NUR 3524 Exam 2 Study Guide- Rasmussen College/NUR 3524 Exam 2 Study Guide- Rasmussen College

NUR 3524 - Exam 2 Focused Review Chapters from Reading Agenda for Exam 2: Lubkin – Chapters: 7 – Quality of Life; 9 – Family Caregiving; 16 – Health Promotion; and 22 – Palliative Car e Mullahy –Patient Engagement– SHARE approach (Mullahy, p.132) Iggy – Our exemplars(see below) covered in Chapters: 25 – Skin; 28, 29, 30 – Respiratory; 35- Cardiac Know and be able to IDENTIFY and EXPLAIN/DESCRIBE IN DETAIL: A. CAUTION – mnemonic for warning signs of cancer • C is a change in bowel or bladder habits • A is a sore that never heals • U is unusual discharge or bleeding • T is thickening or lump in breast or elsewhere • I is indigestion or dysphagia • O is an obvious change in mole or wart • N is a nagging cough or hoarseness B. Know the impacts/considerations/applications in client care for Quality of Life, Health Promotion, and Palliative Care (8 domains of palliative care – handout, barriers to palliative care) • Quality of Life o Impacts/consideration ▪ Varies from person to person (subjective and objective): defined as a person’s satisfaction or dissatisfaction related to their functional ability ▪ Circumstances, experiences, and stages of life contribute to positive and negative subjective quality of life ▪ Consider appraisal of one’s own life, identification of physical, psychological, and social satisfaction, and objective measures to enhance personal evaluation ▪ Chronic illness places a burden on patients and their families typically leading to a decreased QOL o Application ▪ Appropriate measurement is crucial ▪ Patient Reported Outcome Measurement Information System (PROMIS) • a multidimensional measurement tool to help patients accurately report symptoms, functioning, and HRQOL to their healthcare providers ▪ Allow patients to make choices, apply motivational interviewing, customize medication and treatment regimes o Health Promotion ▪ Impacts/consideration • Health promotion is a multidimensional concept that focuses on maintaining or improving the health of individuals, families, and communities. • Defining health promotion in chronic illness • US stance o The CDC emphasizes that chronic diseases are among the most common, costly, and preventable of all health problems. o Four modifiable health-risk behaviors: ▪ lack of physical activity ▪ poor nutrition ▪ tobacco use ▪ excessive alcohol consumption • Challenges and Barriers o Many risks to health—obesity, diabetes, hypertension, heart disease, cancer, and other chronic conditions—result from failure to engage in preventive care. More closely articulated preventive, public health, and policy programs are needed to promote a healthy life. o Reported barriers to health screening and other preventive care must be addressed. o Unfortunately, many people in the United States do not have easy access to healthy foods and safe, convenient places to exercise. o Other barriers exist for health screening, such as fear and embarrassment o Problems with health literacy are commonplace in our society. ▪ Application/intervention • Interventions include o Motivational interviewing o Motivational factors o Health coaching o Mass-media campaigns o Web-based campaigns o contracts • Health literacy o Increased health literacy o Seven steps to address the barriers ▪ (1) increasing sensitivity to the problem; (2) developing a literacy-assessment protocol; (3) creating and evaluating materials for the target populations; (4) providing clear communication; (5) including health literacy in nursing curricula; (6) fostering decision making with patients; and (7) conducting research into literacy issues. o Palliative Care ▪ 8 domains • Structure and processes of care o Interdisciplinary team assessment based on patient/family goals of care, prognosis, disposition (level of care – inpatient, home); safety • Physical aspect of care o Pain, dyspnea, N/V, fatigue, constipation, performance status, medical diagnosis, medications (add/wean/titrate) • Psychological aspect of care o Anxiety, depression, delirium, cognitive, impairment; stress, anticipatory grief, coping strategies, pharm/non-pharm treatments, patient/family grief/bereavement • Social aspect of care o Family/fiend communication/interaction/support; caregiver crisis • Spiritual aspect of care o Spiritual/religious/existential; hope/fears; forgiveness • Cultural aspect of care o Language, ritual, dietary, other • Care of the imminently dying o Presence; recognition and communication to patient/family education/ normalization; prognosis ( hours to days, few days) • Ethical and legal aspect of care o Decision maker, advanced directive ▪ Barriers to palliative care • Medical philosophy that emphasizes cure and prolongation of life over quality of life and relief of suffering • Insurance reimbursement • Lack of public understanding • Research is needed on caregiver stress and palliative care ▪ Interventions • Determining goals of care • Assessment and treatment of symptoms • Advanced directives • Psychosocial, spiritual, and bereavement needs • Culture and palliative care • Education for healthcare professionals • Research • Palliative care and genomics C. *For all of the following exemplars – know the application/considerations in client care and all stages of the nursing process; including risk factors, client teaching, interventions/treatments, and psychosocial considerations. o Skin ▪ Pressure Ulcers - A pressure injury (PrI) is a loss of TISSUE INTEGRITY caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. • risk factors o MINI ▪ Mental status changes ▪ Impaired mobility ▪ Nutritional status ▪ Incontinence o Immobility. This might be due to poor health, spinal cord injury and other causes. ▪ For individuals who are confied to a bed, common sides include • Back or sides of the head • Shoulder blades • Hip, lower back or tailbone • Heels, ankles and skin behind the knee • o Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. ... o Poor nutrition and hydration. ... o Medical conditions affecting blood flow. o Mental status changes and decreased sensation determine whether the patient is a partner in pressure injury prevention. When the patient understands that turning and shifting of weight prevent tissue damage, the risk for pressure injuries decreases. Stroke, head injury, organic brain disease, Alzheimer's disease, sedation, or other cognitive problems increase the risk for pressure injuries. o Wheelchair ▪ Tailbone or buttocks ▪ Shoulder blades and spine ▪ Backs of arms and legs where they rest against the chair • client teaching o Shift your weight frequently. If you use a wheelchair, try shifting your weight about every 15 minutes. Ask for help with repositioning about once an hour. o Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups — raising your body off the seat by pushing on the arms of the chair. o Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure. o Select cushions or a mattress that relieves pressure. Use cushions or a special mattress to relieve pressure and help ensure your body is well- positioned. Do not use doughnut cushions, as they can focus pressure on surrounding tissue. o Adjust the elevation of your bed. If your bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing • interventions/treatments o Keep skin clean and dry. Wash the skin with a gentle cleanser and pat dry. Do this cleansing routine regularly to limit the skin's exposure to moisture, urine and stool. o Protect the skin. Use plain talcum powder to protect skin at friction points. Apply lotion to dry skin. Change bedding and clothing frequently if needed. Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin. o Inspect the skin daily. Look closely at your skin daily for warning signs of a pressure sore • psychosocial considerations o care settings, facilities can use bidirectional video to consult with a wound specialist at the bedside and get recommendations on how to better manage nonhealing wounds ( o The patient with pressure injuries may have an altered body image. Many changes in lifestyle are needed for healing. Chronic injuries are often painful and costly to treat. Assess the patient's and family's knowledge of the desired treatment outcomes during the healing process and adherence to the prescribed treatment regimen. Also assess the patient's skills in cleaning and dressing the wound. Poor adherence to pressure injury care procedures may reflect an inability to cope with the pain, cost, or potential scarring associated with prolonged healing. Depending on the patient's activity level and the ulcer location, family assistance or a home care nurse may be needed to provide pressure injury care at home. o Teach the patient and family specific changes in ADLs to relieve pressure and promote healing. Encourage increased activity whenever possible to enhance circulation to the affected tissue. Leg position changes may be needed for chronic leg ulcers, depending on whether vascular problems are present. For patients who have arterial insufficiency, keeping the legs and feet in a dependent position helps ensure adequate blood flow to the lower legs. When arterial blood flow is adequate but venous return is impaired, elevation of the legs may be needed for healing. When the patient is bedridden, frequent repositioning to relieve pressure can be labor intensive. In the home, repositioning, incontinence management, and dressing changes are often needed around the clock, not only increasing patient discomfort but also disrupting family and creating stress. ▪ Psoriasis is a skin disorder characterized by scaly, dermal patches and caused by overproduction of keratin. It is thought to be an autoimmune disorder and has periods of exacerbations and remissions. Although lesions can appear anywhere, they are commonly present on the elbows, knees, trunk, scalp, sacrum, and the lateral aspects of extremities. Rashes can evolve from acute to chronic, and place the client at increased risk for bacterial infection resulting from breaks in the skin caused by scratching • Assessment findings o Scaly Patches o Bleeding stimulated by removal of scales o Skin lesions primarily on the scalp o Elbows and knees, sacrum, and lateral areas of the extremities o Pitting, crumbling nails • Risk Factors o Infections (severe streptococcal throat infection, Candida infection, upper respiratory infection) o Skin trauma (recent surgery, sunburn) o Genetics o Stress (related to overstimulation of the immune system) o Seasons (warm weather improves symptoms) o Hormones (puberty or menopause) o Medications (lithium, beta-blocker, indomethacin) o Obesity o Female gender • Client teaching and Interventions/ treatments o Topical Therapy ▪ Used to treat moderate-to-severe psoriasis are topical steroids, topical tar and anthralin preparations, and ultraviolet (UV) light. ▪ Topical therapy with anthralin (Zithranol, Anthraforte image, Drithocreme, Psoriatec), a hydrocarbon similar in action to tar, also relieves chronic psoriasis. These drugs can be used alone or in combination with coal tar baths and ultraviolet (UV) light. ▪ Teach the patient to apply the high-potency anthralin, suspended in a stiff paste, to each lesion for short periods of time as directed by the physician. The drug is a strong irritant and can cause chemical burns if left on lesions too long or not washed off completely after each treatment. Remind the patient to check for local tissue reaction and to take care to prevent this drug from coming into contact with uninvolved skin. o Corticosteroids ▪ have anti-inflammatory actions. When applied to psoriatic lesions, they suppress cell division. The effectiveness of a topical steroid depends on its potency and ability to be absorbed into the skin. The more potent agents are used as therapy for patients with psoriasis. Examples of commonly prescribed topical corticosteroids include clobetasol (Temovate, Dermovate image), triamcinolone (Aristocort, Triaderm image), fluocinolone (Synalar, Fluoderm image), and betamethasone (Diprolene). ▪ Teach patients to enhance the skin penetration of these drugs by applying the steroid directly to the skin. When prescribed, using warm, moist dressings and an occlusive outer wrap of plastic (film, gloves, booties, or similar garments) may enhance absorption. Avoid using high potency steroids on the face, scalp, or skinfold areas because of the potential for increased absorption and side effects. o Tar preparations ▪ Tar preparations applied to the skin suppress cell division from impaired CELLULAR REGULATION and reduce inflammation. These drugs are available as solutions, ointments, lotions, gels, and shampoos. The ointments are messy, cause staining, and have an unpleasant odor. o UV Therapy ▪ is limited by exposure time and effects on the surrounding normal skin. The time of exposure is gradually increased to achieve a mild suntan effect without burning or tenderness. The patient's skin pigmentation determines the exposure times. Because of the extremely high intensity of most artificial UVB light sources, therapy is measured in seconds of exposure, and patients must wear eye protection during treatment. Narrow- band UVB light therapy, although intense, can shorten the time to effectiveness and reduce the number of exposures needed to maintain the response. ▪ A (UVA) (PUVA) therapy involves the ingestion of a photosensitizing agent (psoralen) 45 to 60 minutes before exposure to UVA light. Therapy sessions are limited to two or three times a week and are not given on consecutive days. Exposure is gradually increased until tanning occurs. Dosages are adjusted according to the erythema reaction of normal skin and the response of psoriatic lesions. ▪ Teach the patient to check for redness with edema and tenderness. If these are present, treatment must be interrupted until they subside. Because psoralen is a strong photosensitizer, patients must wear dark glasses during treatment and for the rest of the day. o Light therapy ▪ Light therapy with lasers can be effective in controlling mild- to-moderate psoriasis. Laser sources, whether administered in a continuous or pulsed exposure, allow for better focus on the lesions and reduce exposure to the surrounding normal skin. ▪ Teach patients to inspect the skin carefully each day for signs of overexposure. If tenderness on palpation occurs and severe erythema or blister formation develops, notify the primary health care provider before therapy is resumed. o Systemic Therapy ▪ Oral systemic agents are often prescribed when psoriasis fails to respond to topical treatment. Agents commonly used include acitretin (Soriatane), a vitamin A derivative, and apremilast (Otezla), a small molecule inhibitor that inhibits the spontaneous production of tumor necrosis factor alpha (TNF- α). • Psychosocial Considerations o Often patients' self-esteem suffers because of the presence of skin lesions. Encourage the patient and family members to express their feelings about having an incurable skin problem that can alter appearance. Support groups for individuals with psoriasis are available in many communities. Urge patients and families to consider participating in these groups. o The use of touch takes on an added significance for patients with psoriasis. For example, shake the patient's hand during an introduction or place a hand on the patient's shoulder when explaining a procedure. Do not wear gloves during these social interactions. Touch, more than any other gesture, communicates acceptance of the person and the skin problem. • Respiratory o application/considerations in client care and all stages of the nursing process including ▪ Most patients with hypoxia require an oxygen flow of 2 to 4 L/min via nasal cannula or up to 40% via Venturi mask to achieve an oxygen saturation of at least 95%. For a patient who is hypoxemic and has chronic hypercarbia (increased partial pressure of arterial carbon dioxide [PaCO2] levels), the FiO2 delivered should be titrated to correct the hypoxemia and achieve generally acceptable oxygen saturations in the range of 88% to 92%. ▪ Arterial blood gas (ABG) analysis is the best measure to determine the need for oxygen therapy and evaluate its effects o client teaching ▪ Hazards and Complications of Oxygen Therapy ▪ Oxygen-Induced Hypoventilation. ▪ Combustion ▪ Oxygen toxicity ▪ Absorptive atelectasis: due to collapse of alveoli secondary to dilution of nitrogen and leakage of oxygen out of the alveoli. detected as crackles or decreased breathe sounds. o interventions/treatments ▪ before starting oxygen therapy and while caring for a patient receiving oxygen therapy, you must be knowledgeable about oxygen hazards and complications. Know the rationale and the expected outcome related to oxygen therapy for each patient receiving oxygen. Chart 28-1 lists best practices for patients using oxygen therapy. o psychosocial considerations ▪ When home oxygen therapy is prescribed, begin a teaching plan about it. The nurse or respiratory therapist teaches the patient about the equipment needed for home oxygen therapy and the safety aspects of using and maintaining the equipment. Equipment may include oxygen source, delivery devices, and humidity sources. Work with the discharge planner to help the patient select a durable medical equipment (DME) company to deliver oxygen equipment and select a community health nursing agency for follow-up care in the home. Re-evaluation of the need for oxygen therapy occurs on a periodic basis. ▪ While providing discharge planning and teaching, be sensitive to the patient's emotional adjustment to oxygen therapy. Encourage the patient to share feelings and concerns. He or she may be concerned about social acceptance. Help him or her realize that adherence to oxygen therapy is important for being able to participate in ADLs and other events that bring enjoyment. o Home Care preparations ▪ Home oxygen therapy is provided in one of three ways: compressed gas in a tank or a cylinder, liquid oxygen in a reservoir, or an oxygen concentrator. Compressed gas in an oxygen tank (green) is the most often used oxygen source. The large H cylinder may be used as a stationary source, and the smaller E tank is available for transporting the patient (Fig. 28-9). Even smaller cylinders are available for the patient to carry. Teach the patient and family to check the gauge daily to assess the amount of oxygen left in the tank. As a safety precaution, the tanks must always be in a stand or rack. A tank that is accidentally knocked over could suddenly decompress and move around in an uncontrolled manner. • Cardiac o application/considerations in client care and all stages of the nursing process including o risk factors o client teaching ▪ Health teaching is essential for promoting self-management (also called self-care). Many patients are re-admitted to hospitals because they do not maintain their prescribed treatment plan, including lifestyle changes. Because of the need for extensive discharge instructions, most hospitals are using teaching packets with videos, CDs, and easy-to-read information about the importance of adhering to specific self-management strategies at home. One standardized and commonly used self-management plan called MAWDS.Medication reconciliation is also important to be sure that similar drugs are not being prescribed and that patients meet the Core Measure requirements for HF. It is important to perform a learning needs assessment and tailor education to the patient's particular need to see changes in behavior and improved outcomes. ▪ Teach clients taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter the effects of hypokalemia o interventions/treatments ▪ Monitor daily weight and I&O. ▪ Assess for shortness of breath and dyspnea on exertion. ▪ Administer oxygen as prescribed. ▪ Monitor vital signs and hemodynamic pressures. ▪ Position the client to maximize ventilation (high-Fowler’s). ▪ Check ABGs, electrolytes (especially potassium if on diuretics), SaO2, and chest x-ray findings. ▪ Assess for signs of medication toxicity (digoxin toxicity). ▪ Encourage bed rest until the client is stable. ▪ Encourage energy conservation by assisting with care and ADLs. ▪ Maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake). ▪ If the patient is able, the cardiac rehabilitation specialist (or assistive nursing or physical therapy personnel) might time him or her for 6 minutes while walking at a comfortable pace. The distance the patient can walk can be used to determine his or her functional level and activity plan. At discharge, encourage the patient to continue with cardiac rehabilitation. In addition to exercise programs, cardiac rehabilitation provides education on risk factor modification, medication adherence, and diet and weight management o psychosocial considerations ▪ Patients with chronic HF need to make many adjustments in their lifestyles. They must adhere to the collaborative plan of care that includes dietary restrictions, activity, prescriptions, and drug therapy. They need careful, concise explanations of the self-management plan. The community-based nurse in any setting encourages the patient to verbalize fears and concerns about his or her illness and helps to explore coping skills. Patient participation in self-management can help alleviate and control symptoms. ▪ The patient in severe heart failure initially requires physical and emotional rest for energy management. On the first day of hospitalization, he or she may sit up in a chair for meals and perform basic leg exercises while out of bed. Organize nursing care to allow periods of rest. Collaborate with the interprofessional team, including the physician, nurse, respiratory therapist, and clergy, to observe and document the patient's physiologic and emotional response to activity. ▪ As the patient's condition improves, it is important to consult cardiac rehabilitation specialists. The cardiac rehabilitation specialist will start ambulation, usually on hospital day 2. The cardiac rehabilitation specialist or nurse checks the BP, pulse, and oxygen saturation before and after the activity. A BP change of more than 20 mm Hg or a pulse increase of more than 20 beats/min may indicate that the activity is too stressful. Other indications of activity intolerance include dyspnea, fatigue, and chest pain. Ask a patient having any of these symptoms to rate exertion on a scale of 1 to 20, with 20 being the maximum perceived exertion. If the patient rates the exertion more than 12, remind him or her to slow down. If activity is tolerated, the cardiac rehabilitation specialist steadily increases the activity level until the patient is ambulating 200 to 400 feet several times per day. D. Skin: Pressure injuries – stages; ABCDE’s of skin lesion assessment; Skin Cancers: SCC, BCC, Melanoma; Psoriasis o Pressure injuries – stages • Stage 1: o Skin is intact. Area, usually over a bony prominence, is red and does not blanch with external pressure. For patients with darker skin that does not blanch, observe pressure-related alteration of intact skin; changes are compared with an adjacent or opposite area and include one or more of these, Skin color (darker or lighted than the comparison area), Skin temperature (warmth or coolness). Tissue consistency (firm or boggy). Sensation (pain, itching), the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. • Stage 2: o Skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. Ulcer is superficial and may be characterized as an abrasion, a blister (open or fluid-filled), or a shallow crater. Bruising is not present. • Stage 3: o Skin loss is full thickness. Subcutaneous tissues may be damaged or necrotic. Damage extends down to but not through the underlying fascia; bone, tendon, and muscle are not exposed. The depth can vary with anatomic location; areas of thin skin (e.g., the bridge of the nose) may show only a shallow crater, whereas thicker tissue areas with larger amounts of subcutaneous fat may show a deep, crater-like appearance. Undermining and tunneling may or may not be present. • Stage 4: o Skin loss is full thickness with exposed or palpable muscle, tendon, or bone. Often includes undermining and tunneling, Sinus tracts may develop, Slough and eschar are often present on at least part of the wound. • Unstageable: o Skin loss is full thickness; and the base is completely covered with slough or eschar, obscuring the true depth of the wound. o ABCDE’s of skin lesion assessment ▪ A- Asymmetry ▪ B- Border ▪ C- Color ▪ D- diameter ▪ E- Evolve o Skin Cancers: SCC, BCC, Melanoma; Psoriasis ▪ Basal cell carcinoma • Pearly papule and dimple • Least dangerous ▪ Squamous cell carcinoma • Occur in sun exposed areas • Cosmetic issues • Client teaching o Wear sunscreen, reapply every 2 hours o SPF 30 or more o Sunglasses o Umbrella ▪ Melanoma • Most dangerous • ABCDE • Check mole ▪ Psoriasis • Comorbidity with metabolic syndrome • Working with clients o Do not need gloves! o Therapeutic touch o Introduction of hand on shoulder • Risk factors o Hereditary, stress, infection, candida and strep (cold symptoms), age group, female, hormone change, menopause, obesity, weather, recent trauma(burning), meds(lithium, beta blocker, andomethazine for gout) • If a client has excessive bleed or dryness in areas then there risk of infection increases • Finger nail chances such as pitting, crumble and disfiguring • Respiratory: Care of Clients with a Tracheotomy (suctioning), Respiratory Medication Handout, COPD, Cancer, Obstructive Sleep Apnea (remember STOP-Bang), Cystic Fibrosis o Care of Clients with a Tracheotomy (suctioning) ▪ Assess the patient ▪ Secure tracheostomy tubes in place ▪ Prevent accidental decannulation ▪ Hyper oxygenate ▪ Thumb not applying suction while inserting ▪ Withdraw intermittence suctioning/release of thumb ▪ Complication include • Hypoxia • Tissue trauma • Infection • Vagal stimulation, bronchospasm • Cardiac dysrhythmias ▪ Bronchial and oral hygiene • Turn reposition every 1 to 2 hours, support out of bed activities, encourage early ambulation • Coughing and deep breathing, chest percussion, vibration, an postural drainage promote pulmonary care • Avoid glycerin swabs or mouthwash that contains alcohol for oral care • Assess or ulcers, bacterial growth and infection ▪ Nutrition with tracheostomy • Swallowing can be a major problem for patients with tracheostomy tube • If balloon is inflated, can interfere with passage of food through the esophagus • Elevate head of bed for at lest 30 minutes after eating to prevent aspirations during swallowing ▪ Weaning from trach • Cuff is deflated when patient can manage secretions; does not need assisted ventilation • Change from cuffed to uncuffed tube • Size pf tine decreased by capping; use smaller fenestrated tube • Tracheostomy button has potential danger of getting dislodged o Respiratory Medication Handout ▪ Read it o COPD ▪ Emphysema • Loss of lung elasticity • Hyperinflation • Dyspnea • Air trapping ▪ Chronic bronchitis • Inflammation of the bronchi and bronchioles • Caused by chronic expose to irritants • Affects only airways, not alveoli • Production of large amounts of thick mucus ▪ Etiology and prevalence • Cigarette smoking is the greatest risk factors • Alpha 1- antitrypsin • Incidence and prevalence o COPD is the fourth leading cause of morbidity and death ▪ Complications of COPD • Hypoxemia/ tissue anoxia • Acidosis • Respiratory infections • Cardiac failure, especially cor pulmoale • Cardiac dysthymias ▪ Interprofessional collaborative care COPD • Assessment o History ▪ Smoking history ▪ breathing problems and assess whether he or she has any difficulty breathing while talking. ▪ Ask the patient to compare the activity level and shortness of breath now with those of a month ago and a year ago ▪ Difficulty sleeping ▪ Dyspnea and mucus production often result in poor food intake and inadequate nutrition. o appearance ▪ Increasingly severe COPD is thin, with loss of muscle mass in the extremities, although the neck muscles may be enlarged. ▪ He or she tends to be slow moving and slightly stooped. ▪ The patient often sits in a forward-bending posture with the arms held forward, a position known as the orthopedic or tripod position o respiratory chances o cardiac changes ▪ Analysis: interpreting • Decreased gas exchange • Weight loss • Anxiety decreased endurance • Potential for pneumonia ▪ Planning and implementation • Improved gas exchange and reduce carbon dioxide retention o Pursed lipped breathing • Prevent weight loss o Teach the patient to plan the biggest meal of the day for the time when he or she is most hungry and well rested. o Four to six small meals a day may be preferred to three larger ones. o Remind patients to use pursed-lip and abdominal breathing and to use the prescribed bronchodilator 30 minutes before the meal to reduce bronchospasm. o Advise the patient to avoid dry foods that stimulate coughing and caffeine-containing drinks that increase urine output and may lead to dehydration. o Urge the patient to eat high-calorie, high-protein foods • Minimize anxiety o develop a written plan that states exactly what he or she should do if symptoms flare o Support group • Increase endurance o Patient to pace activities and perform as much self-care as possible. o Suggest the use of oxygen during periods of high energy use such as bathing or walking. o Encourage the patient to avoid working with the arms raised. • Prevent respiratory infection o Teach patients to avoid crowds and stress the importance of receiving a pneumonia vaccination and a yearly influenza vaccine. ▪ Nonsurgical management • Breathing techniques • Position o High fowlers • Effective coughing • Oxygen therapy o Safety • Drug Therapy • Suctioning • Hydration o Thins mucus ▪ Drug therapy • Beta Adrenergic • Cholinergic antagonists • Corticosteroids • NSAIDS • mucolytic ▪ Care coordination • Home care management o Long term use of oxygen o Pulmonary rehabilitation program • Self-management education o Drug Therapy o Manifestation of infection o Breathing techniques o Relaxation therapy • Healthcare resources o Cancer ▪ Assessment • Lumps in mouth, throat, and neck • Difficulty swallowing • Color changes in mouth or tongue • Oral lesion or sore that does not heal in 2 weeks • Persistent, unilateral ear pain • Persistent/unexplained oral bleeding • Numbness of mouth lips or fact • Changes in fit of dentures • Hoarseness of change in voice • SOB • Anorexia and weight loss • Change in fit of dentures • Burning sensation when drinking citrus or hot fluids ▪ Care coordination and transition management • Home care management • Self-management education o Stoma care o Communication o Smoking cessation • Psychosocial preparation • Health care resources ▪ Planning and implementation: responding head and neck cancer • Radiation therapy • Chemotherapy o Pancytopenia • Cortectomy • laryngectomy o Communication needs o Obstructive Sleep Apnea (remember STOP-Bang) ▪ STOP BANG assessment • Snoring • Tired • Observed • Pressure • Body mass index • Age • Neck size • gender ▪ Breathing disruption during sleep • 10 seconds 5 times and hour ▪ Excessive daytime sleepiness; inability to concentrate, irritability ▪ Usually involved in overnight sleep study ▪ MAIN CONCEPT IS THEY WAKE UP TIRED ▪ Nonsurgical management • Change of sleep position o High folwer • Weight loss • Positive pressure ventilation o CIPAP or BIPAP ▪ Surgical management ( last resort) • Adenoidectomy • Uvulectomy • ululopalatopharygoplasty o Cystic Fibrosis ▪ Assessment • Non-pulmonary symptoms o Abdominal distention o GERD, rectoal proplapse, foul-smelling stools, statorrhea o Malnourishment, vitamin deficiencies • Pulmonary symptoms o Respiratory infections o Chest congestion and sputum production o Decreased pulmonary function o Limited exercise tolerance ▪ Interventions • Nutritional management o Nutrition management focuses on weight maintenance, vitamin supplementation, diabetes management, and pancreatic enzyme replacement. • Preventive/maintaince therapy o involves the use of positive expiratory pressure, active cycle of breathing technique, and an individualized exercise program. Daily chest physiotherapy with postural drainage is beneficial for the patient with CF. • Exacerbation therapy o Every attempt is made to avoid mechanical ventilation for the patient with CF. o Management focuses on airway clearance, increased GAS EXCHANGE, and antibiotic therapy. ▪ Supplemental oxygen is prescribed on the basis of SpO2 levels.. Bronchodilator and mucolytic therapies are intensified. Steroidal agents are started or increased o Teach patients about protecting themselves by not routinely shaking hands or kissing in social settings. ▪ Handwashing is critical because the organism also can be acquired indirectly from contaminated surfaces such as sinks and tissues. • hydration ▪ Surgery • Lung transplant is not usually implemented because of increased risk of lethal pulmonary infections E. Cardiac: CHF (remember MAWDS) o Right sided verses left sided ▪ Right sided • Causes o Left ventricular failure o Right ventricular MI o Pulmonary Hypertension • Increased volume and pressure in venous system and peripheral edema • Clincial manifestation o Jugular vein distention o Increased abdominal girth o Dependent edema o Hepatomegaly o Hepatojugular reflux o Asceities o Weight is the most reliable indicator of fluid gain/loss ▪ Left sided • Causes o Hypertension o Coronary artery disease o Valvular disease • Clinical manifestation o Weakness o Fatigue o Dizziness o Acute confusion o Pulmonary congestion o Breathlessness o oliguria o Implementation ▪ Increasing gas exchange • Ventilation assistance • Monitor respiration every 1 to 4 hours • Auscultate breath sounds every 4-8 hours • Position in high fowlers if patient is dyspneic • Maintain oxygen saturation of 90% ▪ Improving cardiac output • Increase pump effectiveness- medications • Hemodynamic regulations ▪ Drugs to reduce afterload, preload, and enhance contractility • Drugs used to reduce afterload o ACE inhibitors o ARB o ARNI Human BNP • Interventions to reduce preload o Nutrition ▪ Decrease sodium intake ▪ Balance diet drink fluids with diuretics, safety with regards to orthostatic hypotension, Diuretics in the AM o Drug therapy ▪ Diuretics ▪ Venus vasodilators. • Drugs that enhance contractility o Inotropic drugs ▪ Digoxin • Not given if pulse is less than 60 • No hallows- digoxin toxicity. o Beta adrenergic blockers o Aldosterone antagonist o HCN channel blockers ▪ Surgical management ▪ Decreasing fatigue • Energy maintance • Cardiac rehabilitation o FUction level o Acivity plan o Care coordination and transition management ▪ Home care management • Chart 35-4 ▪ Teaching for self-management • One standardized and commonly used self-management plan called MAWDS o Medications: ▪ Take medications as prescribed and do not run out. ▪ Know the purpose and side effects of each drug. ▪ Avoid NSAIDs to prevent sodium and fluid retention. o Activity: ▪ Stay as active as possible but don't overdo it. ▪ Know your limits. ▪ Be able to carry on a conversation while exercising. o Weight: ▪ Weigh each day at the same time on the same scale to monitor for fluid retention. o Diet: ▪ Limit daily sodium intake to 2 to 3 grams as prescribed. ▪ Limit daily fluid intake to 2 liters. o Symptoms: ▪ Note any new or worsening symptoms and notify the health care provider immediately. • Activity o However, teach the patient not to overdo it. o When exercise is indicated, teach the patient to begin walking 200 to 400 feet per day. At home the patient should try to walk at least 3 times a week and should slowly increase the amount of time walked over several months. If chest pain or severe dyspnea occurs while exercising or the patient has fatigue the next day, he or she is probably advancing the activity too quickly and should slow down • Food o Remind patients with chronic HF to restrict their dietary sodium o Commercial salt substitutes typically contain potassium. Teach patients that their renal status and serum potassium level must be evaluated while using these products ▪ Medication education ▪ Health care resources • A home care nurse, ambulatory care clinic, or nurse-led follow-up program may be needed to assess the patient's adherence to drug and nutrition therapy and to monitor for worsening or recurrent HF. • AHA o Indications of worsening or recurrent heart failure ▪ Rapid weight gain ▪ Decreased in exercise tolerance ▪ Cold symptoms ▪ Excessive awakening at night to urinate ▪ Development of dyspnea/angina at rest ▪ Increased edema in feet, ankles, and hands F. COMFORT model • C- communication • O - orientation • M – mindful communication • F – family caregivers • O – openings • R – relating • T – communication G. SHARE approach (Mullahy, p 132) • S- seek your patient participation • H – Help your patient expose and compare treatment options • A – assess your patient values and goals • R – Reach a decision with your patient • E – Evaluate your patients’ decisions H. TNM • T- Tumor • N - Nodes • M – Metastasis Show Less