HESI Case Study Notes

HESI Case Study Notes HESI - Altered Nutrition • • • • • • When establishing plan of care the nurse should... (Nursing process order...) 1. First complete the assessment 2. Analyze data to identify problem 3. Establish goals + Expected outcomes 4. Plans and implements interventions 5. Evaluate interventions to determine if the expected outcomes and goals were accomplished Occupational therapists - have expertise in helping clients adapt fine motor movements for the provision of self-care Dysphagia patients should have their bed in a HIGH fowlers position while eating and should be kept elevated for at least 1 hr following meals to reduce risk for aspiration Thickening agent to all liquids for dysphagia patients - allows for easier swallowing since it changes the consistency Conjunctiva sac - should be dark pink (pallor of any mucus membranes may indicate anemia) Tenting - may indicate fluid volume deficit Regular weight measurements of clients provides useful measurement of the clients general nutritional status (weight patterns + general assessment and dietary evaluation for a thorough picture of the client's nutritional status) • Average adult requires 20-30 kcal/kg per day • OJ should be restricted in CRF patients due to being K+ rich (they already have high K+ levels; can’t excrete) Total muscle mass of adolescent determined by… • Upper arm circumference – indirect measure of muscle mass o Height + weight = does not distinguish between fat and muscle o Triceps skin folds = measures body fat Normal serum sodium level 135-145 mEq/L Normal serum calcium level 8.6-10.2 mg/dL Normal serum potassium level 3.5-5.0 mEq/L Normal serum protein level 6.4-8.3 g/dL • After PEG tube is in place continue monitoring patient without infusing any solution through the PEG tube. o Feeding supplements are typically initiated when bowel sounds are present usually within 24hrs after PEG tube insertion o Positioning for tube feedings ! Semi-fowlers/fowlers • Dysphagia patients have a more difficult time swallowing LIQUIDS than semi-soft foods (ex. pudding this would be a good food to give them) HESI - Breathing Patterns Scenario - SOB & unable to sleep due to coughing Best technique for assessing RAPID+SHALLOW breathing • Place hand on upper abdomen and observe the rise and fall of the chest • To determine the need for supplemental oxygen via nasal cannula the nurse should measure • O2 saturation = provides info about % of hemoglobin that is saturated with O2 (a valuable reflection of the clients overall oxygenation) • Assessing breath sounds the nurse should ask him to perform what action? Breath slowly ad deeply through a slightly opened mouth for best auscultation of breath sounds • When applying nasal cannula check that the openings in the nasal prongs are aimed into the nose to prevent skin breakdown • Below normal O2 saturation = indicates impaired gas exchange - so this is an ok diagnosis • Restlessness + fatigue are indications of hypoxia • Skin is warm and flushed = does not indicate impaired gas exchange on its own, but could be a manifestation of an infection that resulted in impaired gas exchange • Tenacious sputum = sputum with thick consistency (sticks together) • Larger first dose of an antibiotic (loading dose) used to achieve a therapeutic level more rapidly in the bloodstream to allow it to start working faster • Antitussive medications - reduce the frequency of a cough • Expectorants - class of medication used to liquefy respiratory secretions • When assessing lung sounds you will always start at the apices and move downward comparing both sides Normal Breath Sounds Bronchial Hallow, blowing sounds over trachea and main bronchus (heard on expiration) Bronchovesicular Blowing sounds of medium pitch and intensity over bifurcation of the bronchi (mix of inspiration and expiration) Vesicular Soft, low-pitched sounds over the periphery of the lungs Effective Coughing 1. Take 3 slow, relaxed, deep breaths = this opens the aveoli and gets air behind the mucus in resp tract 2. One the last breath hold for 2-3 seconds = holding breath increases the pressure in chest to produce a more forceful cough 3. Contract abdominal muscles and force the air out through mouth = contraction produces the forceful exhalation that is the cough HESI - Constipation Most important assessment for the nurse to perform = auscultate for bowel sounds: subjective data (bloated and nauseated) and objective data (abdomen firm and distended) suggest the patient might have decreased peristalsis that can be assessed by listening for bowel sounds • • • • • • • • • • Abdominal hysterectomy = surgical procedure that removes uterus through an incision in the lower abdomen (cervix + uterus) Measure abdominal girth if suspect accumulation of fluid in peritoneal cavity Observe incisional staples if suspect wound infection of dehiscence Normal bowel sounds are heard 5-35 times per minute Reduced peristalsis would be considered a probable cause for the constipation rather than documentation of what the nurse heard Open-ended statements encourage patients to express further concern and fears Closed-ended questions? = Best way to collect patient history data in assessment regarding their current health issue Average daily fluid intake for adult = 1,400-2,000mL/day to prevent hardening of stool Immobility = major risk factor for constipation; ask patient how often they get out of bed and walk Barium swallow test = an upper GI series involves swallowing barium liquid that is followed by a series of x-rays taken of the esophagus, stomach, and duodenum Upper endoscopy = endoscopic procedure to visualize the inside of the esophagus, stomach, duodenum, and upper part of small intestine • Colonoscopy = endoscopic procedure to visualize the inside of the rectum and colon • Barium enema = barium inserted into rectum and x-rays are taken at diff. angles of colon Risk factors for development of constipation 1. Decreased mobility 2. Inadequate fluid intake 3. Opioid use Nursing diagnosis: Constipation related to surgery and anesthesia Diagnostic statement uses the correct format and identifies both.. 1. The problem 2. The etiology • Nursing Diagnosis for Bowel Elimination 1. Constipation - Decreased in normal frequency of defecation accompanied by different of incomplete passage of stool and or passage of excessively hard or dry stool 2. Perceived constipation - Self-diagnosis of constipation and abuse of laxatives, enemas, or suppositories to ensure a daily bowel movement 3. Diarrhea - Passage of loose unformed stool 4. Bowel incontinence - A change in normal bowel habits characterized by involuntary passage of stool 5. Risk for constipation - At risk for decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and or passage of excessively dry hard stool 6. Fecal impaction (not NADA approved) 7. Flatulence (not NADA approved) • • • • • Function of laxatives = soften the stool and stimulate rectal mucosa to produce soft or liquid stool Patient position before suppository administration = Sim's position - on the left side with knee flexed Advise client to take several slow deep breaths to relax the anal sphincter and reduce discomfort - deep breathing promotes relaxation of the anal sphincter thereby reducing discomfort when the suppository is inserted Hygiene + comfort care = within the UAP's scope of practice Nurse should always read back the verbal order to the physician and they have to be signed within 24 hrs. from the HCP. Administration documentation 1. Identifies medication 2. Dose 3. Time given 4. Route of administration 5. Reason for administering the medication Documentation describing the outcome for med administration • Documentation will provide the most specific objective data related to the effectiveness of the suppository What procedure is used to determine presence of fecal impaction? 1. Radiographic examination 2. Digital rectal examination Stimulation of the vagal nerve changes what vital sign? • Decreased pulse rate!! - Causes slowing reflex of the heart rate Decrease abdominal cramping with Enema administration 1. Slow rate of administration/lower bag 2. Roll the clamp to stop the enema until cramping subsides Dietary measures to promote bowel regularity? • Whole grain cereals + fruits = good fiber source • High-fiber foods, raw fruits, cooked fruits, greens, raw vegetables, and whole grains = promote peristalsis (bulk forming) • Gas-producing foods (broccoli, cauliflower, onions, and dried beans) can stimulate peristalsis. Factors Influence Bowel Elimination AGE • Infants have a smaller stomach capacity, less secretion of digestive enzymes, and more rapid intestinal peristalsis. The ability to control defecation does not occur until 2 to 3 years of age. • Adolescents experience rapid growth of the large intestine and increased secretion of HCl. • Older adults have decreased chewing ability. Partially chewed food is not digested as easily. Peristalsis declines, and esophageal emptying slows. Absorption by the intestinal mucosa is impaired. Muscle tone in the perineal floor and anal sphincter weakens, causing difficulty in controlling defecation. FLUID INTAKE • Fluid liquefies intestinal contents for easier passage. • Hot beverages and fruit juices soften stool and increase peristalsis. • Large quantities of milk may slow peristalsis and cause constipation. ACTIVITY • Immobilization depresses colon motility, and regular physical exercise promotes peristalsis. PSYCHOLOGICAL FACTORS • Stress, anxiety, or fear can initiate parasympathetic impulses, causing acceleration of digestion and peristalsis. Diarrhea and gaseous distention may result. • Emotional depression can decrease peristalsis and lead to constipation. PERSONAL HABITS • Personal habits such as failing to respond to the need to defecate and lack of privacy interfere with normal elimination patterns and can lead to constipation. • Hospitalized clients often share toilet facilities or use bedpans or bedside commodes. The resulting embarrassment can cause them to ignore the urge to defecate. PAIN • Hemorrhoids, rectal surgery, and abdominal surgery may cause a client to suppress defecation because of pain; constipation develops. MEDICATIONS • Laxatives and cathartics soften stool and promote peristalsis. • Antidiarrheal agents inhibit peristalsis. • Narcotic analgesics, opiates, and anticholinergic drugs depress peristalsis and can cause constipation. • Antibiotics alter normal bowel flora and can produce diarrhea. • Drugs that contain iron may turn the stool black. Antacids may cause a white discoloration. Anticoagulants may result in frank or occult blood in the stool. SURGERY AND ANESTHESIA • General anesthetics may cause slowing or halting of peristalsis. • Surgery involving bowel manipulation temporarily stops peristalsis (paralytic ileus) for 24 to 48 hours. HESI - Mobility Impaired physical mobility = nursing priority to prevent the many potential complications of immobility • Mobility will help drain resp secretions and help move mucus around to help prevent pneumonia in older adults = #1 priority o Remember older adults already have decreased temp, and increased BP • Immobile (bed rest) patients need high-calorie + high-protein o Avoid high calcium foods because they increase the risk of urinary calcification (since kidneys not working as hard = won’t excrete as much) • Immobility + constant contact w/ bed sheets/clothing, excessive heat, moisture in areas where air flow is limited o Contributes to bacterial + fungal growth which leads to… 1. Increase risk of infection 2. Skin break down increased 3. Increased risk for pressure ulcer development Client bedridden for weeks… What puts client at risk for pressure injury? • Rashes in axillary, groin, and skin fold regions o Have to address inflammation + tissue integrity issue Goals 1. Client is always the subject of the goal 2. The action is ALWAYS MEASURABLE (has to be complete) 3. Goal includes what the patient is to achieve and sets a realistic deadline • Dorsiflexion and plantar flex feel in the bed and chair = stimulate circulation by contracting the calf muscles which will increase venous return of the blood to the heart which will decrease the pooling of blood in the legs which helps VTE in the legs • Use of 2 pillows and place one lengthwise under each calf = provides slight elevation of lower legs for comfort but avoids pressure behind the knees which would decrease venous return and decrease the risk for venous thrombosis Safe transfer from bed to chair • Place the chair at a 45-degree angle on the patient's STRONGER side to provide for a safe transfer because it will allow him to pivot easily from the bed into the chair Crackles bilaterally in upper lobes of lungs for someone who has smoked a while = puts patient at risk for pneumonia • As a result teach the patient to take 10 deep breaths/hr while awake to prevent atelectasis (lung collapse: complete or partial), which can lead to pneumonia • Place hands on abdomen above belly button and instruct him to try and breath in and make his hands go up: uses diaphragm (abdominal breathing) to expand lungs Factors assessed in the Braden Scale (development of pressure injury) - low score = higher risk for pressure sore 1. Nutrition 2. Ability to move 3. Degree of activity 4. Moisture on the skin 5. Sensory perception 6. Friction + shear • Active range of motion exercises of legs and arms BID = help prevent contractures but do not help prevent muscle atrophy • Active isometric exercises = strengthen the large muscles of the buttock and thighs to help prevent muscle atrophy • Bedside commode - allows for independence and to be in the correct sitting position to promote bowel action: use when person is concerned about constipation due to immobility and poor diet • Homan’s sign in bilateral extremities • Parasthesia: an abnormal sensation, such as tingling or numbness; it is not a warning sign of thrombus formation • Edema or swelling in one calf is a possible sign of thrombophlebitis • Noticing fine crackles bilaterally in the upper lobes of the lungs the nurse would teach patient to take 10 deep breaths an hour while awake since deep breathing can help prevent atelectasis, which is what can lead to pneumonia • In deep breathing the hands should be placed on his abdomen above the belly button and instruct him to try to breath in and make his hands go up HESI - Perioperative Care Creatinine lab value = 0.6-1.3mg/dL Hemoglobin lab value for adult female = 11.7-15.5 g/dL • Deep breathing = client should inhale through the nose and exhale slowly through the mouth without pursing lips • Nurse may witness the client's signature to sign the consent form if the nurse is able to determine that the client has been sufficiently informed of the necessary information • Immediate postanestheisa period - the nurse should FIST implement positioning the unconscious client on their side to maintain an open airway and promote drainage of secretions • Normal abdominal findings to document after surgery? • Hypoactive bowel = expected finding after general anesthesia so document and continue assessing and monitoring the client What is an expected finding in Atelectasis? 1. Alveoli collapse 2. Dull or absent breath sounds + changes in breathing patters are expected • Packed RBC is ONLY compatible with NS • Blood should be connected to the bag of NS using specialized y-tubing and administered within 1.5-2 hrs (250ml transfused at 125ml/hr for 2 hrs) • Surgical asepsis for wound care = sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing • Only the surgeon can tell pt about the procedure, only the surgeon can get consent before surgery o Nurses can only witness the signature of the consent form o HESI - Urinary Patterns • Background: Pt: unable to control voiding sine experiencing a stroke 1 month ago. Pt. is alert and oriented and has no verbal deficits since stroke Nocturia = voiding frequency at night; incident increases greatly in older men who have enlarged prostates. May indicate an inability to concentrate urine due to poor blood flow to the kidneys • Retention = inability to empty the bladder completely • Oligouria = decreased urinary output • Incontinence = involuntary loss of urine; could be the result of neurologic impairment secondary to a stroke in some patients • Bladder training programs will help with incontinence • Remind patient to void every 2 hrs while awake and call for assistance as needed • Toileting schedule = effective means to retrain the bladder • Voiding should start q2h during the day and q4hr at night and then adapt to patients needs • Ineffective coping related to inability to control urine leakage = patients withdrawn behavior and statements of frustration are evidence that he may be having difficult time dealing with his incontinence • Incontinence the skin is exposed to urine frequently which is irritating and places the client at risk for impaired skin integrity • Braden scale should be completed and make every effort to prevent development of pressure ulcers in the patient (turn q2h, mobility, avoid pressure points, lay at 30 degrees on left side) Water repellent ointments help protect the skin from the acidic effects of urine (mild soap and warm water should also be used to clean the skin) • Most important nursing intervention for male w/ urinary retention? 1. Assess bladder distention Applying the Condom Cath (applying condom cath and skin protectant are useful actions to protect skin with incontinence issue) 1. Clean and dry the penis 2. Wrap the adhesive spirally around the shaft of the penis 3. Place the rolled condom over the glans penis and unroll it gently over the penis 4. Attach large leg drainage bad to reduce the frequency of bag emptying while the client is ambulatory • Catheter placement should be roughly 6-9 inches in to ensure proper placement in the adult male • If begin to inflate the balloon and person cries out in pain then deflate the balloon and insert the catheter farther; typically this just means that it is not inserted far enough • No urine output for 2 hrs, experiencing blood clots, and obvious discomfort = nurse should evaluate the urinary drainage tubing (should consider catheter tubing is obstructed and assess for kinks or pressure on the tubing that might cause an obstruction • Blood clots can also obstruct blood flow What sterile solution should be used to irrigate a catheter? ISOTONIC SALINE (NS) = solution that can be used for internal organ irrigations (ex. bladder or stomach) Hydrogen peroxide = may be diluted and used as an external agent Heparinized saline solution = this will increase bleeding problem since its an anticoagulant Chlorhexidine antimicrobial solution = used externally to cleanse the skin Closed Bladder Irrigation • 3-way indwelling catheter, bag is irrigate with tubing, and a gravity drainage system: irrigate is hung on IV pole and is regulated with a sliding clamp on the tubing • Student should prepare solution, apply gloves, clamp the distal tubing, begin to clean the specimen port on the drainage tubing (maintain aseptic technique) Irrigation can also be preformed by opening the connection between the catheter and drainage tubing, but opening that connection increases the risk of contamination • Avoid instilling air into the catheter • Distal clamp should be released after NS is instilled so that the catheter can drain • If instill more than what was withdrawn, that amount (mL) should be subtracted from the volume emptied from the drainage bag • Nurse may instill irrigate without withdrawing any fluid. Here the entire amount of the irrigate that was instilled would be subtracted by the amount of fluid emptied from the drainage bag to calculate urinary output Urine Color Changes?? Cloudy urine = possible development of UTI - sterile specimen is needed to detect an infection and do a UA Alkaline urine? = Give cranberry juice - believed to increase the acidity of urine making it less desirable for bacterial growth Diagnostic test that would make the nurse concerned that the client is at risk for sepsis? • Urine culture shows resistance to the prescribed antibiotic - ineffective antibiotic puts client at risk for sepsis or generalized infection Nurse concerns with elevated creatinine levels? = drug toxicity due to reduced drug excretion • Elevated creatinine levels refer to a problem w/ kidneys. Unable to excrete drug molecules the drug will remain in body for prolonged periods of time • • Frequency of drug administration is based on HALF LIFE - which describes the length of time required to reduce a drug level to one half of its initial value (shorter half life = drug will have to be given more frequently) Clients should void within 6-8 hrs after catheter removal (needs to be reported if have not gone after 8 hrs) To encourage voiding the intervention of 1. Turning on the tap so water is running when the client attempts to void which will stimulate the urge to void + 2. Positioning clients hands in warm water 3. Schedule (q2h) 4. Give positive feedback for appropriate toileting; never give negative 5. If positive response = assist to toilet; if negative response = encourage to try using the toilet (never force them to use it) Best way to obtain urine sample from an INDWELLING CATHETER! • Remember to NOT BREAK A STERILE SYSTEM! o Obtain a specimen from the port in the drainage tubing using a sterile syringe ! This maintains a closed sterile system ! Urine drainage from the bag does not reflect the clients current urinary function since it has been in the bad for a period of time ! Opening the sterile system = increase risk of infection • So always keep clamp closed! = #1 nursing priority HESI - Skin Integrity Skin Integrity Risk Factors + Nursing Interventions Decreased sensory perception Moisture Friction + Shear Decreased activity/mobility Poor Nutrition 1. Assess pressure points for signs of nonblanching reactive hyperemia 2. Provide pressure-redistribution surfaces 1. Assess need for incontinence management 2. Follow incontinence episode; clean with no-rinse perineal cleanser and protect with moisture barrier ointment (petroleum free) 1. Reposition patient using draw sheet and lifting off surface 2. Provide trapeze to facilitate movement 3. Position patient with HOB limitation to @ 30 degree + lateral turn 1. Establish and post individualized turning schedule - At least q2h 1. Provide adequate nutritional + fluid intake (assist w/ intake when necessary) 2. Consult dietitian for nutritional evaluation • Paraplegia = paralysis of the lower legs and lower body - typically due to spinal injury or disease • Nurse should apply light pressure with finger tips to assess for blanching; normal response is light-skinned clients which indicates there is no tissue perfusion impairment • Area of redness is measured to evaluate progression or healing • Reactive hyperemia = occurs when tissue is relieved of pressure; considered abnormal when the redness lasts longer than 1 hr and the surrounding tissues does not blanch • Mottling = irregular or patchy discoloration of the skin • Dependent rubor = redness that occurs when an area is lower than the heart; commonly seen in the legs • Palpable changes in the consistency of the underlying tissue of boney prominences is described as "spongy" and is indication hat pressure damage has occurred (changes in skin temp and induration may also occur) Wrist Restraints • Can impede circulation and cause tissue damage under restraint and distal to the restraint • Skin integrity and assessment of distal circulation (pulse volume, color, warmth, and sensation) must be assessed q 30 min and restraints must be removed at least q2h to allow for ROM • If hands become blue = loosen restraint to prevent tissue damage To provide pressure relief at night the client should be in a 30-degree lateral inclined position… • This is the best position to reduce pressure on bony prominences; pillow + foam wedges could be used for support and protection in this position Pressure-reducing gel chair cushion = help redistribute weight so that it is not all on the ischium; continue to use and shift weight frequently - Donut-shaped cushions are no longer recommended because they reduce blood supply the area that will worsen the ischemia, which will increase the risk of tissue destruction Transparent film dressing = used in stage 1 pressure ulcer and allows for visualization of the area and protects from shear - Assess pressure points with long handed mirror as well BID - These should be changed once a week Plastic-lined under pads = designed to protect bed linens by retaining moisture; do not wick moisture away from client's skin Intervention to reduce the effect of the diarrhea on skin? • Apply a moisture-repellent ointment to the intact skin areas (skin has to be dry and cleaned) Most effective method to ensure consistent positioning of a client? • A written individualized schedule that is placed in the client’s room without compromising client’s confidentiality Precaution Standards Standard = used for all patients when contact with potentially infectious bodily materials is possible (gloves) Droplet = when known or suspected contagious diseases can be transmitted through large droplets suspended in the air Airborne = when diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods of time Contact = when there is potential for wound drainage and debris to splatter during care MRSA = direct and contact with infected surfaces = mode of transportation - Nurse should be wearing gloves, gown, goggles, + face mask (normal) Best irrigation technique for sinus tracts/tunneling wounds? 1. Apply steady pressure using a 35 mL syringe and a 19-gauge needle 2. Provides 8lbs per square inch (PSI), which applies adequate pressure to ensure effective irrigation 3. Safe effective pressure is between 4-15 PSI and over 15 will drive bacteria into the wound and destroy healthy issue Types of Wound Drainage Serous Clear, water, plasma Purulent Thick, yellow, green, tan, or brown Serrosanguienous Pale, red, watery; mix of serous and sanguineous Sanguineous Bright red: indicated active bleeding Staging of Pressure Ulcers Stage 1 Observable pressure-related alteration of intact skin: Changes in… 1. 2. 3. Skin temperature (warmth or coolness) Tissue consistency (firm or boggy feel) Sensation (pain, itching) • Ulcer appears as a defined area of persistent Intact No dressing – visual assessment Turning schedule, hydration support, and nutritional support (protein) Transparent dressing – protects from shear; do not use if excess moisture present Hydrocolloid – Does not allow shallow visual redness in a lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues Stage II Partial-thickness skin loss involving epidermis and/or dermis or both. • Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater assessment Pressure redistribution measures taken with chair cushion (gel) Composite film – limits shear; heals through reepithelizatation Turning schedule Support hydration Nutritional support Manage incontinence Hydrocolloid – Change when seal of dressing breaks; max wear of 7x days Stage III Full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. • Ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Hydrogel – Provides a moist environment Hydrocolloid- MUST when seal of dressing breaks; max wear of 7x days Heals through granulation and reepithelizatation Evaluate pressure redistribution needs Hydrogel covered w/ foam dressing – Applied over wound to protect and absorb moisture Calcium alginate – used w/ significant exudate Must cover with secondary dressing Gauze – Used with NS; must unfold and make contact with wound Stage IV Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). • Undermining and sinus tracts may also be associated with stage IV pressure ulcers. Growth Factors – Used w/ gauze per manufactures limitations Hydrogel covered w/ foam dressing – Applied over wound to protect and absorb Heals through granulation and reepithelizatation Surgical consultation often needed for closure If wound has black hard surfaces (necrosis or eschar surface) then have to do a WET – MOIST dressing to loosen dead tissue ad then apply HYDROGEL when intact to prevent further damage of the surrounding granulation tissue • When eschar is present you have to remove it by debribment in order to properly stage pressure ulcer • Small amount of serosanguineous drainage does not require a dressing change (just place a circle around the drainage to allow the nurse to compare any changes in the amount of drainage at a later time) Purpose of WET - Dry DRESSING 1. Mechanically debride the tissue: moistened gauze placed on wound and allowed to dry -> will then adhere to the wound tissue and debrides the necrotic or infected tissue as it is removed 2. These dressings actually increase the risk of infection due to frequent dressing changes Transparent dressings = used to protect against contamination + friction while maintain a clean moist surface Exudate absorbers = absorb exudate, support debribment, and provide a moist wound surface; DOES NOT prepare wound for proper wound healing though Hydrogel = liquefies necrotic tissue of slough and rehydrates the wound bed; protects + absorbs moisture (not drainage): DOES NOT address wicking the purulent drainage away from a wound: So if drainage present we have to use a wet – moist dressing first then hydrogel ANTIBIOTIC… Linezolid (antibiotic) should never be shaken: tip upside down 3-5 times • This med can decrease your WBC in the body which will increase the chance of getting an infection • It can also lower platelet count as well which are needed for blood clotting • monitor visual changes since this could be due to possible optic neuropathy • Monitor CBC labs since drug may cause bone marrow suppression, anemia, leukopenia, or pancytopenia Side effects - Visual changes - Diarrhea (might lead to C. diff) - Abdominal cramping - Itching (may be linked to allergic reaction) Diagnostic test to determine drug toxicity Peak + trough = provides info on the amount of drug the individual client has in their blood stream; if trough (lowest level) is greater than acceptable limit for the drug then the next dose should be withheld and the blood level rechecked 6 hours later Therapeutic communication techniques = provides the nurse the opportunity for the patient to deal with his concerns and discuss feelings • Nurses should avoid the phrase "you can't" since this may be perceived as giving advice rather than encouraging further insight and verbalization by the client Primary developmental task = develop intimacy + working toward future goals • Nurse should emphasize interaction with a small group of intimate friends to support this developmental task • Encourage to study with peers and review notes to maintain a sense of normalcy for the young patient Hydrocolloid dressings = provide protection and moist environment to promote healing of ulcers Other Notes • What serum levels indicate to the nurse that the client requires dietary changes to have optimal health? Lab Values… Renal Liver 1. Ca 2+ - 8-10 1. LDL - < 150 2. Mg – 1.5-2.5 2. HDL - >50 3. Phos (PO4) – 3.5-4.5 3. Albumin – 3.4-5.6 Coagulation 4. AST – 10-40 4. PTT – 25-35 sec 5. ALT – 10-50 6. Aphos – 40-140 a. Ability to form blood clots – low levels = 7. Cholesterol <200 can prevent a clot from forming 8. Triglycerides <200 (deficiency will lead to excessive CBC bleeding or easily bruising) 9. RBC – 3.5-5 10. Hgb F: 10-14; M = 12-17 5. Pt – 10-13 sec 11. Hct – 35-45 a. Low levels = lower levels of clotting 12. WBC – 4-10k factors BMP b. Lack of Vit k possible (clotting factor – 13. BUN – 6-20 typically in cirrhosis or liver injury) 14. Creatinine 0.7-1.4 6. INR – 1-2 15. Na – 135-145 16. K – 3.5-5 17. CO2 – 22-26 18. Cl – 97-107 19. Glucose – 70-100 or 60-110 a. High levels = means blood clots more slowly Serum albumin = indicated the clients protein status for a long length of time due to its long half life (body’s best long term indicator of body’s entry into a catabolic state following protein depletion or severe malnutrition or stress of chronic condition) Transferrin = good indicator of iron binding capacity Prealbumin = short half life – sensitive indicator of relevant catabolic changes Urine urea nitrogen = good indicator of negative nitrogen balance • Assertive communication begins with “I need... or I want” • When managing care for a group of clients the nurse should identify, assess, and intervene for the client who is MOST UNSTABLE or at risk for an immediate complication o Client with elevated INR values = at risk for bleeding • What lab values would be decreased in CRF patients? o Hemoglobin (since kidneys won’t be making erythropoietin as much which is necessary for RBC production o Ca2+ decrease due to increase in serum phosphate (inversely related) Medication holds Narcotics held when RR <10-12 Cardiotonics held when apical pulse < 60 (ex digoxin) Tylenol held when low-grade fever (99) present cuz could mask effects of infection Diuretic held when BP is very low (even though it will promote decreased BP) Other… Cognitive Restructioning = effective strategy for changing one’s perceptions (provides a more positive outlook) HESI Exam #1 Notes • What assessment data provides the most accurate determination of proper placement of a NG tube? o Examining a chest x-ray obtained after the tubing is inserted! ALWAYS! ! Aspirating gastric content to assure a pH value of 4 or less + hearing air pass in the stomach after injecting air into the tubing are also methods used to determine proper placement, but you always need an X-ray • Stomas will become smaller when the initial swelling diminishes so inform patient of this if they are upset or concerned that it is bigger than they expected o Post-op swelling causes enlargement of stoma: nurse can teach client that the stoma will decrease in size and this will help reduce the clients anxiety and promote acceptance of the colostomy • NG tube client on low suction feels nauseated; nurse assessed there is no drainage through NG tube for the last 2 hrs, first/immediate action the nurse should take is… o Determine if the tube is functioning correctly which would relieve nausea ! Reposition the client on her side • NG tube patient w/ small-bore tube – core track (tiny tube into the small intestine) had severe coughing what should the nurse do? o After clearing the tube with 30ml air, check the pH of fluid withdrawn from the tube ! Coughing, vomiting, and suctioning can precipitate displacement of the tip of a small bore feeding tube upward into the esophagus placing the client at increased risk of aspiration. Checking sample fluid for acidic (stomach) or alkaline (intestine) values is very important and the nurse should assess tube placement this way prior to taking any other actions • Center of gravity for an elderly person? o Upper torso: due to stooped posture from changes from osteoporosis and normal bone degeneration, hips knees, and elbows flex • Center of gravity for adults? o Hips • Relocation often results in confusion among the elderly! o Stresses in elderly manifest as confusion • Always ask what vitamins and mineral supplements a person takes before surgery • Dark amber urine? o FVD characteristic so nurse should encourage additional fluid intake of juices and water • Anytime blood is administered the nurse should ensure accuracy of the blood type match to prevent hemolytic reaction • Best snack to give client with myasthenia gravis who is at risk for altered nutritional status? o Pudding!! Semisolid snacks that are easy to swallow and require minimal chewing effort provide calories and protein ! At high risk for nutritional deficit because of fatigue, muscle weakness that results in DYSPHAGIA • Pt. with high cholesterol and being taught about diet and lifestyle modifications. What comment indicates teaching has been effective? o “I will limit my intake of beef to 4oz per week) ! Limiting saturated fat from animal sources is an important diet modification for lowering cholesterol • Red meat and all proteins do not need to be eliminated but restrict to lean cuts (2oz servings as well) ! Reducing cholesterol effectively the client should exercise 30min/day or at least 4-6times/week • Proper use of inhaler: When should the client administer the inhaler-delivered medication o During the last part of inhalation! • Client with 24hr TPN w/ central line (54ml/hr). TPN has run out and not available what should the nurse do? – always monitor their glucose levels o Infuse 10% dextrose + water at 54ml/hr (at the prescribed rate of TPN IV) ! This will keep the client from experiencing hypoglycemia until the next TPN solution is ready: client could experience hypoglycemic reaction if the current level of glucose is not maintain or if the TPN is discontinued abruptly Macules = localized flat skin discolorations less than 1cm in diameter = these itch (client complains or right arm itching that reveals rash of multiple flat areas of redness ranging from pinpoint to 0.5cm = Document: localized red rash comprised of flat areas pinpoint to 0.5cm in diameter • When nurse recording finding of macules on skin the nurse should… 1. Describe appearance (rather than stating condition) a. Identifies vesicles (fluid filled blisters) b. Identifies papules (solid elevated lesions) c. Identifies petechial (pinpoint red to purple skin discolorations that DO NOT ITCH) • Low-sodium diet food selection o Skim milk, turkey, bread, ice cream • Most important action for nurse to implement when DONNING sterile gloves? o Keep gloved hands above the elbows! Hemiarthroplasty (partial hip replacement) = at risk for dislocation for 6 months – a year following procedure • Hip precautions to prevent dislocation… 1. Placing pillow between knees to maintain abduction of the hips 2. Avoid bending at the waist Tracheal suctioning: When you insert suction you have the finger lifted off Have to remove in a circular/spiral motion - Intermittently suctioning with finger over port Continuous LOW SUCTIONING Always monitor O2 Can only do 3 passes with each session • Nasotracheal suctioning for 15 seconds then large amounts of thick yellow secretions return. What should the nurse do next? o Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than 10-15 seconds due to the clients oxygenation being compromised during this time = why we always pre-oxygenate Thermal adaptation = body’s receptors adapt over time as they are exposed to heat or cold = loss of sensation occurs (20-30min after application) • Nurse at greatest risk for malpractice judgment for elderly client who requires frequent monitoring and fell and fractures a hip? o The nurse who transferred the client to the chair when the fall occurred – injury occurred while the nurse was in charge of the client’s care 4 Elements of MALPRACTICE 1. Breach of duty owed 2. Failure to adhere to the recognized standard of care (“frequent monitoring”) 3. Direct causation of injury 4. Evidence of actual injury (hip fracture) • Elderly client w/ fractures left hip on strict bed-rest. What nursing measure is ESSENTIAL to the clients nursing care? o Gently lift the client when moving into a desired position ! To avoid shearing forces when repositioning – lift client across a surface since they are already at increased risk of injury and pressure ulcer development cuz they are bedridden • After completing an assessment and determining that the client has a problem, the next action of the nurse should perform… o Determine the etiology of the problem (cause) – will help determine plan of care • Most important reason for starting IV infusions in UPE rather than LE of adults? o A decrease flow rate could result in the formation of a thrombosis ! Better venous return in upper extremities ! Cannulation of the veins in the LE increases risk of thrombus formation • Nurse administering meds to NG patient that’s connected to suction. After ensuring correct tube placement what should the nurse do? o Flush the tube with water (before and in-between each med) o After med admin the NG tube should be clamped for 20 minutes • Passive ROM exercises with contracted shoulder = place hands above and below the elbow o The joint being exercised should be uncovered • Hospice client complaining of pain with prescribe analgesics q4h prn. What action should the nurse implement? o Give an around the clock schedule for administration of analgesics ! Most effective management of pain is achieved by using around-theclock schedule that provides analgesic medications on a regular basis • Client with pneumonia has decreased O2 sat from 94-88 when ambulating. What intervention should the nurse FIRST implement? o Assist the ambulating client back to the bed to minimize O2 demands ! O2 sat < 90% = inadequate oxygenation ! Ambulation is contraindicated here since O2 saturation is depleting • Certified translator > family members to translate: this will ensure the exchanged info is reliable and unaltered • African-Americans refer to pain as “miseries” so nurse should perform a focused assessment on… o Inquiring about the source and type of pain Rotating IV infusion sites minimizes the risk for thrombophlebitis Assault = an intentional threat to engage in harmful contact with another Battery = unwanted touching This could be if client has DNR order but nurse did CPR and brought back to life anyways… Civil Laws = protect individual rights and include intentional torts (assault + battery) • When a client refuses a treatment the EXACT words of the client regarding the clients refusal of care should be documented • Documentation should occur immediately after any component of the nursing process What placement of the stethoscope should the nurse use to hear the client’s abnormal heart sounds? • Use bell over the vascular areas of the anterior chest (abnormal heart sounds best heard with bell since lower-pitched sounds are picked up this way) Goniometer = 2 piece ruler that has a protractor measuring device and measures the degree of flexion and extension over a joint (angles measured) Doppler = used to measure blood flow Calipers – used to measure body fat Tape measure = used to measure body part circumferences Lobes of the Brain Frontal = controls higher mental activities (memory, intellect, language, emotions, + personality) Thalamus = afferent relay center in the brain that directs impulses to the cerebral cortex Hypothalamus = regulates body temp, appetite, maintains a wakeful state + links higher centers w/ ANS + endocrine systems (pituitary) Parietal lobe = Location of sensory + motor functions • What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV meds? o Insert a Hubert-point needle into the port (how implanted ports should be assessed) Genogram = provides info on genetic and familial health disorders; used during health assessment process Intractable pain = pain that cannot be controlled with standard medical care: treatment should focus on managing discomfort Bed cradle = board at the end of the bed that you can tent sheets/covers over Hospice patient w/ audible gurgling sounds on inspiration (characteristic of ineffective clearance of secretions from the lungs or upper airway)= nurses highest priority Inform the family that death is imminent • Nurse should always ensure that the client is competent when refusing medication by evaluating their mental status HIGHEST PRIORITY FOR A IMMOBILE CLIENT = IMPAIRED GAS EXCHANGE (from list of diagnoses) ABC’s! • Turning immobile clients q2h will help move and drain respiratory secretions and prevent pneumonia from occurring = this involves the airway so if everything else is ok then this needs to be #1 Issue Unna’s paste boot = used for leg ulcers due to chronic venous insufficiency so need to check capillary refill of toes on lower extremities “Spiritual distress” diagnosis = best intervention = use of reflective technique when client expresses spiritual doubts = nonjudgemental listening technique which allows the client to feel comfortable • Nurse on accident finds narcotic in pocket after shift = could be accused of diversion • If client not properly informed of procedure and failure to obtain informed consent about the correct procedure = assault and battery (w/ deliberate intent to deviate from the consent form) • When death is impending the nurse must determine who is legally empowered to make decisions regarding end of life measures • Written informed consent is required prior to any invasive procedure o Verbal consent is not enough • Irrigating indwelling catheter w/ open technique – after applying gloves the nurse should… o Draw up the irrigation solution into the syringe o Attach to catheter and instill fluid o Then attach catheter to drainage tubing o Then subtract instilled irrigating fluid from the output whenever it is drained next • Insert rectal suppository have the client o Take slow deep breaths through mouth and stop bearing down • Culturally sensitive care – asks permission before touching a client Written learning objectives should include 4 elements 1. Who will perform the activity or acquire the desired behavior 2. The actual behavior the client will learn to exhibit 3. Condition under which the behavior is to be demonstrated 4. The specific criteria to be used to measure success Ex.) Upon discharge, the client will list 3 ways to protect the feet from injury Durable power of attorney = legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so – this is legally binding as well Macrobiotic diet = diet that is high in whole-grain cereals, veggies, sea veggies, beans, veggie soups, and the client needs essential amino acids to provide complete proteins to heal an infected wound No source of animal protein Components of very pain assessment 1. Sensory patterns 2. Area of pain 3. Intensity of pain 4. Nature of the pain Tachycardia, diaphoresis, and elevated BP are important findings, but should be obtained after doing pain assessment To complete the most assessment data for a client with chronic pain it would be “which activities during a routine day are impacted by your pain” o Chronic pain clients have adapted physiologically to vital sign changes, localized or intensity, so pain assessment should focus on any interference with daily activities WHO Pain Relief Ladder Adjunct medications may be used at any step for anxiety and pain management Step 1 drugs = Non-opioid analgesics (motrin or aspirin) Step 2+3 drugs = Opioid narcotics and to maintain freedom from pain (these drugs should be given around the clock rather than by the clients PRN requests) Postural hypotension = check for pule rate; body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate Orthostatic hypotension = a decrease in cardiac output Peripheral vasoconstriction = of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex Analysis of behavior patterns can identify age-appropriate or arrested development of normal interpersonal skills The successful resolution of a developmental crisis in the later years (65 or older) to include the achievement of a sense of integrity, fulfillment, wisdom, and willingness to face one’s own morality and accept the death of others Wear gloves when coming in contact with body secretions, excretions, or broken skin Sterile Field Adding sterile liquid into the sterile field = consider the field to be contaminated if it becomes wet during the procedure Cap of sterile liquid should be placed outside of the field and facing up To prevent contamination of the sterile field liquids should be held close (6”) to the receptacle when pouring to prevent splashing and the container should be placed near the front edge to avoid reaching over and across the sterile field Roller boards = used when transferring pt from recumbent to and from a stretcher Nursing action to prevent the formation of a sacral ulcer on patient who is immobile? Position prone with a small pillow below the diaphragm to maintain alignment and provide the best pressure Passive ROM for hip + knee = provide support to the joints of the knee and ankle and gently move the limb in a slow, smooth, firm, but gentle manner (bending should be carried out after joints are supported) IV Pumps Cassette pump = accurately delivers large volumes of fluid over longer periods of time with extreme precise (mL/hr) Syringe pump = accurate for low dose continuous infusion of low-dose medication at a basal rate (not large fluid replacement) Volumetric +nonvolumetric controller = count gtt/min to administer fluid volume and are inherently inaccurate due to variation of drop size Central Catheter IV Line Aspiration If aspirate blood then this means that the catheter is in place and the medication should be administered (blood can be pushed back through the client’s bloo dstream and does not need to be withdrawn) Nurse should first flush the tubing, administer med, and then flush the lumen with NS again MOST IMPORTANT ASSESSMENT DATA BEFORE AMUBULATING POST-OP PATIENT? #1 Respiratory rate: mobilization and ambulation increase O2 use so need to assess RR before ambulation to determine tolerance for activity Saline Lock IV obstruction 1. Reposition arm and alleviate any obstruction 2. May need to check for blood return next 3. Remove the dressing 4. Flush with NS 5. Resume intermittent infusion If IV rate was higher than it was suppose to be the nurse should… 1. Slow the IV infusion to keep vein open rate t prevent further risk of fluid volume overload 2. Gather additional assessment data (when IV solution was started + appearance of the IV insertion site before contacting the HCP for further instructions • If patient is dying (hospice or had DNR orders) the primary action of the nurse should be to contact the family immediately