N388 Unit 2 Flashcards
Factors that influence personal hygiene
*Maintaining cleanliness and grooming of the external body
- Implications for NOT maintaining standard of care:
- Increased risk of infection or illness
- Social and psychological aspects can be affected
- Potential for violating cultural and religious considerations
**Do not force changes in hygiene practices unless it affects patients health
EX: IV’s need to be cleaned, can lead to infection
Types of hygiene a nurse can provide
General grooming Back care Perineal care Foot care Oral hygiene Hair care Nail Care Shaving
Reasons for providing personal hygiene
Promotes good habits of personal hygiene
Provides comfort and stimulates circulation
Helps improve self-image
Opportunity to develop a good and caring relationship with the patient
Types of baths
- Complete bed bath: includes all parts of the body & oral
- Partial bed bath: some parts of body; “sponge bath at the sink” provide assistance with hard to reach places
- Tub bath or shower: provide towels and supplies/prepare tub or shower
- Bag bath: pre-moistened clothes in a solution of no rinse surfactant cleanser and emollient dry shampoos
Self-care ability depends on patients condition and…
Ability to help Mental status Muscle strength Flexibility Visual acuity Ability to detect thermal and tactile stimulus
Considerations Across Lifespan
Gentle handling of neonates
Toddlers/School-age active play
Adolescence growth and maturation (know what is happening, what to expect)
Older adults- skin care changes
Safety principles for nurse during personal hygiene
Ensure bed is at working height Ask for assistance if needed Keep side rails up on side opposite Maintain proper body mechanics Wear gloves soiled linen or open lesions Keep soiled linens away from uniform
Reason for Intake/Output
Helps us determine the patient’s fluid status
Hydrated?/Dehydrated?/Fluid overload?
What do you measure for intake
Oral fluids- water, milk, coffee, tea, soda, juices, ice chips;
Foods that tend to become liquid at room temperature (pudding, jello, ice-cream)
Tube feedings parental fluids (IV) catheter or tube irrigants
Units of measure
Milliliter (mL)
1 FL = 30 mL
1 pint = 500 mL
1 quart = 1,000 mL
Recording intake
Often have to estimate Convert all to mL’s Coffee cup (8oz=240 mL) Water pitcher (1000 mL) Soup bowl (6 oz = 180mL) Jello (4oz = 120 mL)
What to measure for Output
Urinary output Bowel movements Vomitus or liquid feces Tube drainage Wound drainage or wound fistulas
Be descriptive: color, consistency of urine, stool, etc.
Circulation of blood through heart
Inferior vena cava Superior vena cava R. atrium Tricuspid valve Right ventricle Pulmonic valve Pulmonary artery Lungs Pulmonary vein Left Atrium Mitral Valve Left ventricle Aortic valve Aorta Body
Chambers of the heart
Right atrium
Right atrium
Receives oxygen-poor blood from the body and pumps it to the right ventricle.
Right ventricle
The right ventricle pumps the oxygen-poor blood to lungs.
Left atrium
The left atrium receives oxygen-rich ; blood from the lungs and pumps it to the left ventricle.
Left ventricle
The left ventricle pumps the oxygen-rich blood to the body
Blood vessels of heart
Arteries
Veins
Capillaries
Arteries
Carry oxygen blood away from heart to tissues
Arteries begin with the aorta, the large artery leaving the heart.
They carry oxygen-rich blood away from the heart to all of the body’s tissues.
They branch several times, becoming smaller and smaller as they carry blood further from the heart.
Veins
Take oxygen poor blood back to the heart
Veins become larger and larger as they get closer to the heart.
The superior vena cava is the large vein that brings blood from the head and arms to the heart, and the inferior vena cava brings blood from the abdomen and legs into the heart.
Capillaries
Thin blood vessels that connect arteries and veins;
Their thin walls allow oxygen, nutrients, carbon dioxide and waste products to and from the tissue cells.
Valves of heart
Semilunar valves:
Aortic & pulmonary valves
In arteries leaving heart
At the bases of the aorta and the pulmonary artery, consisting of three cusps or flaps that prevent the flow of blood back into the heart.
Atrioventricular valves:
Mitral (bicuspid) & tricuspid valves
Between the upper (atria) chambers and lower chambers (ventricles)
Pericardium
Double walled sac heart is located in
Fibrous Pericardium (outside): dense connective tissue, anchors it while beating Serous Pericardium (inside): 3 layers, visceral pericardium (innermost), serous fluid, parietal pericardium
Layers of the heart
Epicardium, Myocardium, Endocardium
General system of heart
All areas (chambers/valves/veins/arteries) work toether to circulate blood around your body
Fluid likes to move from areas of high pressure to areas of low pressure
The heart creates these pressures
4 valves of heart
Pulmonary semilunar valve:
Mitral Valve- (bicuspid valve)
Aortic semilunar valve:
Tricuspid Valve:
Aortic Seminilunar Valve
between the left ventricle and the aorta which carries blood from the heart to the rest of the body
Mitral vavle
(Bicuspid valve) between the left atrium and the left ventricle
Tricuspid valve
between the right atrium and the right ventricle
Pulmonary semilunar valve
between right ventricle and pulmonary artery allows blood to flow from heart to lungs
Lub-dub
blood travels through one valve, can’t go back; this sound is the valves opening and closing
Atria
Receiving chambers of blood coming back to the heart form body (thin walled)
Ventricles
Discharging out of heart (much thicker)
Steps of Blood Circulation
Blood out of semilunar valve into pulmonary trunk
Deoxygenated blood in pulmonary arteries leaves heart and goes to lungs; picks up O2
Circles back to heart via pulmonary veins, finding area of lowest pressure (left atrium)
Left atrium contracts, leaves through mitral valve into left ventricle Steps 1-4 Pulmonary Circuit Loop-now have oxygenated blood
From Left ventricle goes to aortic semilunar valve, rounding through the aorta and going to the rest of the body
Oxygen poor blood then returns to heart vai superior vena cava and inferior vena cava into right atrium
When right atrium contracts, send it through tricuspid valve, into right atrium Steps 5-7 is systemic loop
Lub
S1 sound
Closure of AV valves (tricuspid & mitral)
Start of systole
Loudest at apex (expected finding)
Low systolic=low blood volume, maybe lost a lot of blood or dehydrated
Dub
S2 sound
Closure of semilunar valves (pulmonary and aortic)
End of systole/Start of diastole
Loudest at base (expected finding)
High diastolic- pressure could be high even with lower systolic number
Grade strength of pulses
0 absent (get 2nd opinion) 1+ weak, diminished, barely palpable 2+ normal, expected finding 3+ full or increased (bounding) 4+ bounding
Capillary refill
should be less than 2 seconds
Standard precautions
Assumes blood and body fluid of any patient could be infections
Hand hygiene
Personal protective equipment as warranted
Safe injection practices
Safe handling of potentially contaminated equipment or surfaces
Respiratory hygiene/cough etiquette
Transmission-based precautions
Used in addition to standard precautions when there is an increased risk
Contact Airborne Droplet SPecial enteric? Special airborne? Special droplet Others?
CDC vs. Health Institution
CDC considers public safety (will likely stick to contact, airborne, and droplet)
Health institution monitors the safety that facility and the threat that exists across that population
PPE
Personal Protective Equipment
HAI
Hospital Acquired Infection
SSI
Surgical Site Infection
CLABSI
Central Line Associated Bloodstream Infection
CAUTI
Catheter Associated Urinary Track Infection
MRSA
Methicillin Resistant Staphylococcus Aureus
VRE
Vancomycin Resistant Enterococci
C. Diff
Clostridium Difficile
Types of PPE
Gloves
Gowns
Face protection (masks/shields/goggles)
Respiratory protection (face mask/respirator)
Gloves
Purpose: patient care, environmental
Material: vinyl, latex, nitrile
Sterile or nonsterile
Single use
Gowns
Used with a lot of bodily fluids Purpose: protect skin and/or clothing from fluids, secretions Material: resistant to fluid penetration Reusable or disposable Clean or sterile
Face Protection
Masks
Protects nose and mouth
Should be fully covered
Goggles
Protects eyes
Should snuggly fit over and around
Personal glasses not a substitute for goggles
Face Shields
Protects face, nose, mouth, and yes
Should cover forehead, extend below chin and wrap around side of face
Respiratory Protection
Purpose: protect from inhalation of infectious aerosols
PPE types for respiratory protection
- Particulate respirators
- Half- or full-face elastomeric respirators
- Powered air purifying respirators (PAPR)
Don
= put on Gown Mask/respirator Goggles or face shield Gloves
Doff
= take off (most dirty/contaminated first)
Gloves
Gown
Face shield or goggles
Mask or respirator
Contact Precautions
prevent transmission of agents spread by direct contact with patient or environment
Types of patients: skin infections, rashes, MRSA, VRE< excessive wound drainage, fecal incontinence
PPE:
Hand hygiene
Gloves & gowns are required
Others as appropriate
Care of patient:
Patients with infectious diarrhea need to use a separate bathroom
Dedicated patient material
Special Enteric Precautions
is a subset of contact for things particularly worried about
Types: C diff, norovirus, rotavirus
Same PPE but Soap and Water
brown box
Droplet Precautions
prevent transmission of agents spread through close respiratory or mucous membrane contact with respiratory secretions
Agents: pertussis, influenza, adenovirus, rhinovirus, streptococcus
PPE:
hand hygiene
Face mask
Others as appropriate
Care of patient:
Private room or with patient with same infection
Patient wears mask when exiting room
Airborne Precautions
prevent transmission of agents that are disseminated in droplets or dust particles remains infectious over long distances when suspended in the air
Agents: tuberculosis, measles, chickenpox
PPE:
Hand hygiene
N-95 (respirator mask) donned before entry/removed after exit
Others as appropriate
Care of patient
Private room
Negative pressure isolation room is required
Patient wears face mask out of room
Nursing responsibility: W’s behind the order
Why is this ordered?
What is this for? What makes us think this test is needed?
When should it be done? When will results be back?
Where do I get the specimen from?
Where does it go?
What do I need in order to obtain this specimen?
What does the patient need to know?
What happens after the results are back?
Restraints
Devices used to limit physical activity or movement of a part of the body; can be physical or chemical
Negative outcomes from restraint use
Physical
Emotional
Substandard care
Death
Alternatives to restraint
Environment
Treat underlying cause of restlessness or agitation
Nursing care of patients in restraints
Apply restraints per institutional protocol
Provider must enter prescription (order) for restraints
Follow institutional protocol for monitoring and safety checks
Offer food and fluids
Assess circulation of restrained extremity
Assist with elimination
Assess skin integrity
Assess frequently/document frequently
Assess need for continued restraints
Create soothing environment
Remind them it is temporary and why they have it
What isn’t a restraint?
Devices used to immobilize patient during a diagnostic procedure
Orthopedic supportive devices
Helmets or age-appropriate protective equipment, such as strollers or cribs
Keeping all side rails up on a bed for seizure precautions
Goal regarding restraints?
Restraint free environment
Less restrictive restraints
Less: Mitts, full arm cuffs
More: leather cuffs, vests
Nurse role during first visit
Height & weight Baseline blood pressure Test urine for ketones, protein & glucose Draw labs CBC (HCT/Hgb) Type & RH Rubella Titer Serology (STDs) HIV Antibody Dependent on history Sickle cell Complete urinary analysis
Nagel’s Rule
Gestational Age of the Pregnancy
First day of the last menstrual period Add 7 to the date Count back 3 months Due date (EDD= Expected due date) EX: Jan. 9, 2017 +7 = 16, - 3mo. = 10/16/18
Gravida Para
Pregnancy history:
First time pregnant GRAVIDA 1
Never given birth to any children PARA 0
G1P0
Physician first visit/bimanual exam
Bimanual exam (2 fingers in vagina, 1 on abdomen, push uterus up to hand)- gives sense of size; measure with fingers until 20 weeks then use tape measure;
The nurse is always present in the room; prepares patient, comfort her, help her relax, stay there
Need to make sure the yolk sac lined up and is not in Fallopian tubes; at 5 weeks it could shatter tube
If patient is suddenly bigger- could be twins
Due date is determined by ultrasound and pelvic exam
Nurse takes heart tones to see if pregnancy is along as you think
Term pregnancy
37-42
37(before premature) - 42 weeks (after post-mature)
Next day would be 7th day so 6.0
Don’t induce unless you medically have to
Placenta is not meant to live longer than 42 weeks, baby won’t get correct nutrients after that
Gestational Age in Weeks
Gestational Age in Weeks from the LMP (last menstrual period)
5 weeks, 6 days = 5.6
next day would be 6.0
Education during initial prenatal visit
Nutrition 25-35 lobs for the pregnancy
Counteract nausea and vomiting
*At about 12 weeks the placenta with hormones takes over and N&V should go down)
N&V is most common discomfort, try low fats, fruit smoothies, small frequent meals, bland diet
Signs and symptoms to call provider
Exercise
-Low impact, don’t start anything new
Sex
- safe positions, continue to do it
When to return to clinic (4 weeks)
Trimesters
1st: conception to 12 weeks
2nd: 13 to 26 weeks
3rd: 27-40+ weeks
1st Trimester
Nutrition Exercise Danger signs (especially bleeding) Common discomforts Avoidance of toxic substances (household chemicals, smoke, street drugs, alcohol) Sexuality Reaction to pregnancy: Ambivalence Genetic testing (referral)
2nd Trimester topics
“Acceptance stage” Infant feeding How to get baby out of body What has to change in family dynamic (prepare children, baby sleeps) Signing up for birthing classes Circumcision- both sides
3rd trimester
Birth center vs. hospital Signs and symptoms of labor (true vs false) What to pack for hospital Birth control methods Baby care How to go back to work
Clinic visits based on gestational age
After the first visit: 6 weeks to 28 weeks gestation= every 4 weeks
28-36 weeks = every 2 weeks
36-40 weeks = every week
40-birth = 2x a week
Composition of gestational visits
Weight Blood pressure Screen for symptoms Listen for heart tones, estimate of fetal size Labs by trimester Teaching topic by gestation
Developmental components in pediatrics
Physical
Cognitive(Piaget)- how kids learn/think/reason
Psychosocial(Freud)- parts of kids bodies at certain stages
Psychosocial (Erickson)- conflicts in children to make one trust vs. mistrust
Infant approach
Approach in parent’s lap, listen when they are quiet, leave uncomfortable stuff for last, beware of pee
Toddler approach
Approach: Most challenging, talk to parent first, allow to touch equipment, leave uncomfy for last
Preschool approach
Approach: More cooperative but still need parents close by Erickson: give jobs, getting independent Have them tdo jobs Handle equipment, play Head to toe Get things in order that you can
School age approach
Approach: warm up, ask them questions too, head to toe, respect modesty, time to teach
Adolescent approach
Approach: who will be present and for what part, talk to them both individually, head to toe, invite parent back after exam, puberty, talk about normal
Anthropometric Measures
Weight, height, head circumference, BMI Growth charts (trends) Trends are most important Changes in any of the above may be the first sign of a serious health status change
Infancy (Physical Development)
Birth weight doubles by end of first 6 months, triples by end of year 1
Birth length increased by about 50% by end of year 1
Rapid growth in brain and body
Tone, strength and coordination increase from head to toe
Early intervention is key if anything is abnormal
Need opportunity to play with toys and food
Toddlers/Preschool (Physical Development)
Birth weight quadruples by 2 ½ years, yearly gain 4.4-6.6 lbs
Height at 2 years is approx 50% of eventual adult height
Height gain during 2nd year- 4.8 in during 3rd year 2.4-3.2 in
Increase in strength, coordination and dexterity; fearless and tireless
School age (Physical Development)
Yearly weight gain 4.4-6.6 lbs
Yearly height gain after 6 years of age- 2 in
Female Adolescent (physical Development
Growth spurt 10-14 years
Weight gain 15-55 lbs (mean 38lbs)
Height gain 2-10 in;
95% of mature height achieved by menarche or skeletal age of 13
Male Adolescent (Physical Development)
Male Growth spurt 12-16 years Weight gain 15-65 lbs (mean 52 lbs) Height gain 4-12 in (mean 11) 95% of mature height achieved by skeletal age of 15 years
Health History of Pediatric
Perinatal, obstetric history Birth- wt, apgar, overall health Immunization Growth and development- major milestones Habits & other hot topics
*who is giving this information?
Temperature in kids
Route
Key points: Document site, trends are important, validate if out of range
Rectal- only if exact measurement is needed
Tympanic- down and back if less than 3; up and back if over 3
Axillary- Infant, young children, immunosuppressed, oral surgery, neuro impaired
Oral- older than 5 ot 6
Pulse in kids
See specific guidelines Apical site if less than 2, history of CHD or irregular Less than 7 left MCL and 4th ICS Older than 7 left MCL and 5th ICS Radial for all others Count for one minute Changes with breathing are normal
Respiration in kids
See specific guidelines
Count for 1 full minute
Periodic breathing is normal
Auscultate especially in infant, young child
Blood Pressure in kids
Save for last Appropriate cuff size is a must “Hug” feel how strong Upper arms and legs Document site, stay with same site Normal- age, height, gender
Fontanels
Posterior closes: 2-3 months
Anterior closes: 12-18 months
10 Rights of Medication Administration
Medication Dose Time Route Client/Patient Education Documentation ..to Refuse Assessment Evaluation
Purposes of medication administration
Pain Nausea Swelling Illness Health promotion Disease prevention
Pharmacological Concepts Overview
Classification of drugs (family)
Similar characteristics
Name of drugs
Brand or trade name
Generic
Form of drug
Tablet, caplet, capsule, elixir
Injection, ointment, suppository
Role in Medication Administration
Prescribe: Physician, Nurse Practicioner, Dentist, Physician Assistants
Prepares & Distributes: Pharamacist (Pharmacy Tech)
Prepare, administer, evaluate response: Nurses (RN & LPN)
Types of Orders
Standing orders or routine orders (carried out until cancelled or limits up)
PRN orders: As needed
Single orders: given just once
STAT orders: immediately once
Standard Assessment vs. Focused Assessment
SA: Exam techniques, I, P, P, A Some subjective data Establishes baseline/used for comparing subsequent assessments Completed at certain “times” VS important FA: Examp techniques: I, P, P, A Problem based: actual or at-risk More subjective Establishes baseline/used for comparing subsequent assessments Used to identify changes in clinical status More frequent than standard assessments VS important
Focused Assessment
Problem based (actual or at-risk problems)
Individualized: problem based
More in-depth than standard
Includes subjective data
Extends to related systems
Physical assessment but extends to psycho-social
May be conducted more frequently than standard
When to do a focused assessment
Nursing knowledge
Institutional policy
Unexpected findings in a standard assessment
Clues from patients/family members
Focused Neuro (Subjective/Objective)
Subjective: Review of system Reason for visit or problem “Pain” “Weakness” “Dizziness: Prior head injury/other related injury/surgery/limitations
Objective: HEENT Inspect and palpate head TMJ (I &P) Eyes (Symmetry,PEERL, EOMs Ears (I & Assess hearing) Face (Assess motor functiono f CN VII)
C.N. I
Olfactory: Sensory: Smell
C.N. II
Optic: Sensory: Vision
C.N. III
Oculomotor: Mixed
Motor- most EOM movement, opening of eyelids
Parasympathetic- pupil constriction, lens shape
C.N. IV
4- Trochlear: Motor
Down and inward movement of eye
C.N. V
5- Trigeminal: Mixed
Motor- muscles of mastication
Sensory- sensation of face and scalp, cornea, mucous membranes of mouth and nose
C.N. VI
6- Abducers Motor
Lateral movement of eye
C.N. VII
7- Facial Mixed
Motor- facial muscles, close eye, labial speech, close mouth
Sensory- taste (sweet, salty, sour, bitter) on anterior two thirds of tongue
Parasympathetic- saliva and tear secretion
C.N. VIII
8 Acoustic Sensory
Hearing and equilibrium
C.N. IX
9 Glassopharyngeal- Mixed
Motor- pharynx (phonation and swallowing)
Sensory: taste on posterior one third of tongue, pharynx (gag reflex)
Parasympathetic- parotid gland, carotid reflex
C.N. X
10- Vagus- Mixed
Motor- pharynx and larynx (talking and swallowing)
Sensory- general sensation from carotid body, carotid sinus, pharynx, viscera)
Parasympathetic- carotid reflex
C.N. XI
11- spinal- motor
movement of trapezius and sternomastoid muscles
C.N. XII
12- hypoglossal- motor
movement of tongue
Pupillary light reflex
Assesses CN II and III
Direct and consensual response to light (both sides)
Extraocular Movements
Six Cardinal Positions of Gaze
Assesses function of CN III, IV, VI (3, 4, 6)
Snellen chart
alphabet letters 20 ft away (20/20)
20/40 would be can see at 20 feet what others can see at 40
Rosenbaum card
same idea as snellen but at 14 inches
Focused musculo-skeletal (subjective/objective)
Subjective
Review of system
MS System: pain, limited function, injury
History of injury/illness/surgery/limitations
Objective:
Inspect (symmetry, deformities) and palpate for tenderness, warmth, muscle tone/strength
Active ROM
Muscle strength
0- no strength
1- 10% normal strength
2- 25% normal strength
3- 50% normal strength
4- 75% normal strength
5- 100% normal strength
ROM cervical/lumbar spine: flexion/extension
Upper extremities (shoulders/elbows/wrist/fingers)
Lower extremities (hips/knees/ankles/toes)
Medication education
side effects, safety concerns, why getting what giving
Essential components of medicine order
Patient name
Generic name
Dosage/route/frequency/time
EMAR
Electronic Medication Administration Record
NKDA
No known drug allergies
PRN
as needed
BID
2x/day
Not necessarily every 12 hours, may be diuretic
Q12
Every 12 hours
TID
3x/day (usually related to meals)
HS
@ bed time
Tanner Scale
used to measure physical development on external primary and secondary sex characteristics such as size of breasts, genitals, testicular volume and development of pubic hair
Rooting reflex
begins when corner of baby’s mouth is stroked the baby will turn towards and open his or her mouth; used to find breast
Suck reflex
stroke inside of mouth, baby will begin sucking
Moro reflex
startled baby; baby throws back his or her head and extends arms and legs then pulls it all back in
Tonic neck reflex
“fencing position” head turned to one side, arm pointed in that direction
Grasp reflex
stroke palm they will close their hands around finger
Babinski
sole of foot stroked they will spread toes
Step reflex
when held upright they appear to be taking steps
Girls: Secondary Sex Characteristics
7- Breasts
8- Pubic hair
8- Vagina grows larger and outer lips (labia) more pronounced
9- body taller and heavier
11- Hair begins to grow under arms
11 Glands in skin/scalp produce more = blemishes
Boys: Secondary Sex Characteristics
10- testicles enlarge and scrotum darker/coarser 10- Pubic hair 10- Body grows taller and heavier 11- Penis longer/fuller 11- Voice deepens 11- Become fertile 12- Hair under arms and on face 12- Glands in skin/scalp produce more= blemishes
