#29

I didn't see this posted yet so here it is:



#29 Discuss the rationale of how weakness and fatigue is a risk factor
for pressure ulcers. Kozier p.857-8

Immobility due to paralysis, extreme weakness, pain, or any cause of decreased activity can hinder a person's ability to change positions independently and
relieve the pressure, even if the person can perceive the pressure.

This is one of several factors contributing to the development of pressure ulcers.

FYI - Other factors are:

Inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Diminished sensation
Excessive body heat
Advanced age
Presence of certain chronic conditions (i.e. diabetes, cardiovascular disease)

Thank You!

I Just Wanted To Say, "We Really Work Well Together To Get The Job Done"! I went to work this morning and there were a few questions done and I just got home and they are almost done. That says alot about us, as a Class. Thank you Classmates!

#13

13.) Describe the procedure of the surgical client when received in the PACU

Initial assessment includes a summary of the complete anesthesia report. Priority care includes monitoring and management of respiratory and circulatory function, pain, temperature, and surgical site.
Respiratory function
Patency, rate and quality of respirations with auscultation in all lung fields
O2 therapy used if ordered via nasal cannula or face mask – helps in elimination of anesthetic gases and meets increased O2 demand due to decreased blood volume or increased cellular metabolism. Monitor O2 sat.
Circulatory function
ECG Monitoring to determine cardiac rate and rhythm
BP monitored and compared with baseline data
Assess temp. and skin color and condition
Neuro. Assessment
Focused on levels of consciousness; orientation; sensory and motor status; size, equality, reactivity of pupils
Urinary Assessment
I & O and fluid balance
Note presence of IV lines, irrigation solutions and infusions
Output devices including catheters and wound drains
Surgical site assessment
Note condition of dressings and type and amount of any drainage
Institute post-op orders related to site care
Special considerations: Hearing is first sense to return in the unconscious patient so explain all activities from the moment of admission to PACU. Explain surgery is complete, patient is in recovery room and family has been notified. Also explain who nurse is caring for the patient, what is being done, and what time it is.
Common post-op problems that should be anticipated are airway compromise (obstruction), respiratory insufficiency (hypoxemia and hypercarbia), cardiac compromise (hypotension, hypertension, arrythymias), neurologic compromise (emergence delirium and delayed awakening), hypothermia, pain, nausea and vomiting.

SJDC ADN Class of 2008

#30 Discuss the theraputic communication needed for the immobile person.
Immobility is the reduction in the amount and control of movement taht a person has. Normally people change positions when they are uncomfortable, which reduces pressure to any given area. For those with mobility impairments such as paralysis, pain, weakness or any other problem that limits freedom of movement adjusting position to aleviate pressure or discomfort can be difficult or impossible.
Immobility can lead to disuse syndromes, contractures, stiffness in joints and pressure ulcers.
Nursing strategies are aimed at preventing the complications of immobility, at risk clients should be identified early to prevent complications before they arise. Braden scales are used as identifiers. Patients should have physcians orders that specify activity levels, "such as out of bed w/assist". Most clients require assistance, it is up to the nurse to determine how much assistance is required.
Theraputic communication promotes understanding and fosters a constructive relationship with the client that is goal directed. The nurse should gather data, determin limitations and assistance required. (preinteraction phase). Then clarify the desired task to the client with expectations for each. ( introductory phase) followed by the (working phase) exploring thoughts and feelings and implementing the task. lastly the (termination phase) where summarization occurs.
Clients should be involved in their own care if possible.

here's 2 and 3

2. Discuss the nursing interventions for the surgical client when ambulating. (fundamentals pg. 920)

Leg exercises
Encourage client to do leg exercises every 1-2 hours during waking hours. Muscle contractions compress veins, preventing stasis of blood in the veins, which can cause thrombus. Contractions also promote arterial blood flow. This will prepare the client for ambulation.

Moving and Ambulation
Encourage client to move from side to side, at least every 2 hours. This will make it easier for client to get up from bed.

Client should ambulate as soon as possible after surgery in accordance w/ surgeons orders. Usually the evening of the surgery. Early ambulation prevents respiratory, circulatory, urinary and gastro-intestinal complications. As well as general musclo-skeletal weakness. Offer pain medication or determine client comfort prior to scheduling ambulation. Start gradually , assisting the client to a sitting position at side of bed with feet dangling. Teach splinting techniques if necessary. Remember non-skid shoes!!!!

Remain at clients side for safety. Assess client needs IE walker, wheelchair nearby, level of assistance required. Monitor client for toleration IE Orthostatic reactions, increased pain, exertional shortness of breath… Document client participation and toleration.


3. Discuss the nursing implications for the surgical client when pain medication is administered. ( fundamentals pg. 919 ,1143)

Pain is described as a sensory and emotional experience. Pain can have detrimental effects in the post-surgical patient,leading to stimulation of the SNS, tachycardia, shallow breathing, atelectasis, altered gas exchange, immobility, and immunosupression.
Pain is greater 12-36 hours post-op, decreasing by second or third day. During initial post op period PCA’s are used via IV or epidural catheter. The nurse monitors the infusion or amount administered by PCA and assesses clients pain relief. If pain is uncontrolled then PRN medications or analgesics should be given routinely every 2 to 6 hours for the first 24-36 hours. Pre medication can be offered prior to scheduled activities ie wound care, ambulation… anti- inflammatories are also given w/ narcotic analgesics to enhance pain relief. Analgesics work best when taken on a regular basis, before pain becomes severe.
Non-pharmacological measures to aid in controlling pain include back rubs, repositioning, diversional activities, and guided imagery.
Remember pain is whatever the client says it is …
P-Provoked: What brought on your pain?
Q-Quality: What does your pain feel like?
R-Region/ Radiation: Where is your pain located? Does it travel?
S-Severity: On a scale of 1-10, 1 being no pain and 10 the worst, what is yours?
T-Timing: When did the pain start?

another med mistake from same hospital that gave lethal doses to premature babies

Hospital mistake paralyzes new mom
Sun Oct 15, 11:54 AM ET
A hospital that gave lethal doses of a drug to three premature babies has made another medication mistake, giving a new mother a painkiller 10 times faster than intended and making her temporarily unable to walk.
Amber Baise, 18, of Indianapolis, who received the painkiller during childbirth, has regained some movement in her legs as she recovers from what Methodist Hospital on Friday called a doctor's mistake.
"We remain hopeful that she will receive a full recovery. That is our hope. That is our commitment," said Bill Stephan, a spokesman for Clarian Health Partners, which operates Methodist and Indiana University's hospitals.
Baise entered Methodist on Oct. 8 to give birth to her first child and a doctor started her on an epidural. An improperly programmed pump gave her 10 hours worth of painkiller in just one hour.
Baise delivered a healthy girl.
The doctor who made the error works for an anesthesia practice that contracts with Methodist. The doctor has decades of experience and a good record, Stephan said. He did not release the doctor's name.
Baise's attorney, Nathaniel, said the physician's good record was irrelevant.
"There are certain mistakes that you can't make, that you shouldn't make, regardless of your education, regardless of your training, and this is the kind of mistake that you shouldn't make," Lee said.

Good Work Ladies!!

Just a few questions left out there: 2, 3, 12, 13, 24, 29, 30 Lets finish this tonight.......anybody new out there want to add to our study guide??

Great Teamwork!!!!

#20

#20 Discuss safety implications for insulin and heparin
Insulin- obtain FSBS to assess amount needed. Mix by rolling the vials not shaking, shaking can cause particules to foam up. Never drawl an insulin with a modify protein (cloudy insulin NPH or Lente) before the clear (regular insulin). The protein slows absorption, so inject air for the amount you will need into cloudy without touching the insulin inside the vial, and then inject and drawl out the amount of regular insulin you need. Next drawl up the cloudy, but be careful not to over drawl because you cannot put excess back, and be careful not to drawl up air bubbles. Inject at a 45 degree angle, and rotate injection sites to prevent skin break down.
Heparin- Do not aspirate when giving heparin by SC injection. Aspiration can possibly damage the surrounding tissue and cause bleeding as well as bruising. Do not massage the site after the injection. Massaging could cause bleeding and ecchymosis and hasten drug absorption. Alternate the sites of subsequent injections.

pharm practice questions

http://www.pharmacology2000.com/Autonomics/unit_practice_exam_index.htm

#17 Discuss assessment and interventions for IV therapy

# 17 Discuss the assessment and nursing interventions for the client
receiving IV therapy

Maintaining Infusions: (Kozier, skills bk.pg.549)

Once an intravenous infusion has been established, it is the nurse’s responsibility to maintain the prescribed flow rate and to prevent complications associated with IV therapy. (Fluid volume excess, electrolyte imbalance) Current research indicates that routine change of peripheral IV catherers/needles and IV tubing can be performed every 72 hours (or according to agency policy). Dressings should be changed on the IV site only when soiled, wet, or dislodged.

In maintaining the infusion, the nurse will examine the appearance of infusion site; patency of system; type of fluid being infused and rate of flow; and the response of the client. From physician’s order, determine the type and sequence of solutions to be infused. Determine the rate of flow and infusion schedule.

-Ensure that the correct solution is being infused.
-Observe the rate of flow every hour.
-Observe the position of the solution container. (should be 3 ft. above the IV site)
-If the rate is too fast, check agency policy, the physician may need to be notified.
-If the rate is too slow, adjust the IV to the prescribed rate. (check with facility policy)
-If prescribed rate of flow is 150mL/hr or more, check the rate of flow more frequently, for
example, every 30 min.
-Inspect the patency of the IV tubing and needle.(make appropriate changes/corrections when
nec.)
-Inspect the insertion site for fluid infiltration
-Inspect the insertion site for phelbitis
-Inspect the intravenous site for bleeding
-Teach the client ways to help maintain the infusion system(avoid twisting or turning the
arm/hand w/IV)


ATI book pg. 416-417 Says:

Monitor IV infusion at least every hour, count drip rate, check tubing for kinking/leaks, observe settings on pump, inspect site for swelling, pain, coolness, or pallor which may indicate infiltration.

-Inspect insertion site for redness, swelling, heat, and pain which may indicate phelbitis.
-Change tubing every 48-72 hours depending on policy
-Change tubing when hanging new solution container.
-Verify solution type and flow rate
-Peripheral IV dressings should be changed when damp or soiled or every 48-72 hours
depending on protocol.
-Label the dressing and secure the IV tubing

#28

28) List the nursing diagnoses for the client with impaired skin integrity.
Risk for Impaired Skin Integrity related to incontinence and immobility/At risk for skin being adversely altered.
Impaired Skin Integrity (stage II pressure ulcer)related to friction/Altered epidermis and/or dermis
Kozier pg 868
Impaired Skin Integrity
Related to:
mechanical factors (pressure, shear, friction, moisture)
altered circulation
altered sensation
radiation
medications
As evidenced by:
disruption of skin surface (incision, rash, excoriation, open wound(s) (specify type, location)

handout from Mary Lou

#26

26) Discuss why the elderly are at risk for impaired skin integrity.
The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following:
*Loss of lean body mass
*Generalized thinning of the epidermis
*Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis
*Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands
*Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch.
Kozier pg 858

I'll take 17

#23

23) Explain the purpose of administering an intramuscular medication by the Z-track method.
Inserting an intramuscular needle at a 90-degreee angle using the Z-track method. (a) skin pulled to the side; (b) skin released. When the skin returns to its normal position after the needle is withdrawn, a seal is formed over the intramuscular site. This prevents seepage of the medication into the subcutaneous tissues and subsequent discomfort. Using a quick motion lessens the client's discomfort. Permits the medication to disperse into the muscle tissue, thus decreasing the client's discomfort.
skills book pg 558 and Kozier pg 831

#19

19) Discuss the various sites for insulin and heparin.
Among the many kinds of drugs administered subcutaneously (just below the skin) are vaccines, preoperative medications, narcotics, insulin, and heparin. Common sites for subcutaneous (SC or SQ) injections are the outer aspect of the thighs. These areas are conventient and normally have good blood circulation. Other areas that can be used are the abdomen, the scapular areas of the upper back, and the upper ventrogluteal and dorsogluteal areas. Only small doses (0.5 to 1.0 ml) of medication are usually injected via the subcutaneous route.
Insulin-The most important consideration is the depth of the subcutaneous tissue in the area to be injected. If the client has more than 1/2 inch of adipose tissue in the injection site, it would be safe to administer the injection at a 90-degree angle with the skin spread. If the client is thin or lean and lacks adipose tissue, the subcutaneous injection should be given with the skin pinched and at a 45- to 60-degree angle.
Heparin-the subcutaneous administration of heparin requires special precautions because of the drug's anticoagulant properties. Select a site on the abdomen away from the umbilicus and above the level of the iliac crests.

#21

#21 Discuss the assessment needed when administering oral medications; medications via NG tube

1. Always check with the pharmacist to see if the clients medications come in liquid form because these are less likely to cause tube obstruction.
2. If meds do not come in liquid form, check to see if they may be crushed (enteric-coated, sustained action, buccal, and sublingual meds should never be crushed).
3. Crush a tablet into a fine powder and dissolve in at least 30ml of warm water. Cold liquids may cause client discomfort. Use only water for mixing and flushing.
4. Read medication labels carefully before opening a capsule. Open capsules and mix the contents with water only with the pharmacists advice.
5. Do not administer whole or undissolved meds because they will clog the tube.
   Assess tube placement.
6. Before giving the med, aspirate all the stomach contents and measure the residual volume. Check Agency policy if residual volume is greater than 100ml.
7. When administering the meds
   

• remove the plunger from the syringe and connect the syringe to the pinched or kinked tube. Pinching or kinking the tube prevents excess air from entering the stomach and causing distention.
• Put 15-30ml (5-10ml for children) of water into the syringe barrel to flush the tube before administering the first med. Raise or lower the barrel of the syringe to adjust the flow as needed. Pinch or clamp the tubing before all the water is instilled to avoid excess air entering the stomach.
• Pour liquid or dissolved med into syringe barrel and allow to slow by gravity into the enteral tube.
• If you re giving several meds, administer each one separately and flush with at least 15-30ml (5-10ml for children) of tap water between each med
• When you have finished administering all meds, flush with another 15-30ml (5-10ml for children) of warm water to clear the tube.
• If the tube is connected to suction, disconnect the suction and keep the tube clamped for 20-30min after giving the med to enhance absorption.

Kozier pg 811

#22

#22 Discuss the aging process and medicaiton administration
· Altered memory- they may think they took their med, when they haven’t, or think they haven’t taken the med and take it again causing an overdose.
· Less acute vision- impaired vision may lead them to take the wrong med, or the wrong dose, or at the wrong times.
· Decrease in renal function, resulting in slower elimination of drugs and higher drug concentrations in the blood stream for longer peroids, so they may require smaller doses fo a drug because the drug and its metabolites may accumulate in the body.
· Less complete and slower absorption form the gastrointestinal tract
· Decreased liver funciton, which hinders biotransformation of drugs, creating a cumulative effect.
· Decreased organ sensitivity, which means theat the response to the same drug concentration in the vicinity of the target organ is less in older peole than in the young.
· Altered quality of organ responsiveness, resulting in dverse effects becoming pronounced before therapuetic eggects are achieved
· Decreased in manual dexterity due to arthitis and or decrease in felexibility makes it diffcult to open and adminster meds.
Kozier pg 805

# 14

List the relevant nursing diagnoses for the surgical client.

Preoperative Nursing Diagnoses: Deficient Knowledge.
Fear
Disturbed sleep pattern.
Anticipatory grieving.
Ineffective coping.

Intraoperative Nursing DX: Risk for aspiration.
Ineffective protection.
Impaired skin integrity.
Risk for perioperative-positioning Injury.
Risk for imbalanced temperature.
Ineffective tissue perfusion.
Risk for deficient fluid volume deficit.

Postoperative Nursing diagnoses: Acute pain.
Risk for infection.
Risk for injury.
Risk for deficient fluid volume.
Ineffective airway clearance.
Ineffective breathing pattern.
Self care deficit.
(Bathing/Hygiene, dressing, grooming, toileting)
Ineffective Health maintenance.
Disturbed Body image.

Fundamentals pgs: 901, 911, 914

#31 Legal implications of delegation

#31 Explain the legal implications of delegation.
(pwr.pt.notes 10/12, kozier 470-473)

Delegation: (definition) Transference of responsibility and authority for the
performance of an activity to a competent individual.


Delegate-assumes responsibility for the actual performance of the task or procedure.(LVN,practical nurses, LPT,UAP,C.NA,surg. Tech, pt.care tech.)

Delegator- retains accountability for the outcome.

Delegation-
 Is a tool that allows the manager to devote more time to tasks that cannot be delegated.
 Enhances the skills and abilities of the delegate which can build self-esteem, promotes morale, and enhances team work and attainment of organizational goals.
 In nursing, refers to indirect care.

5 “Rights” of Delegation
 Right task
 Right circumstances
 Right person
 Right direction/communication
 Right supervision/evaluation

You as the RN/delgator are legally responsible for the delegate and the task for which you have delegated. Know the scopes of practice for the LVN,C.NA’s, assistants and their limitations. Review the charts Fig 26-2 Kozier pg.471, Fig 26-1 pg.470, Delegation decision-making grid pg 472 Kozier.

#18 Explain health behaviors

#18 Explain health behaviors (Kozier, pg.125,1455, ATI pg. 7)

Health Behaviors: (definition) the actions a person takes to understand his or her
health state, maintain an optimal state of belief, prevent illness and injury and
reach his or her maximum physical and mental potential.

Cognitive-perceptual factors in health promoting behaviors:

These are considered the main motivators for engaging in healthy behaviors.

 Importance the person places on health
 How much control a person feels he/she has over own health
 Perceived self-efficacy (belief that he/she can be successful in carrying out the behavior)
 The person’s definition of health
 The person’s perception of his/her health status
 Whether the person perceives that there will be benefits from the healthy behaviors
 Perceived barriers (how difficult the person thinks the behaviors/activities will be)

Modifying factors: are those that affect the cognitive-perceptual factors.

 Demographic factors (sex, age, education, income)
 Biologic characteristics (body build)
 Interpersonal characteristics (expectations of significant others)
 Situational factors (ease/difficulty accessing healthy alternatives, balanced meals, etc.)
 Behavioral factors (previous experience knowledge and skill)
 Cues to action (things that make person aware of potential for growth)