NURS 356 Test 1 Notes - Outline for all the lectures leading up to Test 1 PDF

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Outline for all the lectures leading up to Test 1...

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NURS 356 Test 1 Notes YOU CANNOT MEMORIZE EVERYTHING. UNDERSTAND THE CONCEPTS & THEMES & COMPLICATIONS. WHAT YOU CAN DO TO PREVENT COMPLICATIONS AND KEEP PATIENTS SAFE CONCEPTS MESH TOGETHER A LITTLE BIT EVERYTIME THERE IS A MULTIPLE ITEM RESPONSE, THERE IS DEFINETLY MORE THAN 1 Chapter 24: Infection Control Components of Infection Cycle Infectious agent: bacteria, virus, fungi Reservoir: natural habitat of organism Portal of exit Means of transmission: Direct: two people touching each other Indirect: involve contact with fomite (object) where another person touches a contaminated fomite Airborne: pathogens can travel through air (heating, air conditioning systems) Droplet transmission: Portal of entry Susceptible host: person with inadequate defenses Break in infectious cycle can help kill a disease Incubation period: organism growing and multiplying Prodromal stage: where person is most infection because they don’t feel right and don’t really understand they are sick yet Full stage of illness: clear signs and symptoms Convalescent: recovery period Acute: rapid, sudden Chronic: slow, progressive Latent: presents with no symptoms HIV, AIDS Factor Indicating Infection Elevated WBC count Normal 5k-10k Increase in WBC/shift to the left Elevated erythrocyte sedimentation rate Prescence of pathogen in urine, blood, draining culture, sputum (mucous) Factors Affecting organism’s potential to produce disease Virulence: severity of disease

Host defenses/ immune system Length of contact between person and pathogen

Factors Effecting Host susceptibility Intact skin or mucous membranes? Normal pH levels? WBC count? Stress?

Age, sex, race, hereditary factors Immunity? Natural or acquired? Nutrition, fatigue? Use of invasive/indwelling medical devices?

Common portals of exit Anywhere, there is an opening in the body or where things can leave the body Respiratory: coughing sneezing gastrointestinal: pooping Genitourinary: peeing breaks in skin Blood and tissue

Defenses Inflammation Local: limited to one area Systemic: infection spread through blood and lymph Very bad!! HAI: hospital acquired infection Nosocomial: infection acquired from healthcare/hospital Exogenous: comes from another patient, pathogen, environment Endogenous: caused when normal flora multiply and cause infection Flora Flora: normal microbes on person’s skin Transient: sits loosely on skin, removed easily Resident: found in creases of skin, requires friction Factor determining disinfection methods -nature of pathogen -number of pathogens -available means of disinfection

-type of equipment -use of equipment -time

Aseptic Technique Medical asepsis: clean technique Used pretty much everywhere Prevents the growth of additional microbes CANNOT GET RID OF BACTERIAL SPORES

Surgical asepsis: sterile technique When doing a procedure or with a patient When inserting something IN THE OPERATING ROOM Rooms Droplet precautions: patients can be a normal room Negative pressure room: air is pumped out of a negative pressure room and filtered before being recirculated or getting rid of -air from the hallway is pulled in from the hallway and gotten rid of from the hospital -if it wasn’t negative pressure, the airborne disease could go back into the hallway and infect other people FOR PATIENT WITH AIRBORNE DISEASE Positive pressure room: air from the room is sent back out into the hallway and air from the hallway does not come into the room Mostly for immunocompromised patients

Chapter 31: Hygiene Factors effecting Hygiene -culture -socioeconomic class -health state: cuts?

-spiritual practices -developmental level -person preferences

Skin assessment -cleanliness -color skin to ensure redness and return to normal shape) -temperature -turgor/rigidity -moisture -sensation

-vascularity (press down on -lesions

Oral care NOTE IF TEETH ARE MISSING PATIENT NEEDS MOUTH CARE EVERY TWO HOURS IF THEY ARE NPO (NOTHING PER OS) NOTHING BY MOUTH -important even if patient is not alert: every two hours Could be choking hazard, turn them on side -dentures as well -flossing Early morning care -assist patient with toileting -wash hands and face -hair care -dressing

-comfort measure to prepare patient for day -mouth care -special skin measure -positioning for comfort

NEVER CUT PATIENTS TOENAILS Afternoon care -ensure patient comfort -straighten bed linen

-toileting, handwashing, oral care -help patient mobility/repositioning

Hour of sleep care -toileting, washing, oral care -change soiled linen -ensure everything is within reach

PRN care/ as needed care -individual hygiene measures as needed -oral care as needed Back massage -general body conditioner -improves circulation -decrease pain/anxiety Bathing -clean skin -musculoskeletal exercise -improve self image

-offer back massage -position patient comfortably

-change of linen as needed

-relives muscles and promotes relaxation -opportunity to observe skin of breakdown -may improve sleep

-helps relax -promotes circulation -comfort -stimulates rate & depth of respirations -promotes nurse and patient relationship

Bed Bath -provide bathing articles on overbed table/bedside stand -assist patient who cannot bathe themselves

-privacy -use bath blanket

Care of Eyes -clean from inner to outer canthus (from nose to temple) -use tear solution if patient cannot blink -clean glasses if needed Ear & nose care -Wash ear with washcloth finger -have patient blow nose

-no q tips -remove crust from nose

Hair care -don’t cut patient’s hair unless asked

-shampoo hair

Perineal and vaginal care -always wipe from front to back

-do it in dignified manner

Bedside safety -lowest bed position -call bell in reach -DOCUMENT

-locked wheels -side rails up (upper side rails) -cell phone in reach

Chapter 27: Safety Factors effecting safety -reduces chance of illness & injury -improves/maintains functions -developmental considerations (age) -social behavior: -mobility: how does patient move? -knowledge: does patient know their risk? -physical & psychosocial health state

-prevent extended length of treatment -increase patient’s sense of well being -lifestyle: what risk does age group have -environment: safe to be outside? -sensory perception: do they have senses? -ability to communicate

Focus of safety assessment 1st is patient: ALWAYS ASSESS ABC: AIRWAY, BREATHING, CIRCULATION 2nd is environment and risk factors in environment Safety is basic human need Nursing History -ask patient history when they come in -do they have a history of this? -patient who has history of falls will more likely fall again -why did they fall? Icy? Poor mobility? Pain? Dizzy? Identify cause of fall -sometimes may need to get info from family members; keep in mind confidentiality Orthostatic hypotension: when blood pressure drops really low and heart rate goes up to try to compensate -patient will feel dizzy during this -happens when you get up too quick Does patient have assistive devices? Cane, walker, brace?

Physical Examination -assess mobility -ability to communicate -identify risk; shoes untied? Stairs? -sensory perception -identify domestic violence -awareness/orientation (time, day, where, who?) -non-skid socks Falling Factors

-weakness -gait/balance issues -psychoactive meds -hazards in home

-poor vision -feet problems (pain/sores) -dizziness

Patient Outcomes for Safety -identify risk -implement safety measures in hospitals and ADLs (cleaning, eating, dressing, bathroom) -use resources (PT, OT) Root cause analysis (RCA): used to discover cause of injury and helps discover trends -not a punishment or guilt trip -helps re-evaluate strategies Teaching for Older Adults -aging is normal process= chronic illness is not; it is a pathological process Causes of Accidental Injuries in Older Adults -decreases senses -loss of strength -slower reflexes -chronic illness and medication side effects -poor finances -mental impairments Dementia: loss of memory Alzheimer: worsening dementia Sundowning: confusion in late afternoon and night. Body clock Cascade Iatrogenesis: multiple adverse effects Elder Abuse -financially -emotion -neglect

-sexually -psychological

Restraints: used to restrict patient movement/access to body to prevent injury to self or others Physical: mechanical device used to restrict movement Chemical: medication/sedative/psychotropic agents to disrupt behavior NEEDS A PHYSCIAN ORDER Hazards with restraints -increased possibility of injury due to fall -contractures (muscle atrophy) -depression -anxiety -death

-skin breakdown -lack of voluntary control delirium: confusion -aspiration

MUST HAVE REALLY GOOD DOCUMENTATION WHY RESTRAINT IS NECSSARY MUST HAVE RESTRAINT THAT IS LEAST RESTRICITIVE AND GIVES PATIENT MOST DIGNITY POSSIBLE If patient is restrained, must move them every two hours Restraint guidelines -never attach to moveable surface (side rail) -document -assess every 2hrs -check ABCs

-slip knots tied -educate why it is applied -pad bony prominences

Selecting Restraint -least restrictive possible -readily changeable -safe for particular client -least obvious to others -does not interfere with treatment or health problem Restraint Legal Implications -legal implications because restricts freedom -only use as last resort

-can injure patients with restrain -be aware of policies

Fire safety Race R: rescue those in immediate danger A: activate fire code/alarm & notify appropriate personnel C: confide fire; close doors and windows E: evacuate patients Incident/Safety Event Reports If anything goes wrong, must be documented -circumstance of accident -details patient response and treatment of incident -completed immediately -not part of medical record

Chapter 33: Activity & Mobility Activity and exercise involve mobility Body alignment Coordination ROM

balance joint mobility Evaluate Friction (especially in bed rest)

Effects of Immobility -atrophy -constipation: can’t move bowel -atelectasis: fluid collecting in lung -urinary tract infection: easier to pee with gravity -venous stasis: poor blood movement -sleep disturbances -glucose intolerance: not able to use up their sugar Anytime you are getting a client up after a long period of time: CHECK ORTHOSTATIC HYPOTENSION HAVE THEM DANGLE THEIR FEET Factors Influencing Mobility -developmental considerations (age) -mental health -attitude & values -External Factors

-physical health -Lifestyle -Fatigue and Stress

Types of Exercise Isotonic: muscle shortening, active movement Isometric: muscle contraction without shortening; can be done in bed Isokinetic: muscle contraction with resistance (using equipment) Exercise Benefits Cardiovascular Better heart efficient Increased blood flow Respiratory Improved alveolar ventilation Improved diaphragm Musculoskeletal Increased strength and flexibility Reduced bone loss

Physical Assessment for Mobility -ease of movement & gait? -joint structure and function? -muscle mass, tone, strength?

decrease heart rate and blood pressure better venous return decreased work breathing

increased coordination increased nerve impulse transmission

-alignment? -ROM? -endurance?

Protective Positioning Sims position: laying on their side, slightly on their chest Protective Supine: laying flat on their back Fowler’s: sitting as if they were in a chair Semi fowlers: less than 45 degrees

High fowlers: 90 degrees (when eating) Prone: person lying on their chest Medical Aids for walking Walker: move walker out, then step with affected leg Cane: cane goes on dominant side Chapter 25: Vital Signs Vital Signs -Temperature -Respiration -Oxygen Saturation

-Pulse -Blood Pressure -Pain

Temp: 98.6 Pulse rate 60-100 (80 average) Tachy > 100 Brady < 60 Respirations: 12-20 breaths/min Blood pressure: 120/80 When to assess vital signs -upon admission -change in patient condition -anytime loss of consciousness -before and after invasive procedures -before administering medications (that affect cardiovascular and respiratory function) -before and after activity that may increase risk -following institutional policies -assess pain levels shortly after giving pain reliver Temperature Recorded in Celsius many times (F-32) x 5/9= C Core temperature: deep tissues of body; more invasive Surface temperature: skin -temporal -tympanic -oral -axillary Heat production Increase in temperature is due to increased metabolism -infection -movement (burning calories) Assessing Body temperature Oral: wait 30 minutes after eating Blue probe Document PO

Rectal: sims position with Red probe -use lubricant Document R Axillary: Document Ax Tympanic membrane: document T

Transfer of Body Heat to External Environment Radiation: diffusion of heat from uncovered surface Convection: dissemination: fan blows over surface of warm body Evaporation: sweat evaporates Conduction: body transfer heat to another object by direct person Eliminating and Eliminated feces decreases heat Warming and humidifying inspired air decreases heat

Pyrexia: fever, increased body temp antipyretic: fever medication Hyperthermia: fever, increased body temp Febrile: fever, increased body temp Afebrile: no fever Factors Affecting body temp. Circadian rhythms: body temp lowest in the morning Don’t check fever temp in the morning Age: older  lower temp Gender: males are higher Physical activity: State of health:

Environmental temperature Characteristics of Peripheral Pulse -Rate -Amplitude (strong/weak) -Rhythm/pattern -Volume of blood ejected (stroke volume) Count pulse for 15 x 4 if normal Count pulse for 30 x 2 if normal

Factors Effecting Pulse -gender: men are lower -fever: increases pulse -hypovolemia: volume of blood -Position changes: orthostatic hypotension

Exercise: athletes have lower pulse & big amplitude Medications: Stress: sympathetic nervous system Pathology: decrease oxygen increased heart rate (anemic)

Arrhythmia: irregular beats Respirations Diffusion: exchange between lungs and blood Perfusion: exchange between blood and tissues Monitor: Rate depth (deep, shallow, normal) Rhythm effectiveness (uptake and transportation of O2) Eupnea: normal breathing (12-20 breaths per minute) One breath per four heartbeats Tachypnea: high respiration rate Bradypnea: low respiratory rate Apnea: periods when no breathing occurs Dyspnea: difficulty breathing (DOE= dyspnea on exertion; tied from using bathroom) Orthopnea: changes in breath when sitting or standing Ortho: erect/straightening out Assessing respirations 30sex x 2 if normal pattern 60sec for irregular Make sure client is relaxed and doesn’t know u are counting respirations Chest movements Intercostal, substernal, and suprasternal retraction Means patient is using many muscles just to breathe Factors affecting respiration

-exercise -low O2 concentration

-stress

Blood pressure -Measures pressure against arterial walls and elasticity of arteries Pumping action of heart peripheral vascular resistance Blood volume blood viscosity -avoid taking BP on injured or compromised parts of the body Hypertension: above normal Systolic: 130mmHg or higher Diastolic: 80mmHg or higher Hypotension: below normal 90/60mmHg We want systolic around 120 (120-139= prehypertension) We want diastolic around 80 (80-90= prehypertension) Factors Affect BP Age Gender Race Emotional state/stress Drug/medications

Food intake Exercise Weight body position circadian rhythm: lowest in morning

Pulse pressure: difference between systolic and diastolic BP Korotkoff sounds First sound: systolic Last sound: diastolic A single elevated BP reading requires as a reassessment Auscultatory gap: temporary disappearance of sounds normally heard over brachial artery Hypertension Primary: don’t know what the cause is Secondary: we know the cause; it is caused by another disease/disorder Hypotension: Orthostatic hypotension: Systolic: 85-110mmHg Know patient’s normal baseline numbers in order to identify is something is abnormal Oxygen Saturation

Percent of hemoglobin binding sites saturated with oxygen. percent of oxygen on hemoglobin Anemic and blood loss patients still may not be having enough blood because they don’t have enough binding sites even though the number looks good Normal is 95-100% Factors Assessing O2 -impaired circulation -excessive movement -carbon monoxide poisoning Shows 100% binding sites but it is carbon monoxide. Test only shows if something in bound to hemoglobin. Doesn’t show what is bound though Pain Use numerical scale 1-10 Chapter 32 Sterile Technique and Wound Care Factors Determining Use of Sterilization and Disinfection Methods -nature of organism -number of organisms -type of equipment -use of equipment -time -available means of sterilization & disinfection Aseptic technique: method used to keep an area clean; free from as many microorganisms are possible -activities to prevent or break chain of infection Sterile: area that has 0 microorganisms. Done by heat, autoclave, etc -takes place in the OR If an area is CLEAN it is NOT STERILE Medical asepsis: practice intended to limit growth and transmission of microorganisms Surgical asepsis: sterile technique; keeping area free from all microorganisms Use of surgical asepsis/ sterile technique -operating room and labor & delivery areas -certain diagnostic testing areas -patient bedside (insertion of catheter, needles, etc) Principle of Sterile Technique -all objects in sterile field must be sterile -they become unsterile when: Touched by nonsterile objects drops below the waist They are out of vision -when using tools, point them down to limit their interactions with airborne microorganisms -Skin cannot be sterilized

But we can use sterile technique with skin to limit transfer/growth of microorganisms -wear sterile gloves to handle sterile items Establishing sterile field -ensure equipment packet is intact and not tampered with -check expiration dates -use 1 inch border Functions of skin -protection -body temperature regulation -psychosocial -sensation -vitamin D production -immunologic -absorption -elimination Factors Affecting the Skin -unbroken skin and mucous membranes are defenses -moisturize skin to prevent it from breaking -adequate circulation -turn the patient Age Old people: have skin easier to break; at higher risk for skin breakdown. Decreased elasticity so more at risk for damage from pressure Babies: have thin skin so high risk for skin breakdown (diaper rash) Causes of Skin alterations -Obese and very thin people Dehydration Loose and flabby skin -Excessive sweat during illness may cause skin to breakdown Or having wet clothes/sheets -jaundice causes itchy skin -skin diseases Eczema, psoriasis Types of wounds Unintentional: accident, contaminated with bacteria Ex. Scraping your knee after falling off your bike Intentional: health care wounds, surgery, etc Wound Healing Primary intention: surgical wound where two ends are stitched together; not much tissue loss Secondary intention: body heals wound with scar tissue; happens more with unintentional wounds

The body will undergo its normal inflammatory/immune response of a wound whether it is intentional or not -adequate blood supply is needed -normal healing is promoted when the wound is free of foreign objects -extent of damage and person’s overall health impacts wound healing -response to wound is better with better nutrition Phases of Wound Healing Hemostasis -occurs immediately after injury. Involves vessels constrict and blood clotting -process to prevent bleeding Inflammatory: swelling and pain; WBCs, macrophages, leukocytes, etc move to wound -wound culture done ...