Rasmussen College: NUR 2115 summer Fundamentals of nursing exam 2 study guide,100% CORRECT

Rasmussen College: NUR 2115 summer Fundamentals of nursing exam 2 study guide Module 4 – clinical judgement and nursing process The nursing process - is a systematic method that directs the nurse and patient, as together they accomplish the following: (1) assess the patient to determine the need for nursing care, (2) determine nursing diagnoses for actual and potential health problems, (3) identify expected out- comes and plan care, (4) implement the care, and (5) evaluate the results. • Systematically collect patient data (assessing) • Clearly identify patient strengths and actual and potential problems (diagnosing) • Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning) • Execute the plan of care (implementing). An example of the nursing process in action: Assessing You are checking on a patient who had abdominal surgery yesterday and hear that the patient has considerable pain: “It kept me up all night.” The patient has been reluctant to ask for any pain medication, fearing effects of the drug. “I don’t want to become a junkie.” The patient’s blood pressure and pulse rate are slightly elevated. Diagnosing You analyze the data just described and write the nursing diagnosis: Unrelieved pain related to a fear of taking pain-relieving medications. The patient agrees that this is becoming a problem. Outcome Identification and Planning You decide to work with the patient to achieve the outcome: By 3:00 pm, patient reports sufficient relief of pain to enable him to rest and to get out of bed to go to the bathroom. The patient wants to accomplish the outcome. You identify teaching as the primary nursing intervention. Implementing After asking the patient about his experiences with pain- relieving medications, you explain that although many of these drugs are addictive when abused, there is no harm if they are taken as prescribed postoperatively. You also explain that it is important for him to experience enough pain relief to be able to cough and deep breath, ambulate, and do other things important to his recovery. You suggest that the medication will be most effective if taken before his pain peaks and becomes intense. You administer the prescribed medication for pain when the patient indicates that he is willing to give it a try. Evaluating After enough time has elapsed for the medication to take effect, you check back with the patient to evaluate whether he has obtained relief and met his outcome. If the patient is satisfied and you both feel that comfort is no longer a problem, you terminate the plan of care for this diagnosis. If the patient still feels pain or is dissatisfied with the medication, each of the preceding steps of the nursing process is re-evaluated, and necessary changes are made in the plan of care. Nursing process continues… Assessing is the systematic and continuous collection, analysis, validation, and communication of patient data, or information. Assessing - Preparing for data collection • Collecting data • Indentifying cues and making inferences • Validating data • Clustering related data and indentifying patterns • Reporting and recording data Types of assessments Nursing assessments include: ▪ comprehensive initial assessment ▪ focused assessment ▪ emergency assessment ▪ time-lapsed assessment Initial assessment The initial assessment is performed shortly after the patient is admitted to a health care agency or service. Focused Assessment In a focused assessment, the nurse gathers data about a specific problem that has already been identified. Helpful questions include: • What are your signs and symptoms? • When did they start? • Were you doing anything different than usual when they started? • What makes your symptoms better? Worse? • Are you taking any remedies (medical or natural) for your symptoms? Emergency Assessment When a physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life- threatening problems. A long-term care facility resident who begins choking in the dining room, a bleeding patient brought to the emergency department with a stab wound, an unresponsive patient in the rehabilitation unit, and a factory worker threatening violence are all candidates for an emergency assessment. Time-lapsed Assessment The time-lapsed assessment is scheduled to compare a patient’s current status to the baseline data obtained earlier. Most patients in residential settings and those receiving nursing care over longer periods of time, such as home- bound patients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the plan of care. This assessment can be comprehensive or focused Collecting DATA There are two types of data: subjective and objective. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly, and experiencing pain. Subjective data also are called symptoms or covert data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient. Examples of objective data are an elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data Sources of data Patient - The patient is the primary and usually the best source of information. Family and Significant Others - Family members, friends, and caregivers are especially helpful sources of data when the patient is a child or has limited capacity to share information with the nurse. Patient Record - Records prepared by different members of the health care team provide information essential to comprehensive nursing care. Assessment Technology - Nurses can also gain valuable data about patients from technologies such as cardiac and respiratory monitors. Methods of data collection The nursing history and physical assessment are primary components of data collection Nursing History Ideally, the nursing history captures and records the uniqueness of the patient so that care may be planned to meet the patient’s individual needs. COMPONENTS of A NURSING HISTORY Components of a nursing history include: • Profile: name, age, sex, race/ethnicity, marital status, religion, occupation, education • Reason for seeking health care • Usual health habits and patterns and related needs for nursing assistance • Cultural considerations in relation to diet, decision making, and activities • Current state of health, functioning of body systems, degree of pain, and past medical and surgical history • Current medications, allergies, and record of immunizations and exposure to communicable diseases • Perception of health status and what health and illness mean to the patient, as well as usual responses or coping patterns • Developmental history, family history, environmental history, and psychosocial history • Patient’s and family’s expectations of nursing and of the health care team • Patient’s and family’s educational needs and ability and willingness to learn • Patient’s and family’s ability and willingness to participate in the plan of care • Whether an advance directive exists or if the patient wants help to prepare an advance directive • Patient’s personal resources (strengths) and deficits • Patient’s potential for injury PATIENT INTERVIEW The nurse obtains the nursing history by interviewing the patient. An interview is a planned communication. Physical Assessment Physical assessment is the examination of the patient for objective data that may better define the patient’s condition and help the nurse plan care. The nursing physical assessment involves the examination of all body systems, called the review of systems (ROS), in a systematic manner, commonly using a head-to-toe format Four methods - are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. IDENTIFYING CUESAND MAKING INFERENCES (“the patient does not respond when I speak to him on his left side”) is a cue that something may be wrong. The judgment you reach about the cue (the patient’s hearing may be impaired on his left side) is an inference. VALIDATING DATA Validation is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. CLUSTERING RELATED DATA AND IDENTIFYING PATTERNS As described earlier, as you prepare to collect your data you also decide how to organize or cluster the data. Example: models for organization clustering data Human Needs (Maslow) - Physiologic (Survival) Needs: Food, fluids, oxygen, elimination, warmth, physical - Comfort Safety and Security Needs: Things necessary for physical safety (e.g., a cane) and psychological security (e.g., a child’s favorite toy) - Love and Belonging Needs: Family and significant others - Self-Esteem Needs: Things that make people feel good about themselves and confident in their abilities (e.g., being well groomed, having accomplishments recognized) - Self-Actualization Needs: Need to grow, change, and accomplish goals REPORTING AND RECORING DATA The patient data the nurse collects, both initially and as patient contact continues, are of no benefit to the patient and the health care team unless they are appropriately communicated. Diagnosing The purposes of diagnosing are to (1) identify how a person, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment. The data help the nurse identify patient strengths and health problems. A health problem is a condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness. • Recognizing safety and infection–transmission risks and addressing these immediately. • Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients’ lives—and promoting optimum function, independence, and quality of life • Anticipating possible complications and taking steps to prevent them • Initiating urgent interventions—you do not want to wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses Diagnosis • Creating a list of suspected problems/diagnoses • Ruling out similar problems/diagnoses • Naming actual and potential problems/diagnoses and clarifying what’s causing or contributing to them • Determining risk factors that must be managed • Identifying resources, strengths, and areas for health promotion Planning is the third step, during planning the nurse identifies outcomes and formulates goals for the patient, family or community. Outcomes should be specific, measurable, attainable, reasonable and time-specific. (S.M.A.R.T) • Informal planning may occur at any time such as an emergency or simply when a nursing is thinking about how they could better help their patients. Informal planning if formal planning without documentation. • Outcome identification and planning allows the nurse to set priorities, identify expected patient outcomes, select necessary interventions to achieve these outcomes and communicate the plan of care among the patient, family and other staff involved in the patient’s care. • Initial planning – performed by the nurse along with the initial assessment. A comprehensive plan that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. • Ongoing planning – This planning is completed each time the nurse interacts with the patient. Data is collected to ensure the plan or care is kept up to date to resolve identified health problems, manage risk factors and promote function. During ongoing planning nursing diagnosis may be clarified or modified and new planning may be implemented. • Discharge planning – Ensures that the patient and family outcomes and needs are met as the patient moves from a care setting to home, or from one care setting to another. Education about continuity of care at home or in another health care setting is provided by the nurse upon discharge. • Care planning may include standardized templates set on the EHR, concept mapping, ISBARR during patient hand-off, and clinical pathways. Implementation is the fourth step in which the nurse carries out actions that were set for the patient in the planning step of the nursing process. • During implementation the nurse carries out the plan, assesses how the patient is responding to it, documents and modifies it to achieve the outcome. Be sure your interventions are supported by evidence-based practice. • Assess, re-asses and record. • During implementation determine the patient's new/continuing need for nursing, promote their self-care and assist the patient and their family to achieve health outcomes. Evaluation includes the nurse and the patient and/or their family working together to determine how well the patient outcomes have been achieved. Is there a need for a new plan of care? Continuity of care? Or has the outcome been successfully met? • There are five elements to evaluation. Identify evaluative standards and criteria. Collect data to determine if the standards and criteria were met. Interpret and summarize the findings. Document your nursing judgement. Terminate, continue or modify your plan of care. • There are different outcomes that are set for the patient to meet, these are psychomotor outcomes, cognitive outcomes, affective outcomes, and physiologic outcomes. • Evaluative outcomes are documented as: Outcome met/partially met/not met. If the outcome is only partially met plan of care should continue, if the outcome is not at all met the plan of care should be modified. • Patient variables (willingness to follow plan of care), nursing variables (burnout) and health care system variables (staffing) all affect how the outcome is met. • Quality assurance is a part of the evaluation of the patient’s care. (HCAHPS) NANDA nursing diagnosis for oxygenation and gas exchange, infection, inflammation and thermoregulation along with tissue integrity • Impaired gas exchange • Risk for/ Ineffective peripheral tissue perfusion • Risk for infection • Ineffective airway clearance • Risk for/ impaired skin integrity • Risk for thermal injury • Hypothermia • Hyperthermia • Impaired thermoregulation Module 6 – infection, inflammation, and thermoregulation An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body. An infection occurs as a result of a cyclic process, consisting of six components. • Infectious agent • Reservoir • Portal of exit • Means of transmission • Portals of entry • Susceptible host Signs and symptoms of infection - Redness - Heat - Swelling - Pain - Loss of function Infectious Agent Some of the more prevalent agents that causes infection are bacteria, viruses, and fungi. Bacteria - They are categorized by shape as spherical (cocci), rod shaped (bacilli), or corkscrew shaped (spirochetes). Bacteria can be categorized as either gram positive or gram negative, based on their reaction to the Gram stain. For example, gram-positive bacteria have a thick cell wall that resists decolorization (loss of color) and are stained violet. How- ever, gram-negative bacteria have chemically more complex cell walls and can be decolorized by alcohol. Thus, gram- negative bacteria do not stain. bacteria require oxygen to live and grow and are, therefore, referred to as aerobic. Those that can live without oxygen are anaerobic bacteria. A virus is the smallest of all microorganisms, visible only with an electron microscope. Viruses cause many infections, including the common cold, hepatitis B and C, and acquired immunodeficiency syndrome (AIDS). Antibiotics have no effect on viruses. However, there are some antiviral medications available that are effective with some viral infections. When given in the prodromal stage of certain viruses, these medications can shorten the full stage of the illness. Fungi, plant-like organisms (molds and yeasts) that also can cause infection, are present in the air, soil, and water. Some examples of infections caused by fungi include athlete’s foot, ringworm, and yeast infections. These infections are treated with antifungal medications; however, many infections due to fungi are resistant to treatment. Parasites are organisms that live on or in a host and rely on it for nourishment. Malaria is a serious disease that occurs when a parasite infects a certain type of mosquito that then feeds on humans. Reservoir The reservoir for growth and multiplication of microorganisms is the natural habitat of the organism. Possible reservoirs that support organisms pathogenic to humans include other people, animals, soil, food, water, milk, and inanimate objects. Portal of Exit The portal of exit is the point of escape for the organism from the reservoir. The organism cannot extend its influence unless it moves away from its original reservoir. Usually, each type of microorganism has a primary exit route. In humans, common portals of exit or escape routes include the respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin. Blood and tissue can also be portals of exit for pathogens. Means of Transmission An organism may be transmitted from its reservoir by various means or routes. Some organisms can be transmitted by more than one route. Organisms can enter the body by way of the contact route, either directly or indirectly. Direct contact involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual intercourse. Health care workers have the potential to directly transmit organisms to susceptible people through touching. The indirect contact route involves personal contact with an inanimate object, such as touching a contaminated instrument. Recent research indicated that pathogenic bacteria were found on more than 60% of nurses’ scrubs. Contaminated blood, food, water, or inanimate objects (fomites) are vehicles of transmission. Vectors, such as mosquitoes, ticks, and lice, are nonhuman carriers that transmit organisms from one host to another by injecting salivary fluid when a human bite occurs. Microorganisms can also be spread through the airborne route when an infected host coughs, sneezes, or talks, or when the organism becomes attached to dust particles. Another means of transmission is through droplets. Droplet transmission is similar to airborne transmission. However, airborne particles are less than 5 mcm, and droplet particles are greater than 5 mcm. Portal of Entry The portal of entry is the point at which organisms enter a new host. The organism must find a portal of entry to a host or it may die. The entry route into the new host often is the table 23-1 same as the exit route from the prior reservoir. The urinary, respiratory, and gastrointestinal tracts and the skin are common portals of entry. Susceptible Host Microorganisms can continue to exist only in a source that is acceptable (a host) and only if they overcome any resistance mounted by the host’s defenses. Susceptibility is the degree of resistance the potential host has to the pathogen. Hospital patients are often in a weakened state of health because of illness and have less resistance. Thus, they are more susceptible for infection. Stages of Infection • Incubation period The incubation period is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. For example, the common cold has an incubation period of 1 to 2 days, whereas tetanus has an incubation period ranging from 2 to 21 days. • Prodromal stage A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low- grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spread. • Full stage of illness The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. Symptoms that are limited or occur in only one body area are referred to as localized symptoms, whereas symptoms manifested throughout the entire body are referred to as systemic symptoms • Convalescent period The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the patient’s general condition. The signs and symptoms disappear, and the person returns to a healthy state. However, depending on the type of infection, there may be a temporary or permanent change in the patient’s previous health state even after the convalescent period. the Body’s Defense Against Infection One of the first lines of defense against infection is the body’s normal flora. Flora helps to keep potentially harmful bacteria from invading the body. In addition to the normal flora that inhabit various body sites, other defense systems help a person combat infection. These include the inflammatory response and immune response. Inflammatory Response The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair. Immune Response Another defense system is the immune response. The immune response involves specific body responses to an invading foreign protein, such as bacteria, or in some cases, to the body’s own proteins. Infection in a patient may alter their vital signs:  Elevation in temperature  Elevation in heart rate  Elevation in respirations due to increased metabolic rate  Elevation of blood pressure in relation to pain and/or increased metabolic rate may occur. factors Affecting the Risk for Infection Integrity of skin and mucous membranes, which protect the body against microbial invasion • pH levels of the gastrointestinal and genitourinary tracts, as well as the skin, which help to ward off microbial invasion • Integrity and number of the body’s white blood cells, which provide resistance to certain pathogens • Age, sex, race, and hereditary, which influence susceptibility. Neonates and older adults appear to be more vulnerable to infection. (See the accompanying box, Focus on the Older Adult.) • Immunizations, natural or acquired, which act to resist infection • Level of fatigue, nutritional and general health status, the presence of preexisting illnesses, previous or current treatments, and certain medications, which play a part in the susceptibility of a potential host • Stress level, which if increased, may adversely affect the body’s normal defense mechanisms • Use of invasive or indwelling medical devices, which provide exposure to and entry for more potential sources of disease-producing organisms, particularly in a patient whose defenses are already weakened by disease laboratory data Indicating an Infection • Elevated white blood cell (leukocyte) count—normal value is 5,000 to 10,000/mm3 • Increase in specific types of white blood cells (differential count or percentage of each cell type) • Neutrophils - 60%–70% • Lymphocytes - 20%–40% • Monocytes - 2%–8% • Eosinophil - 1%–4% • Basophil - 0.5%–1% • Elevated erythrocyte sedimentation rate—red blood cells settle more rapidly to the bottom of a tube of whole blood when an inflammation is present • Presence of pathogen in urine, blood, sputum, or other draining cultures Diagnosing The potential for infection or the presence of an infection in a patient suggests possible nursing diagnoses. o Risk for Infection related to presence of chronic disease; altered immune response; effects of medication; altered skin integrity; malnutrition; presence of invasive or indwelling medical device; lack of proper immunization o Social Isolation related to presence of communicable disease (AIDS) o Impaired Oral Mucous Membrane related to ineffective dental hygiene; trauma; side effect of medication; presence of invasive medical device o Deficient Diversional Activity related to lack of visitors; restrictions imposed by airborne precautions o Risk for Imbalanced Body Temperature related to infectious process; dehydration o Anxiety related to high risk for infection; social isolation o Activity Intolerance related to Effects of infectious process Generalized weakness Preventing Health Care–Associated Infections nosocomial is used specifically to indicate something originating or taking place in a hospital. An infection is referred to as exogenous when the causative organism is acquired from other people. An endogenous infection occurs when the causative organism comes from microbial life harbored in the person. An infection is referred to as iatrogenic when it results from a treatment or diagnostic procedure. Not all nosocomial infections are iatrogenic. Using standard and Transmission-Based Isolation Precautions Standard Precautions - Follow hand hygiene techniques - Wear clean nonsterile gloves - Wear personal protective equipments - Follow respiratory hygiene/cough etiquette - Avoid recapping used needles. - Use safe injection practices including single-dose vials - Wear face mask if placing a catheter or injecting material - Handle used patient care equipment that is soiled - Use adequate environmental controls to ensure that routine care, cleaning, and disinfection procedures are followed - Review room assignments carefully. Transmission-Based Precautions (Tier 2) Airborne Precautions Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly SARS (severe acute respiratory syndrome). - Place patient in a private room that has monitored negative air pressure - Wear a mask or respirator when entering room of patient - Transport patient out of room only when necessary and place a surgical mask on the patient if possible. - Consult CDC Guidelines for additional prevention strategies for tuberculosis Droplet Precautions Use these for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. Door may remain open. • Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment. • Transport patient out of room only when necessary and place a surgical mask on the patient if possible. • Keep visitors 3 feet from the infected person. Contact Precautions Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO). Place the patient in a private room, if available. • Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient’s environment. Change gloves after having contact with infective material. Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. • Limit movement of the patient out of the room. • Avoid sharing patient-care equipment. Reporting accidental exposures Washing the exposed area immediately with warm water and soap Module 5 – oxygenation and gas exchange Alterations in Respiratory Function Hypoxia - is a condition in which an inadequate amount of oxygen is available to cells. Terminology - Dyspnea – is difficult or labored breathing - Tachypnea – rapid breathing (an increased respiratory rate) - Bradypnea – slow breathing (a decrease in respiratory rate) - Cyanosis – is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. - Apnea – refers to periods during which there is no breathing. - Pallor – paleness of the skin - Anemia – a decrease in the amount of red blood cells. Results in insufficient hemoglobin and hypoxemia. Normal values for respirations and pulse oximeter Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. - range of 95% to 100% is considered normal SpO2; values ≤90% are abnormal Respirations - 12 to 20 Signs and symptoms of hypoxia - most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Anxiety, restlessness, confusion, and drowsiness also are common signs of hypoxia. Types of adventitious lung sounds Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors Rhonchi Course snoring quality of sounds. Coughing may clear the sounds; indicative of air passing through or around secretions. The patient inhales deeply and exhales forcefully into a spirometer, an instrument that measures lung volumes and airflow. Patients also use spirometers to promote deep breathing while recovering from surgery, and to monitor health status in management of chronic asthma. Proper method for auscultation of breath sounds. Examples of nanda-i nursing diagnoses Ineffective Airway Clearance related to Fatigue; decreased intake of fluids; poor nutrition, a 20- year history of COPD, with recent development of pneumonia. Impaired Gas Exchange related to Smokes one pack of cigarettes per day; works with asbestos in auto factory; has had a cold for 7 days. Ineffective Breathing Pattern related to Anxious about results of cardiac catheterization and possible cardiac surgery. Signs and symptoms of respiratory distress Desaturated oxygen (Pg. 1414) Altered mental status Anxiety, hyperventilation Use of accessory muscles oxygen Delivery systems nasal cannula, also called nasal prongs, is the most commonly used oxygen delivery device. The cannula is a disposable plastic device with two protruding prongs that are inserted into the nostrils. The cannula is connected to an oxygen source with a flow meter and, many times, a humidifier. Low Flow 1–2 L/min = 23%–30% 3–5 L/min = 30%–40% 6 L/min = 42% face masks. Disposable and reusable face masks are available. Fit the mask carefully to the patient’s face to avoid leakage of oxygen. It should be comfortably snug but not tight against the face. The most commonly used types of masks are the simple face mask. Low Flow 6–8 L/min = 40%–60% (5 L/min is minimum setting) Medications which could potentially cause respiratory depression: • opioids • narcotic or sedative Alterations in Oxygenation as the Problem Examples of nursing diagnoses indicating alterations in oxygenation include: • Ineffective Airway Clearance • Decreased Cardiac Output • Impaired Gas Exchange Alterations in Oxygenation as the Etiology o Activity Intolerance related to imbalance between oxygen supply and demand o Anxiety related to feeling of suffocation o Fatigue related to impaired oxygen transport system o Imbalanced Nutrition: Less Than Body Requirements, related to difficulty breathing o Disturbed Sleep Pattern related to orthopnea and bronchodilators Deep breathing When hypoventilation occurs, a decreased amount of air enters and leaves the lungs. However, deep-breathing exercises can be used to overcome hypoventilation. Instruct the patient to make each breath deep enough to move the bottom ribs. Unless the patient has a nasal condition that prohibits or prevents normal breathing, have the patient start slowly taking deep ventilations nasally and then expiring slowly through the mouth. Breathing through the nose warms, filters, and humidifies the air. Pursed-lip breathing Pursed-lip breathing can assist in reducing dyspnea and feelings of panic. Pursed lip breathing effectively slows and prolongs expiration which is thought to prevent the collapse of small airways. Pursed-lip breathing helps the patient to control the rate and depth of respiration. While sitting up-right the patient inhales through the nose while counting to three, then exhales slowly against pursed lips while counting to seven. Importance of coughing - A cough is a cleansing mechanism of the body. It is a means of helping to keep the airway clear of secretions and other debris. - A cough that is dry is termed a non- productive cough. - A cough that produces respiratory secretions is termed a productive cough. The respiratory secretion expelled by coughing or clearing the throat is called sputum. Miscellaneous Normal values for vital signs: Body temperature is the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees. Normal body temperature ranges from 35.9°C to 38°C (96.7°F to 100.5°F), depending on the route used for measurement (Jensen, 2011). The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The peripheral pulse is a throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats/min. Respiratory rate Under normal conditions, healthy adults breathe about 12 to 20 times each minute Blood pressure refers to the force of the moving blood against arterial walls. 120/80 mm Hg. A rise or fall of 20 to 30 mm Hg in a person’s blood pressure is significant, even if it is within the generally accepted normal range. Techniques of Physical Assessment The four primary assessment techniques are inspection, palpation, percussion, and auscultation. These techniques are most often used in the sequence listed; - Inspection is the process of performing deliberate, purposeful observations in a systematic manner. - Palpation uses the sense of touch. The hands and fingers are sensitive tools that can assess skin temperature, turgor, texture, and moisture, as well as vibrations within the body (such as the heart) and shape or structures within the body (e.g., the bones). - Percussion is the act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves. - Auscultation is the act of listening with a stethoscope to sounds produced within the body. Auscultation is performed by placing the stethoscope diaphragm or bell against the body part being assessed. Subjective data: is what is spoken by the patient (i.e. pain level) Objective data: is what is observed by the nurse (i.e. wound drainage, skin feels hot/cold to touch) Module 7 – Tissue Integrity Functions of the Skin and mucous membranes - functions of the Skin and mucous membranes The skin has multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production. Phases of Wound Healing - Hemostasis Occurs immediately after injury. A liquid called exudate is made up of plasma and blood components leak out into the injured area causing swelling and pain. Blood vessels constrict. - Inflammatory phase Lasts about 4-6 days. WBCs move to the wound to ingest debris and release growth factor to initiate tissue proliferation. During this phase the patient has a mildly elevated body temperature and an increase in plasma WBCs. - Proliferation phase Lasts several weeks. Granulation tissue forms the foundation for scar tissue development. Collagen synthesis and accumulation continue based on the size of the wound. Connective tissue forms over time. During this phase adequate nutrition and oxygenation are important patient care considerations. - Maturation phase The final stage of healing begins about 3 weeks after the injury occurrence. Collagen is remodeled and strengthened. A scar forms. Stages of pressure ulcers Stage 1 – Skin is intact but reddened and non-blanchable. Localized area typically over a bony prominence. The affected area may be cooler, warmer, painful or soft to the touch. Stage 2 – Partial thickness loss of dermis. Visually a shallow open area. Stage 3 – Full thickness loss of tissue. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. May include undermining or tunneling. Stage 4 – Full thickness loss of tissue with bone, tendon or muscle being visible. Slough or eschar may be present, this wound often includes undermining or tunneling. Unsaleable pressure ulcers – The base of the ulcer is covered by slough or eschar in the wound bed and must be removed before the wound can properly be staged. Stable eschar should not be removed. - Dehiscence – The partial or total separation of wound layers because of excessive stress on wounds that are not healed. - Evisceration – A complication of wound dehiscence. The wound completely separates with a protrusion of viscera through the incisional area. Nourishment is an important factor in the prevention of wound formation. Well- nourished and hydrated cells are resistant to injury. Dehydration makes the skin appear loose and flabby, making it more vulnerable to injury. Wound healing requires adequate proteins, carbohydrates, fats, vitamins and minerals. Calories and protein are necessary to rebuild cells and tissues. Vitamin A and C are essential for epithelization and collagen synthesis. Zinc plays a role in proliferation of cells. Fluid balance is necessary for optimal cell function.