Exam 3 Flashcards by Grace McCormick

why are women at a greater risk for UTI?

shorter urethra

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developmental considerations
food and fluid intake
psychological variables
activity and muscle tone
pathologic conditions
medications

factors affecting micturtion

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Toilet training 2-3 years old, enuresis (bed-wetting)

May see child potty trained sooner also

children developmental considers (micturtion)

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Nocturia: urinating at night

Increased frequency

Urine retention and statis

Voluntary control affected by physical problems

effects of aging on micturtion

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anuria
bacteriuria
dysuria
enuresis
frequency
hematuria
hesitancy
incontinence
nocturia
oliguria
polyuria
proteinuria
urgency

problems associated with changes in voiding

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urine output <50 mL/day
possible etiology: acute or chronic renal failure

anuria

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what is the normal volume of urine that should be voided per hour?

30 mL

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bacterial count >100,000 colonies/mL in the urine
etiology: infection

bacteriuria

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painful or difficulty voiding
etiology: lower UTI, inflammation of the bladder or urethra, acute prostatitis, stones, foreign bodies, tumors in bladder

dysuria

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involuntary voiding during sleep
often seen in pediatric pt
etiology: delay in functional maturation of CNS

enuresis

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frequent voiding - more than every 3 hr

frequency

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RBC in urine

hematuria

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delay, difficulty in initiating voiding

hesitancy

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involuntary loss of urine

incontinence

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awakening during the night to urinate

nocturia

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urine output <0.05 mL/kg/h

oliguria

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increased volume of urine voided

polyuria

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protein in urine

proteinuria

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strong desire to void

urgency

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which conditions relate to urinary output

1) polyuria
2) anuria
3) oliguria

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which conditions relate to urine composition?

1) hematuria
2) bacteriuria
3) glucosuria
4) proteinuria

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1) intake 3L of water
2) generally recommended to drink 6-8 cups of water per day - consider indirect intakes of water
3) normal output is 1 mL/kg/hr; oliguria is 0.5 mL/kg/hr

urine output

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multiply weight (in kg) by 0.5 and subtract amount voiding

if weight is given, then do based on pt weigh to see if urine output is normal
if UO is given, but no weight, then go on general basis that 30 mL (or CC) /her is normal

how to calculate urine output

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fluids can be lost through many sources: urine, feces, seat, evaporation via lungs

intake: water, coffee, juice, tea, IV, foods

I & O

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- pt w/ CHF - sign on door to notify everyone about restrictions

strict I&O

- voiding patterns, habits, past history of problems - what color is your urine? - do you frequently get UTI? - how frequent? is it painful?

urine assessment

- Physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; and examination of urine - Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment. - Urinary bladder: Palpate and percuss the bladder or use a bedside scanner. - Urethral orifice: Inspect for signs of infection, discharge, or odor. - Skin: Assess for color, texture, turgor, and excretion of wastes. - Urine: Assess for color, odor, clarity, and sediment.

physical assessment of urine/bladder/kidneys

Explore its duration, severity, and precipitating factors Note the patient's perception of the problem Check the adequacy of the patient's self-care behaviors

Assessing a problem with voiding

- Voiding: within normal pattern - Urine: Color: straw-colored; Consistency: clear; Odorless - Bladder: not distended - Catheter type: Indwelling (in patient; foley)/ straight (doesn't have foley bag, removed after releasing bladder)/ 3-way (bleeding in the bladder; 2 bags of saline, one foley bag)/ suprapubic - Secured? or Patency: patent (free-flowing)

NANDA Normal Urinary Findings

Dysuria Polyuria oliguria

Impaired Urinary Elimination

Caused by factors outside the urinary tract

Functional urinary incontinence

Overdistention and overflow of bladder

Overflow urinary incontinence

Emptying of the bladder without sensation of need to void

Reflex urinary incontinence

Involuntary loss of urine related to an increase in intra-abdominal pressure

Stress urinary incontinence

Overactive bladder, sudden desire to urinate

Urge urinary incontinence

Urine not coming out Symptoms: distended bladder, No urinary output; may see anuria or oliguria, Pain Nursing intervention - Bladder scan: noninvasive ultrasound - Over 400 cc of urine --> straight cath

Urinary retention

True or False: Urinary Incontinence is a normal part of aging

False

- Produce sufficient quantity of urine to maintain fluid, electrolyte, and acid-base balance - Empty bladder completely at regular intervals without discomfort - Provider care for urinary diversion and know when to notify physician - Develop plan to modify factors contributing to current or future urinary problems - Correct unhealthy urinary habits

Patient Goal Urinary Elimination

- Maintaining normal voiding habits: schedule, urge to void, privacy, position on toilet/bedpan, hygiene - promoting fluid intake - strengthening muscle tone: Kegel, pelvic floor muscles - assisting with toileting

Promoting normal urination

A postoperative client hasn't been able to void. The provider has ordered a foley catheter. Nurse can facilitate insertion by asking client to:

bear down as if trying to void

A urine specimen from a patient with an indwelling catheter should be obtain from the collection receptable. True or False

False

A pt with an indwelling urinary catheter is suspected of having a UTI. The nurse should collect a urine specimen for urinalysis and culture and sensitivity by

Clamp drainage tube below the post, using sterile needle, aspirate a specimen of urine via the port

If you have a pt who is available to follow instructions (A&O 3 or 4) - Instruct pt to clean urethral orifice Female anatomy: front to back Male anatomy: starting from tip clean from center outward (circular motion outwards) - Before voiding in the cup, will tell pt to pee a little bit then place cup underneath

Clean Catch

- Urinary retention - Prolonged patient immobilization - Obtaining urine specimen when patient is unable to void voluntarily - Accurate measurement of urinary output in critically ill patients - Assisting in healing open sacral or perineal wounds in incontinent patients - Surgery - Providing improved comfort for end-of-life care

Reasons for Catheterization

- Female - Sexually active (and diaphragm) - Menopause - Catheters - Co-morbidities that affect immune system - Anything leading to urinary stasis in bladder

Risk for UTI

- Explain reason for diversion and rationale for treatment - Demonstrate effective self-care behaviors - Describe follow-up care and support resources - Report where supplies may be obtained in the community - Verbalize related fears and concerns - Demonstrate a positive body image

Pt Education for Urinary Diversion

- Normal is 1.015-1.025 - If it is low --> dilute; too much water - If it is high --> concentrated; pt may be dehyrdated - The higher it gets, the more concentrated, closer to amber color

Urine specific Gravity (USG)

- pink = hematuria, kidney damage, anticoagulants, drank too much ginger tea - tea color/brown = sever kidney or liver failure - orange = medication (ex, Rofampin) - black = medication (ex, Iron or Levadopa) - blue = medication (ex, amytriptaline)

urine color

- ensure easy access to bathroom or commode - discourage fluid intake at bedtime - discourage alcohol use before bedtime - evaluate medication regimen and schedule, particularly diuretics and drugs that produce sedation or confusion - use a night light - use clothing that is easily removed for voiding - keep assistive ambulatory devices readily available - evaluate gait and ability to ambulate safely - asses for UTI

nursing strategies for nocturia

- maintain fluid intake of 1,5000-2,000 mL/day - discourage sue of alcohol, artificial sweeteners, and caffeine - provide easy access to the bathroom - assess factors that influence voiding - use assistive devices when necessary - use collection devices when necessary - ensure safety when ambulating - encourage use of whole, unprocessed, coarse wheat bran to prevent constipation and fecal impaction - perform pelvic floor muscle training exercises several times a day - encourage participation in a bladder retraining program

nursing strategies for incontinence

- maintain liberal fluid intake - encourage shower instead of tub bath to decrease opportunity for bacteria in bath water to enter urethra - encourage appropriate perineal care and frequent changing of incontinence briefs - void at frequent intervals; every 2 hours if possible - void immediately after sexual intercourse - women should avoid use of potentially irritating feminine products, such as deodorant sprays, douches, and powders in the genital area

nursing strategies for UTI

Nursing interventions for patient who has not voided for past 5 hours, on standard bladder protocol

1) Assist client with urinal or to bedside commode or bathroom 2) Encourage increase fluid intake 3) Assess with bladder scanner 4) Notify provider 5) Offer client straight catheter

- potassium is usually inside the cell - sodium usually has high concentration outside of the cell

fluid components

- Risk for electrolyte imbalance - Risk for imbalanced fluid volume - Deficient fluid volume - Risk for deficient fluid volume - Excess fluid volume - Risk for excess fluid volume

NANDA Dx for Fluids

- aka, hypovolemia, dehydration - causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, or decrease fluid intake - BP: lower w/ dehydration bc of loss of volume - HR: increased with dehydration - BUN: decreased - USG: increased, urine will be concentrated - Hematocrit: increased, not enough plasma

Deficient fluid volume

- Impaired cognitive function - Fatigue - Headache - Dizzy - Loss of skin or tongue turgor - Hypotension, orthostatic hypotension - Tachycardia, often with weak, thready pulse; Not enough fluid in body --> weak - Dark urine, increased specific gravity, oliguria - Decreased weight: Rapid loss of 1 kg (2.2 lbs) = loss of 1 L of fluid; 5-10% of weight is serious

signs of dehydration

- in the morning after voiding - in hospital gown - on same scale

weighing pt

- Refusal to drink for fear of incontinence - Dementia or delirium - Decreased sense of thirst with age - Multiple meds, often with diuretics - Frailty - Reliance on others to supply fluids

elderly at greater risk for dehydration

Fluid overload (contributing factors: excessive dietary sodium or 0.9% NS containing IV solutions) Diminished homeostatic mechanism (risk factors: heart, liver, or renal failure)

causes of excessive fluid volume (hypervolemia)

- Edema, 2+ Pitting? - Distended neck veins, JVD - Abnormal lung sounds - Crackles; Too much fluid - probably in lungs - Tachycardia - Thready pulse - Increased blood pressure - Increased weight: > 2 kg (4.4 lbs) in 2 days or 2.5 kg (5 lbs) in a weak - Increased urine output

signs of hypervolemia

- Daily weights (Can be delegated) - I&Os - Lung sounds - Edema - Monitor responses to medications - diuretics (esp Potassium - connection to cardiac) - Patient teaching related to sodium and fluid restrictions - Promote rest - Semi-fowlers position for orthopnea - Skin care, positioning/turning

Nursing Management for hypervolemia

- Shift of fluids into transcellular compartments - Pleural (pleural effusion) - Peritoneal (Ascites) - Leads to deficit in ECF volume - Retention - holding onto fluid

third spacing

sodium <135

hyponatremia

sodium >145

hypernatremia

- isotonic - lactated ringers - dextrose - hypotonic - hypertonic

IV fluid types

- similar concentration of blood - use when pt is dehydrated - volume expander - given to treat hypovolemia - main medication is 0.9% NS

isotonic

- has electrolytes - might be given for burns

lactated ringers

- D5 - given when sodium level is high - 0.45% NS

hypotonic

- more solute; 3-5% NS - dextrose: D10W

hypertonic

- Maintain daily fluid restriction 1500-2000 mL or 1.5-2 L - Sodium < 2000 mg/day (note: 2300 mg in a teaspoon) - Maintain urine specific gravity within normal range (1.010-1.025) - Maintain urine output of 1 mL/kg/hr

possible expected outcomes for hypovolemia/hypervolemia

self-care activities such as bathing, dressing, toileting, transferring, continence, feeding

Activities of daily living (ADLs)

permanently contracted state of a muscle

Contractures

complication resulting from extended plantar flexion

Footdrop

the activities of daily living needed for independent living such as managing finances and meal preparation

Instrumental activities of daily living (IADLs)

exercise involving muscle contractions with resistance varying at a constant rate (muscle contraction with resistance)

Isokinetic exercise

exercise in which muscle tension occurs without a significant change in muscle length (muscle contraction without shortening)

Isometric exercise

movement in which muscles shorten (contract) and move (muscle shortening and active movement)

Isotonic exercise

complete extent of movement of which a joint is normally capable

Range of motion

- Assist patient with toileting - Wash face with hands - Provide mouth care

AM care before breakfast

- Toileting - Oral care - Bathing - Special skin measures: lotion, barrier cream, no baby power - Hair care - Dressing - Positioning for comfort - Refreshing or changing bed linens - Tidying up bedside - Falls precautions

AM care after breakfast

- Offer individual hygiene measures as needed - Change clothing and bed linens of diaphoretic patients - Provide oral care every 2 hours if indicated

PRN care

- offer assistance with toileting, washing, and oral care - Offer a back massage - Change any soiled bed linens or clothing - Position patient comfortably - Ensure that call light and other objects patient requires are within reach

Hour of sleep (HS) care

used for pt with bad hips

fracture bedpan

- Clean from inner to outer canthus with wet, warm cloth, cotton ball or compress - Use artificial tear solution or normal saline q4H if blink reflex is absent (unconscious patients) - Care for eyeglasses or contact lens, if indicated

Eye care

- Wash external ear with washcloth-covered finger - Preform hearing aid teaching and care if indicated - Remove crusted secretions around nose by applying warm, moist compress

Ear and Nose Care

- Note any history of hair/scalp problems (e.g., dandruff, hair loss, baldness, alopecia) - Shampoo and groom hair

Hair Care

- if the lens is not centered over the cornea, apply gentle pressure on the lower eyelid to center the lens - gently pull the outer cornea of the eye toward the ear - position the other hand below the lens to receive it and ask the patient to blink

rigid gas permeable (RGP) lenses

- have the pt look forward - retract the lower lid with one hand. using the pad of the index finger on the other hand, move the lens down on the sclera - using the pads of the thumb and index finger, grasp the lens with a gentle pinching motion and remove

soft contact lenses

- bathe the feet in mild soap and water - avoid soaking the feet - dry feet thoroughly, including the area between the toes - apply moisturize to feet if they are dry - use antifungal foot powder if necessary - diabetic pt should file nails; avoid using scissors or nail clippers - consult a podiatrist to cut nails - wear appropriate footwear and cotton socks - avoid using heating pads

foot care

1) isotonic 2) isometric 3) isokinetic

muscle contraction

active movement and ADLs

isotonic muscle contraction

muscle contraction without shortening, ex. wall sit or plank

isometric muscle contraction

muscle contraction with weights

isokinetic muscle contraction

1) aerobics 2) stretching 3) strengthening and endurance 4) movement and ADLs

body movement

- general ease of movement - gait and posture - alignment - joint structure and function - muscle mass, tone, and strength - endurance

assessment of activity

- Activity intolerance - Impaired transfer ability - Risk for activity intolerance - Risk for constipation - Risk for injury

NANDA Dx Activity

- Ergonomics to prevent injury - Safe patient handling and movement - Safe transfer, equipment and assistive devices, E.g., gait belts, transfer devices, lifts - Positioning patient in bed - Devices for correct alignment, e.g., Foam wedges and pillows, trapeze, foot board or shoes (re: footdrop), hand roll, trochanter roll - Protective positioning - Repositioning Q2H - Used graduated compression stockings (remove when bathing) - Moving a patient up in bed - Moving a patient from bed to stretcher or chair - Assisting with active/passive ROM exercises - Assisting with ambulation

Nursing Interventions for Activity

1) Verify the order 2) Patient identification and education 3) Hand hygiene 4) Collect the sample 5) Label the sample at the bedside (avoid errors) 6) Transport the sample to the lab

role of nurse in specimen collection

1) Verify the order 2) Patient identification and education 3) Prep as needed for the ordered test 4) Monitor the patient as needed post test

Role of nurse in imaging studies

evaluates the concentration, variety, and quantity of blood cells

complete blood count (CBC)

what is the reference range for WBC?

5,000-10,000 mm3

what is the reference range for hemoglobin?

12-18 g/dL

what is the reference range for hematocrit?

40-50%

- WBC count - hemoglobin - hematocrit - RBC - mean corpuscular volume - mean corpuscular Hgb - Mean corpuscular Hgb Concentration - Red cell distribution width - platelet count

CBC

- neutrophils - lymphocytes - monocytes - eosinophils - basophils - band forms

differential blood panel

- sodium - potassium - calcium - chloride - CO2 - glucose - blood urea nitrogen (BUN) - creatinine

basic metabolic panel (BMP)

what is the sodium reference range?

135-145 mEq/L

What is the potassium reference range?

3.5-5.- mEq/L

What is the reference range for BUN?

8.0-20 mg/dL

What is the reference range for creatinine?

0.7-1.4 mg/dL

What is the reference range for creatinine?

0.7-1.4 mg/dL

what is BUN and creatinine indicative of?

kidney

what is the sodium lab indicative of?

hydration

what is the potassium lab indicative of?

cardiac

basic CBC + additional: - albumin - magnesium - alkaline phosphatase - ALT/SGPT - AST/SGOT - total bilirubin

complete metabolic panel (CMP)

what is the reference range for albumin and what is it indicative of?

3.5-5.5 g/dL and nutrition

what is the reference range for bilirubin and what is it indicative of?

0.3-1.9 mg/dL and liver

- Require immediate action - Out of normal range - Lab will call and tell the nurse the critical value --> nurse will repeat and confirm the lab value

critical lab values

Pt admitted to the emergency room complaining of fatigue and weakness. He reports large amounts of bloody stools. What labs would you assess and why?

HNH (looking for anemia) and platelet (looking for clotting issue)

Pt admitted to the med-surg floor with a laceration (cut) to his left thigh. He reports that he acquired the cut playing basketball but came to the hospital when he was not feeling well. The laceration continues to bleed despite pressure being applied to the site. What labs would you assess and why?

platelet

- sodium (Na) - potassium (K) - calcium (Ca) - magnesium (Mg) - chloride (Cl) - bicarbonate (HCO3) - phosphate (PO)

electrolytes

- prothrombin time (PT) - international normalized ratio (INR) - partial thromboplastin time/activated partial thromboplastin time (PTT/aPTT)

coagulation studies

what is the reference range of prothrombin time (PT)?

10-13.1 seconds

- Ref range: 0.88-1.16 - 2.0-3.0 for anticoagulant therapy - 2.5-3.5 for mechanical heart valves

INR reference range

- Ref range: 27.5-37.4 seconds - Heparin therapy monitoring ref range: 58-99 seconds

PTT/aPTT reference range

What is the lab value PTT used for?

Heparin

What is the lab value aPTT used for?

anticoagulant

which is drawn first, blood cultures or blood tubes

cultures and taken 15 min apart

- coagulation (light-blue) - chemistry, serology, immunology (red/gold) - stat and routine chemistry (green) - hematology and blood bank (lavender or pink) - glucose, blood alcohol, lactic acid (gray)

blood tubes

Your patient reports body aches, is diaphoretic, has an oral temp of 102.4 F, what abnormal lab result would you expect to find?

increased WBC

A pt presents to the ED with a GI bleed, what abnormal lab result would you expect to find?

increased RBC

a pt's BMP results show a K level of 6.3: what order does the nurse anticipate?

Doppler peripheral pulses

- Obstructions, strictures, fractures, etc. - No contrast used - Emits radiation - Normal = negative

X-rays

- Cross-sectional images of bones and tissue - May use oral or IV contrast to illuminate images - Ask about allergies to iodine or shellfish - Emits radiation - Normal = negative

CT scans

- Detailed anatomic views - No radiation emitted - May use IV contrast to illuminate images - Normal = negative - NO MEDALS

MRI

- Visualizes organs, soft tissues, blood flow through vessels, etc. - E.g., kidneys, carotid arteries, legs for DVT - No contrast used, no radiation - Normal = negative

ultrasound

sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group

culture

situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

culture conflict

those feelings, usually negative, a person experiences when placed. In a different culture

culture shock

belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs

Ethnocentrism

process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different

Cultural assimilation

the process of ignoring differences in people and proceeding as though the differences do not exist

Cultural blindness

care delivered with an awareness of the aspects of the patient's culture

Cultural competence

tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group

Cultural imposition

ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter

Linguistic competence

assigning characteristics to a group of people without considering specific individuality

Stereotyping

providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society

Transcultural nursing

Which of the following occurs when members of a minority gorup, living with a dominant group, begins to blend in and lost characteristics?

cultural assimilation

A nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for patients to get a special tray of their favorite foods

cultural conflict

A nurse is telling a new mother from Africa that she couldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias?

cultural imposition

A nurse states, "that patient is 78 y/o - too old to learn how to change a dressing". What is the nurse demonstrating?

stereotyping

A Muslim patient asks to coordinate tests and treatments with the nurse to allow for his daily prayers. The nurse ignores this request and schedules testing according to department availability as with all her other patients.

cultural blindness

- reactions to pain - biological sex roles - language/communication - food and nutrition - family support - socioeconomic status

cultural influences on health care

- Develop an awareness of one's own existence, sensations, thoughts and environment in relation to others - Demonstrate knowledge and understanding of the patient's culture, health-related needs, and culturally specific meanings of health and illness - Accept responsibility for one's own education in cultural competence - Not assuming that the health care provider's beliefs and values are the same as the patient's - Accept and respect cultural differences - Be open to and communicate with cultural encounters - Resisting judgmental attitudes

culturally respectful nursing care

- Recognize that each person holds various beliefs about pain and that pain is what the patient says it is - Respect the patient's right to respond to pain in one's own fashion - Never stereotype a patient's responses to pain based on the patient's culture - Be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area or avoiding activities that intensity the pain

culturally competent nursing care - pt in pain

- Beliefs, values, traditions and practices of a culture - Culturally defined, health-related needs of individuals, families, and communities - Culturally based belief systems of the etiology of illness and disease and those related to health and healing - Attitudes toward seeking help from health care providers

Cultural Assessment/Areas Nurses Need to Understand

- Developing self-awareness - Demonstrating knowledge and understanding of a patient’s culture - Accepting and respecting cultural differences - Not assuming that the health care provider’s beliefs and values are the same as the client’s - Resisting judgmental attitudes such as “different is not as good” - Being open to and comfortable with cultural encounters - Accepting responsibility for one’s own cultural competency

Elements of Cultural Competence

- Develop cultural self-awareness. - Develop cultural knowledge. - Accommodate cultural practices in health care. - Respect culturally based family roles. - Avoid mandating change. - Seek cultural assistance.

Guidelines for Providing Culturally Competent Nursing Care

- Patients, families, physicians, and institutions increasingly expect practicing nurses to be knowledgeable about CHA. - Many patients use these types of therapies as outpatients and want to continue their use as inpatients. - Patients/family members may expect nurses to administer herbal preparations/nutritional supplements. - Many nurses are expanding their clinical practice by incorporating CHA. Many institutions now provide complementary therapies to inpatients as part of total patient care in an effort to provide integrative health care.

Why Nurses Need to Know CHA

procedure consisting of placing very thin, short, sterile needles at particular acupoints, believed to be centers of nerve and vascular tissue, along a meridian to either increase or decrease the flow of chi along the meridian, restoring the balance of yin and yang, and thereby contributing to healing

acupuncture

the term generally used to describe “traditional” medical care (biomedicine), dominant for about 100 years, which spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools

allopathic medicine

a science of life that delineates the diet, medicines, and behaviors that are beneficial or harmful for life and considers that balance among people, the environment, and the larger cosmos is integral to human health

ayurveda

interventions that can be used with conventional medical interventions

complementary health approaches

using all five senses to imagine an event or body process unfolding according to a plan, focusing on evoking pleasant images to replace negative or stressful feelings and to promote relaxation

guided imagery

nursing practice built on a holistic philosophy

Holistic nursing

practice of medicine based on the belief of supporting the body while the symptoms are allowed to “run their course” to stimulate and strengthen the immune system and promote healing

Homeopathy

combination of complementary health and conventional health approaches in a coordinated way

Integrative health

system of posture, exercise (both gentle and dynamic), breathing techniques, and visualization that regulates the qi

Qi gong

belief that illness originates in the spirit world and usually involves a loss of power; treatment consists of first, restoring the individual’s power, and second, treating symptoms

Shamanism

originated in ancient China and has evolved over thousands of years. TCM practitioners use herbs, acupuncture, and other methods to treat a range of conditions. In the US, TCM is considered a complementary health approach

Traditional Chinese Medicine

- conventional medicine - lifestyle and self-care - complementary and alternative healthcare

integrative health

- mind, body, and spirit are integrated and tougher influence health and illness - health is a balance of body systems: mental, social and spiritual, as well as physical - illness is a manifestation of imbalance and disharmony - symptoms are a sign or reflection of a deeper instability within the person; restoring physical and mental harmony will alleviate the symptoms. Healing is a slow process that involves the whole person - emphasis is on health. Healing is done by the patient; care is individualized

complementary and integrative health approaches

- illness occurs in either the mind or the body, which are separate entities - health is the absence of disease - the main causes of illness are considered to be pathogens (bacteria or viruses) or biochemical imbalances - curing seeks to destroy the invading organism or repair the affected part - emphasis is on disease and high technology. Drugs, surgery, and radiation are among the key tools for dealing with medical problems

allopathic therapies

- Relaxation - Mediation - Guided imagery - Yoga - Qi gong & Tai Chi - Acupuncture - Chiropractic care - Aromatherapy - Energy healing therapies: Therapeutic touch, healing touch, sound healing - Manipulative and body based practices

mind-body practices

- Botanicals and nutritional supplements - Nutritional therapy

natural products

- Ayurveda - Traditional Chinese Medicine - Shamanism - Homeopathy - Naturopathy

Other Complementary Health Practices

- natural products - deep breathing - yoga - chiropractic and osteopathic - meditations - massage

most frequently used CHAs

- Relaxation - Mediation - Guided imagery - Yoga - Qi gong and Tai Chi - Acupuncture - energy healing therapies: therapeutic touch, healing touch, sound healing - manipulative and body based practices

Mind-Body Practices

- kava can cause liver damage - ginkgo - always ask about OTC drugs and natural or herbal supplements

natural practices

- 4000 years old medical system originating in India - Balance of mind, body, spirit

ayurveda

- Yin-yang theory - Holistic history-taking - Tx: acupuncture, diet, herbs, massage, energy exercises

traditional Chinese medicine

- Indigenous origins globally - Illness r/t spirit

Shamanism

- "Like cures like" - Law of minimum dose

Homeopathy

- Health is a dynamic state - Variety of treatments

Naturopathy

- Reduces anxiety - Reduces muscle tension and pain - Improves function of immune system - Enhances sleep and rest Improves sense of well-being

benefits of relaxation for patients

- Developmental level - Gender - Sociocultural differences - Roles and responsibilities - Space and territoriality - Physical, mental, and emotional state - Values - Environment

Factors influencing communication

- Verbal (language) - Nonverbal (body language)

forms of communication

- Facial expressions, touch, eye contact - Posture, gait, gestures - General physical appearance - Mode of dress and grooming - Sounds, silence - Electronic communication

Nonverbal (body language)

- Intrapersonal: Self-talk; communication within a person - Interpersonal: Occurs between two or more people with a goal to exchange messages - Group: Small-group, Organizational communication, Group dynamics

levels of communication

- social media - e-mail - text message

electronic communication

- The risk for violating patient privacy and confidentiality exists any time a message is sent electronically. - Health care agencies usually have security measures in place to safeguard e-mail and text communications.

E-mail and text messages

- Does not occur spontaneously à Purposeful and time limited - Characterized by an unequal sharing of information & unequal focus: patient-centered - Built on the patient’s needs - The nurse is the helper, and the patient is the person being helped - Nurse is professionally accountable for actions & outcomes - Communication is the means used to establish rapport and helping–trust relationships - Dynamic

the helping relationship

- Orientation phase - Working phase - Termination phase

phases of the helping relationship

- The patient will call the nurse by name. - The patient will accurately describe the roles of the participants in the relationship. - The patient and nurse will establish an agreement about: Goals of the relationship; Location, frequency, and length of the contacts; Duration of the relationship.

goals of the orientation phase

- The patient will actively participate in the relationship. - The patient will cooperate in activities that work toward achieving mutually acceptable goals. - The patient will express feelings and concerns to the nurse.

Goals of the Working Phase

- The patient will participate in identifying the goals accomplished or the progress made toward goals. - The patient will verbalize feelings about the termination of the relationship

goals of the termination phase

Which activity generally occurs during the orientation phase of the helping relationship?

an agreement contract about the relationship is established

* Touch * Eye contact * Facial expressions * Posture * Gait * Gestures * General physical appearance * Mode of dress & grooming * Sounds Silence

types of nonverbal communication

stand up for yourself and other with open, honest, and direct communication; clear, concise I statements

assertive

asserting one’s own rights in negative manner that violates the rights of others; communication tries to assert superiority through destructive comments targeted at others (*note: cocky borders on this)

aggressive

failing to stand-up for oneself or to communicate in clear, confident manner; often person will feet hurt or angry after the communication

non-assertive

* Confident; open body posture * Use of clear, concise “I” statements * Ability to share effectively one’s thoughts, feelings, and emotions * Working to capacity with or without supervision * Remaining calm under supervision * Asking for help when necessary * Giving and accepting compliments * Admitting mistakes and taking responsibility for them

characteristics of the assertive nurse's self-presentation

dispositional traits and rapport builders

factors that promote effective communications

* Warmth and friendliness * Openness and respect * Empathy * Honesty, authenticity, trust * Caring *Competence * Read the room * Humble confidence Come in neutral

dispositional traits

* Specific objectives * Comfortable environment * Privacy * Confidentiality * Patient vs. task focus * Utilization of nursing observations * Optimal pacing

rapport builders

* Failure to perceive the patient as a human being * Failure to listen * Nontherapeutic comments and questions * Using clichés * Using closed questions * Using questions containing the words “why” and “how” * Using questions that probe for information

blocks to communications

- incivility - bullying: horizontal violence, nurse bullying, negative communication between nurse and physician

disruptive interpersonal behavior

* R/T cultural incongruence * AEB inability to speak language of caregiver * Primary language is Hindi, minimal English * R/T previous cerebrovascular accident (CVA, aka stroke) OR previous lack of perfusion to cerebral tissue OR physiologic condition * AEB difficulty speaking, slurred speech, delayed processing * R/T alteration in sensory perception * AEB bilateral (Med dx: mild, moderate, severe, profound) hearing loss OR decreased/absent hearing

impaired verbal communication

hand-off nurse communications

SBAR

how old is midd age?

40-65

how old is young old?

65-75

how old is middle old?

75-85

how old is old old

85+

* Physiologic: gradual internal and external physiologic changes occur * Cognitive: little change from young adulthood * Psychosocial: time of increased personal freedom, economic stability, and social relationship

development of the middle adult

* Accept and adjust to physical changes * Maintain a satisfactory occupation * Assist children to become responsible adults * Adjust to aging parents * Relate to one's spouse or partner as a person

developmental tasks of middle adulthood

* Employment * Relationship with a spouse * Relationships with adult children * Relationships with aging parents * Midlife transition

life changes of the middle years

* Malignant neoplasms * Cardiovascular disease * Unintentional injury including poisoning, motor vehicle accidents, and falls * Diabetes melitus * Chronic lower respiratory disease * Cerebrovascular causes

leading causes of death in middle adulthood

- Rheumatoid arthritis - Obesity - alcoholism - depression

major health problems

* Teach the dangers of substance abuse, smoking, and alcohol consumption * Teach adults to eat a diet low in fat and cholesterol * Teach the importance of regular exercise

role of nurse in promoting healthy aging

7: generatively vs. stagnation 8: integrity vs. despair

erikson's stages of psychosocial development

* Physiologic: all organ systems undergo some degree of decline; body less efficient * Cognitive: does not change appreciably, may take longer to respond and react * Psychosocial: self-concept is relatively stable throughout adult life * Disengagement theory: an older adult may substitute activities but does disengage from society * Erikson" Ego integrity vs. Despair and disgust; life review * Havighurst: Major tasks are maintenance of social contacts and relationships

development of older adult

* Physical strength and health * Retirement and reduced income * Health of spouse * Relating to one's age group * Social roles * Living arrangements * Family and role reversal

changes of older adult

* Aging is a normal process, and chronic illness is a pathologic process, but both often occur at same time * Meeting expenses of health care is often difficult * Family members must learn to cope with needs of the ill person - caregiver role strain * Family members must adapt to psychological stressors

basis for teaching plan for older adults

* Changes in vision and hearing * Loss of mass and strength of muscles * Slower reflexes and reaction time * Decreased sensory ability ○ Pain, temperature ○ Wear nonskid socks, inspect feet with mirror * Combined effects of chronic illness and medications * Economic factors

causes of accidental injuries in older adults

* Dementia * Alzheimer disease * Sundowning syndrome * Cascading iatrogenesis

mental impairment in older adults

* Home modifications * Homesharing * Accessory apartments * Elderly cottage housing opportunities * Senior retirement communities * Continuing care retirement communities * Assisted living * Board and care homes; nursing homes * Adult family and group homes * Long-term care facilities

housing options for older adults

True or false, sundowning syndrome is a temporary state of confusion that can last from hours to weeks and resolves with treatment

false

* Promote independent function * Support individual strengths * Prevent complications of illness * Secure a safe and comfortable environment Promote return to health

goal of nursing care

S: sleep disorders P: problems with eating or feeding I: incontinence C: confusion E: evidence of falls S: skin breakdown

SPICES

* Based on recent studies, it is estimated that 10% of adults aged 60 or older who live in the community are abused * Victims are more likely to be women, young-old, lower income, or isolated, with a lack of social support * Elder abuse includes physical abuse, sexual abuse, psychological or emotional abuse, financial abuse or exploitation, and neglect

elder abuse

▪ Normal to have thickening and discoloration, but we worry when pt has complications (ex, pt with diabetes) ▪ How are they caring for their feet? ▪ Educate pt to inspect their feet, ask for help, file nails, see a podiatrist to cut their toenail ▪ If they want to cut their own toenails – cut straight across

physical assessment in aging adult: thick discolored toenails

▪ Areas of hemorrhaging ▪ Normal: skin is thinner, more fragile, a slight bump can easily bruise ▪ Worry: signs of elder abuse, cardiovascular diseases, anticoagulant therapy (assess PT/PTT)

physical assessment of aging adult: purport

- changes that affect appetite and thirst - changes that impact intake

changes in eating and drinking of older adult

○ Decrease in taste buds ○ Decrease in saliva Decrease in thirst sensation

changes that affect appetite and thirst

- Dentures that don't fit - Changes in dentation

changes that impact intake

what is the greatest risk for older adults in eating and drinking?

swallowing difficulty that leads to risk for aspiration

* Loss of calcium from bones (esp post-meno women) --> risk? * Cardiac output decreases --> what is the effect? ○ Heart rate decreasing ○ BP increases * Decreased visual and hearing acuity --> consider safety * What about vital sign changes? ○ Review ECG strip – know normal, tachycardia, and bradycardia ○ Decreased HR ○ Increased BP * But, good news, cognitive function does not decline! May need more processing time due to large memory storage. Short-term memory may decrease. So let's avoid ageism

expected changes in aging adult

5 or more prescribed drugs

polypharmacy

- multiple prescribers may use multiple pharmacies increasing the risk for contraindicated meds/duplicate meds - increased risk for non-compliance - increases risk side effects

poly pharmacy

education and systems change

ways to change risk for polypharmacy

- sudden/abrupt - short duration - impaired attention - reversible

Delirium

- slow onset - chronic and progressive - not reversible

dementia

montreal cogntiive assessement

tests for dementia

- variable onset - variable duration - worse in morning - reversible

depression

- seems depressed, confused, or withdrawn - isolated from family and friends - has unexplained bruises, burns, or scars - appears dirty, underfed, dehydrated, over/under medicated - bed sores - recent changes in banking or spending patterns

signs of elder abuse

rhythm that completes a full cycle every 24 hours; synonym for diurnal rhythm

Circadian rhythm

a natural chemical produced at night that decreases wakefulness and promotes sleep

Melatonin

in adults, five or more predominantly obstructive respiratory events (the absence of breathing [apnea] or diminished breathing efforts [hyponea] or respiratory effort-related arousals) during sleep, accompanied by sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, or observed apnea and associated health disorders (hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, stroke, diabetes, cognitive dysfunction, or mood disorder)

Obstructive sleep apnea (OSA)

condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed

Rest

a condition in which patients are unable to lie still and report experiencing unpleasant creeping, crawling, or tingling sensations in the legs

Restless legs syndrome (RLS)

state of altered consciousness throughout which varying degrees of stimuli preclude wakefulness

Sleep

nonpharmacologic recommendations like reviewing and changing lifestyles and environment that help an individual get a better night's sleep

Sleep hygiene

- non-rapid eye movement (NREM) - rapid eye movement (REM)

stages of sleep

▪ Stages I and II: 5% to 50% of sleep, light sleep ▪ Stages III and IV – 10% of sleep, deep-sleep states (delta sleep)

NREM

○ 20-25% of a person's nightly sleep time ○ Pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase; skeletal muscle tone and deep tendon reflexes are depressed

REM

1) wakefulness 2) NREM Stage I 3) NREM Stage II 4) NREM Stage III 5) NREM Stage IV 6) NREM Stage III 7) NREM Stage II 8) REM 9) NREM Stage II

a single normal sleep cycle

* The person passes consecutively through four stages of NREM sleep * The pattern is then reversed ○ Return from stage IV to III to II ○ Enter REM sleep instead of re-entering stage I * The person re-enters NREM sleep at stage II and moves on to III and IV

sleep cycle

* Developmental considerations * Motivation * Culture * Lifestyle and habits * Environmental factors * Psychological stress * Illness * Medications

factors affecting sleep

* Newborns (0-3 months): 14-17 hours * Infants (4-11 months): 12-15 hours * Toddlers (1-2 years): 11-14 hours * Preschoolers (3-5 years): 10-13 hours * Children (6-13 years): 9-11 hours * Teenagers (14-17 years): 8-10 hours * Young adults (18-25 years): 7-9 hours * Adults (26-64 years): 7-9 hours * Older adults (=> 65 years): 7-8 hours

recommended hours of sleep

* Gastroesophageal reflux * Coronary artery diseases * Epilepsy * Liver failure and encephalitis * Hypothyroidism * End-stage renal disease

illnesses associated with sleep disturbances

- insomnia - narcolepsy - obstructive sleep apnea - restless leg syndrome

sleep disorders

* Difficulty falling asleep, intermittent sleep or difficulty maintaining sleep, despite adequate opportunity and circumstances to sleep * 30-35% of US adults complain of insomnia * History of depression are more likely to experience insomnia * Related to disruptions in circadian rhythms * May be short-term or chronic Treatment: nonpharm (CBT), pharm

insomnia

- physical exercise, but not right before bed - avoid food, beverages, or OTC meds that have caffeine in the evening - eat a light dinner - eat a light protein and a complex carb - wake up at same time every day - get out of bed and go into another room if you can't sleep

tips to help rest and sleep

* Excessive daytime sleepiness and frequent overwhelming urgers to sleep or inadvertent daytime lapses into sleep * <= 70% also have cataplexy lasting from seconds to 1-2 minutes * Treatment: medications and behavior therapy ○ CNS stimulants: methylphenidate, modafinil Treatment for cataplxy: sodium oxybate

narcolepsy

- Loud snore, then snort, then silence, then pt jolted awake - Partners usually notice

sleep apnea

○ Respiratory effort-related arousals during sleep, coupled with sleepiness, fatigue, insomnia, or snoring ○ Subjective nocturnal respiratory disturbance Observed apnea and associated health disorders

obstructive sleep apnea

* Aka, Willis-Ekbom Disease (WED) * Affects up to 15% of the population, most often middle-aged and older adults * Cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs * Pharmacologic and nonpharmacologic treatments (leg massages, walking, knee bends, stretching)

restless leg syndrome

Chronic or recurrent pattern of sleep-wake rhythm disruption ○ An alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and sleep-wake schedule desired or required ○ A sleep-wake disturbance (e.g., insomnia or excessive sleepiness) ○ Associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder)

circadian rhythm sleep-wake disorders

* Nature of problem * Cause of problem * Related signs and symptoms * When the problem began and how often it occurs * How the problem affects everyday living * Severity of the problem and how it can be treated * How the patient is coping with the problem and success of treatments attempted

sleep history

* Restlessness * Sleep postures * Sleep activities * Snoring Leg jerking

sleep characteristics to assess

* Time patient retires * Time patient tries to fall asleep * Approximate time patient falls asleep * Time of any awakening during the night and resumption of sleep * Time of awakening in morning * Presence of any stressors affecting sleep * Record of food, drink, or medication affecting sleep * Record of physical and mental activities * Record of activities performed 2-3 hours before bedtime * Presence of worries or anxieties affecting sleep

information recorded in a sleep diary

* Energy level * Facial characteristics * Behavioral characteristics * Physical data suggestive of sleep problems

physical assessment for rest and sleep

* Physical or emotional discomfort or pain * Changes in bedtime rituals or sleep environment * Disruption of circadian rhythm * Exercise and diet before sleep * Drug dependency and withdrawal * Symptoms of physical illness

common etiologies for sleep/rest nursing Dx

- pharmacologic therapy: sedatives and hypnotics - nonpharmacologic therapy: cognitive behavioral therapy

treatment for dyssomnias

▪ Progressive muscle relaxation measures ▪ Stimulus control ▪ Sleep restriction; sleep hygiene measures Biofeedback and relaxation therapy

cognitive behavioral therapy

1) prepare a restful environment 2) promote bedtime rituals 3) offer appropriate bedtime snacks and beverages 4) promote relaxation and comfort 5) respect normal sleep-wake patterns 6) schedule nursing care to avoid disturbances 7) Use medication to produce sleep 8) teach about rest and sleep

nursing interventions for sleep and rest

○ Verbalize feeling rested or having had a restful night's sleep ○ Identify factors that interfere with or disrupts the normal sleep pattern ○ Use techniques that promote sleep and provide a restful environment ○ Concentrate and function effectively during waking hours Eliminate behaviors related to sleep deprivation

nursing evaluation for rest and sleep

can be recognized by others

actual loss

is felt by person but intangible to others

perceived loss

loss has not yet taken place

anticipatory loss

internal emotional reaction to loss

grief

state of grieving from loss of a loved one

bereavement

actions and expressions of grief, including the symbols and ceremonies that make up outward expression of grief

mourning

* Shock and disbelief * Developing awareness * Restitution * Resolving the loss * Idealization * Outcome

Engel's Six Stages of Grief

* Denial and isolation * Anger * Bargaining * Depression Acceptance

Kuber-Ross's Five Stages of Grief

* Developmental considerations * Family * Socioeconomic factors * Cultural, gender, and religious influences Cause of death

factors affecting grief and dying

an individual who has sustained either 1) irreversible cessation of all functions of circulatory and respiratory functions or 2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead

uniform definition of death act

cessation of breathing, no response to deep painful stimuli, and lack of reflexes (such as the gag or corneal reflex) and spontaneous movement, flat encephalogram

medical criteria used to certify a death

* Control of symptoms * Preparation for death * Opportunity to have a sense of completion in one's life * Good relationship with health care professionals

components of a good death

Legal document to make future health provisions, can include 3 components ○ Indicate who will make decisions for the patient in case the patient is unable ○ Indicate the kind of medical treatment the patient wants or doesn't want ○ Indicate how comfortable the patient wants to be ○ Indicate how the patient wants to be treated by others ○ Indicate what the patient wants loved ones to know

advanced directive

Medical order indicating patient's wishes regarding treatments, commonly used in medical criss for current treatment

POLST/MOLST

No further life-sustaining measures, including care like dialysis, blood transfusions, abx, etc.

comfort care only

Written instructions to explain healthcare wishes

living will

agent who persons trusts to make decisions in the event of subsequent incapacity

durable healthcare power of attorney/proxy

Medical order, no CPR in event that heart or breathing stops; sometimes called No code or Allow Natural Death

DNR

withdrawal from mechanical ventilation

terminal weaning

* Allow natural death, do-not-resuscitate, or no-code orders * Terminal weaning * Voluntary cessation of eating and drinking * Active and passive euthanasia Palliative sedation

special orders

* Physiologic needs: physical needs, such as hygiene, pain control, nutritional needs * Psychological needs: patient needs control over fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation * Needs for intimacy: patient needs ways to be physically intimate that meets needs of both partners Spiritual needs: patient needs meaning and purpose, love and relatedness, forgiveness and hope

needs of dying patients

* Explain the patient's condition and treatment * Teach self-care and promoting self-esteem * Teach family members to assist in care * Meet the needs of the dying patient Meet family needs

developing a trusting nurse-patient relationship

give patients with life-threatening illnesses the best quality of life they can have by the aggressive treatment of symptoms

goal of palliative care

Joint commission requires nondiscriminatory policy * Provider may not trust decisions of same-sex spouse due to anti-gay bias * Chosen family vs. Family of origin Importance of spirituality and faith

LGBTQ+ Rights

* After the patient passes (no apical pulse + breathing cessation), notify the provider to pronounce death and complete death certificate * There are different scenarios, but in acute care, typically we prepare the body while the provider notifies the family * Of Note: procedures change if body being prepared for autopsy or organ donation - Preparing the body - care of the family

postmortem care

○ Place the body in anatomic position, laying flat, arms and legs outstretched ○ Important to begin soon after death to avoid contractures due to rigor mortis ○ Close eyes, hold for a few seconds ○ Close mouth, place towel beneath neck to help ○ Replace dressings, remove tubes ○ Clean patient, place new linens, new gown, comb hair, add chux or brief

preparing the body

○ Tidy up the room, bring chairs to bedside, provide tissue ○ Turn off all monitors, soften lightening ○ Bring family members to view the body ○ Provide as much privacy as possible for family to begin grieving ○ It is appropriate for the nurse to attend the funeral if asked ○ Once family has left, place identification tag on patient, place body in morturary shroud (post-mortem bag), place identification on outside of bag and notify mortuary

caring for the family postmortem