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Fundamentals. Kaplan Review. Hypoxia. Inadequate tissue oxygenation Life threatening If untreated, fatal cardiac dysrrythmias Causes Decreased O2 level and lowered oxygen carrying capacity of the blood Diminished concentration if inspired O2: high altitudes
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Fundamentals Kaplan Review
Hypoxia • Inadequate tissue oxygenation • Life threatening • If untreated, fatal cardiac dysrrythmias • Causes • Decreased O2 level and lowered oxygen carrying capacity of the blood • Diminished concentration if inspired O2: high altitudes • Inability of the tissues to extract O2 from the blood: cyanide poisoning • Decreased diffusion of O2 from the alveoli to the blood: Pneumonia • Poor tissue perfusion with oxygenated blood: Shock • Impaired ventilation: multiple rib fxs or chest trauma
Hypoxia • Clinical S/S: • Apprehension; restlessness; inability to concentrate; decreased LOC; dizziness; behavioral changes • Patient: • Unable to lay flat; appears fatigued and agitated Vital Sign changes include: inc pulse rate; inc rate and depth in respirations Early stages: BP is elevated: unless Shock As it worsens: Resp rate declines- resp muscle fatigue Cyanosis: blue discoloration of the skin and mucous membranes- presence of desaturated hemoglobin in capillaries: late sign of hypoxia. It’s not a reliable measure of O2 status. Central : tongue; soft palate; and conjunctiva of eye-blood flow is high- cyanosis Peripheral: extremities; nail beds; ear lobes- vasoconstriction and stagnant blood flow
Documentation • Guidelines: • Factual: descriptive, objective- what the nurse sees, hears, smells and feels-direct observation and measurement • Accurate: exact measurements- example: “Intake, 360mL” is more accurate than “ drank adequate amounts of water” • Complete: contains appropriate and essential information. Your nursing care and patient’s response. • Current: immediate documentation is essential to avoid delays in patient care. • Organized: logical order, clear, concise and to the point. Ex. Patient complaint, intervention, evaluation
Documentation • Acuityreports: • Not a part of the medical record; never state on the chart that an incident report has been filed • Discharge starts with admission • Kardex: contains patient care summary • Telephone/verbal orders: read back to doctor and right rb at the end of written order • Purposes of documentation/recording: • Communication; legal documentation; financial billing; education; research and auditing/monitoring
Confidentiality • Protects patient personal information • Nurses are legally and ethically obligated to keep information about patients confidential. • They may not discussed patient’s examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient’s care.
Therapeutic Communication Providing information Clarifying Focusing Paraphrasing Asking relevant questions Summarizing Self-disclosure Confronting • Active listening • Sharing observations • Sharing empathy • Sharing hope • Sharing humor • Sharing feelings • Using touch • Using silence
Non-Therapeutic Communication • Asking personal questions • Giving personal opinions • Changing the subject • Automatic responses • False reassurance • Sympathy • Asking for explanations • Approval or disapproval • Defensive responses • Passive or aggressive responses • Arguing
Informed Consent • A person’s agreement to allow something to happen such as surgery or an invasive diagnostic procedure, based on a full disclosure of risk, benefits, alternatives, and consequences of refusal. • Creates a legal duty of the healthcare provider to disclose facts in terms understood by the patient. • Failure to obtain consent- may result in a claim of battery; negligence. • Emergencies- patient is at risk of death/harm, and cant give consent, no one next to kin is available. • Explanation- surgeon or whoever is performing the procedure: brief explanation, names of those involved, description of risks/discomfort, description of alternative therapies and risks of doing nothing, right to refuse, even after it has started • Witnessed- RN only witness that patient voluntarily gave consent; signature is authentic; patient appears competent; student nurses are NOT allowed! • Who can give consent? Adult patient; if unconscious- legally authorized person; a parent of a minor; if divorce, legal custody; mental illness patients must also give consent, unless incompetent-in which the court will decide.
Good Samaritan Law • Providing emergency assistance at an accident scene. • Limit liability and offer legal immunity if a nurse helps at the scene of an accident- • Action must be within acceptable standards- • Someone who performs a procedure that he/she is not trained for- will be liable for any injury caused by the act • Once committed to assist patient- the nurse must stay with the person until can safely transfer care to someone who can provide needed care • Failure to do so- liability for abandonment; responsible for any injury suffered after leaving • “failure to act”- laws that make it a crime not to provide Good Samaritan care ( Lousianna, Minnesota; Vermont)
Ethics • The ideal of right and wrong behavior. • Places caring in the center of a decision making. • Ethic of Care- concerned with relationships between people and with a nurse’s character and attitude towards others. • An ethic care places the nurse as an advocate, solving ethical dilemmas by attending to relationships and by giving priority to each patient’s unique personhood.
Toileting/ Bedpan • Providing comfort; privacy; time • Help a male patient to stand to urinate/urinal-unless contraindicated • Proper position of bed pan reduces patient’s back strain. • Position immobilized patient on bed pan- lower head of bed; help patient roll onto one side (back side towards nurse); apply small powder to bedpan rim or to patient’s buttocks; place bedpan firmly against buttocks; push bedpan down into mattress with open rim toward feet; place one hand against bedpan; place other hand around patient’s fore hip; ask patient or help turn patient on his/her back; raise head of the bed to 30 degrees; place a rolled towel under lumbar curve; raise knee gatch (unless contraindicated) or ask patient to bend knees to help assume squat position.
Impaired Skin Integrity • Skin- larger organ of the body; 15% of adult body weight; protective barrier against disease; sensory organ; synthesizes vit D • Nurses’ most important responsibilities: assess and monitor skin integrity; identifying problems; and planning, implementing, and evaluating interventions to maintain skin integrity • Primary intention- wound is closed, surgical wound, sutured/stapled, heals quickly, minimal scar • Secondary intention-edges not proximal, pressure ulcers, surgical wounds that have tissue loss, heals by granulation, long healing process, lots scar tissue • Tertiary intention-left open for several days, then edges are approximated, contaminated wounds, closure is delayed until risk for infection resolved • Emergency setting: inspect for bleeding; foreign bodies; size; dirty penetrating object-tetanus shot? • Abrasion- superficial; laceration- may bleed profusely; puncture-bleed in relation to depth and size (internal bleeding and infection) • Stabilized setting: patient’s condition; wound appearance (dehiscence/evisceration); skin discoloration (bruising/bleeding); character of wound drainage (smell, color, amount, consistency); drains; closures (staples/sutires); palpate wound; wound cultures (clean wound first with NS; never collect from old drainage)
Pressure Ulcers • Pressure ulcers; pressure sores; bedsores; decubitus ulcers: stage 1(red, intact, non-blancheable); stage 2 (partial thickness loss of dermis, shallow open ulcer, red/pink bed without slough; or an intact blister filled of serous/serousanguineous fluid); stage 3 (full thickness tissue loss, SQ fat may be visible, bone, tendon, muscle are NOT exposed, some slough may be present, may have some undermining/tunneling); stage 4 (full thickness tissue loss, exposed bone, muscle, and/or tendons, slough or eschar may be present, often underminning/tunneling); unstegeable (cannot be visualized, depth of injury is unknown, full thickness, completely obscured by slough and or eschar); suspected deep tissue injury (purpled/maroon area if discolored intact skin or blood filled blister) • Caused by: prolonged, unrelieved pressure over bony prominence-combination of shear/friction; tissue ischemia • Contributing related factors: pressure intensity, pressure duration, tissue tolerance • Risk factors: impaired mobility; impaired sensory perception; alterations in LOC; shear; friction; moisture • Dark pigmented skin: difficult to assess-proper lighting (natural or halogen) is important • Braden Scale: risk-assessment tool for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction/shear
Changing Dressings • Reduce exposure to microorganisms • Primary function: absorb drainage • Clean technique, unless fresh surgical wound • Pressure ulcers don’t need sterile gloves; packaged gauze is sterile; keep aseptic clean technique • Dressing sticking to wound: moisten with NS for easier removal, do not pull dry! • Purposes: protect from contamination; aids in hemostasis; promotes healing by absorbing drainage and debriding wound; supports/splints the wound site; protects patient from seeing the wound; promotes thermal insulation; provides a moist environment • Type of dressing; presence of underlying drains/tubing; supplies needed for wound care • Guidelines: assess skin beneath tape; hand hygiene; sterile gloves (for a fresh surgical wound) or clean gloves; remove and change over closed wounds when wounds become wet, s/s of infection and as ordered; evaluate pain (analgesics if needed); describe steps; gather supplies; recognize normal signs of healing; answer questions; teaching and evaluation may be needed
Wet to Dry Dressings • When wounds such as necrotic wounds require debriding: place moist dressing into the wound and allow to dry • For a clean granulating wound: maintain a moisten environment-do not let moisten gauze to dry • Secondary intention- dressing needs to support a moist wound environment- allowing the wound to resurface as quickly as possible • Packing a wound- assess size, depth and shape; determine appropriate type of dressing; saturate it with the ordered solution, wring it out, unfold, and lightly pack into the wound. • Do not pack the wound too tightly- it causes pressure of the tissue on the wound bed; pack the wound only until it reaches the surface; do not extend higher than the surface of the wound; do not overlap onto the wound edges- causes maceration to healthy tissue around wound
Wound Irrigation • Special way of cleaning wounds • Requires a sterile technique • Use an irrigation syringe (35mL with 19-gauge needle) to flush area From least contaminated area. • Do not allow needle to touch skin/wound
Heat/Cold Therapy • Causes systematic and localize response • Before applying heat or cold therapy: assess patient physical condition (intolerance of heat/cold) • Assessment: Observe are to be treated; assess skin, open areas; neurological system for sensation; mental status for ability to communicate problems; contraindication to heat/cold therapy • Contraindications: Heat (sweating and vasodilation)- avoid on bleeding areas; acute, localized inflammation (ex. appendicitis-will rupture); large areas of body of patient with cardiovascular problems-may result is massive vasodilation to vital organs • Cold (vasocontriction and piloerection)- avoid on edematous areas (it further retards circulation to the area/prevents absorption); impaired circulation (arteriosclerosis- it further reduces blood supply to affected area ); neuropathy (unable to perceive temperature change causing damage from extreme temperature); shivering (intensifies shivering-may cause dangerously increased body temperature)
Hemoptysis • Bloody sputum • Describe according to amount and color; whether it is mixed with sputum. • Bloody or blood-tinged sputum: sputum specimens; chest X-rays; bronchoscopy; other x-rays • Determine if is associated with coughing and bleeding from the upper respiratory system tract, sinus drainage or the GI tract (hematemesis- bloody vomit) • Has an alkaline pH, and hematemesis has an acidic pH- pH testing can help determine source
Maslow • Hierarchy of basic human needs; includes 5 levels of priorities • Interdisciplinary theory that is useful for designating priorities of nursing care • First level- most basic- physiological needs ( air, water and food); first priority • Second level: safety and security needs (physical and psychological security); first priority • Third level: love and belonging needs (friendship, social relationships and sexual love) • Fourth level: encompasses esteem and self-esteem needs (self-confidence, usefulness, achievement , and self-worth • Fifth level- final level: need for self-actualization ( the state of fully achieving potential and having the ability to solve problems an cope realistically with situations of life)
Pulse Sites • Carotid- side of neck; used with CPR • Brachial- groove between bicepts/tricepts; antecubital fossa • Radial- wrist; parallel with the thumb • Ulnar- wrist; parallel with the pinky finger; used when evaluating arterial insufficiency of hand • Femoral- below inguinal ligament; midway between symphysis pubis and anterosuperior iliac spine; deep palpation may be necessary to feel pulse • Popliteal- behind the knee; with knee slightly bent; maybe difficult to feel • Dorsalis pedis- top of the foot; maybe absent • Posterior tibia-inner side of each ankle; with foot relaxed and slightly extended
Apical Pulse • 4th -5th intercostal space at left midclavicular line (apex of the heart) • Requires a stethoscope • To assess heart; and an abnormally slow, rapid or irregular pulse • Listen for 1 minute
Fowler’s Position • Head of the bed elevated 45-60 degrees • Supported Fowler’s: Head resting on bed or small pillow; use pillows to support arms and hands; position pillow at lower back; small pillow under the thighs; elevate heels • Positioning a hemiplegic in a supported Fowler’s: sitting position as straight as possible; head on a small pillow with chin slightly forward (if patient unable to control head movement, avoid hyperextension of neck); flex hips and knees by using pillows or folded blankets under knees; place trochanter rolls along sides of patient’s legs; support feet in dorsiflexion with foot support such as ankle or foot boots
Body Mechanics • Body mechanics alone do not protect the nurse from injury to the musculoskeletal system when moving, lifting or transferring patients • Coordinated musculoskeletal activity is necessary when positioning and transferring patients • Strain on the lumbar back muscles-most common back injuries • Steps to prevent injury: • -Keep weight to be lifted as close to the body as possible (places object in the same plane as the lifter and closer to the center of gravity for balance) • -Bend at the knees (helps maintain the center of gravity and uses the stronger leg muscles to do the lifting • -Tighten abdominal muscles and tuck the pelvis (provides balance and help protect the back) • -Maintain the trunk erect and knees bent (so multiple muscle groups work together in a coordinated matter)
Transfer Techniques • Assess situation before transferring patients- weight to be lifted; assistance needed; available resources; patient handling equipment when patient unable to assist (standing lift; full body sling; mechanical lifts; lift team) • Use proper body mechanics; ergonomic programs • Bed to chair; explain procedure to patient; use gait/transfer belt; wheel chair must have arm rests; have patient help with strong side; stand on weak/injured side of patient
Positioning • Fowler’s – HOB raised to 45 degrees or more; semi sitting position; feet may also be raised at the knee • Eating; placement of NG tube; nasotracheal suctioning • Semi-Fowler’s – HOB raised appx 30 degrees; less inclination the Fowler’s; feet may also be raised • Promote lung expansion; ventilator assisted patients; gastric feedings • Trendelensburg’s – entire bed frame tilted with HOB down • Postural drainage; facilitates venous return in patients with poor peripheral perfussion • Reverse Trendelensburg’s – entire bed frame tilted with foot of bed down • Infrequent; promotes gastric emptying; prevents esophageal reflux • Flat – entire bed frame horizontally parallel with floor • Vertebrae injuries; cervical traction; hypotensive; sleeping
Ambulation • Increases joint mobility • May need supportive devices: cane, crutches, W/C… • Assess patient’s activity tolerance, strength, coordination, baseline VS and balance; determine type of assistance needed; assess orientation and determination, or signs of distress; evaluate safe environment (remove obstacles; clean, dry floor; identification of rest points; supportive, non-skid socks/shoes); have patient sit and dangle feet on the side of the bed 1-2 min before standing • Methods: several; support at the waist-gait belt • S/S hypotension: dizziness, lightheadedness, nausea, tachycardia, pallor, and/or fainting • Fainting (syncope episode): assume wide base of support with one foot in front of the other- supporting patients body weight; extend one leg- let patient slide against leg; gently lower patient to floor-protecting head • Attempting to ambulate again: proceed slowly; monitor dizziness; check BP before and during and after
Hazards of Immobility • Metabolic: Slow wound healing; Muscle atrophy; Decreased amount of subcutaneous fat; generalized edema; (negative nitrogen balance) • Respiratory: asymmetrical chest wall movement; dyspnea; increased respiratory rate; crackles; wheezes; (atelectasis; hypostatic pneumonia) • Cardiovascular: orthostatic hypotension; increased heart rate; third heart sound; weak peripheral pulses; peripheral edema; (thrombus) • Musculoskeletal: decreased ROM; erythema; increased diameter in calf or thigh; joint contracture; activity intolerance; (footdrop; diusseosteoporosis) • Skin: break in skin • Elimination: dehydration; infections; decreased urine output; cloudy or concentrated urine; urine stasis; development of stones; decreased frequency of bowel movements; decreased bowel sounds; distended bladder and abdomen
Range of Motion (ROM) • Goniometer is used to measure ROM • Comparison of both active and passive; compare same body parts for equality of movement • Flexion- elbow, fingers, knees • Extension- elbow, fingers, knees • Hyperextension- head • Pronation- forearm; hand • Supination- forearm; hand • Abduction-leg, arms, fingers • Adduction- legs, arms, fingers • Internal rotation- knee, hip • External rotation- knee, hip • Eversion- foot • Inversion- foot • Dorsiflexion- foot • Plantar flexion- foot
Isometric Exercises • Tightening or tensing muscles without moving body parts (isometric contraction) • Examples: quadriceps set exercises; contraction of gluteal muscles • Ideal for patients who do not tolerate increased activity; immobilized patient in bed • Benefits: increased muscle mass, tone and strength-decreasing the potential of muscle wasting; increased circulation to the involved body part; increase osteoblastic activity • Resistive isometric exercises: it helps promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity • An individual contracts muscle while pushing against a stationary object (ex. push ups and hip lifting- patient is sitting on a chair and pushes against arm of the chair while raising hips; using a footboard to push against it with feet)
Preoperative Exercises • Diaphragmatic breathing (3-5min): semi-Fowler’s; instruct patient to place hands across from each other along lower borders of rib cage; show patient to take slow, deep breaths, inhaling through nose and pushing abdomen against hands; avoid using chest and shoulder while breathing; hold slow deep breath for count of 3 and then slowly exhale through mouth (pursed lips) • Incentive spirometry- semi or high Fowler’s (bariatric patient-reverse T • Coughing: controlled coughing; splinting- cough 2-3 times every 2 h while awake- facilitates diaphragm excursion and enhances thorax expansion; facilitates effects of coughing; help remove mucus more effectively • Turning: splint incision area to help turn (supports and minimizes pulling on suture line during turning); abdominal surgery- bend rt knee and keep lt knee straight (stabilizes patient’s position); back surgery- log roll Leg exercises: maintain joint mobility; promote venous return to prevent thrombi
Making an Occupied Bed See SKILL 39-5, pages 813-817 on your Fundamentals of Nursing textbook.
Seizures • Seizure – hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity (rigidity of muscles), and clonicity (jerking of muscles). • Tonic-clonic- (Grand-mal)- Lasts appx 2 mins (not more than 5) and is characterized by a cry and loss of consciousness with falling, tonicity, clonicity, and incontinence. Musculoskeletal injuries can occur. • Aura is reported before seizure, as a warning. Bright light; smell or taste • During a seizure – shallow breathing, cyanosis, and loss of bladder and bowel control • Postictal phase- follows: amnesia or confusion, falls in deep sleep • Medical attention- repeated seizures; single seizure lasts longer than 5 min without any signs of slowing down or unusual in some way; trouble breathing afterwards; appears injured or in pain; recovery is different than usual • Status epilepticus- prolongued/repeated – emergency; req intensive monitoring and tx • Precautions- protect from traumatic injury; adequate position (ventilation and drainage of secretions); privacy and support
Intake and Output • Measuring and recording all I&Os during a 24 hr period is important in fluid balance; it’s a comparison of intake and output; if appx equal- normal • Doctor’s order (most facilities), or nurse’s judgement (if suspects necessary): change in urine output is a significant indicator of fluid alterations or kidney disease • It can be delegated to a NAP; however, only Nurses are responsible for recording any IV or tube feeding input and drainage from tubes (output) • Use graduated receptacle to measure accurate urinary output; label container with patient’s name; each patient must have its own to prevent cross-contamination; rinse container after emptying; secure and clamp tubing from urinary draining bags, and clean the end with alcohol before putting it back in the holder • Report any decrease or increase in urine volume: normal daily output generally ranges from 1200 to 1500 mL of urine; an hourly output of less than 30mL for more than 2 consecutive hours is cause for concern; or consistently high volumes (polyuria): ex. 2000 to 2500mL per day
Intake and Output • Interpretation of situations in which I&Os are substantially different is determined by the individual patient. Examples: • 1. If intake is substantially greater than output, there are 2 possibilities: the patient may be gaining excessive fluid, or maybe returning to normal fluid status by replacing fluid lost previously from the body • 2. if output is substantially greater than intake, there are also 2 possibilities: the patient maybe loosing needed fluid from the body and developing ECV deficit and/or hypernatremia, or may be returning to normal fluid status by excreting excessive fluid gained previously • Fluid intake includes all liquids that a person eats or drinks, administrated IV fluids (includes blood), or receives through a feeding tube: ex. gelatin, ice cream, soups, water, coffee, juice, IV flushes, and feeding tube flushes. • Fluid output includes: urine, diarrhea, vomitus, gastric suction, and postop drainage from wounds or tubes • Teach family and patient how to measure and record I&Os, and to notify the nurse or NAP of any input or output every time
NG Tube Insertion • See SKILL 46-2, pages 1115-1120
Incentive Spirometry (IS) • It promotes deep breathing and prevents or treats atelectasis and pulmonary complications in the postop patient (specially abdominal surgery). • Encourages patients to use visual feedback to maximally inflate their lungs and sustaining it. • A postop inspiration capacity one half- three fourth of the pre-op volume is acceptable because of postop pain. • Flow-oriented IS; consists of 1 or more plastic chamber(s) that contain freely moving colored balls; has a bellows that is raised to a predetermined volume by an inhaled breath; an achievement light or counter is used to provide feedback. • A patient inhales slowly and with an even flow to elevate thee balls and keep them flowing as long as possible to ensure maximal inhalation. • The AARC guidelines recommends 5 to 10 breaths per session every hour while awake • Pain med can be given prior to the session to assist with deep breathing by reducing pain/splinting.
Suctioning • Suctioning is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures. • Suctioning techniques include oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and suctioning of an artificial airway • Each type of suctioning requires the use of a round-tipped, flexible catheter with holes on the sides and end of the catheter. When suctioning, you apply negative pressures (not greater than 150 mm Hg) during withdrawal of the catheter, never on insertion. • Oropharyngeal and nasopharyngeal - Used when the patient can cough effectively but is not able to clear secretions • Orotracheal and nasotracheal- Used when the patient is unable to manage secretions • Tracheal - Used with an artificial airway • You will differentiate between when to use sterile and when to use clean techniques. If you suction the patient too much, he or she can be at risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs.
