2800 Exam Four Flashcards
Total blindness
absence of all sight
legal blindness
central visual acuity of 20/200 or less in better eye with correction
OR very narrow peripheral vision field (20 degrees or less)
severe visual impairment
being unable to read newsprint even with correction
what is almost all blindness in the US caused by?
common eye diseases like cataracts, glaucoma, diabetic retinopathy, or age related macular degeneration
what are nursing interventions to protect vision?
regular hand washing screening and early detection sunglasses regular eye exams for diabetics proper nutrition eye protection during hazardous activities
what is the “sighted guide technique”?
the guiding person stands to the side and slightly in front of the visually impaired person, who is holding onto the guide’s elbow
what are some ways to help clients adjust to decreased vision?
have corrective devices clean and available use large print books or magazines provide good lighting uncluttered/safe environment have things within reach introduce yourself speak before touching the client describe things and explain sounds
what can vision problems lead to in older adults?
loss of freedom, functional ability, or self esteem
disorientation
confusion
social isolation
what is conductive hearing loss?
hearing loss caused by problems in the outer or middle ear
what are some common causes of conductive hearing loss?
otitis media
earwax accumulation
foreign bodies in the ear
what is sensorineural hearing loss?
impairment of inner ear function or vestibulocochlear nerve damage
what are some common causes of sensorineural hearing loss?
noise genetics nerve damage ototoxicity tympanic membrane trauma
what are some assessment findings/manifestations for hearing loss?
not responding when spoken to answering questions inappropriately asking people to speak up/repeat things reading lips straining to hear impacted social/familial relationships
what are some nursing interventions to prevent hearing loss?
control environmental noise use ear protection MMR immunization avoidance/proper use of ototoxic medications (chemo, loop diuretics, mercury) hearing screenings
what are some good practices when communicating with a hearing impaired client?
use hand movements have face in good light speak into patient's good ear lower tone of voice minimize distractions speak normally and slowly dont over-enunciate write out hard words rephrase if necessary
how can the nurse help a client adapt to using a hearing aid?
make sure it’s properly fitted
determine the patient’s readiness to use it
educate on care and use
have them start using it in a quiet environment to get used to it
how do we care for hearing aids?
clean ear and hearing aid regularly make sure battery works protect it from heat and chemicals store in a cool dry place disconnect battery when hearing aid not in ear
what intervention will help if a whistling or ringing is coming from the hearing aid?
reposition in the patient’s ear and adjust the volume level
what is dementia?
a neurocognitive disorder characterized by dysfunction or loss of memory, orientation, language, judgment, and reasoning
what is the most common type of dementia?
alzheimers
what are general assessment findings with any type of dementia?
memory loss disorientation problems with words and numbers decreased judgment mood and behavior changes personality changes
what is alzheimers disease?
the most common form of dementia. it’s a chronic, progressive neurodegenerative brain disease
what are some early manifestations of Alzheimer’s?
getting lost in familiar areas memory loss time and place disorientation problems with calculations problems with familiar tasks language issues behavior/personality changes
How do memory issues often manifest in alzheimers?
short term memory problems first
what are some later stage manifestations/complications of Alzheimers?
incontinence delusions wandering all cognitive functions impaired immobility inability to speak or understand need for complete care (loss of functional ability)
what is apraxia?
inability to manipulate objects or perform purposeful actions
what is visual agnosia?
inability to recognize objects by sight
what is dysgraphia?
difficulty communicating by writing or recognizing written language
what is retrogenesis?
process in alzheimer’s disease where degenerative changes occur in reverse order in which they were acquired (person becomes more like an infant as disease progresses)
what is the top choice for a cognitive tool to screen for alzheimers and monitor disease progression?
Mini-mental status examination (MMSE or mini-mental)
what other diagnosis should be screened for and ruled out when alzheimer’s is suspected?
depression
why is early recognition and treatment important in Alzheimers?
in order to monitor disease progression and maximize functional ability at every stage, as well as ensure patient safety
what are some measures that may help prevent alzheimers?
regular exercise challenging your mind staying socially active avoiding harmful substances avoiding brain trauma (like repeat concussions) treat depression early sleep healthy diet diabetes and cardiovascular health management
what are some nursing interventions to prevent behavioral problems in Alzheimers?
assess physical status and for pain assess environment assess for infection frequently redirect and distract maintain familiar routines
what is sundowning?
patient getting more confused, disoriented, and combative in late afternoon and evening
what can be done to prevent sundowning?
calm environment, maximum exposure to sunlight, limit naps and caffeine, drug treatment if necessary
what are some good communication techniques for alzheimers patients?
don't rush them minimize distractions don't argue ask simple questions don't tell them no or ask why
what would some other signs of pain be in Alzheimer’s patients if they cannot say they have pain?
agitation
withdrawal
increased vocalization
what nursing interventions can help with eating and swallowing difficulties in Alzheimers?
pureed food and thickened liquids nutrition supplements finger foods moist foods bite sized pieces quiet and unhurried environment
what are oral care considerations for Alzheimers?
ensure good oral care (either by patient or by nurse)
regular mouth inspection for pocketed food
how can nurses help support caregivers of those with Alzheimers?
assess stressors and coping strategies
assess caregiver expectations
support groups
teaching based on disease stage
what are top goals for patients with Alzheimers?
maintain safety and maximize remaining social and functional ability
what are autism spectrum disorders?
group of complex neurodevelopmental disorders
what are basic clinical manifestations in autism spectrum disorders?
core deficits in social interaction, communication, and behavior
what is seen in relation to social interaction with ASD?
less interest in socializing
abnormal eye contact
decreased imitation
decreased response to their own name
what is seen in relation to communication in ASD?
absent or delayed speech
not meeting speech milestones
what does echolalia mean?
unsolicited, meaningless repetition of vocalizations made by another person (often seen in ASD)
what can improve prognosis for children with ASD?
early detection and intense early intervention
what is seen in terms of behavioral patterns with ASD?
unusual fixations, preferences, or repetitive behaviors
what are important interventions/actions when a child with ASD is hospitalized?
parent staying with child and being involved in planning
individualized assessment and treatment
decreased stimulation
presence of comfort items
as much structure and routine as possible
what should the nurse keep in mind in relation to physical contact for patients with ASD?
minimal holding and eye contact
what should the nurse keep in mind in relation to feeding and eating for patients with ASD?
may be fussy eaters
may gag or willfully starve themselves
may hoard food or swallow non-food items
may refuse food and end up with nutrient deficiencies
how should children with ASD be introduced to new things?
slowly and cautiously
what are good approaches in terms of communicating with patients with ASD?
tell them directly what to do
be brief and concrete
be appropriate to developmental level
reward desired behavior
how can the nurse support the family of a child with ASD?
educate the parent and make sure they know the autism is not their fault
direct them to expert counseling and resources
encourage care by the family as much/as long as possible
use creative approaches to managing child’s care and behavior
an undesired change or removal of a valued person, object, or situation is..
loss
how is grief defined?
the physical, psychological, and spiritual responses to a loss
actual loss
a tangible, physical loss (loved one, loss of limb, etc)
perceived loss
a loss felt only by the person, such as loss of freedom, future, relationship, etc
what are some things that impact coping?
family and support system
spirituality
developmental stage
what is bereavement?
the process of mourning and the period of adjustment after a loss
what are some major factors that affect grief?
significance of the loss support systems available unresolved conflict circumstances of the loss other recent losses spiritual beliefs and practices time circumstances of the loss
how do infants and toddlers view death?
they cannot comprehend the absence of life and dont know how to accept permanence of death
how will infants and toddlers react to death of a loved one?
changes in eating and sleeping
anxiety and sadness often caused by changes in routines and sadness of those around them
how do preschoolers understand death?
they struggle with the permanence of death
believe their thoughts can cause death (may struggle with guilt and shame)
may distance themselves from loss and grief
how do school aged children understand death?
guilt is an issue, but have a more concrete understanding of death
may be fascinated by death
fear unknown quality of death
how do adolescents understand and cope with death?
they understand it but struggle with guilt and shame
have the most difficulty coping with death and may feel very alone in their grief
when do adults start to accept their own mortality?
usually between the ages of 45 and 65
why might coping with death be challenging for older adults?
because they are preparing for/thinking of their own deaths, and often have experienced lots of cumulative losses
uncomplicated/normal grief
natural response to a loss, with intense emotions that gradually diminish. person can still take care of themselves during grief process
complicated grief
prolonged acute grief that lasts for longer than 6 months with maladaptive and overwhelming grief responses
how do we distinguish whether a person’s grief is complicated or normal?
by evaluating their functional/self-care abilities
definition of death
irreversible cessation of all functions of the brain and brainstem
higher brain death
irreversible cessation of higher brain function even if the brainstem still works (respiration and cardiac activity might continue)
what are the stages of grief?
denial anger bargaining depression acceptance
what are some goals of palliative care?
regard dying as a normal process provide pain relief not hastening death or postponing it enhance quality of life support patient to live as actively as possibly until death support patient's family
what is the difference between palliative care and hospice?
palliative care allows for both curative and comfort cares, while hospice is only comfort cares
what are the two criteria for admission to a hospice program?
patient must desire the service and agree to only hospice care (not curative care)
patient must be considered eligible with 2 physicians saying they probably only have 6 months or less to live
why is spiritual assessment important in the dying and grieving process?
Because spirituality shapes how people view death and cope with it, as well as the rituals people have surrounding death
what are some characteristics of spiritual distress?
anger towards God
changes in mood or behavior
desire for spiritual assistance
displaced anger towards clergy
what are some ways that culture affects reactions to death?
culture impacts rituals around death, how grief is expressed, and how families find comfort
what is the nurses role in regards to spiritual and cultural practices surrounding death?
facilitate and support these practices
who makes the decision to donate organs?
the patient before death or the family after death
who on the healthcare team makes organ donation requests?
specially trained professional for that specific role
what are advanced directives?
document signed by a competent individual regarding the patient’s wishes about care and their designated medical spokesperson
what is a living will?
document in lay terms giving specific directions about future care and life sustaining measures
what is a durable power of attorney for healthcare?
a document stating who makes your healthcare decisions if you cannot (and if the living will is not clear on an issue)
what does DNR mean?
do not resuscitate (take comfort measures only, but no CPR or intubation)
describe AND (allow natural death)
pain control and symptom management are allowed and done, but natural progression to death is not hindered
why do opioids not hasten death at the end of life?
because pain is the counteracting agent to opioid-induced respiratory depression, so the opioids given for comfort will not depress respirations fatally
what happens to our senses at the end of life?
hearing is the last to go decreased sensation and pain perception blurred vision glazed eyes absent blink reflexes eyes half open
what are cardiovascular manifestations at the end of life?
increased HR, then decreased
irregular heart rhythm
decreased BP
delayed drug absorption
respiratory manifestations at end of life
increased respirations
inability to clear secretions
death rattle
noisy, congested breathing due to not being able to clear secretions
cheyne stokes respirations
alternating periods of apnea and deep, rapid breathing
urinary manifestations at the end of life
decreased urinary output or anuria
incontinence
GI manifestations at the end of life
slowed/stopped GI processes gas accumulation nausea incontinence bowel movement right before or at time of death
musculoskeletal manifestations at the end of life
loss of ability to move
loss of muscle tone and gag reflex
difficulty speaking and swallowing
jaw sagging
integumentary manifestations at the end of life
mottling
cold/clammy skin
cyanosis
wax-like appearance
psychosocial manifestations at the end of life
altered decision making anxiety/restlessness fear decreased socialization life review peacefulness saying goodbye unusual communication or vision-like experiences
what are some psychosocial nursing interventions for end of life care?
converse with the patient encourage family to talk to them whether conscious or not affirm dying person's experience allow privacy assess spiritual needs
what are four specific fears associated with death?
pain
shortness of breath
loneliness/abandonment
meaninglessness
how can nurses help alleviate the fear of pain?
prompt pain assessment and management
management of drug side effects
how can nurses alleviate fear of shortness of breath for the dying patient?
use of opioids, bronchodilators, oxygen, and anti-anxiety meds
how can nurses alleviate the fear of loneliness in dying patients?
hold their hands and use touch
listen
be present and have loved ones present too
how can nurses help alleviate the fear of meaninglessness for the dying patient?
facilitate life review process and listen
how can nurses help children deal with loss?
dont force them to go to the funeral spend as much time with them as possible use play therapy care for the whole family reassure child that it's not their fault
how can nurses manage end of life dehydration?
assess mucous membranes often
know that dying patient might be comfortable being dehydrated
moist swabs in mouth
don’t force them to eat or drink
how can nurses manage end of life dyspnea?
elevate head fan or air conditioning pursed lip breathing expectorants opioids suction oxygen
how can nurses manage end of life skin breakdown?
control drainage
dress wounds properly
manage incontinence
use blankets (not heat) for warmth
how can nurses manage end of life bowel patterns?
assess function assess for impaction use laxatives as needed for comfort watch for constipation fiber/fluids/movement as wanted and tolerated
what is involved in post-mortem care?
close eyes replace dentures wash the body remove tubes and dressings straighten body and prop up head allow family time and privacy with the body
how do we support families and caregivers after a death?
recognize their stress and grief watch for abnormal grieving and those dealing with concurrent crises keep them informed refer to counseling encourage use of support systems
what is included in an assessment of mental health?
physical assessment psychosocial history stress level coping ability spiritual/religious/cultural beliefs mental status
what are stigmas that exist in relation to mental health?
belief that it is taboo or not real
belief that you are crazy
belief that it’s all a spiritual influence/possession
what is included in a mental status examination?
level of consciousness
physical appearance
behavior
cognitive and intellectual abilities
what are the four stages of mental status/alertness?
alert
lethargic
stuporous
comatose
alert
patient is responsive and responds appropriately
lethargic
patient can open eyes and respond but is drowsy and falls asleep easily
stuporous
vigorous or painful stimuli is necessary to elicit even a brief response in the patient
comatose
unconscious, with no response to painful stimuli
what is the difference between mood and affect?
mood is the emotion the client is feeling
affect is the objective expression of the mood (flat, blunted, smiling, crying, etc)
what are some elements of cognitive and intellectual ability that the nurse should note?
orientation memory level of knowledge about illness and perception of illness ability to calculate abstract thinking judgment rate and volume of speech
what are some standardized screening tools used in screening mental status?
mini mental state examination (MMSE)
pain assessment
what are some questions included in a mini-mental?
orientation
attention span
registration and recall of objects
language abilities
what should the nurse ask children/adolescents in a mental health assessment?
home environment education and employment performance activities drug and substance use sexuality depression and suicide assessment how safe they feel
what are risk factors in children for developing a mental health disorder?
genetic predisposition
biochemical imbalances
family problems or environmental conflict
cultural/ethnic issues or assimilation
resiliency level
witnessing or experiencing traumatic events
low socioeconomic level
what should the nurse ask older adults when assessing mental health?
functional ability economic and social status environmental factors questions from standardized screening tools substance use
what should be assessed in relation to adaptation and coping?
health status functional ability living arrangements employability personality caregiver and family assessments level of information and knowledge medications and other services used
what is milieu therapy?
creating an environment that is supportive, therapeutic, and safe. managing the total environment to create the least amount of stress for the client
what are characteristics of the physical setting with milieu therapy?
clean orderly comfortable safe attractive age-appropriate space for alone time and opportunity for interaction
what are the phases of the therapeutic relationship in the mental health setting?
orientation
working phase
termination
characteristics of the orientation phase
setting limits
setting goals
introductions and defining rolls
getting informed consent from the patient
characteristics of the working phase
ongoing assessment problem solving learning coping skills client feeling open and able to share listening on the part of the nurse
characteristics of the termination phase
discussing feelings about ending of therapeutic relationship
talk about separation and loss
learn how to integrate coping and other skills into normal life
transference
common issue in mental health care where client views the healthcare worker as having characteristics of another significant person in their life
countertransference
problem where healthcare worker displaces characteristics of someone in their life or their past onto their current client
what are some common activities within the therapeutic milieu?
community meetings individual and group therapy psychoeducational groups recreation activities unstructured free time
what are focuses and goals of individual therapy?
the needs of one client is the focus, with the goals of good decision making, productive life decisions, and stronger sense of self
what is the focus of family therapy?
improving family functioning by addressing family needs and problems
what are some goals of family therapy?
effective coping within the family
improved understanding of mental health issues
more positive family interactions
what is the focus of group therapy?
individuals developing more functional and satisfying relationships within the group
what are goals of group therapy?
discovering commonality among group members and seeing positive behavior changes in regards to social interaction
what is a maintenance role in a therapy group?
someone who helps maintain the purpose and process of the group
what are task roles in a therapy group?
people who take on tasks within the group process
what are individual roles in group therapy settings?
roles taken on by individuals to promote their own agendas, which usually hinders the group goals
what is depression?
a mood disorder characterized by depressed mood, sleep disturbances, indecisiveness, suicidal ideation, inability to feel pleasure, and/or weight changes
what are common comorbidities with depression?
anxiety and psychotic disorders
substance use
eating and personality disorders
what are some different types of depressive disorders?
major depressive disorder seasonal affective disorder persistent depressive disorder premenstrual dysphoric disorder substance-induced depressive disorder
what are risk factors for depression in children and adolescents?
family history past abuse homelessness parental or environmental conflict bullying high-risk behaviors learning disabilities chronic illness
what are expected findings with children and teens with depressive disorders?
sadness temper tantrums loss of appetite health complaints isolation crying loss of energy irritability aggression/risky behavior suicidal thoughts and actions
what is depression often associated with in older age?
dementia
what are the phases of a major depressive disorder?
acute
continuation
maintenance
what are goals for care in an acute phase of depression?
reduction of depressive manifestations. this phase may require hospitalization and suicide monitoring
what is the goal of care in a continuation phase of depression?
relapse prevention through education, medications, and psychotherapy
what is the goal of care in the maintenance phase of depression?
prevention of future depressive episodes
who is at risk for depression?
women
those with a family history
those in early adulthood or over 65
those with neurotransmitter deficiencies
what are assessment findings with depression?
sadness blunted affect poor grooming/hygiene psychomotor retardation and agitation social isolation slowed speech and delayed response anergia anhedonia
what are vegetative findings in depression?
changes in eating patterns
changes in bowel patterns (usually constipation)
changes in sexual activity and sleep habits
somatic complaints
remember there are several types of depression screening scales!
use the correct one for the correct population group
what is included in milieu therapy for patients with depression?
suicide risk assessment self-care assessment communication with patient and IDT maintaining safe environment counseling
what are some alternative therapies for depression?
light therapy
St. John’s wort
exercise and good nutrition
what are important patient teaching points for depression?
manifestations of depression
effects and adverse effects of medications
benefits/importance of treatment adherence
importance of regular exercise
how to prevent relapse
what is electroconvulsive therapy (ECT)?
using electrical currents to induce a brief seizure while client is sedated
what are nursing considerations during ECT treatment?
obtaining informed consent
med management and side effects
client education
understanding normal and desired patient responses
what indicates the need for ECT in a major depressive disorder?
unresponsive to pharmacological interventions
when risks outweigh benefits for other treatments
suicidal/homicidal clients who need rapid intervention
those experiencing psychotic manifestations
what meds will be given to a client undergoing ECT?
muscle relaxant to prevent injury
anticholinergics to counteract secretions and prevent aspiration
how long does a course of ECT last?
2-3 times per week for a total of 6-12 treatments
what should the nurse monitor before, during, and after ECT?
BP
ECG
oxygen saturation
what are potential complications of ECT?
memory loss and confusion
anasthesia reaction
cardiovascular changes
relapse of depression
what are nursing actions to be taken to prevent/counteract complications of ECT?
frequent orientation and safety focus after treatment
monitoring during and after treatment for anesthesia reaction
monitor vitals and cardiac rhythm
encourage maintenance ECT to prevent relapse q
what is transcranial magnetic stimulation?
using MRI strength magnetic pulsations to stimulate the cerebral cortex
what are indications for use of TMS?
major depressive disorder when pharmacological intervention doesnt work
what is bipolar disorder?
mood disorder with recurrent episodes of depression and mania that usually emerges in early adulthood
what is the acute phase of bipolar?
acute mania, where patient might need hospitalization and extra safety measures
what is the continuation phase of bipolar?
remission of manifestations, with a focus on treatment and relapse prevention techniques
what is the maintenance phase of bipolar?
increased ability to function with the goal of preventing future manic episodes
what is mania?
abnormally elevated mood (irritable, expansive) lasting at least one week
what is hypomania?
less severe episode of mania lasting at least 4 days with 3 or more manic characteristics. less severe, hospitalization may not be needed
what is rapid cycling?
four or more episodes of mania or hypomania in one year
what are manic characteristics in bipolar?
euphoria agitation/irritability restlessness intolerance of criticism flight of ideas impulsivity and poor judgment attention seeking behaviors decreased sleep ADL neglect delusions and hallucinations rapid speech
what are depressive characteristics in bipolar?
blunted affect crying lack of energy anhedonia pain poor focus self-destructive behavior decrease in hygiene disturbed sleeping and eating psychomotor retardation
what populations are at risk for bipolar?
those with genetic predisposition
those with environmental stress
those with neurobiologic and neuroendocrine disorders
what are collaborative therapies for those with bipolar?
electroconvulsive therapy
medications
what are nursing considerations in acute manic episodes?
safety suicide assessment decrease stimulation supervision rest and physical activity nutrition support protection from impulsivity and poor judgment
what are important teaching points for clients with bipolar?
follow up care benefits of therapy adherence psychotherapy reference long-term/lifelong treatment regular sleep and eating schedule med adherence indicators and precipitating factors for relapse
what are some criteria for substance use disorders?
impaired control of substance intake social impairment due to use risky use of substance dependence on substance taking substance for longer than intended or failing to quit using
addiction
psychological and physical inability to stop consuming something despite it’s negative impacts
intoxication
clinically significant behavioral or psychological changes following the use of a substance
tolerance
reduced reaction to a drug or substance following repeated use
withdrawal
physical/psychological manifestations experienced when a patient discontinues a med or drug to which they are addicted
who is at risk for substance use disorder?
chronically stressed genetically predisposed trauma history low self esteem isolation risk takers alaska natives native americans older adults those facing peer presusre
what are some manifestations/findings with substance use disorders?
fatigue insomnia headache seizures mood changes anorexia looking aged/unkempt sexual dysfunction DWI defensive or evasive behaviors or actions life function issues
what are assessment findings of intoxication with stimulants?
palpitations and dysrhythmias increased BP and HR MI impending doom feelings euphoria agitation seizures combativeness paranoia confusion fever
what are signs of withdrawal from stimulants?
fatigue depression excess sleeping vivid dreams irritability increased appetite disorientation craving the drug
what are findings for intoxication with depressants?
aggression agitation confusion lethargy hallucinations slurred speech pinpoint pupils seizures weak pulse and dysrhythmias decreased BP respiratory depression
what are signs of withdrawal from sedative hypnotics?
weakness anxiety insomnia fever orthostatic hypotension disorientation delirium seizures respiratory and cardiac arrect
what are signs of opioid withdrawal?
cravings diaphoresis GI issues restlessness fever insomnia tremors aches runny nose
what are some priority care measures for clients with substance abuse disorders?
airway/ABCs IV access and fluids ECG monitoring drugs for dysrhythmias, HTN, angina, seizures, and psychotic manifestations vitals LOC cooling measures info about drugs and amounts taken antidotes/gastric lavage
what are gerentologic considerations for substance use disorders?
hard to recognize
can be mistaken for a medical condition
greater risk for medical issues caused by substance use
what is ADHD?
inability to control behaviors requiring sustained attention
what is inattention?
difficulty paying attention, listening, and focusing
what is hyperactivity?
fidgeting, inability to sit still, excess talking, problems playing quietly, excess running and climbing
what is impulsivity?
interrupting, impatience, or acting without considering the consequences
what are clinical manifestations of ADHD?
distractibility immaturity selective attention risk taking lack of regard for consequences hyperactivity inappropriate social behaviors
what is necessary for a patient to be diagnosed with ADHD?
associated behaviors must be present before age 12 and in more than one setting
what are the three main treatment plans for children with ADHD?
behavior therapy
environmental manipulation
classroom placement
what does behavior therapy for ADHD consist of?
rewarding good behavior and preventing undesired behavior by using contingencies, rewards, and organizational charts
what does environmental manipulation consist of for clients with ADHD?
consistency in expectations and discipline and structure between school and home
having the child take responsibility for actions and choices
decreasing environmental distractions
what is important for classroom placement for children with ADHD?
orderly, predictable, consistent classroom with clear and consistent rules
interspersed breaks
bulk of learning in the morning
intersperse activities of high and low levels of interest
what is the goal for children with ADHD?
help them identify areas of weakness and compensate for them, and promote healthy interventions and adaptation
what are the rights of a patient with a voluntary mental health admission?
right to refuse medication and treatment
what is a temporary emergency admission?
receiving emergent mental health care due to being unable to make decisions regarding care
what is an involuntary admission?
client enters mental health facility against their will for an indefinite time period
what is the length of time to which an involuntary admission is limited?
60 days
how long are long-term involuntary admissions?
60-180 days
what are the three categories of restraints?
physical
chemical
environmental
what potential unmet physiologic or psychosocial needs could result in disruptive behaviors by an older adult?
need for toileting or not being able to speak
what are some restraint alternatives that should be considered?
low beds body props bed/chair alarms distractions/mentally stimulating activities floor mats family visits safety assistants or direct observation
what must occur for use of seclusion or restraints?
less restrictive measures must fail
doctor’s order must be written
time limit
frequent assessment and documentation
what documentation needs to be completed in relation to restraints?
events leading up to restraint measures alternatives attempted time restraint began and ended current behavior vitals food and fluid offered skin assessment meds administered
how often does restraint documentation need to be completed?
every 15-30 minutes (facility dependent)
what is a tort?
a civil wrong-doing in which money can potentially be collected and awarded
false imprisonment
confining a client physically, verbally, or by using chemical restraint when not part of the treatment plan
assault
making a threat to the client’s person
battery
harmful or offensive touch
what documentation needs to be completed in relation to violent or unusual episodes?
record of client behavior in a clear and objective manner
staff response with timelines and extent of responses
time nurse notified provider
prescriptions/orders received
what are arterial ulcers?
ulcers caused by arterial insufficiency in the extremities
what are causes/reasons that arterial ulcers develop?
inadequate circulation of oxygenated blood, leading to ischemia and tissue damage
what are characteristics of arterial ulcers?
"punched out" appearance small and round smooth borders pale base usually on lower extremity surrounding skin thin/shiny/cool/dry loss of hair delayed capillary refill and delayed or absent pedal pulses pain that increases with activity
what are venous stasis ulcers?
ulcers caused by venous insufficiency or issues
what causes venous ulcers?
incompetent venous valves, deep vein obstruction, or inadequate calf muscle function
how will venous insufficiency manifest in the leg?
venous pooling
edema
impaired microcirculation
what are characteristics of venous stasis ulcers?
located on lower calf or inner ankle usually
surrounding skin is red, brown, or edemateous
shallow with irregular margins
beefy/granular/red wound bed
moderate to heavy drainage
pain when legs are in dependent position
what is considered a chronic wound?
a wound that exceeds expected length of recovery and has trouble healing
what are diabetic food ulcers?
ulcers that occur due to narrowing of arteries, which decreases oxygenation and blood to feet
what about diabetes increases the risk of foot ulcer development?
neuropathy (patient wont necessarily feel a wound)
are diabetic foot ulcers arterial or venous ulcers?
arterial
what labs would need to be done for a patient with chronic wounds?
albumin culture and sensitivity CBC glucose thyroid iron coagulation
what are three chronic complications of wound healing?
adhesions
fistulas
keloids
what is an adhesion?
band of scar tissue forming between or around organs
what is a fistula?
abnormal passage between organs or between a hollow organ and the skin
what are keloids?
protrusions of scar tissue that extend beyond wound edges in a healing/healed wound
what are some other factors that delay wound healing?
nutrient deficiencies inadequate blood supply steroid use infection smoking friction age obesity diabetes poor health anemia
what is negative pressure wound therapy?
a vacuum source being used to create negative pressure in the wound to remove fluid, exudate, and infectious materials. helps prepare the wound for healing and closure
what should the nurse monitor in patients with negative pressure wound therapy?
serum protein
fluid and electrolyte balance
platelets
PT and PTT
What are nutrition considerations for patients with chronic wounds?
high fluid intake needed
undernutrition is a risk for poor healing
protein/carbs/fat are crucial
vitamin C and A are crucial
what are psychological implications for patients with wounds?
fear of scarring and disfigurement
drainage or odor can cause alarm
may want to understand the healing process
what are assessment considerations for dark skinned patients with wounds?
look for color changes in the skin use natural or halogen light (not fluorescent) assess skin temperature touch to feel skin consistency ask about pain and itching
what is a pressure ulcer?
localized injury caused by pressure on an area of tissue
where are the most common sites of presusre injuries?
heels
elbows
sacrum
scapulae
what are intrensic/internal risk factors for pressure ulcer development?
immobility impaired sensation or circulation poor nutrition edema aging fever mental deterioration diabetes moisture/incontinence
what are extrensic/external risk factors for pressure ulcers?
friction
shearing
moisture
compression
what are shearing forces?
epidermal layer sliding over the dermis, damaging the vascular bed
example: sliding down in bed
what is friction?
the epidermis sliding against another surface
stage I pressure ulcer findings
intact skin
non-blanchable redness
usually over a bony prominence
stage II pressure ulcer
partial thickness loss of dermis
shallow open ulcer with red/pink wound bed
no slough
can look like an open blister
stage III pressure ulcer
full thickness tissue loss
subcutaneous fat may be visible
slough present but doesnt obscure depth
possible undermining/tunneling
stage IV pressure ulcer
full thickness tissue loss with exposed or palpable bone, tendon, or muscle
slough and eschar possible
unstagable pressure ulcer
depth of ulcer is obscured by slough or eschar, but will either be a stage III or IV ulcer
why is reverse staging of pressure ulcers inaccurate?
because while the wound is getting more shallow, the lost bone/muscle/tissue is not being replaced, it’s just being filled with granular tissue. Once it’s a certain stage, its always that stage
how do you document a healing ulcer?
by writing “healing stage __ ulcer”
what is a common tool for assessing pressure ulcers?
PUSH tool
how often should patients be assessed for pressure ulcer risk?
upon admission (very thoroughly), then every 48-72 hours or according to policy
with the Braden scale, is a high or low score good?
a high score is good (indicates low risk)
what should we remember about turning patients every 2 hours?
its not evidence based. patients may need to be turned more often, or maybe not as often depending on individualized risk
what interventions will likely be used in care of the pressure ulcer?
debridement wound cleaning dressing application pressure relief (float heels, padding, special mattresses or chairs) moisture management good documentation
what will be needed for pressure ulcers with necrotic tissue or eschar?
tissue removal by debridement
what are important patient/caregiver teachings related to pressure ulcer wound care?
risk factors how to manage incontinence correct positioning and repositioning put a clean dressing over the sterile dressing daily skin inspection good nutrition
what is peripheral arterial disease?
progressive narrowing of arteries in upper and lower limbs
how is peripheral arterial disease different from venous diseases?
PAD has no peripheral pulses, capillary refill greater than 3 seconds, thick nails, thin shiny skin, cool skin, and no edema
what are assessment findings in PAD?
intermittent claudication
numbness and tingling
reactive hyperemia
pain at night
what is intermittent claudication?
ischemic muscle pain caused by exercise
how should patients with intermittent claudication be instructed to exercise?
exercise, then rest when pain begins, and resume exercise when pain subsides
what are potential complications of PAD?
skin/muscle atrophy delayed healing infection necrosis possible amputation
what are modifiable risk factors for PAD?
tobacco use blood pressure exercise/weight diet glucose control/diabetes management lipid control
what diet is recommended for PAD?
dash diet
what are exercise therapy recommendations for PAD?
supervised exercise program consisting of 30-45 minutes/day, 3 or more days a week, for at least 3 months
what are nutritional considerations for PAD?
reduced calories and salt
keep waist circumference at healthy level
what nursing interventions should be considered for home/ambulatory care for PAD?
long term antiplatelets supervised exercise foot assessment and care proper shoes diet modification
what is chronic venous insufficiency?
functional abnormalities of the venous system in the legs
what are assessment findings of chronic venous insufficiency?
leathery brownish skin edema eczema itching venous ulcers (often above medial maleolus) pain
what are potential complications of chronic venous insufficiency?
osteomyelitis
malignant changes
venous stasis ulcers
what does interprofessional care and nursing management for chronic venous insufficiency consist of?
compression therapy
nutrition therapy
what are skin care considerations for chronic venous insufficiency?
compression moist environment for wounds dressings frequent assessment moisturizing skin educate patient on how to put on compression stockings
what are nutrition recommendations for chronic venous insufficiency?
high protein, vitamin C, and zinc
what are activity and rest recommendations for chronic venous insufficiency?
avoid standing or sitting for long periods of time
elevate legs frequently
begin daily walking once ulcers heal
avoid leg trauma
