nursing Flashcards
week 1
subjective data- general principles
objective data- physical exam
GALS (gait, arms/ legs/ spine)
Neurovascular observations
5ps(pain. pulse, pallor, parenthesis, paralysis)
Infants and children
– Spinal curve changes
– Developmental dysplasia of the hip
* The pregnant woman
– Increased joint mobility (relaxation of joints due to
oestrogen and relaxin)
– Progressive lordosis
* Late adulthood
– Osteoporosis
– Postural changes
– Musculoskeletal changes
Additional history for infants and children
Labour trauma, resuscitation, Wellness, Broken bones/bruising/dislocations Bone deformity
adolescents Sport participation, Bone/spine deformity
older Change/increasing in weakness, falls, walking aid
NEXUS Requires at least 2 health care workers: 1 Immobilise, 1 competent in applying c-spine
collar
RICER( rest, ice, compression, elevation, referral)
Compartment Syndrome- Pressure buildup reduces
capillary blood flow to that space
2
BGL: 4-8mmol/L
type1: little or no insulin produced [immunological, environmental epigenetic factors]
type 2 reduced insulin production Treated initially with diet and exercise [family history,obesity, ethnicity, age, impaired glucose tolerance, hypertension cholesterol]
Gestational: Glucose intolerance occurring during pregnancy= placental hormone
Dietary management, meal planning, exercise
Acute: Hyperglycaemia & Hypoglycaemia, Diabetic ketoacidosis
Hypoglycaemia [Give 15 g of fast-acting, concentrated carbohydrate= retest] tachycardia, sweat, hunger
hyperglycaemia [sick day management plan]
long term: Coronary artery disease
poly uria, dypsia, phagia= Fatigue, weakness, vision
changes, dry skin
DKA(14-22mmol/L) absence of or inadequate insulin resulting in abnormal metabolism of carbohydrate, protein and fat. IV continuous infusion using regular insulin
sulfonylureas: increasing the release of insulin from the pancreas by beta cells
biguanides: stop glucose production from liver
glucagon: by alpha cells= which elevates blood glucose
modify T2: physical inactivity, body weight, high BP, high cholesterol
non: fam history, over 45YO, race, history gestational diabetes,
GI: how much a food increases blood glucose
3
health history:infection, medication, surgery, lifestyle, fluid intake, past medical history
physical exam: Skin, Hair and Nails, oedema eyes/ legs. Smell in saliva. enlarged abdomen
Palpation: kidneys, bladder,
Auscultation:Renal Arteries heard above the
umbilicus
Dialysis Fistula bruit noise normal in fistula (turbulent flow through the
fistula), abnormal in other arteries
percussion: Murphy’s Kidney Punch: clenched
fist to strike renal angle. pain= infection
Shifting Dullness Test=presence of
free fluid in the abdomen Listen for shifting dullness
use Fluid Balance Chart accurate
measurement of input/output, Voiding Chart Records voiding patterns,
volume, incontinence, pain and
associated symptoms, urine colour, full ward test [pee test], bladder scan
PVR volume is measured to determine
how completely the bladder
empties with voiding <50= normal
development: Kidneys occupy a large
proportion of the abdomen at birth.
Cannot perform a bladder
scan on a woman who is
pregnant or postpartum.
Decreased oestrogen
results in changes to the
female urethra, bladder,
vagina and pelvic floor
Social and Cultural: Higher incidence of CKD in Maori and Pacific Islander people
Urinary incontinence affects 50% of women over 50 years of age and
30% of men over 70
4
Movement of fluids: Osmosis, Filtration
electrolytes:diffusion active transport
The body has three major
fluid compartments:
– Intracellular space
– Interstitial space
– Intravascular space
▪ Separating compartments
are two semi-permeable
barriers
– Capillary wall
– Cell membrane
Oncotic pressure keeps fluid within the intravascular space
Crystalloid solutions contain water soluble electrolytes, = tonicity blood
Molecules are too large to pass through the semipermeable membranes so they expand intravascular volume but exerting
colloid osmotic pressure
Peripheral Venous Cannulas, Central Venous Catheters subclavian or internal jugular vein into superior vena
cava using guidewire sit above right
atrium Access for IV fluids, blood products, parenteral nutrition, medication, Haemodynamic monitoring, Blood sampling, implanted ports tip in subclavian or
jugular vein, PICCS basillic or
cephalic veins tip reaches superior
vena cava Parenteral nutrition
● Chemotherapy (or other specific medications)
● Blood components
● Blood sampling
Fluid order
▪ Prescribed fluid
▪ Cannula
▪ Giving Set
▪ Cleanser/disinfectant
▪ Gloves
▪ Tape
▪ Dressing
▪ Armboard
Complications: fluid overload (kids, elder, cardiac/ renal disease), Air enters, infection, local com plication Infiltration. Extravasation
Macrodrip giving rates
– Chamber 20 drops per ml
▪ Adults
– Chamber 60 drops per ml
▪ Paediatrics/elderly
Hand hygiene, check for cracks in IV, IV area, replace equip,
Doctors prescribe the fluid and the rate that it should be given, Nurses maintain the flow rate
cannula
Size 14 and 16 – large bore,
used in high risk surgery –
requires a large vein.
– Size 18 – used in trauma, blood
transfusions, CT with contrast
– Size 20 – most commonly used.
Ok for fluids and blood.
– Size 22 and 24 – used for
smaller veins. In elderly or
paediatric patients.
5
health history: previous GI disease, Dietary history, pain, ingestion, Changes in bowel habits, stool characteristics
physical: Look for ulcers, swelling, discolouration and inflammation.skin colour or scars, umbilicus enlarged,
everted or sunken contour and symmetry bulging
Light palpation identifies:
– muscular resistance
– abdominal tenderness
– some superficial organs and masses
Deep palpation is used to delineate abdominal masses
When absorption does not occur- Watery stool
- Stool remains too long in colon- Stool dry and hard
Infants: 4-6 [yellow/brown] Adult: daily [brown, black]
abnormal: reddish, loose, compact, unique odour
Stool tests, Abdominal ultrasonography an image of abdominal organs, X-rays Detects obstructions, inflammatory disease, tumours, ulcers and lesions, mri abdominal soft tissue, blood
vessels,Endoscopy lining of
the oesophageal, flexible tube that transmit light into
the organ
Infant- depends on breastfeeds or formula
Toddler- bowel training depends on physiological maturity
Older adult Decreased salivation
6
constipation
causes: Medications, rectal disorder, Colon/acute disease
Health History, Medication, Signs and symptoms of constipation, patient education,
diarrhoea
auscultation/palpation, stool charts and FBC, Infection precautions, Rehydration, skin care
nausea and vomiting
assess airway, pain, monitor nausea, FBC, LOC hydration status, Infection precautions, Rehydration, Nutrition
7
Acute (usually heal within 6 weeks)
Chronic (take longer than 3 months)
Malignant (healing not typical outcome)
Intentional & non Intentional Wound
Superficial- epidermis layer
Partial-thickness- epidermis and upper dermis layer
Full-thickness- all the way to deeper structures
red normal granulation tissue
yellow fibrinous slough or purulent exudate from bacteria need to be clean properly
black n dried necrotic tissue need to remove
Defensive Phase Haemostasis and inflammation occurs
Proliferative Granulation tissue production and wound closure
Maturation Collagen remodelling occurs to increase strength
Primary Intention Tissue surfaces are closed and there is minimal tissue loss
Secondary Intention Extensive wound and considerable tissue loss heals through process of granulation
Tertiary Intention Wounds left open for 3-5 days Primary intention closure
movement) of fluid and cells from the vascular space into the wound occurs defensive phase Transport of leukocytes and plasma proteins Removal of bacterial toxins
Serous exudate is serum and is watery and has a low protein count and is yellow in colour.
▪ Purulent exudate is also called pus and is thick, yellow or green, dead pathogens and cells debris.
▪ Haemorrhagic exudate has red blood cells and is usually bright red in colour.
Local Factors
– Pressure
– Desiccation
– Maceration
– Trauma
– Oedema
– Infection
Systemic Factors
– Age
– Oxygenation and Circulation
– Nutritional Status
– Medication and General Health
– Glucose Control
– Immunosuppression
– Smoking
– Connective Tissues Disorders
– Obesity
Time(tissue, infection or inflammation, moisture & edge of wound)
Moist Wound Healing Decreased dehydration, pain and cell death
dressing products: sutures, gel, staples foams
Colostomy lower bowel removed /Ileostomy (bowel)
– Bowel obstruction
– Trauma (burns)
– Infection
– Inflammatory bowel disease
Ileal Conduit (bladder)
– Bladder cancer
– Traumatic bladder injury
– Severe intractable incontinence
– Neurogenic bladder
Ostomy Appliances: Ostomy pouch
cut perfect fitting, recieve monthly supply
Stoma Complications: Necrosis, Altered body image, Food bolus blockage, Inactive stoma
8
Urinary Incontinence: escape of urine.
Stress, Urge, overflow Incontinence.
Behavioural Therapy, medication, surgery
Investigations
▪ Detailed health history assessment
▪ Voiding history
▪ Fluid intake
▪ Post-void residual volume
▪ Urinalysis
Nursing Management: – Support for behaviour therapy interventions, bladder control program, pharmacological interventions, Educate about when to take diuretic medications
Complications
▪ Embarrassment
▪ Social isolation
▪ Loss of employment and income
UTI: Inflammation and infection of
the urinary tract
movement of microorganisms into the
urethra and bladder from gut
lower UT: urethra bladder
upper: kidney ureter
Urgency and frequency, Dysuria, Pain during sex
Investigations: Urinalysis, Pelvic examination, Sexually transmitted diseases
Nursing Management: Drink 8-10 glasses of water daily, Take showers, wear cotton underwear, clean properly,
Complications
▪ Recurrent infections
▪ Kidney failure
▪ Reduced quality of life
▪ Constipation
Acute Pyelonephritis: Infection is caused by ascending microorganisms along the ureters.
Fever Hypotension Tachycardia Confusion Shivering
Investigations: health history and physical examination, Pregnancy testing, Urinalysis
Nursing Management: Water intake, antibiotics
Complications
▪ Acute kidney injury
▪ Chronic kidney disease
Renal Colic: normally water soluble material supersaturates the urine which begins the process of crystallisation
Urolithiasis refers to calculi
within the ureter.
– Nephrolithiasis refers to
calculi within the kidney.
irritation, block urine flow,
Investigations: ultrasound, urine test, Chemical analysis
Nursing Management: – Non-steroidal anti-inflammatory drugs, IV opioids, analgesia, Hot baths or heat packs, Straining of urine, water intake, vital signs
Complications: chronic pain, Chronic kidney disease, Renal failure
