Exam 1 Flashcards
Evidence Based Practice
Description of best practice that has been derived from review of research
Considers the setting, patient preferences and values, and clinical judgment
Pay for Performance
Reimburses providers for meeting or exceeding demonstrations of cost efficient and quality care
Nursing Care Center National Patient Safety Goals
Prevent infection (use proven guidelines to prevent infections of the urinary tract that are caused by catheters)
Improve staff communication (get important test results to the right staff person on time)
Core Measures
Sets of performance measures for hospitals
Gauge how well hospital gives care compared to evidence based guidelines and standards
Evidence Based Practice Tools
Bundles (sets of 3-5 EPB)
Clinical guidelines
Algorithms
Care mapping
Multidisciplinary action plans (MAPs)
Clinical pathways
Chronic Diseases
Most common causes of death in the US
7/10 leading causes of death
Include cardiovascular, chronic lung disease, cancers, diabetes
Primary Prevention
Health promotion
Specific protection
Secondary Prevention
Early diagnosis and prompt treatment
Disability limitation
Tertiary Prevention
Rehabilitation
Management of Chronic Illness
Live with symptoms or disabilities
Identity changes may occur (complications can interfere with ADLs)
Lifestyle changes (learn to manage their chronic diseases and change their schedule and ADLs accordingly)
Emotional reactions such as shock, anger, resentment
Chronic Illness Pre-Trajectory
Genetic or lifestyle predisposition
Encourage genetic counseling
Primary prevention would be helped with by the nurse
Chronic Illness Trajectory Onset
Appearance of noticeable symptoms
Diagnosis work up
Nurse must explain exams and procedures, help with emotional space
Chronic Illness Stable
Illness is under control
Nurse gives positive reinforcement, encourages health screenings
Chronic Illness Unstable
Inability to control symptoms
May have problems with ADLs, may need more diagnostic tests
Nurse reinforces previous education, educates on new additions
Chronic Illness Acute
Severe or unrelieved symptoms
Management in hospital or acute care facility
Nurse provides direct care and emotional support
Chronic Illness Crisis
Critical or life-threatening situation
Nurse will be providing direct care and emotional support
Chronic Illness Comeback
Gradual return to acceptable way of life
Presence of some disabilities
Nurse provides positive support
Chronic Illness Downward
Progressive (rapid or gradual) decline in health
Increasing physical disability
Continually readapting to illness
Home-care, community-based care
Nurse helps to identify and encourage end-of-life preferences and planning
Chronic Illness Dying
Final weeks before death
Disengagement and closure
No longer able to make end-of-life preferences
Nurse provides direct and supportive care to the patient and family
Disability
Lack of ability to complete an activity in a normal manner
Severe Disability
Unable to perform one or more activities, uses an assistive device for mobility or needs help from another person to accomplish basic activities, receives federal benefits because of an inability to work
Impairment
Loss or abnormality in body structure or function, including mental function
Categories of Disabilities
Developmental (birth-22 years old)
Acquired
Sensory, Learning, Communication, Limit Participation, Visible vs. Invisible
Acquired Disabilities
Acute Traumatic: traumatic brain injury, spinal cord injury
Acute Non Traumatic: stroke, heart attack
Chronic Progressive: arthritis, rheumatoid arthritis, multiple sclerosis
Endocrine Effects of Pain
Increase: ACTH, cortisol, ADH, catecholamines, GH, renin, angiotensin II, aldosterone, glucagon, interleukin-1
Decrease: insulin, testosterone
Metabolic Effects of Pain
Hyperglycemia, muscle protein catabolism
Cardiovascular Effects of Pain
Increase: HR, cardiac workload, PVR, SVR, HTN, coronary vascular resistance, myocardial oxygen consumption, hypercoagulation, DVT
Respiratory Effects of Pain
Decrease: flow in volumes, hypoventilation, can cause atelectasis, leads to hypoxemia, decreased cough, retention of sputum
Genitourinary Effects of Pain
Decrease: urine output, urinary retention, fluid overload, hypokalemia
Gastrointestinal Effects of Pain
Decrease motility
Musculoskeletal Effects of Pain
Muscle spasms, impaired muscle functioning, fatigue, resistance to movement
Cognitive Effects of Pain
Confusion
Immunological Effects of Pain
Depression in immune response
Developmental Effects of Pain
Increased responses to pain
Changes in temperament
Vulnerable to stress disorders, addictive behavior, and anxiety states
Future Pain Effects of Pain
Phantom pain
Post-herpetic neuralgia (pain along the nerve tract affected by herpes)
Quality of Life Effects of Pain
Sleeplessness, anxiety, fear, hopelessness, thoughts of suicide
Nociceptive Pain
Normal physiological pain, normal nerve impulse
Neuropathic Pain
Related to abnormal sensory input, occurs when nerves are damaged
Acute Pain
Short duration
Decreases as healing occurs
Usually recent onset
Indicates damage
Chronic Pain
Prolonged duration
Persists past expected healing
Poorly defined onset and difficult to treat
Recurrent pain
Preoperative Phase
Begins with decision for surgery and ends when client goes into the OR
Focuses include obtaining consent, identifying risk factors, physical/psychological assessments, and education
Intraoperative Phase
Begins when admitted to the OR and ends when admitted to PACU
Post Operative Phase
Begins immediately after surgery with admission to PACU and ends with complete recovery from surgery
Two phases: PACU and Inpatient Setting
Focus on protecting patient and preventing post operative complications
Respiratory Post Op Complications
Airway obstruction, hypoxia/hypoxemia, atelectasis, pneumonia
Cardiovascular Post Op Complications
Hypotension/shock, hypertension, dysrhythmias, DVT/thrombophlebitis/PE
Fluid and Electrolytes Post Op Complications
Fluid overload, fluid deficit, electrolyte imbalances, acid-base imbalances
Psychologic Post Op Complications
Emergence delirium, delayed emergence, anxiety, postoperative cognitive dysfunction, alcohol withdrawal delirium
Temperature Post Op Complications
Hypothermia/shivering, fever
Low-grade fever post-op is typically an indication that the patient needs to TCDB and requires ambulation
Gastrointestinal Post Op Complications
Nausea/vomiting, ileus/obstruction, delayed gastric emptying, hiccups, constipation
Urinary Post Op Complications
Retention, oliguria, infection
Surgical Site Post Op Complications
Infection
Dehiscence: when the wound falls apart
Evisceration: insides fall out of the wound
Primary Intention
Wound edges are approximated
No complications such as infection, necrosis, or abnormal scar formation
Heal with minimal scarring after 4-14 days
Secondary Intention
Wound edges are not closely approximated
Wounds have greater tissue loss usually from excessive trauma
Granulation tissue fills the wound slowly, long healing time, large scars
Tertiary Intention
Wound left open to allow edema and/or infection to resolve
Wound is surgically closed later
Wound Healing Phase 1
Inflammatory
Characterized by erythema, edema, heat, and pain
Time frame: injury to 4-6 days post injury
Histamines and prostaglandins are released in response to injury
Small vessels dilate, plasma and electrolytes leak into interstitial spaces
Bacteria are destroyed by leukocytes
Platelets form a clot and fibrin slowly bridges the wound edges
Wound Healing Phase 2
Proliferative
Lasts 4-24 days
Characterized by granulation tissue, should be red, beefy, and shiny
New blood vessels form, collagen adds strength and margins contract
Epithelialization occurs resulting in a scar
Wound Healing Phase 3
Maturation
Lasts 24 days to 2 years
Collagen fibers reorganize, mature, and gain strength
Wound shrinks, metabolic demands decrease, surface capillaries regress and the scar pales
Factors that Impede Healing
Pressure (blood supply to capillary network is disrupted)
Moist environment (wounds heal 3-5 times faster in dry environment)
Trauma (wounds heal slowly or not at all)
Edema (interferes with oxygen transport and cellular nutrition)
Necrosis (dead/devitalized tissue)
Incontinence (alters skin integrity)
Infection
Slough
Hydrated, loose, stringy tissue that is typically yellow
Eschar
Dehydrated, thick, leathery, black
Systemic Factors that Impede Healing
Age (geriatrics heal slower)
Body build (bariatric and emaciated clients are poor healers, adipose has poor blood supply, lack of oxygen and nutritional stores)
Chronic diseases (CAD, PVD, cancers, diabetes, alcoholism)
Nutritional status (watch albumin, prealbumin, lymph counts, and transferrin)
Electrolyte imbalance
Vascular insufficiencies (decreased/impaired blood supply and pressure lead to lower extremity ulcers)
Immunosuppression/radiation
Long OR or immobility times
Wound Classifications
Cause (surgical or nonsurgical, acute or chronic)
Depth of tissue affected (superficial, partial thickness, full thickness)
Color (red, yellow, black)
Superficial Wound
Involves only the epidermis
Partial-Thickness Wound
Extends into the dermis
Full-Thickness Wound
Deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone
Wound Drainage
Sanguineous, serosanguineous, serous, and purulent
T-Tube
Drains from the gallbladder/liver
Red Wounds
Protect the wound
Gentle cleaning if needed
Use dressing material that keeps the wound surface clean and slightly moist to promote epithelialization
Yellow Wounds
Use a dressing that absorbs exudate and cleanses the wound surface
Hydrocolloid dressing/DuoDerm (left in place for 7 days)
Black Wounds
Debridement of nonviable, eschar tissue
Wound Cleansing
Antiseptics should not be used as a cleaning agent
Avoid peroxide, betadine, and general soaps
Commercial wound cleansers and normal saline are best
Dressings for Dry Wounds
Use hydrogel
Dressings for Infected Wounds
Silver-based products
Dressings for Draining Wounds
Use absorptive dressings
Dressings for Necrotic Wounds
Honey products
Dressings for Wounds with Potential Delayed Healing
VAC
Hydrogels
Add moisture to dry wounds/to debride necrotic tissue
Use Skin Prep to reduce chance or periwound maceration
Need cover dressing
Hydrocolloids
Help with debridement
Do not use with infected wounds, highly draining wounds, or fragile skin
Transparent Films
Used for partial thickness wounds with low drainage
Honey Products
Leptopermum or Manuka Honey
Lowers pH of wound which is beneficial for chronic wounds
Negative-Pressure Wound Therapy
Suction removes drainage and speeds healing
Must monitor serum protein levels, fluid and electrolyte balance, and coagulation studies
Wound types suitable include acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers
Hyperbaric Oxygen Therapy
Delivers oxygen at an increased atmospheric pressure, allows oxygen to diffuse into serum
Stimulates angiogenesis, kills anaerobic bacteria, and increases the killing power of WBCs and certain antibiotics
Becaplermin (Regranex)
Recombinant human platelet-derived growth factor gel that actively stimulates wound healing and should only be used when the wound is free of devitalized tissue and infection
Nutritional Therapy for Wound Healing
Diet high in protein, carbohydrates, and vitamins with moderate fat
Vitamin C: needed for capillary synthesis and collagen production
B-Complex Vitamins: necessary as coenzymes for metabolic reactions
Vitamin A: aids in the process of epithelialization
Shear
Causes skin to be separated from underlying tissue
Friction
Abrades to top layer of skin
Stage I Pressure Ulcer
Nonblanchable erythema of intact skin
Stage II Pressure Ulcer
Partial thickness skin loss involving epidermis, dermis, or both
Stage III Pressure Ulcer
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying fascia
Stage IV Pressure Ulcer
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear
Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer/cooler as compared to adjacent tissue
Unstageable Pressure Ulcer
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar
Kennedy Terminal Ulcer
Pressure ulcer that occurs in a dying patient, usually on coccyx or sacrum
Sudden onset, rapidly develop in size/depth
Borders are irregular with a pear or butterfly shape
Braden Scale Scoring
Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear
23 points possible, < 16 indicates risk and interventions should be initiated
Incontinence Associated Dermatitis
Skin damage caused by exposure to stool and/or urine
“Top-Down Injury”
Do not classify as a pressure ulcer
Prevent by using gentle cleansing with a no-rinse cleanser, moisturize, and apply moisture barrier product
Skin Tears
Directly related to lack of internal hydration and topical moisturization
Infants and elderly are at risk
Most frequently on upper extremities
Identify cause and address
Category I Skin Tear
No tissue loss, tear can be fully approximated
Category II Skin Tear
Partial tissue loss (epidermal loss)
Category III Skin Tear
Complete tissue loss (epidermal flap is absent)
Prevention of Skin Tears
Prevention is best (padding, long clothes, uncluttered environment, short nails)
Silicone mesh recommended
Avoid hydrocolloids, transparent films and steri-strips (can cause further damage to skin)
Venous Stasis Ulcers
Usually found between knee and ankle
Moderate to heavy exudate
Irregular shape
Beefy red
Calcification in wound base
Pain improves with elevation
Arterial Insufficiency Ulcers
Occurs distal to area of impaired arterial supply
Pale, gray or yellow in color
Commonly accompanied by eschar
Minimal exudate
Shape is smooth, even, and regular
Pain increases with elevation and ambulation
Diabetic Ulcer
Any site on the foot and lower limb that is subjected to constant pressure, friction, or trauma
Often a deep necrotic area that may be dry with infection present
Minimal to moderate exudate
Smooth and even
No sensation
Sexuality Includes…
Perception of self, quality of sexual relationships, and concerns
Sexual Assessment
Why: to open up discussion of sexual matters, address health holistically, clear up myths
When: usually at the end of the interview, when talking about GU system
Be nonjudgmental, remove biases, use language appropriate to the background and culture of the patient
Sexual Concerns of Young Women
Irregular periods, STIs, contraception, tampons, emergency contraceptive, pregnancy
Sexual Concerns of Post Menopausal Women
Vaginal dryness, discomfort with intercourse, relationships and sexual satisfaction, orgasm, masturbation
Sexual Concerns of Men
Relationships and sexual satisfaction, orgasm, masturbation, erectile dysfuction
Cancer and Sexuality
Physiological problems, treatments, psychosocial implications, problems especially with breast cancer and genital cancer
Diabetes and Sexuality
Impotence for men caused by neuropathy, decreased libido, prone to UTIs and vaginitis, difficulty with orgasm
Prostatectomy and Sexuality
Difficulty with erection
Cerebrovascular Accident and Sexuality
Neurological implications, include assessment about sexual history before the stroke, assess medications
Multiple Sclerosis and Sexuality
Need for position changes, bladder and bowel incontinence, plan for sex when partner is least fatigued
Cardiovascular Disease and Sexuality
Scared for sex post-heart attack, depression is common, check into medications
Aging and Sexuality: Men and Women
Longer to become sexually aroused, longer to complete intercourse, longer before arousal can occur again, less intense response to sexual stimulation, decline in sexual activity BUT DOES NOT DISAPPEAR
Aging and Sexuality: Female
Vaginal narrowing and decreased elasticity
Decreased vaginal secretions, slower sexual response
S/S include painful intercourse and bleeding, vaginal itching and irritation, delayed orgasm
Nursing: vaginal estrogen replacement, gyn/uro follow up and use lubricant
Aging and Sexuality: Males
Less firm testes and decreased sperm production
Delayed erection and achievement of orgasm
Slower sexual response
Erectile dysfunction likely related to other health problems, not aging
Nursing: monitor for medication side effects and other health problems
Erectile Dysfunction Medications
Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
DO NOT USE THESE ED MEDICATIONS IF YOU TAKE NITRATES SUCH AS NITROGLYCERIN AS THIS CAN CAUSE DANGEROUSLY LOW BLOOD PRESSURE
CALL DOCTOR IF YOU EXPERIENCE VISION LOSS
Reasons for Urinary Diversions
Removal of bladder from cancer
Neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and chronic infections with deterioration of renal function
Incontinent Urinary Diversions
Ileal Conduit
Cutaneous ureterostomy
Nephrostomy
Ileal Conduit
Most common type
Ureters implanted into a segment of the ileum that has been resected
No valve or voluntary control
Advantages: good urine flow with few physiologic alterations
Disadvantages: surgical procedure is complex, must wear an external collecting device, must care for stoma and drainage bag
Cutaneous Ureterostomy
Ureters are excised from the bladder and brought through the abdominal wall to form a stoma
Advantages: not considered a major surgery
Disadvantages: external collecting device must be worn, possibility of stricture or stenosis of small stoma
Nephrostomy
Catheter inserted into pelvis of the kidney
Most frequently done in advanced disease as a palliative measure
Advantage: no need for major surgery
Disadvantages: high risk of renal infection, predisposition to calculus formation, may have to be changed every month
Catheter should remain open
Kock Pouch
Loops of intestine are anastomosed together and then connected to the abdomen via the stomal segment
Ureters are attached to the pouch above a valve, which prevents urine reflux
Second valve is placed in the intestinal segment leading to the stoma
Indiana Pouch
Ureters are anastomosed to the colon portion of the reservoir in a manner to prevent reflux
Ileocecal valve is used to provide continence and the section of ileum that extends from the intestinal reservoir to the skin is made narrower to prevent urine leakage
Continent Urinary Diversions
Stoma is usually flush with the skin and placed lower on the abdomen than the ileal conduit stoma
Patient will need to self-catheterize every 4-6 hours and will need to irrigate the internal reservoir to remove mucus
Will not need to wear an external collection device
Complications of Urinary Diversions
Breakdown of the anastomoses in the GI tract
Leakage from the uteroileal or uterosigmois anastomosis
Paralytic ileus
Obstruction of ureters
Wound infection
Mucocutaneous separation
Stomal necrosis
Pre-Op Care for Urinary Diversions
Patient will require a complete bowel clean-out, assist as needed with a bowel prep
Post-Op Care for Urinary Diversions
Stents placed in ileal conduit for 7-10 days to promote urinary drainage. If continent urostomy, will have catheter or stent in stoma (sutured in place) to allow drainage from reservoir
Drain tube in pelvic area for drainage of blood and surgical fluids
May have NG tube until effective intestinal peristalsis returned. May then start on clear liquids to advance as tolerated
Monitor urine output carefully
Greater risk for UTI
Strive to keep urine acidic
High fluid intake is encouraged
Ascending Colostomy
Semi-liquid stool consistency, increased fluid requirements, needs appliance and skin barriers, cannot be irrigated
Indications for surgery: perforating diverticulitis in lower colon, trauma, inoperable tumors of colon rectum or pelvis, rectovaginal fistula
Transverse Colostomy
Semi-formed stool consistency, possibly increased fluid requirement, uncommon bowel regulation, requires appliance and skin barrier, cannot irrigate
Indications for surgery: same for ascending colostomy, may also be performed in children who are born with imperforate anus
Sigmoid Colostomy
Formed stool consistency, no change in fluid requirements, bowel regulation possible with irrigations and/or diet, need for appliances and barriers dependent on regulation
Indications for surgery: cancer of the rectum or rectosigmoid area, perforating diverticulum, trauma
Ileostomy
Opening from the ileum or small intestine through the abdominal wall.
Bypasses the entire large intestine.
Stool is liquid to semiliquid consistency and contains preoteolytic enzymes.
Increased fluid requirement. No bowel regulation or irrigation. Requires wearing an appliance and skin barrier.
Indications for surgery: ulcerative colitis, Crohn’s disease, trauma, cancer, birth defect, familial polyposis
Loop Stoma
Closure of colostomy is anticipated. One stoma with a proximal (drains stool) and distal (drains mucus) opening and an intact posterior wall that separates the two openings.
End Stoma
One stoma formed from the proximal end of the bowel with the portion of the GI tract either removed (permanent) or sewn closed (Hartmann’s pouch) and left in the abdominal cavity
Double-Barrel Stoma
Bowel is surgically severed and two ends are brought out onto the abdomen as two separate stomas.
Proximal is functional stoma, distal is nonfunctioning/mucus fistula
Temporary diversion in cases where resection is required due to perforation or necrosis
Ileoanal Pull-Through
Continent diversion
Colon is removed and ileum is anastomosed or connected to an intact anal sphincter
Ileoanal Reservoir
Continent diversion
Internal pouch created from ileum. End of pouch sewn or anastomosed to the anus.
Special Considerations for Patients Who Have Ileoanal Reservoirs
Kegel exercises will help to strengthen the pelvic floor
May have mucus discharge from the rectum
May have frequent stools
Increase fiber and decrease sugars
May need Metamucil, antidiarrheals
May have night incontinence
Assessing a Stoma
Volume
Color
Consistency
Diet on Colostomy
No restrictions
Foods to Avoid with Ileostomy
Celery, coconut, corn, coleslaw, peas, popcorn, spinach, dried fruits, nuts, pineapple, seeds
Palliative Care
Prevents and relieves suffering and supports the best possible quality of life for patients and their families REGARDLESS OF THE STAGE OF THE DISEASE OR THE NEED FOR OTHER THERAPIES
Concentration of symptom management
Hospice
Usually performed on those with terminal prognoses, concentration on comfort care
Advance Health Care Directives
Living will
Durable power of attorney for health care
POLST form
Pain Management during Death
Opioids such as morphine given
Atypical pain medications such as steroids, neurontin, tramadol, lidocaine patches
Dyspnea Management during Death
Assess RR, O2 Sat, ABG
Manage with bronchodilators, corticosteroids, opioids, oxygen, positioning, energy conservation, glycopyrolate
Nutrition and Hydration Management during Death
May lose the appetite/taste for food
Kidney/Liver failure unable to metabolize and eliminate nutrients
Cytokines trigger immune response which leads to catabolism –> cachexia
Delirium/Confusion During Death
Reversible in 50% of cases, may be result of disease
Benzodiazepines, haloperidol
May be the result of under-treated pain
Ethnocentrism
The belief in the inherent superiority of one’s own culture or ethnic group
Urinary Catheter
Catheter with a hollow flexible tube that lets urine come out of the bladder for collection
GOES IN THE DIRECTION OF LEAST RESISTANCE/PRESSURE
Catheters require…
A physician’s order
Aseptic technique in an institutional setting
Inserting a Catheter in a Female
Dorsal recumbent position
Clean out out in in and then down the middle
Inserting a Catheter in a Male
Laying down, spread legs slightly
Continue if they have an erection
Clean in a bull’s eye fashion
Factors in Risk for Infection with Catheters
Poor technique
Inadequate fluid intake
Poor hygiene
Trauma
Retrograde urine flow
Bladder Irrigation
Must have an order
Clamp drainage tube
Run in amount
Wait time ordered
Unclamp
Leave open to drain
Record irrigate as intake
Nonopioid Analgesics
Aceteminophen
NSAIDs
Neurontin
Gerontologic Pain Considerations
Low and slow
Risk for NSAID-induced GI toxicity
TENS
Transcutaneous Electrical Nerve Stimulation used for small nerves
Nonpharmacologic pain management technique
