MDC EXAM 1 Review PDF

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EXAM REVIEW...

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CLIENT CENTERED CARE- CARING FOR A CLIENT AS A WHOLE, CONSIDERING THEIR CULTURE, BELIEFS, VALUES, INCLUDING THEM AND THEIR FAMILY IN ALL PARTS OF THEIR CARE. THE PATIENT FEELS SAFE, FREE FROM ANXIETY, PATIENT IS COMFORTABLE, MORE HOLISTIC APPROACH. Terms to know § § § § § § §

QSEN-Quality, Safety, and Education in Nursing CLABSI- Central Line Associated Blood Stream Infection CAUTI’s- Catheter Associated UTI RACE- Rescue, press the Alarm, contain the fire/close doors, and extinguish only small, contained area PASS- Pull the PIN, aim at base of fire, Squeeze handle, Sweep side to side at the base ISBAR- Situation, Background, Assessment, Recommendation communication STEPPS- Strategies, Tools, Enhance, Patterns, Patient, Safety

Maslow’s Hierarchy of Needs Abraham Maslow (1968) theorized that a person could not meet the needs of love and belonging and selfesteem without meeting basic physiological needs (Taylor, Lillis, Lynn & LeMone, 2015). Florence Nightingale modified the environment of care to meet the basic care and comfort needs of the men injured during the Crimean war. Miss Nightingale is known as the first nurse researcher and epidemiologist in our field. The focus of the next four modules is on the physiological, safety, and security needs of the client for basic care and comfort. Self-Actualization (5TH LEVEL) § The need for self-actualization is met when the person reaches maximum potential and acts in an unselfish manner. Esteem (4TH LEVEL) § Self-esteem needs are met when a person feels a sense of accomplishment and are recognized by others for that achievement Safety and security (3RD LEVEL) § Safety and security needs mean freedom from physical harm and feelings of fear and anxiety. Love and belonging (2ND LEVEL) § Love and belonging needs are met when the person seeks personal relationships with others. Physiological (1st level) this level is priority § Basic physiological needs include those needs that are essential for maintenance of life. Basic needs consist of:  Air  Food / Nutrition  Water  Temperature  Elimination  Rest / Sleep- Effects: caffeine, anxiety, location, pain, noise  Sexuality

 Physical Activity / Mobility Assessment  Safety and Security 1. Protection from physical harm- falls easily preventable injuries 2. Adequate Shelter- providing resources 3. Freedom from fear and anxiety- Fear normally associates with comfort / Pain from an illness.

Comfort- State of physical well-being, pleasure, and absence of pain or stress. Issues with comfortability can delay healing. Risk factors Associated with Comfort include : Physical-Pain, Nausea, Vomiting or more Emotional- Anxiety, Depression, Stress Physiological Consequences Affecting rest/comfort: Immune system imbalance, Obesity, Depression, Stress, Diabetes Interventions: § Assessment: Assess level of comfort, Assess pain level, Identify emotional status, Determine the underlying cause § Interventions to Prevent & Promote: Maintain a proper pain level, address any emotional stress, Ensure the patient is well-rested by creating a restful environment (clean linen, dark quiet room, etc.), Promote relaxation techniques (back rubs, guided imagery, etc.) Avoid caffeine, smoking and alcohol at bedtime. As this could making it harder for the patient to get restless, provide a snack before bedtime instead of eating a large meal. § Interventions for Maintenance (follow-up measures): Identify comfort level, implement treatment based on the need, Involve the interdisciplinary team (Social worker, case manager, counselor, etc.)

Pain Many consider pain the fifth vital sign. Vital signs are increased with pain A pain assessment plays a role in the client’s rest and comfort needs and in the area of anxiety, fear, depression, related to illness recovery. Nonverbal signs of pain: Grimacing, guarding, verbalization, and holding or touching the affected Verbal descriptive words of pain: mild, sharp, dull, aching, constant, and intermittent.

Complications associated with pain: Fear, Anxiey, Depression, Delayed recovery and healing Listed below are the different types of pain.       

Cutaneous pain: burning-of skin subcutaneous tissue Idiopathic: Pain without a cause or reason Visceral pain: deep internal menstrual cramps, labor pains, or gastrointestinal infections. Deep Somatic pain: fractures or sprains. Radiating pain: Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head. Referred pain: Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw. Phantom pain: Pain from an amputated limb.

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Neuropathic pain: injury of one or more nerves Acute pain: Short duration, rapid onset, and associated with some kind of injury. Chronic pain: Last 6 months or longer and interferes with activities of daily living.

Assessment of pain should be done before and after treatment. Subjective Data: –Patient description of symptoms is the most reliable information. –Individuals react to pain differently ---“Do not assume”

PQRST     

P (what Provoked it, Palliation-what makes it ease?) Q (Quality and Quantity what does it feel like, how much is it) R (Region-where is it? Radiation-does it spread?) S (Severity-does it interfere with activities? Scale:1-10) T (Time when did it start)

PAIN ASSESSMENT (1-6)  Show the pain scale and what its used for  Explain what it means 0-10 or smile to frown, switch if pt. does not understand  Let them know pain is anything they feel any discomfort (sharp, dull, stabbing, burning)  Verify the pt. understands the pain scale  Ask them to show you.  Set function/comfort goals. Ok you're at a 6 where can we do to make the pain not interfere with your daily life?

Pharmacological Interventions: NSAIDS, OPIODS-PCA, IM, EPIDURAL, TRANSDERMAL Medication For Pain may cause LOW BP, HR, sedation, respiratory depression, constipation, urinary retention, nausea and vomiting, and orthostatic hypotension (dizziness upon standing low BP.

Non-Pharmacological Interventions:      

Cognitive: Change the way client perceives pain, physical approaches to improve pain Imagery: thoughts, concentration Distraction: ambulation, deep breathing, television, music, games, repositioning Relaxation: yoga, meditation, muscle relaxation, aromatherapy Acupressure, acupuncture Cutaneous stimulations: warm/cold therapies, touch, massage, TENS

Nutrition Nutrition is needed for adequate body function. The body requires energy to function. The body cannot produce energy without the nutrients consumed in the food we eat. The main energy sources for the body are carbohydrates, fats, and proteins. Without the intake of these food sources, the body would be unable to obtain the resources it needs to meet basic care and comfort needs.

Risk Factors that affect Nutrition: Genetics, High stress, Depression, and social isolation, especially among older adults, Consuming fad diets that do not provide, adequate nutrients, Obesity, Lack of money to purchase food, Impaired food intake caused by dysphagia, poor appetite, or poor oral health, Thyroid disorders, Chronic diseases: COPD & cancer, Gastrointestinal (GI): diarrhea or vomiting, Anorexia or bulimia nervosa

Consequences of Decreased Nutrition: Decreased wound healing-low protein, Osteoporosis-low vitamin D & Calcium, Anorexia-iron decency, Aspiration risk- Esp in elderly, stroke, dementia, Alzheimer's. Also lead to increased edema: fluid unable to remain in vascular space. Elderly ability to chew and swallow decreases with age and could also affect nutrition.

Different forms of nutrition: Oral: Taking all nutritional intake by mouth Enteral: Taking all nutritional intake through an MG tube, G-Tube, Peg Tube Jejunostomy tube Parenteral: Taking nutrition through a centrally inserted IV line such as a PICC or central venous access device

Interventions:  

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Assessment- Ask about current or recent GI issues: nausea, vomiting, constipation, and diarrhea, (BMI). Assess skin, hair, and nails. Labs can check for protein, calcium, albumin levels. Interventions to Prevent & Promote: Suggest regular exercise and adequate nutrients, educate about avoiding high-calorie, high-fat foods with no nutritive value. Collaborate with the interprofessional team to implement the appropriate interventions (Dietician, Social Worker for meal on wheels, community resources) Interventions for Maintenance (follow-up): Include high-protein oral supplements, enteral supplements (either oral or by feeding tube), or parenteral nutrition, collaborate with the registered dietitian for specific instructions regarding enteral feedings; consult with the pharmacist to administer parenteral therapy. Weight the patient at least once a week or as prescribed, using the same scale at the same time of day and preferably before breakfast. Any orders will need Doctors Prior Approval

WATER Hydration status refers to the amount of fluid the client drinks and the amount of fluid the client loses from the body. If the client has a higher output of fluid, then the intake of fluid needs to be greater. Older adults have a diminished thirst sensation so special attention to oral intake may need to be considered. Fluids should be offered at regular intervals and left within the client's reach. It is important to take into consideration the clients who may have fluid restrictions such as clients who have a problem with fluid volume excess such as chronic renal failure, heart failure, and SIADH. Medications that affect hydration status include diuretics, laxatives, enemas, over-the–counter medications, and herbal remedies. Maintaining proper hydration and fluid imbalance is essential for normal body functioning, especially the heart and brain. Fluid Imbalances: Defect: Can lead to Dehydration Excess: Can lead to Edema Electrolyte Imbalance: Defect: Low Calcium (Hypocalcemia) Excess: High Calcium (Hypercalcemia)

Common Risk Factors for Fluid and Electrolyte Imbalance § § § § § §

Risk factors that can alter a person’s fluid and electrolyte balance include: Acute illnesses (e.g., vomiting and diarrhea) Severe burns Serious injury or trauma Chronic kidney disease Major surgery

§ Poor nutritional intake Older adults are especially at risk for imbalances in fluids and electrolytes because they have less body water, often have inadequate nutrition, and are most likely to experience acute and chronic illnesses.

Physiologic Consequences of Fluid and Electrolyte Imbalance §

lack of poor perfusion (blood flow) and oxygen delivery to all parts of the body.

Common Fluid Imbalances Fluid volume deficit (dehydration) Fluid volume excess (overload)

Common Electrolyte Imbalances

Hyponatremia (low serum sodium) Hypernatremia (high serum sodium) Hypokalemia (low serum potassium) Hyperkalemia (high serum potassium) Hypocalcemia (low serum calcium) Hypercalcemia (high serum calcium) Hypomagnesemia (low serum magnesium) Hypermagnesemia (high serum magnesium) hypotension (low blood pressure).

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A decrease in blood volume leads to

ELIMINATION is the excretion of waste from the body by the GI tract (as feces) and renal/urinary system (as urine). Bowel elimination occurs as a result of food and fluid intake and ends with passage of feces (stool) or solid waste products from food into the rectum of the colon. Urinary elimination control also depends on multiple factors, including muscle strength and nerve function. The primary interrelated concepts are fluid and electrolyte balance, tissue integrity, and nutrition.

Common Risk Factors for Changes in Elimination

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Incontinence of either the bowel or bladder can occur as a result of aging when pelvic floor muscles become weaker. Neurologic disorders such as stroke, dementia, and multiple sclerosis. Excessive use of laxatives may cause fecal (diarrheal) incontinence. Diarrhea also results from acute GI infections such as gastroenteritis and chronic inflammatory bowel diseases such as Crohn’s disease. Irritable bowel syndrome causes frequent diarrhea, constipation Retention of stool, or obstipation, is also common in older adults who have lack of adequate dietary fiber and fluids to promote fecal passage. Lack of exercise and use of certain medications such as opioids, diuretics, and psychoactive drugs can contribute to constipation in adults of any age. Spinal cord and brain injuries or diseases often cause involuntary control or retention of both bowel and bladder (neurogenic bowel and bladder). Chronic kidney disease can cause changes in the amount of urinary output, depending on the stage of the disease. UTI’s- ENCOURAGE CLINENTS TO WIPE FROM FRONT TO BACK, WOMEN ARE MORE SUSCEPTIBLE DO TO SHORTER URETHAS AND ITS LOCATION BY THE ANUS. NOT VOIDING AFTER SEXUAL INTERCOURSE, NOT WIPING FRONT TO BACK, SIT BATHS, DEHYDRATION CAN LEAD TO UTI’s CAUTI’s (frequent catheter use)

Physiologic and Psychosocial Consequences of Changes in Elimination Adults who have urinary or bowel incontinence are at risk for damage to tissue integrity. If not removed promptly from the skin, stool and urine can cause skin irritation, fungal infection, and/or skin breakdown, which are very uncomfortable. MUST WIPE EACH TIME THEY USE THE RESTROOM!! Elimination Terminology: § Stress incontinence: Involuntary loss of urine associated with sneezing or laughing. § Urge incontinence: Involuntary loss of large amounts of urine accompanied by a strong urge to urinate. § Overflow incontinence: Loss of urine along with a distended bladder. § Functional incontinence: Loss of urinary control related to immobility or external obstacles, or problems in thinking or communicating that prevent the client from reaching the bathroom. § Unconscious incontinence: Loss of urine when the person does not realize the bladder is full and has no urge to urinate Nursing interventions: Assessment § Monitor intake and output § Look at labs § Skin Integrity § Did the pt. have surgery? What medications are they on that could decrease output? Prevention/Promotion: § Promote proper nutrition-Fiber § Exercises- Kegel to strengthen floor wall Interventions for Maintenance (follow up) § Monitor for fluid/ electrolyte imbalances

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Teach incontinence pt.s about bladder training Talk about high fiber foods

REST/SLEEP- Sleep is necessary for the body’s normal function. Studies have linked “short sleeper”, as a person who sleeps less than 6 hours per night, to several longer term health effects. Studies have confirmed that adults and children who slept less the recommended length of hours per night were more likely to suffer from obesity (Taylor, Lillis and Lynn, 2015). Rest is defined as the body being in a decreased state of activity. Sleep is defined as a state of rest accompanied by an alteration of consciousness and inactivity. Insomnia: problem with falling and staying asleep Nurse can dim the lights, ask the client what helps them stay asleep at home

SEXSexuality is a complex integration of physiologic, emotional, and social aspects of well-being related to intimacy, self-concept, and role relationships. It is different from reproduction, which is the process of conceiving and having a child. Sexuality involves sex, sexual acts, and sexual orientation; these terms are different from gender identity, which is discussed later in. The primary interrelated concept is comfort. Not all changes in sex pattern are related to mental, it could be that the male or female is experiencing menopause or erectile dysfunction which is common in men with diabetes and decreased testosterone. As nurse it is best to assess to see if it relates more as physiological (normal things that happen to the body) or if it is psychological (more of a mind/mental thing). Physiological aspects can be addressed with drug therapy. Mental aspects should be encouraged to follow up with provider for further review. During assessment nurse should look at the patient's overall outlook on sexuality, ask probing question: how often, how many partners, is protection being used. Because these things could also interfere with a client's perception of sexuality/sex.

PHYSICAL ACTIVITYMobility is the ability of an individual to perform purposeful physical movement of the body. When a person can move, he or she can usually perform activities of daily living (ADLs) such as eating, dressing, and walking. This ability depends primarily on the function of the central and peripheral nervous system and the musculoskeletal system and is sometimes referred to as functional ability. The primary interrelated concepts are pain and sensory perception. A lack of physical activity could leave a client more susceptible to develop pressure ulcers and a list of other things related to decreased mobility.

Assessment of Mobility Observe patients within the environment to determine their mobility level. The mobility level of the patient is adequate if he or she can move purposely to walk with an erect posture and coordinated gait and perform ADLs without assistance. Assessment of muscle strength and joint range of motion (ROM) can also be measured using a scale of 0 to 5, with 5 being normal and 0 indicating no muscle contractility.

Health Promotion Strategies to Maintain Mobility and Prevent Decreased Mobility First assess the patients who are most at risk for decreased mobility. patient at home or in a health care facility:

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Teach patients to do active ROM exercises every 2 hours. Teach patients to perform “heel pump” activities and drink adequate fluids to help prevent venous thromboembolism (VTE) such as deep vein thrombosis (DVT). In collaboration with the occupational therapist, evaluate the patient’s need for assistive devices to promote ADL independence such as a plate guard or splint; encourage self-care. Evaluate the patient’s need for ambulatory aids such as a cane or walker; encourage ambulation; collaborate with the physical therapist if needed.

Vital Signs One of the most important nursing interventions the nurse has is the ability to monitor and interpret the client’s vital signs. Vital signs include the measurement of temperature, pulse, blood pressure and respirations. Temperature allows the nurse to assess client’s body temperature Temperature regulation, or thermoregulation, is determined by the client’s temperature. Normal temperature: 96.4 -99.5 degrees Fahrenheit / 35.7-7.5 Degrees Celcius Different methods a temperature can be taken: Orally-mouth, Axillary-under arm, Rectally-in anus, Temporal artery-forehead, Tympanic-ear Terms associated with temperatures: Hypothermia: temperature below the normal range that may be related to exposure to a cold environment Nursing Interventions: Warm patient with blankets, provide warm drinks Hyperthermia: temperature above the normal range that may be related to exercise or exposure to an abnormally hot environment: Nursing Interventions: encourage fluid intake by mouth

(Heart Rate) Pulse- allows the nurse to assess the how adequate the heart is pumping the blood to the body. Normal values: 60-100 beats per minute Pulse points:  carotid-(side of neck),  radial-(wrist by thumb)  brachial-(inner arm fold)  femoral-(sides of private area),  popliteal-(behind knee),  posterior tibial-(front of ankle)  dorsalis pedis arteries-(top of foot) Rate, Rhythm (regular or irregular), and Quality (strong, weak or bounding)

Blood Pressure allows the nurse to assess the force required to pump the blood through the body  Normal values: 120/80 (systolic ventricle constricts / diastolic ventricle relaxes)

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