FINAL REVIEW FUNDAMENTALS APRIL 17, 2013

**INFECTION**
RISK FOR INFECTIONS BURNS, PRESSURE ULCERS, IMBALANCED
NUTRITION.
STAPH AUREUS (NORMAL FLORA) PROTECTS THE BODY FROM INFECTION,
HOWEVER, CAN GIVE US INFECTION IF SKIN IS BROKEN. IF PT HAS
SURGICAL WOUND MUST CLEAN DRAIN FROM IN TO OUT (FROM INCISION
OUT) TO AVOID STAPH AUREUS COMING IN CONTACT WITH WOUND THIS
IS A ASEPTIC TECHNIQUE
NOSOCOMIAL INFECTIONS: OCCURS IN HEALTHCARE SETTING AS A
RESULT OF INVASIVE PROCEDURES, OVERUSE OF ANTIBIOTICS,
MULTIDRUG RESISTANT ORGANISMS, CAN CAUSE THIS TYPE OF
INFECTION.
ECOLI IN BOWEL: TO PREVENT UTI MUST CLEAN CLIENT FROM FRONT TO
BACK.
INCUBATION PERIOD: INTERVAL BETWEEN ENTRANCE OF PATHOGEN INTO
BODY AND APPEARANCE OF FIRST SYMPTOM.
PRODROMAL STAGE: BEGINNING STAGE OF DISEASE SYMPTOMS EX.
MALAISE, LOW GRADE FEVER, FATIGUE,
ILLNESS STAGE: INTERVAL WHEN DISEASE SPECIFIC SYMPTOMS ARE
DEMOSTRATED EX. STEP THROAT MANIFESTED BY SORE THROAT, PAIN,
SWELLING.
CONVALESCENCE: INTERVAL WHEN ACUTE SYMPTOMS OF INFECTION
DISAPPEARS.
STERILE FIELD: BELOW THE WAIST LEVEL NON STERILE
IV INSERTION:
PREP SKIN CORRECTLY, USE PROPER GLOVES AND CLEAN PATIENTS SKIN
HAND WASHING ALWAYS FOR PREVENTION OF INFECTION!
MASLOW HEIRARCHY OF NEEDS: ALWAYS KNOW WHAT IS MORE
IMPORTANT, (ON THE LOWER REIGM OF PYRAMID) PHYSICAL NEEDS ARE
THE MOST IMPORTANT.
1. PHYSICAL NEEDS
2. SECURITY
3. LOV/BELONGING
4. SELF-ESTEEM
5. SELF ACTUALIZATION
STERILE GLOVES TECHNIQUES:
SUCTIONING TRACHE PATIENT / INSERTING INDWELLING CATHETAR/
CENTRAL LINE
CLEAN GLOVES TECHNIQUES:
IV INSERTION/ N/G INSERTION/IM INJECTIONS/ SUBQ INJECTIONS
USE STANDARD PRECAUTIONS
WHEN YOURE EXPOSED TO CONTAMINATION: EX., FECES,
URINE,DIARRHEA, BODY FLUIDS, BLOOD, AND OPEN SORES (USE CLEAN
GLOVES).
INTACT SKIN CAN BE TOUCHED WITHOUT GLOVES.
**ASSESSMENT**
RN MUST:
PREPARE FOR EXAM, GOOD LIGHTING, WARMTH, OLDER ADULT NEEDS
MORE TIME, TAKE DEFECITS INTO ACCOUNT. OLDER ADULTS CAN LEARN
BUT MAKE ALLOWANCES WITH MOBILITY/VISUAL/HEARING IMPAIRMENTS.

**INSPECT**AUSCULTATE**PERCUSSION**PALPATE**
***PALPATE TENDER AREA LAST **
AUSCULATE BOWEL SOUNDS ON ALL 4 QUADRANTS MUST BE LISTENED
TOO CLOCKWISE , CHECK FOR 5 MINUTES.
ADPIE: ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION,
EVALULATION.
ALWAYS DOCUMENT FINDINGS AS YOU SEE IT NOT AS MEDICAL DXS WE
ARE NOT DOCTORS. EX., HEART RATE 68 AND IRREGULAR, RESPIRATIONS
40, SHALLOW, LABORED, COLOR CYANOTIC AND PALE. WE DO NOT SAY
PNEUMONIA OR MI THAT IS A MEDICAL DX.
RESPONSE TO LIGHT: PUPILS CONSTRICTS TO LIGHT/DILATE TO DARK
CONSENSUAL REFLEX: WHEN YOU TEST ONE EYE THE OTHER EYE WILL
REACT THE SAME EX. IF ONE EYE DILATES THE OTHER DOES AS WELL.
ACCOMODATION: PUPILS DILATE TO DISTANCE OF OBJECT AND WILL
CONSTRICT AS IT GETS CLOSE UP.
MYOPIA: NEAR SIGHTEDNESS (SEEING CLOSE UP)
PRESYOBIA: REDUCTION OF SEEING THINGS CLOSE UP (NORMAL CHANGES
OF AGING)
LUNGS NORMAL BREATH SOUNDS ARE:
BRONCHIAL SOUNDS- HIGH PITCH, HOLLOW , TRACHEA
BRONCHOVESICULAR- BLOWING SOUND, ANTERIORLY OVER
BRONCHIOLES, POSTERIOLY OVER SCAPULA
VESICULAR- SOFT BREEZY, LOW PITCH, BASE OF LUNGS.
CARDIOVASCULAR:
LUB S-1- FIRST HEART SOUND HEARD BEST AT THE APICAL AREA OVER
THE MITRAL VALVE CREATED BY THE CLOSURE OF THE MITRAL
/TRICUSPID.
DUB S-2- SECOND HEART SOUND CREATED BY THE CLOSURE OF THE
AORTIC/ PULMONIC VALVES.
**MOBILITY**
THERE ARE 3 ASSESSMENT COMPONENTS FOR MOBILITY:
ROM: RANGE OF MOTION
GAIT: STYLE OF WALKING, DRAWS CONCLUSIONS ABOUT BALANCE,
POSTURE, ABILITY TO WALK WITHOUT ASSISTANCE.
EXERCISE: CONDITIONS THE BODY AND IMPROVES HEALTH AND FITNESS.
NEVER LIFT PATIENT ALONE ALWAYS ARRANGE FOR HELP. USE PATIENT
HANDLING EQUIPMENT, EX., FRICTION REDUCING SLIDING SHEETS.
ENCOURAGE PATIENTS TO ASSIST AS MUCH AS POSSIBLE.
RN MUST: KEEP BACK, NECK, PELVIS, AND FEET ALIGNED. DONT TWIST-
USE GOOD BODY MECHANICS. **FLEX KNEES, KEEP FEET WIDE APART FOR
WIDE BASE OF SUPPORT**POSITION YOURSELF CLOSE TO PATIENT**RAISE
BED TO WAIST LEVEL**USE ARMS AND LEGS- NOT BACK! SLIDE PATIENT
TOWARD BODY USING PULL SHEET OR SLIDE BOARD.
IMMOBILITY PHYSIOLOGICAL RESPONSES: DECREASE IN MUSCLE
STRENGTH, DECREASE IN PHYSICAL STABILITY, MUSCLE ATROPHY,
OSTEOPOROSIS, STIFF PAINFUL JOINTS, MUSCLE CONTRACTURES.
RN INTERVENTIONS: BODY REPOSITIONING EVERY 2 HOURS**WEIGHT
BEARING ACTIVITIES**INDEPENDENCE IN ADL**ACTIVE/PASSIVE ROM
EXCERCISES.
ORTHOSTATIC HYPOTENSION: INCREASE IN HR OF MORE THAN 15% AND A
DROP OF 15MM HG OR MORE IN SYSTOLIC B/P OR A DROP OF 10 MM HG OR
MORE IN DIASTOLIC B/P WHEN THE CLIENT CHANGES FROM THE SUPINE
TO STANDING POSITION.
THROMBUS: ACCUMULATION OF PLATELETS, FIBRIN, CLOTTING FACTORS
AND CELLULAR ELEMENTS OF THE BLOOD ATTACHED TO THE INTERIOR
WALL OF A VEIN OR ARTERY-THIS CAN BLOCK THE VESSEL.
RN INTERVENTIONS: MOVEMENT & EXERCISE/VERTICAL
POSITIONS/ENCOURAGE NORMAL BREATHING PATTERN/ELASTIC
STOCKING.
RESPIRATORY SYSTEM: REDUCE GASEOUS EXCHANGE/RESPIRATORY
ACIDOSIS/
ATELECTASIS: COLLAPSE OF ALVEOLI
HYPOSTATIC PNEUMONIA: INFLAMMATION OF THE LUNG FROM STASIS OR
POOL OF SECRETIONS**UPPER RESPIRATORY TRACT INFECTIONS.
RN INTERVENTIONS:
DEEP BREATHING AND COUGHING EXERCISE/CHANGING POSITION AND
EXERCISE.
**SAFETY**
TRANSFER CLIENTS FROM PATIENTS STRONG SIDE.
ILLUMINATE PATHWAY TO THE BATHROOM FOR OLDER ADULT TO
MINIMIZE RISK OF INJURY
PUT BED RAILS UP ON OPPOSITE SIDE OF BED WHEN MOVING AN IMMOBLE
PATIENT WITHOUT HELP. ALL FOUR SIDERAILS ARE USED ONLY FOR
RESTRAINTS PURPOSES. LOWER BED TO LOWEST POSITION WHILE
PATIENT IN BED AND RAISE BED TO RNS WAIST LEVEL WHEN WORKING
WITH PATIENT.
RESTRAINTS: ANY METHOD (MANUAL DEVICE OR DRUG) WHICH
RESTRICTS MOVEMENT OR ACCESS TO ONES OWN BODY.
NEED MD ORDER EVERY 24 HOURS WITH SPECIFIC RESTRAINT LISTED
RELEASE EVERY 2 HOURS: CHECK CIRCULATION, ASSESS PATIENTS
NEEDS.
PSYSIOLOGIC HAZARDS DUE TO RESTRAINTS; IMPAIRED CIRCULATION,
ALTERED SKIN INTEGRITY (PRESSURE ULCERS), DIMINISHED
MUSCLE/BONE MASS, FRACTURES, ALTERED NUTRITION AND HYDRATION,
ASPIRATON, BREATHING DIFFICULTIES, INCONTINENCE, CHANGES IN
MENTAL STATUS.
APHASIA: INABILITY TO COMMUNICATE
EXPRESSIVE APHASIA: CANNOT EXPRESS THEMSELVES (CANNOT TALK)
BUT UNDERSTANDS WHAT OTHER PERSON IS SAYING.
SCHOOL AGE CHILDERN 5-14- BICYCLE SAFETY INJURIES (MUST USE
HELMET) 1/3 OF ALL DEATH FROM BIKE ACCIDENTS.
ADOLESCENTS: IDENTITY ISSUES, RISKY BEHAVIORS SUCH AS ALCOHOL
CONSUMPTION, SMOKING, SEX, AND DRUGS.**AUTO ACCIDIENTS #1 CAUSE
OF INJURY /DEATH
OLDER ADULTS: FALLS #1 CAUSE OF UNINTENTIONAL DEATH/ RN MUST
CONDUCT RISK ASSESSMENTS IF PT IS AT RISK FOR FALLS.
R-RESCUE REMOVE, A- ALARM/ALERT. C-CONFINE, E-
EXTINGUISH/EVACUATE

**ALTERED NUTRITION**
ENTERAL- ROUTES OF ADMINISTRATION VIA GI TRACT
PARENTERAL AVOIDS GI TRACT (IV MED)
PATIENT WITH POOR APPETITE CAN BE ANOREXIC, PHYSIOLOGIC AND
EMOTIONALLY STRESSED. MEDS CAN INTERFERE WITH TASTE OR CAUSE
NAUSEA.
RN MUST EDUCATE PATIENTS ON:
DYSPHAGIA- CHOKING CAN CAUSE ASPIRATION AND FLUIDS CAN GO TO
LUNGS AND CAUSE PNEUMONIA.
PROVIDE 30 MINUTES REST PERIOD BEFORE EATING. POSITION CLIENT IN
CHAIR HEAD OF BED SHOULD BE 90 DEGREES.
PATIENT CAN SLIGHTLY FLEX HEAD TO CHIN DOWN POSITION TO HELP
PREVENT ASPIRATION.
SHOULD NEVER LAY PATIENT SUPINE!
ENTERAL TUBE FEEDINGS;
FULLY SUPPORTED FEEDING VIA TUBES, THIS METHOD IS USED FOR
NUTRITIONAL SUPPORT IF GI TRACT IS WORKING.
NASOGASTRIC OR ORAL GASTRIC, PATIENTS WITH LOW RISK OF GASTRIC
REFLUX RECEIVE GASTRIC FEEDINGS; THOSE AT RISK RECEIVE JEJUNAL
TUBE.
PEG TUBE WILL BE PLACED DIRECTLY INTO STOMACH IF PATIENT HAS
HIGH RISK FOR GASTRIC REFLUX.
TUBE FEEDING CAN BE SHORT TERM (UP TO 4 WEEKS)
LONG TERM PLACEMENT, PATIENT CAN TAKE IN FOOD OR FLUIDS
ORALLY DEPENDING ON INDIVIDIUAL SITUATION.
LONG TERM (LONGER THAN 4 WEEKS) WILL NEED PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY (PEG) WHICH IS A SURGICAL PROCEDURE
JEJUNOSTOMY TUBE (LONG TERM) (J-TUBE IS PLACED BELOW THE
STOMACH IN THE LOWER INTESTINES).
GASTROSTOMY TUBE- (LONG TERM) (G TUBE IS PLACED HIGHER IN THE
STOMACH)
OROGASTRIC TUBE- SHORT TERM TUBE PLACED ORALLY
NASOGASTRIC TUBE- SHORT TERM TUBE PLACED THROUGH NOSTRILS
REASONS WHY NGT/OGT ARE USED:
HYPEREMESIS- EXCESSIVE VOMITING CAN MAKE SUTURES OPEN AFTER
SURGERY.
GI OBSTRUCTION- IMPACTED FECES, NGT CAN BE USED TO COMPRESS
STOMACH AND SUCTION OUT GASTRIC JUICES AND GAS. ALSO CAN BE
USE IF THERE IS GI BLEEDING, TUBE CAN SUCTION OUT BLOOD.
DECREASE THE RISK OF VOMITING AND DIARRHEA.
**MULTIPLE FACIAL FRACTURES ARE CONTRAINDICATED FOR NGT AND
OGT TUBE PLACEMENTS.**
NG TUBE PLACEMENT RN MUST ASSESS:
CHECK NOSE FOR NOSE BLEEDS PT CAN ASPIRATE/ FEEL FOR
RESISTANCE IN THE NARES.
ANTICOULAGANT THINS BLOOD THIS CAN BE A PROBLEM
ASSESS MENTAL STATUS
ASSESS FOR BOWEL SOUNDS BEFORE NG TUBE PLACEMENT/ALWAYS
EXPLAIN TO CLIENT PROCEDURE AND SIT THEM UP.
TUBE MEASUREMENT: MEASURE THE DISTANCE FROM TIP OF THE NOSE
TO EARLOBE TO XIPHOID PROCESS OF STERNUM.
PATIENT TEACHING FOR INSERTION OF N/G TUBE. ASK PT TO LEAN
FORWARD SWALLOW WATER THROUGH STRAW WILL HELP TUBE
ADVANCE DOWN THE ESOPHAGUS. PROCESS IS VERY UNCOMFORTABLE.
ALWAYS BE HONEST LET THEM KNOW IT WILL GIVE THEM A SORE
THROAT.
1. AFTER PLACEMENT OF N/G TUBE FIRST STEP TO ENSURE EVERYTHING
IS OK IS THE CHEST XRAY.(AUSCULATING THE PLACEMENT IS NOT
RELIABLE AND CAN BE DANGEROUS)
2. PH TEST FOR ACIDITY SHOULD BE 0-4. ASPIRATE FLUID FROM N/G
TUBE AND TEST ON PH SHEET.
3. AFTER CHECKING THE PH RETURN THE ASPIRATED CONTENT BACK TO
THE STOMACH.
4. ANCHOR THE TUBE TO THE NOSE TO AVOID PRESSURE ON NARES.
5. FASTEN THE END OF THE TUBE TO THE PATIENTS GOWN WITH THE
TAPE (DO NOT USE SAFETY PIN)
N/G FEEDING PATIENT SHOULD BE IN MID FOWLERS POSITION (45
DEGREES).
INDICATIONS FOR SUPPORTED FEEDINGS FOR PEG TUBES (G-TUBE/J-
TUBE):
DSYPHAGIA/ANOREXIA/DEMENTIA/UNCONSCIOUS/ORAL MALFORMATION
OR TRAUMATIC INJURY
**EXPLAIN ADVANTAGES OF IT** FOLLOW MD ORDER FOR
ADMINISTRATION OF FEEDINGS** NEVER CHANGE FLOW OF FEEDING**
ADMINISTRATION OF FEEDING STARTS VERY SLOWLY / RNS
RESPONSIBILITY TO MONITOR PATIENTS RESPONSE.
**CHECK FOR FVD, FVE, DISTENTION,AND DIARRHEA**THIS CAN OCCUR
WHEN N/G IS FIRST STARTED
NURSING CONSIDERATIONS:
ASPIRATION, SKIN BREAKDOWN, DUMPING SYNDROME- FOOD NOT BEING
ABSORBED AND PASSING QUICKLY THROUGH GI, WILL CAUSE INCREASED
H/R, SWEATING, NAUSEA, DIARRHEA, AND PALE LOOKING SKIN.
IF AIR ACCUMULATES LOOK FOR SIGNS FOR DISTENDED ABDOMEN.
TURN AND POSITION THE PATIENT TO DECREASE AIR ACCUMULATION.
BOLUS FEEDING (ENTERAL FEEDING)
GRAVITY WITH FEEDING BAG SET, 1 CAN OF FORMUAL (240 ML) THROUGH
LARGE SYRINGE (30/60 ML)
PUMP- INCREASE RATE GRADUALLY (HOURLY RATE EVERY 8 TO 12
HOURS IF NO SIGNS OF INTOLERANCE APPEAR.
ORAL CARE MUST BE DONE EVEN IF PATIENT HAS TUBE PLACED.
TUBE CARE: DO WHEN MD ORDERS IT 15-30 CC OF WATER. VERIFY
AGENCYS POLICY SOME USE STERILE WATER WHILE OTHERS USE TAP
WATER.
FLUSH THE TUBE BEFORE AND AFTER ADMINISTERING MEDICATIONS AND
FEEDING UNLESS THE PATIENT IS ON STRICT FLUID RESTRICTIONS.
**NO SALINE IT CONTAINS SODIUM**WILL THROW OFF ELECTROLYTES**
RESIDUAL: CHECK RESIDUAL PER MD ORDER (EVER 4 HRS) DURING
CONTINOUS AND PRE-BOLUS FEEDINGS.
HOLD FEEDINGS IF RESIDUAL EXCEEDS 250 ML AND NOTIFY MD. IF 250 ML
OR LESS RETURN CONTENTS TO PATIENT.
PARENTERAL NUTRITION:
CENTRAL LINE: CENTRAL VENOUS CATHETHER PLACED IN THE
SUBCLAVIAN, AXILLARY, GROIN (FEMORAL), OR INTERAL JUGULAR VEINS.
ITS USED TO ADMINISTER MEDS OR FLUIDS, (STERILE TECHNIQUE
PROCEDURE)
PICC LINE: PERIPHERALY INSERTED CENTRAL CATHETER
USED FOR PORLONGED TIME, PLACED IN THE BRACHIAL VEIN (DEEPER
VEIN PLACEMENT SO IT CAN STAY ON LONGER). PICC LINE HAS LOW RISK
FOR PNEUMOTHORAX (LUNG COLLAPSE) **MUST CHECK CORRECT
PLACEMENT THROUGH XRAY**
INTRALIPIDS: LIPIDS ARE TRADITIONALLY GIVE SEPARATELY FROM THE
BASE TPN DUE TO POTENTIAL RISK FOR ADVERSE REACTION (ALLERGIES)
THE PATIENT NEEDS TO BE MONITORED CLOSELY.
INDICATIONS FOR TPN:
MALABSORPTION SYNDROME**ANOREXIA**DEBILITATING ILLNESS
PRESENT FOR MORE THAN 2 WEEKS**SERUM ALBUMIN LESS THAN 3.5
NURSING IMPLICATIONS: THE RIGHTS OF MEDICATION ADMINISTRATION
STERILE THECHNIQUE**CENTRAL LINE/PICC LINE**FSBS PROTOCOL
EVERY 4-6 HOURS**DAILY WEIGHTS**MONITOR FOR S/S OF
INFECTION**PATIENTS RESPONSE TO THE INTERVENTION.
DRESSING CHANGES MUST BE STERILE**INFECTION WILL GO RIGHT TO
HEART**ALWAYS W/CENTRAL LINE USE STERILE GLOVES**
**PAIN**
ACUTE PAIN (TRANSIENT) PROTECTIVE, IDENTIFIABLE, SHORT DURATION,
USUALLY RESOLVES, WITH OR WITHOUT TRATMENT.
CHRONIC PAIN (PERSISTENT AND EPISODIC)- NOT PROTECTIVE, NOT
ALWAYS IDENTIFIABLE, EXTENDED DURATION 6 MONTHS OR LONGER. EX.
ARTHRITIS, LOW BACK PAIN, HEADACHES.
IDIOPATHIC-CHRONIC PAIN WHERE WE DONT KNOW THE CAUSE.
CHRONIC PAIN CONSULTS NUMEROUS HEALTHCARE PROVIDERS AND IS
LABELED A DRUG SEEKER THEY ARE REALLY JUST SEEKIG HELP FOR THE
PAIN.
CLIENT IS EXPERT ON PAIN, MEASURE INTENSITY OF PAIN BY USING PAIN
SCALE 0-10. ASK CLIENT WHAT LEVEL OF CONTROL HE WANTS TO GET
TOO. TO HELP PATIENT ACHIEVE PAIN CONTROL ASSESS:
SENSORY PATTERN, AREA, INTENSITY, NATURE OF PAIN
LOOK FOR PATIENTS RESPONSE TO PAIN MEDICATION THAT IS
INTENSITY. PATIENT SHOULD HAVE REALISTIC EXPECTATIONS ON PAIN
MANAGEMENT.
QUALITY OF PAIN: CHRONIC PAIN CANNOT BE UNDER CONTROL ASSESS
PATIENT FOR INTENSITY AND OTHER FACTORS.
P-PATTERN
A-AREA
I-INTENSITY
N-NATURE
TEACH PATIENT RELAXTION TECHNIQUES WHEN THEY ARE
COMFORTABLE AND NOT IN PAIN.
POST OP PAIN- ITS BETTER TO TAKE PAIN MEDS AND TRY TO AMBULATE.
RN RESPONSIBILITY IS TO GET PATIENTS MOBILE. TEACH PT BENEFITS
OF AMBULATION** IMMOBILITY CAUSES HEALTH PROBLEMS**
PCA PUMPS- ALLOWS PT SOME CONTROL OF PAIN, ONLY PATIENT PUSHES
THE BUTTON *FAMILY CANNOT PUSH PCA ONLY PATIENT*FAMILY DOES
NOT MAKE DECISIONS WHEN PATIENT NEEDS MED* CANNOT OVERDOSE
ON MEDS IT IS SET TO A CONTROLLED AMOUNT OF MEDS. WHEN PT HAS
PCA PUMP IT IS THE ONLY MED THE PATIENT WILL BE ON WILL NOT BE
COMBINED WITH ANY OTHER. ** ORDER IS USUALLY FOR 72 HOURS**
EPIDURAL ANALGESIA: MONITOR URINE OUTPUT **FVE CAN OCCUR**
ODTENS MACHINE- AN ELECTRICAL STIMULATION TO AREA WHERE
THERE IS PAIN. SHOULD BE TURNED ON THE MINUTE PT RECEIVES PAIN
SETTINGS ARE SET IN LOW, MEDIUM, HIGH. **HARMLESS, CAN STAY ON
ALL NIGHT NO CONTRAINDICATIONS* BATTERY OPERATED MACHINE*
GATE CONTROL THERAPY- ONLY SO MUCH STIMULATION THAT CAN GO
INTO YOUR BRAIN. CERTAIN INTERVENTIONS CLOSE THE GATE OF
STIMULATION. PLEASANT EXPERIENCES WILL CLOSE THE GATE OF PAIN
WITH SCALP MASSAGE, BACK MASSAGE, TURNING AND POSITIONING,
BRUSHING HAIR, TALKING TO THEM, WALKING THEM, THINGS THAT
DISTRACT CLIENT FROM PAIN, (PLEASANT STIMULI). THIS TECHNIQUE
HAS BEEN PROVEN TO DECREASE PAIN IN PATIENTS.

**SENSORY**
OLFACTORY-IMPAIRMENT MAY DECREASE APPETITE AND ABILITY TO
SMELL SMOKE- NEED SMOKE DETECTOR.
GUSTATORY STIMULATION: USE MORE SPICES STIMULATE TASTE BUDS,
MAKE FOOD LOOK.
HEARING IMPAIRED:
PRESBYCUSUS: NORMAL LOSS OF HEARING OF HIGH PITCHED TONES,
OCCURS WITH AGE.
USE VISUAL AIDS SUCH AS HANDS AND EYES WHEN SPEAKING. SPEAK TO
PATIENT IN A QUIET ROOM, SHUT DOOR IF TOO MUCH BACKGROUND
NOISE. LOWER TV WHEN SPEAKING WITH PATIENT. ADJUST YOUR VOICE
ACCORDINGLY IF PATIENT USES HEARING AID CHECK BATTERIES.
EVALUATE FOR IMPACTED CERUMEN COMMON IN OLDER ADULT DUE TO
CHANGE IN HAIR IN EARS. IT TRAPS WAX WHICH CAUSES HEARING LOSS.
HIGHEST PRIORITY FOR RN IS THE RISK FOR FALL FOR HEARING IMPAIRIED
CLIENT & VISUALLY IMPAIRED.
VISUALLY IMPAIRED:
PRESBYOPIA- IMPAIRED NEAR VISION IN MIDDLE AGE AND OLDER ADULTS
CAUSED BY LOSS OF ELASTICITY OF LENS OF EYE, ASSOCIATED WITH
AGING.
TELL PT WHEN YOU ENTER/EXIT ROOM. TELL PATIENT YOUR NAME;
EXPLAIN EVERYTHING YOU ARE DOING AND ALL PROCEDURES. ASK
PERMISSION BEFORE TOUCHING, REDUCE CLUTTER. **MAKE SURE
CALL LIGHT IN REACH!! NEVER TAKE DEPENDENCE AWAY FROM
PATIENT. PATIENT SHOULD USE INCANDESCENT LIGHTING AT 75 WATTS
AT HOME IF PATIENT HAS INCREASED SENSITIVITY TO GLARE.
YELLOW/RED COLOR FOR THINGS THAT CAN BE DANGEROUSE TO THE
OLDER ADULT.
WHEN WALKING WITH BLIND CLIENTS RN SHOULD WALK ONE HALF STEP
AHEAD AND SLIGHTLY TO THE SIDE, CLIENT PLACES HANDS ON NURSES
FOREARM. WARN PATIENT OF UPCOMING CURBS OR STEPS.
**CLIENT IS THE ONLY PERSON WHO CAN TELL YOU IF SENSORY ABILITY
HAS IMPROVED AS A RESULT OF NURSING INTERVENTIONS.**THE CLIENT
IS YOUR PRIMARY SOURCE OF INFORMATION**
IMPORTANT THING RN MUST IMPLEMENT IS: ORIENT PATIENT TO
ARRANGEMENT OF ROOM, CLEAR PATHS,
**DECREASED TACTILE SENSATION**
NOTE COMPLAINTS OF NUMBNESS, TINGLING PARAESTHESIA.
WONT DO WELL WITH SHOE LACES, USE VELCROS. PROBLEMS WITH
TOUCH, AND USING ZIPPERS, BUTTONS.
AT RISK FOR BURNS AND PRESSURE ULCERS DUE TO LACK OF FEELING
PAIN AND PRESSURE ON THE SKIN. TURN AND POSITION PATIENT.
CLIENTS IN THE ICU AT RISK FOR CONFUSION (SENSORY OVERLOAD) DUE
TO NO PRIVACY. RN MUST DO V/S EVERY 15 MINUTES.
RN INTERVENTIONS: DIM LIGHTS, DO ALL CARE AT ONE TIME IF POSSIBLE
TO AVOID OVERSTIMULATING. CLOSE SHADES, HELP PATIENT RELAX &
SPEAK CALMLY.
ASSIST PATIENT ALWAYS ON THE WEAKER SIDE FIRST!
SENSORY ALTERATIONS: ALWAYS ORIENT PTS WHETHER DEFECIT OR
OVERLOADED!!
RN INTERVENTION WITH A PATIENT WITH HYPERESTHESIA (ABNORMAL
INCREASE IN SENSITIVITY TO STIMULI) IS KEEPING THE CLIENT LOOSELY
COVERED WITH SHEETS/BLANKETS.
SENSORY DEPRIVATION: LACK OF ENVIROMENTAL STIMULI RELATED TO
HOSPITAL SETTING, ISOLATION, BED REST.
OR INABILITY TO RECEIVE OR INTERPRET INCOMING STIMULI, RELATED
TO IMPAIRED HEARING, VISION, CASTS, DRESSINGS, BRAIN DAMAGE,
SPINAL CORD INJURY, AND DEMENTIA.
**VITAL SIGNS**
WAIT 15-30 MINUTES AFTER INGESTION OF HOT OR COLD FOOD OR FLUID,
SMOKING OR CHEWING GUM FOR ORAL TEMP READING.
ORAL PROBE- USUALLY BLUE, RECTAL IS RED
RECTAL READING: DONE IN SIMS POSITION/ SOURCE OF
EMBARASSMENT/ANXIETY FOR PATIENT. NOT TO BE GIVEN TO PATIENTS
WITH DIARRHEA, RECTAL SURGERY, FECAL IMPACTION, AND BLEEDING
TENDENCIES.
AXILLARY READING: DELAY 15-30 MINUTES AFTER A BATH. USED ON
NEWBORNS, UNCONSCIOUS PATIENTS. USE ON ADULTS WITH JAW WIRED
OR MOUTH TRAUMA.
TYMPANIC READING- GOOD FOR YOUNG CONFUSED OR UNCONSCIOUS
PATIENTS. PLACE PROBE SNUGLY IN THE EAR, READING USUALLY TAKES
2-5 SECONDS.
AFEBRILE: NORMAL BODY TEMPERATURE
FEBRILE: FEVER (PYREXIA)
HYPERPYREXIA: HIGH FEVER USUALLY ABOVE 105.8 DEGREES
HYPERTHERMIA: RAISED BODY TEMP FROM BODYS INABILITY TO
PROMOTE HEAT LOSS OR REDUCE HEAT PRODUCTION
HYPOTHERMIA: OCCURS WITH EXPOSURE TO COLD. DEATH MAY OCCUR
BELOW 93.2. SKIN BECOMES CYANOTIC, H/R, R/R, B/P FALL. CARDIAC
DYSRHYTHMIAS, LOSS OF CONCIOUSNESS.
HEAT STROKE: OCCURS FROM PROLONGED EXPOSURE TO THE SUN OR
HIGH ENVIRONMENTAL TEMPERATURES. THIS MAY OCCUR IN THOSE WHO
SPEND TIME OUTSIDE, SUCH AS ATHLETES & CONSTRUCTION WORKERS.
S/S- (DRY SKIN) CONFUSION, GIDDINESS, DELIRIUM, EXCESSIVE THIRST,
NAUSEA, MUSCLE CRAMPS, VISUAL DISTURBANCES, BODY TEMP & H/R
RISES AND B/P DECREASES.
HEAT EXHAUSTION- OCCURS WHEN PROFUSE DIAPHORESIS RESULTS IN
WATER & ELECTROLYTES LOSS.
REMITTENT TEMP- FLUCTUATES SEVERAL DEGRESS MORE THAN 3.6
DEGRESS ABOVE NORMAL BUT DOES NOT REACH NORMAL BETWEEN
FLUCTUATIONS.
INTERMITTENT TEMP- ALTERNATES REGULARLY BETWEEN A PERIOD OF
FEVER AND A PERIOD OF NORMAL OR SUBNORMAL TEMP.
SUSTAINED TEMP- REMAINS CONSISTENTLY ELEVATED AND
FLUCTUATES LESS THAN 3.6 DEGREES.
INTERVENTIONS FOR TREATING FEVER:
MINIMIZE HEAT PRODUCTION, REST/MAXIMIZE HEAT LOSS-LESS
COVER/INCREASED BMR- OXYGEN, MEALS, FLUIDS/ORAL HYGIENE/DRY
LINEN/DAMP CLOTH TO FACE/ANTIPYRETIC MEDS/HYPOTHERMIA
BLANKET (COOLING BLANKET)
STETHOSCOPE:
DIAPHRAGM TRANSMITS HIGH PITCHED SOUNNDS FROM AIR AND BLOOD;
ALSO USED TO AUSCULTATE BOWEL, LUNG, HEART SOUNDS;
BELL TRANSMITS LOW PITCHED SOUNDS: AUSCULTATE HEART AND
VASCULAR SOUNDS USE LIGHT PRESSURE
RANGES OF HR RESPIRATION RATE RANGES
INFANT 120-160 NEW BORN 35-40
TODDLER 90-140 INFANT (6 MOS) 30-50
PRESCHOOLER 80-110 TODDLER (2 YRS) 25-32
SCHOOL AGE 75-100 CHILD 20-30
ADOLESCENT 60-90 ADOLESCENT 16-20
ADULTS 60-100 ADULT 12-20
NORMAL EUPNEA PATTERNS;
TACHYPNEA- RATE GREATER THAN 24/MINUTE. CAUSES FEVER, ANXIETY,
EXERCISE, RESPIRATORY DISORDERS.
BRADYNPNEA- RATE LESS THAN 10/MINUTES. SLOW SHALLOW
BREATHING CAUSED BY MEDS OR BRAIN DAMAGE.
CHEYNE STOKES- ALTERNATING PERIODS OF DEEP, RAPID BREATHING
FOLLOWED BY PERIODS OF APNEA. CAUSES DRUG OVERDOSE, HEART
FAILURE, INCREASED ICP, RENAL FAILURE.
HYPOXEMIA- LOW LEVELS OF ARTERIAL OXYGEN. PATIETS WITH COPD OR
CHRONIC LUNG DISEASE HAVE LOW LEVELS OF OXYGEN. TOO MUCH
OXYGEN GIVEN CAN BE FATAL FOR THOSE WITH LUNG DISEASE.
ORTHOPNEA- NEED TO SIT UPRIGHT TO BREATHE, CANNOT LIE
FLAT.
DYSPNEA- LABORED PAINFUL, DIFFICULT RESPIRATION (USUALLY RAPID
AND SHALLOW). A DYSPNEIC PATIENT USUALLY HAS SHALLOW
RESPIRATIONS AND APPEARS ANXIOUS.
APNEA- PERIODS OF NO BREATHING .
ANOXIA- LACK OF OXYGEN IN TISSUES
CYANOSIS- A BLUISH COLOR OF SKIN AND MUCUS MEMBRANE
**SURGICAL PATIENT**
GENERAL ANESTHESIA: ADMINISTERED BY INHALATION, INTRAVENOUS
ROUTE. MUSCLE RELAXANTS, PARALYZING AGENTS, NARCOTICS, GASES.
REGIONAL: (SPINAL OR EPIDURAL) FROM WAIST DOWN. ANESTHETIC
INJECTED NEAR A NERVE OR NERVE PATHWAY OR AROUND OPERATIVE
SITE BLOCKS IMPULSES.
TOPICAL AND LOCAL: USED ON MUCOUS MEMBRANES, OPEN SKIN,
WOUNDS, AND BURNS. EX., BIOPOSYS PROCEDURES.
CONSCIOUS SEDATION/ANALGESIA: USED FOR SHORT-TERM PROCEDURES,
IV SEDATION AND ANALGESIA, TWILIGHT SLEEP, AROUSABLE, EX.
COLONOSCOPY, BRONCHOSCOPY.
**WITH OLDER ADULTS MDS USE ONLY REGIONAL, LOCAL, OR TWILIGHT
ANESTHESIA** ITS VERY DIFFICULT TO EXTUBATE OLDER ADULTS**
PREOPERTATIVE PHASE: PREOP TEACHING NEEDS TO BE, WILL RELIEVE
ANXIETY WITH EDUCATION. **MUST BE DONE 24 HOURS PRIOR TO
SURGERY**
INTRAOPERATIVWE PHASE: EXTENDS FROM ADMISSION TO SURGICAL
DEPARTMENT (OPERATING ROOM) TO TRANSFER TO RECEOVERY ROOM
OR PACU.
POSTOPERATIVE PHASE: LASTS FROM ADMISSION TO RECOVERY ROOM OR
PACU TO COMPLETE RECOVERY FROM SURGERY, ENDS WITH RESOLUTION
OF ALL SURGICAL CONSEQUENCES.
**POST-OP PATIENTS LASTS 6-8 WEEKS**
PRE OP CONCERNS FOR THE RN:
CLIENTS ON ASPIRIN, HEPARIN, COUMADIN (WARFARIN) (ANTI-
COUGLANTS), WILL INCREASE CHANCE OF BLEEDING. (STEROIDS
DECREASES IMMUNE SYSTEM), TRANQUILIZERS, AND ANTI-DEPRESSANTS
(WILL CAUSE HYPOTENSION).
PATIENTS WHO HAVE A FEVER, AND OR OBESE PATIENTS WITH POOR
WOUND HEALING (FAT DOES NOT HAVE GOOD CIRCULATION) CAN BE A
PROBLEM IN PRE-OP STAGE. EKG AND CHEST X-RAY NOT DONE.EATING
FOOD AFTER MIDNIGHT ARE ALL REASONS SURGERY CAN BE CANCELED.
**PATIENTS MUST NOT TAKE ANTI-COUGALANTS A WEEK PRIOR TO SURGERY **
**ENEMAS ARE GIVEN PRIOR TO SURGERY (FOR INTESTINAL OR GASTRO
SURGERY ONLY)**
PATIENTS WHO SMOKE HAVE A 10X RISK FOR LUNG CANCER,
PNEUMONIA, ATELETATIS (LUNG COLLAPSE), CILIA (HAIR ON LUNGS TO
HELP SECRETE MUCOUS) CAN BE AFFECTED.
PATIENT MUST URINATE BEFORE PRE-OP MEDS ONCE MEDS ARE GIVEN
SIDERAILS GO UP.
RN MUST WITNESS PT SIGNING CONSENT FORM PRIOR TO ANY PRE-OP
MEDS GIVEN.
COPD, EMPHESIMA, OBESE CLIENTS, ARE HIGH RISK SURGICAL CLIENTS.


RN DIAGNOSES PRE-OP:
ANXIETY RELATED TO LACK OF KNOWLEDGE AS EVIDENCE BY QUESTIONS
RELATED TO UPCOMING SURGERY
KNOWLEDGE DEFECIT RELATED TO PRE OP PROCEDURES AS EVIDENCE BY
QUESTIONS
INEFFECTIVE AIR WAY CLEARANCE RELATED TO SMOKING FOR 30 YRS AS
EVIDENCE BY INABILITY TO SPECTUATE SPETUM.
HISTAMINE RECEPTOR ANTHISTAMINES- (PRE-OP MEDS) BLOCKS
HISTAMINE RECEPTORS WHICH CAUSES HEART BURN/NAUSEA EX.
ZANTAC. THESE ARE COMMON SIDE EFFECTS FROM ANESTHESIA.
POST-OP PAIN MANAGEMENT:
PATIENTS MUST GET UP AND AMBULATE AND COUGH /DEEP BREATHE
EVERY 2 HOURS, POSITION PATIENT.
URINE INPUT/OUT VERY IMPORTANT MUST VOID 30 ML AT LEAST EVERY
HOUR POST-OP. IF NOT IV MUST BE INCREASED CALLED FLUID
CHALLENGE.
INCENTIVE SPIROMETRY- (SEAL LIPS AROUND & TAKE A DEEP BREATH)
EXPANDS LUNGS DECREASE CHANCES OF ATELECTATIS.
LEG EXCERCISES PREVENTS DEEP VEIN THROMBUS (DVT)
SPLINTING- PREVENTS WOUND OR INCISION TO OPEN AND EVISARATING.
DEHISCENCE- WHEN WOUND OPENS
EVISCERATION- BOWEL OR ORGANS COMES THROUGH INCISION.**USE N/S
AND STERILE TOWELS, LAY IN SUPINE POSITION.
POST OP NURSING INTERVENTIONS:
PROMOTE WELLNESS!! TO ASSIST RETURN OF PERITALSIS EARLY (BOWEL
MOVEMENT).
ASSIST PATIENT OUT OF BED. AMBULATING PROMOTES INDEPENDENCE.
ESTABLISH THERAPEUTIC RELATIONSHIP & ALLOW PATIENTS TO
VERBALIZE FEARS AND CONCERNS. USE ACTIVE LISTENING, TOUCH TO
DEMOSTRATE GENUINE EMPATHY AND CARING.
PRIOR TO DISCHARGE FROM PACU PATIENT CANNOT HAVE:
HYPODERMIC 95 DEGREES AND BELOW/O2 SAT AT LEAST 94/PAIN LESS
THAN 4/ ADEQUATE URINE OUTPUT/ WOUND DRAINAGE HAS TO BE
UNDER CONTROL.
AMBULATORY CARE: PATIENT MUST BE ALERT/ORIENTED AND WALKING
AROUND. MUST DRINK FLUIDS AND NOT HAVE NAUSEA/VOMITING. POST-
OP TEACHING DONE PRIOR TO DISCHARGE.
S/S POST OP COMPLICATIONS
PERISTALSIS
ACTIVE INTESTINES (PT WILL NOT EAT UNTIL THIS HAPPENS).
PERISTALSIS RETURN WILL BE ASSESSED BY RN THROUGH LISTENING FOR
BOWEL SOUNDS.ONCE PATIENT CAN EAT, A DIET OF CLEAR LIQUIDS WILL
BEGIN, FOLLOWED BY FULL LIQUID DIET, TO SOFT DIET.
WILL PROGRESS DIET UNLESS PATIENT HAS
NAUSEA/VOMITING/DISTENDED ABDOMEN.
SOME PATIENTS COME FROM SURGERY WITH NASOGASTRIC TUBE
USUALLY FROM GI SURGERY. GASTRIC ACID IS SUCTIONED OUT INTO
CANNISTER.
CARDIOVASCULAR STATUS: COLOR OF LIPS AND NAILS, NEED PULSES AND
GOOD CIRCULATION., VITAL SIGNS FREQUENTLY.
CARDIO COMPLICATIONS:
HEMORRHAGE-RESTLESNESS, HYPOTENSION, TACHYCARDIA, COOL
CLAMMY SKIN.
HYPOVOLEMIC SHOCK- CIRCULATORY COLLAPSE R/T HEMORRHAGE WITH
ADDITIONAL S/S OF OLGUIRA AND CHANGE IN MENTAL STATUS.
THROMBPHLEBITIS- (HOMANS SIGN) PAIN IN CALF CAN BE DVT. BLOOD
CLOT IN VEIN CAUSES VENOUS INFLAMMATION AND STASIS RESULTING
IN PAIN, SWELLING, REDNESS. **HOMAN SIGN TEST BY PUSHING FOOT
WITH YOUR PALM IF CLIENT HAS PAIN IN THE MUSCLE ITS POSITIVE FOR
HOMANS SIGN** PREVENTION ANKLE ROTATION, FLEX KNEES BACK, FOOT
PUMPS** ANTI EMBOLUS STOCKINGS/COMPRESSION STOCKINGS
IMMEDIATELY PUT ON IN THE PACU**
PULMONARY EMBOLUS- BLOOD CLOT IN LUNG CAUSES SUDDEN CHEST
PAIN, SOB, TACHYPNEA, TACHYCARDIA, ANXIETY. **SUDDEN AND ACUTE
LIKE A PLUG NO OXYGEN GETS THROUGH**
MYOCARDIAL INFRACTION- CLOT IN THE HEART, SUDDEN AND ACUTE,
CHANGES IN VITAL SIGNS, NECK PAIN, SHOULDER PAIN, CYANOSIS.
RESPIRATORY STATUS- CHECK BREATHING AND AIRWAY. COUGHING
/TURNING POSITIONING PATIENT. USE INCENTIVE SPIROMETER. PUT
PILLOW OVER INCISION TO COUGH. DEEP BREATHING IN TO EXPAND
LUNGS TO PREVENT ATELETATIS. DEEP BREATHING IN THROUGH THE
NOSE AND OUT THROUGH THE MOUTH. THROUGH PURSE LIPS DECREASES
AIR RESISTANCE AND INCREASE LUNG COMPLIANCE
NEUROLOGICAL STATUS: LEVEL OF CONCSIOUS
SKIN INTEGRITY- LOOK FOR DRAINAGE ON SURGICAL BANDAGE. IF
DRAINAGE NOTED CIRCLE IT & PUT TIME AND RNS INITIALS. IF THE
CIRCLE KEEPS INCREASING CALL SURGEON.
IF BANDAGE IS SOAKED IT BECOMES PERMABLE,WHICH CAN BE EXPOSED
TO MICROORGANISMS.**RN CAN RE-ENFORCE SURGICAL SITE WITH A
CLEAN BANDAGE.
**RN NEVER CHANGES FIRST SURGICAL BANDAGE, ONLY SURGEON
ALLOWED**
WOUND INFECTIONS DOES NOT HAPPEN TILL 4-6 DAYS AFTER SURGERY.



**OXYGENATION**
ALWAYS DOCUMNT FINDINGS AS YOU SEE IT NOT AS MEDICAL DXS WE
ARE NOT DOCTORS. EX., HEART RATE 68 AND IRREGULAR, RESPIRATIONS
40, SHALOW, LABORED, COLOR CYANOTIC AND PALE. WE DO NOT SAY
PNEUMONIA OR MI THAT IS A MEDICAL DX.
ADVENTITOUS BREATH SOUNDS:
CRACKELS: FLUID IN THE LUNGS/ WILL NOT CLEAR WITH COUGH
RHONCHI:CONGESTION MIGHT CLEAR WITH COUGH
PUPIL RESPONSE PERRLA (PUPIL, REACTIVE, ROUND, TO LIGHT AND
ACCOMODITATION.
PUPILS CONSTRICTS TO LIGHT/DILATE TO DARK
CONSENSUAL REFLEX: WHEN YOU TEST ONE EYE THE OTHER EYE WILL
REACT THE SAME EX. IF ONE EYE DILATES THE OTHER DOES AS WELL.
ACCOMODATION: PUPILS DILATE TO DISTANCE OF OBJECT AND WILL
CONSTRICT AS IT GETS CLOSE UP.
KUSSMAUL- FRUITY BREATH SMELL (FROM DIABETIC PATIENTS)
RESONANCE- LOUD NORMAL LUNG SOUNDS.
PULSE OX CHECKS OXYGENT LEVELS. PATIENTS WITH PERIPHERAL
VASCULAR DISEASE AND DEMENTIA ARE POOR CANDIDATE FOR PULSE
OXIMETER TEST.
TRACHE SUCTIONING: SUCTION ONCE YOU ARE IN AND COMING OUT.
LIMIT SUCTION TO 10-15 SECONDS. HYPEROXYGENATE 100% RIGHT
BEFORE AND AFTER SUCTIONING.
NASAL CANNULA: MOST COMMONLY USED DEVICE. DELIVERY
CONCENTRATION 24-44%
SIMPLE FACE MASK- CONNECTED TO O2 FLOWMETER AND HUMIDIFIER
FITS SNUGLY TO FACE. DELIVERY CONCENTRATION 30-60%
PARTIAL REBREATHER- FACE MASK WITH A RESERVOIR BAG FOR THE
COLLECTION OF ABOUT THE FIRST 1/3 OF THE PATIENTS EXPIRED AIR
WHICH WILL MIX WITH 100% O2 FOR THE NEXT INHALATION, DELIVERS
70-90%
NONBREATHER- HIGHEST CONCENTRATION, RESERVOIR BAG IS FILLED
WITH O2 DELIVERS 60-95% O2.
VENTURI MASK- GOOD FOR COPD PATINTS DELIVERS THE MOST PRECISE
CONCENTRATION OF O2, DELIVERY CONCENTRATION IS 24-60%.
RN INDEPENENT INTERVENTIONS: MEASURE PULSE OX, RAISE BED 90
DEGREES, PUT ON NASAL CANNULA AT LOWEST SETTINGS OF 2 L/MIN IF
NO MD ORDER.
CARDIAC ASSESSMENT:
PMI (PULSE OF MAXIMAL IMPULSE) THE SAME AS APICAL RATE, KNOW
THE 4-5
TH
INTERCOSTAL SPACE MID CALVICLIUM LINE (RIGHT UNDER
NIPPLE ON LEFT SIDE OF PATIENT)
PULSATIONS CAN BE SEEN AT THE PMI ON A PATIENT THAT IS NOT
OVERWEIGHT AND LYING SUPINE IT IS NORMAL
IF YOU SEE PULSATIONS ON THE CORATOID ITS NOT NORMAL. IF YOU
LISTEN TO ARTERY YOU SHOULD NOT HEAR BLOOD FLOW THROUGH
ARTERY.
BURIT- NOISY BLOOD IS CORATOID ARTERY DISEASE (FAT PLAGUES).
PETAL PULSES/DORSAL PULSES DONE WHEN RN DOES PERIPHERAL
VASCULAR ASSESSMENT
**PREOP PATIENT/PROCEDURES AND TEACHING
REMEMBER TO TEACH PURSE LIPS, IT HELPS TO PROMOTE EXHALING.
COMPLIANT LUNG IS SOFTER LESS RIGID AND NOT STIFF. CLIENTS WITH
COPD HAVE RESIDUAL AIR, MAKING LUNGS RIGID AND STIFF. COPD
PATIENTS ON RESPIRATOR ARE DIFFICULT TO COME OFF OF IT.
ORTHOPRIA- POSITIONAL BREATHING/ 2 PILLOW ORTHOPRIA/3 PILLOW
ORTHOPRIA/**PT THAT SLEEPS WITH 3 PILLOWS IS IN WORST
CONDITION**
HYPOXIA: INADEQUATE AMOUNT OF OXYGEN AVAILABLE TO CELLS.
EARLY S/S IS (R-A-T) RESTLESSNESS, ANXIETY, AND
TACHYCARDIA/TACHYPNEA.
LATE SIGNS OF HYPOXIA IS (B-E-D) BRADYCARDIA, EXTREME
RESTLESSNESS, DYSPNEA.
PERFUSION: THE CARDIOVASCULAR SYSTEM PUMPS OXYGENATED BLOOD
TO THE TISSUES AND RETURN DEOXYGENATED BLOOD TO THE LUNGS.
TACTILE FREMITUS: MEANS VIBRATION, PLACE PALM ON PATIENTS CHEST
WALL AND HAVE HIM REPEAT 99 VIBRATIONS SHOULD FEEL EQUALLY
BILATERAL. IF YOU CANT FEEL VIBRATION FLUID RETENTION IS
SUSPECTED.
**SKIN INTEGRITY**
PRESSURE ULCER IS AN IMPAIRED SKIN INTERGRITY RELATED TO
UNRELIEVED PROLONGED PRESSURE. USUALLY OVER A BONY
PROMINENCE.
ISCHEMIA IS TISSUE DEATH
TISSUE BLANCHES= HEALTHY SKIN
NON-BLANCING= HIGH RISK FOR SKIN BREAKDOWN
RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT:
IMPAIRED SENSORY PERCEPTION/ IMPAIRED MOBILITY/ ALTERATION IN
LOC (LEVEL OF CONCIOUSNESS)/SHEAR/FRICTION SHEET BURN/URINE IS
ACIDIC CAN CAUSE MOISTURE THAT CAN INCREASE ULCER FORMATION.
WOUND CULTURE NEEDED FOR SPECIMEN COLLECTION, CLEAN WOUND
WITH N/S AND USE A STERILE QTIP
STAGE 1 INTACT SKIN WITH NONBLANCHABLE REDNESS
STAGE 2 PARTIAL-THICKNESS SKIN LOSS INVOLIVING EPIDERMIS, DERMIS,
OR BOTH. ULCER IS SUPERFICIAL AND LOOKS LIKE AN ABRASION,
BLISTER, OR SHADOW CRATER.
STAGE 3-FULL THICKNESS TISSUE LOSS WITH VISIBLE FAT. SLOUGH
(YELLOW, TAN, GRAY, GREEN, BROWN) MAY BE PRESENT BUT DOES NOT
OBSCURE THE DEPTH OF TISSUE LOSS
STAGE 4- FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, MUSCLE,
OR TENDON. SLOUGH OR ESCHAR (BLACK/BROWN NECROTIC TISSUE) MAY
BE PRESENT ON SOME PARTS OF THE WOUND. OFTEN INCLUDES
UNDERMINING TUNNELING.
UNSTAGEABLE WOUNDS: THE WOUND WHICH CANNOT BE VISUALIZED.
FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS
COVERED BY SLOUGH (YELLOW, TAN, GRAY, BROWN) OR ESCHAR (TAN,
BROWN, OR BLACK).
GRANULATION TISSUE: RED MOIST TISSUE COMPOSED OF NEW BLOOD
VESSELS, THE PRESENCE OF WHICH INDICATES PROGRESSION TOWARDS
HEALING.
WOUND EXUDATE: DESCRIBES THE AMOUNT, COLOR, CONSISTENCY AND
ODOR OF WOUND DRAINAGE AND IS PART OF THE WOUND ASSESSMENT;
EXCESSIVE INDICATES INFECTION (CAN BE PUSS)
PURULENT DISCHARGE- THICK YELLOW TAN FLUID WITH AN
UNPLEASANT ODOR.
WOUND DRESSINGS:
HYDROGEL DRESSINGS ARE GOOD FOR PAINFUL WOUNDS CAUSED BY
BURN AND RADIATION DAMAGE. THESE CAN BE REFRIGERATED ITS A GEL
AND IS VERY SOOTHING. MAINTAINS A MOSIT SURFACE TO SUPPORT
HEALING.
HYDROCOLLOID DRESSING: PROTECTS THE WOUND FROM SURFACE
CONTAMINATION. THICKER TYPE OF DRESSING CAN STAY ON FOR UP TO
7 DAYS.
TRANSPARENT DRESSING: GOOD FOR STAGE I & II P/U HELPS CLIENT
SLIDE, PREVENTS FRICTION,
WOUND VAC- USES NEGATIVE PRESSURE TO SUPPORT WOUND HEALING
WET/DRY DRESSING- (DEBRIDEMENT) USUALLY INVOLVES LAYERS OF
MOISTENED IN N/S SOLUTION, GAUZE COVERED BY DRY GAUZE (ALWAYS
PACK TO THE SURFACE), AND SECURE WITH TAPE, ONCE IT DRYS YOU
PULL DRESSING OFF AND ALL DEAD TISSUE AND DEBRIS WILL BE
ATTACHED TO DRESSING.
BEST PREVENTION FOR PRESSURE ULCERS IS TO TURN AND POSITION
PATIENT EVERY 2 HOURS
PREVENTION OF P/U USE GEL CUSHION/ PT MUST SHIFT WEIGHT EVERY
30 MINUTES IF ON CHAIR.
**POSITION PATIENT NO HIGHER THAN 30 DEGREES LATERAL INCLINED
POSITION FOR PATIENTS W/ P/U OR AT RISK FOR P/U**
ANYTHING HIGHER THAN 30 DEGREES WILL ADD PRESSURE TO SACRAL
AREA.
NOSOCOMIAL INFECTION IS A COMMON CAUSE OF NON HEALING WOUNDS
(IS A HOSPITAL INFECTION)
MRSA (STAPHYLOCCUS AUREUS INFECTION REQUIRES RN TO USE
PROTECTIVE EQUIPMENT OF GLOVES, GOWN, GOGGLES, AND FACE MASK.
USE STERILE COTTON-TIPPED APPLICATOR TO ASSESS THE LENGTH OF
SINUS TRACT OR TUNNELING IN WOUNDS.
DEHISCENCE: LAYERS OF THE SKIN AND TISSUE SEPARATE AND WOUND
FAILS TO HEAL PROPERLY (OCCURS 3-11 DAYS AFTER INJURY). THIS IS A
PARTIAL WOUND LAYERS SEPARATION. OBESITY, POOR NUTRITION,
CONTSTANT STRAIN ON THE WOUND ARE RISK FACTORS FOR
DEHISCENCE.
ADVISE PTS TO USE PILLOW OVER THE WOUND WHEN COUGHING TO
DECREASE THE PRESSURE ON THE WOUND.
EVISCERATION: WITH TOTAL SEPARATION OF WOUND LAYERS PROTUSION
OF VISCERAL ORGANS THROUGH A WOUND OPENING CAN OCCUR.
IF THIS OCCURS***RN MUST USE STERILE TOWELS SOAKED IN N/S TO
REDUCE RISK OF INFECTION**
BRADEN SCALE: IS A SCALE TO ASSESS PATIENTS SENSORY PERCEPTION,
MOISTURE, ACTIVITY, MOBILITY, NUTRITION, AND FRICTION/SHEAR.
SCORES RANGE FROM 6-23, LOWER SCORE INDICATES HIGHER RISK FOR
PRESSURE ULCER
MUST DOCUMENT WOUND: MEASUREMENT, SIZE, SHAPE, LOCATION,
COLOR, DISCHARGE, INVOLVEMENT OF SURROUNDING TISSUE.
NUTRITION: PROPER HYDRATION, HIGH PROTEIN INTAKE, (MEAT, FISH,
BEANS, EGGS, MILK PRODUCTS). NEED HIGH CALORIC INTAKE
VITAMINS IN A & C HELPS PROMOTE WOUND HEALING.
**URINARY & BOWEL**
FACTORS INFLUENCING URINATION: RENAL CONDITIONS, DIABETES
MELLITUS AND NEUROMUSCULAR DISEASES SUCH AS M/S
BENIGN PROSTATIC HYPERPLASIA (BPH- ENLARGED PROSTATE) MAKES
MEN PRONE TO RETENTION AND INCONTINENCE. **THESE MEN ARE AT
HIGH RISK FOR FALLS BECAUSE THEY HAVE FREQUENT SENSATION TO
URINATE**
STRESS INCONTINENCE IN WOMEN DURING COUGHING, LAUGHING, AND
WOMEN AVE INCREASED RISK FOR UTI.
BLADDER RETRAINING -RN MUST BRING PT TO BATHROOM EVERY 2
HOURS WHILE PATIENT AWAKE, AND EVERY 4 HOURS DURING THE NIGHT.
(DONT PUT DIAPERS). PELVIC FLOOR EXCERCISES ARE HELPFUL KNOWN
AS KEGEL EXCERCISES.
NOCTURIA- AWAKENING TO VOID ONE OR MORE TIMES AT NIGHT
POLYURIA- EXCESSIVE OUTPUT OF URINE
OLIGURIA- DECREASED URINE OUTPUT DESPITE NORMAL INTAKE.
DYSURIA- PAINFUL OR BURING UPON URINATION
ANURIA- NO URINE PRODUCED (SEVERE KIDNEY DISEASE)
UTI (ALSO CALLED CYSTITIS) ECOLI RESPONSIBLE FOR 75 TO 95% OF
UNCOMPLICATED INFECTIONS.
ECOLI PATHOGENS ARE TRANSMITTED DURING SURGICAL OR
CATHERTERIZATION PROCEDURES.
AVOID FLUIDS 2 HRS PRIOR TO BEDTIME TO PREVENT NOCTURIA
URINARY INCONTINENCE: INVOLUNTARY LEAKAGE OF URIN MOST
COMMON IN OLDER ADULTS. **CAN CREATE POTENTIAL SKIN TO
BREAKDOWN**
UAP CAN ASSIST WITH:
REPORTING IF PATIENT HAS VOIDED AFTER CATHETER HAS BEEN
REMOVED WITHIN 6 TO 8 HOURS
UAP CAN ALSO TURN ON TAP WATER TO HELP PATIENT ATTEMPT TO
VOID.
RN CARE FOR INDWELLING CATHETAR
CLEAN FROM PREINEUM DOWN, IF YOU NEED A SPECIMEN FROM
INDWELLING CATHETAR DONT OPEN SYSTEM, ITS A CLOSED SYSTEM.
CLOSE DRAINAGE TUBE AS SOON AS YOU GET SPECIMEN OUT. DONT
RAISE BAG OVER PTS BLADDER.
PREVENT CONSTIPATION: HYDRATION, FIBER, WALKING FRUITS, VEGGIES.
NARCOTICS HAVE CONSTIPATION EFFECT ON BOWELS. LACK OF
HYDRATION.
STOOL SOFTNERS DONT HELP WITH CONSTIPATION IT HELPS WITH
HEMMORROIDS.
FIBER IS A FORM OF BULK ITS GOOD FOR CONSTIPATED OR DIARRHEA.
**ENEMAS ADMINISTRATION:
WEAR CLEAN GLOVES, EXPLAIN PROCEDURE, PRECAUTIONS TO AVOID
DISCOMFORT, PATIENT MUS LAY IN LEFT SIDE LYING POSITION. **STOP IF
PATIENT FEELS PAIN!!**