are:
a. used first line in the treatment of depression.
b. reserved for patients who have not responded to SSRIs and TCAs.
c. used in patients who have developed serotonergic syndrome.
d. indicated for patients who have difficulty sleeping.
42. The drug that has replaced lithium as the treatment of choice for bipolar disorder is:
a. carbamazepine.
b. valproic acid.
c. olanzapine.
d. risperidone.
43. The only benzodiazepines that is commonly used to relieve muscle spasm is:
a. Diazepam.
b. Lorazepam.
c. Estazolam.
d. Clonazepam.
44. If taken alone, large doses or oral benzodiazepines:
a. cause significant toxicity.
b. antagonize effects of other CNS drugs.
c. cause profound respiratory depression.
d. are rarely lethal.
45. Which category of drugs is used for all types of anxiety disorders?
a. Benzodiazepines
b. Selective serotonin reuptake inhibitors
c. Barbiturates
d. Anticonvulsants
46. An important component of patient education for the patient on buspirone is to:
a. not take the medication with grapefruit juice.
b. avoid alcohol containing products.
c. never take the medication with food.
d. beware of signs of dependence and abuse.
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