The NEXT Middy! Flashcards
What is nursing
the protection, promotion, and optimization of health and abilities,
prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response,
and advocacy in the care of individuals, families, communities, and populations
How is nursing an ART
- Based on a framework of caring and dignity
- Acknowledging the dynamic processes of spirituality, healing, empathy, and mutual respect
- Embraces healing through compassion, helping, competence, being present, tolerance, acceptance, and nurturing
How is nursing a science?
- Based on critical thinking
- Requires clinical decision-making
- Relies on evidence to guide practice
- Uses strategies to provide optimal outcomes
What are Florence nightingale’s contributions?
- Demonstrated efficient and knowledgeable nursing care
- Defined nursing practice as separate and distinct from medical practice,
- Differentiated between health nursing and illness nursing.
- Focus on environment
- Stressed the need for continuing education for nurses
- Recognize components of nursing: Health & Illness
- Emphasized nutrition was important for health
- Maintained accurate records/beginning of nursing research
- Defined nursing as an art & science
- Standards for management
- Nursing education and nursing respected occupation for women
Nursing as we know it began when?
19th-20th century
based on practices and beliefs of Florence Nightingale
4 aims of nursing
Promote health
Prevent illness
Restore health
Facilitate coping - with death and disability
How do we achieve/ meet the aims of nursing
Cognitive- thinking
Technical- applying skills
Interpersonal- communication
Ethical/legal- documentation
What makes nursing a profession
Service orientation
Research
Recognized authority
Autonomy
Code of ethics
Knowledge base (unique)
Set Standards
SR. RACKS
ANA
AMERICAN NURSES ASSOCIATION
The professional organization for nurses in the US
Fosters high standards of nursing practice
Promotes safe ethical work environment, health and wellness for nurses, advocates on healthcare issues that affect nurses
NLN
NATIONAL LEAGUE FOR NURSES
Foster the development and improvement of all nursing services and nursing education
Primary source of research data about nursing education
Open to all people
NSNA
NATIONAL STUDENT NURSES ASSOCIATION
Prepares students to participate in professional nursing organizations
Founded in 1952 with the assistance of the ANA and NLN
ICN
INTERNATIONAL NURSING ORGANIZATION
Provides a way for national nursing organizations to work together
National nursing organizations
ANA
NLN
AACN
NSNA
AACN
AMERICAN ASSOCIATION OF COLLEGES OF NURSING
National voice for BSN and HIGHER nursing education programs
National accreditation of nursing programs is provided through the AACN by the CCNE
Who wrote the 2015 scope and standards of practice?
ANA
What are standards of practice
Steps
What are standards of professional performance
Key concepts
ANA standards of practice
Assessment
Diagnoses
Outcomes identification
Planning
Implementation
Coordination of care
Health teaching
Evaluation
A-DO-PICH-E
Standards of professional performance
Education
EBP
Environmental health
Ethics
Culturally congruent practice
Communication
Leadership
Resource utilization
Quality of practice
Professional practice evaluation
Nurse practice acts
Laws established in each state to regulate the practice of nursing. Broadly worded
Nursing Process
Major guidelines for nursing practice. Used by the nurse to ID the patient’s healthcare needs and strengths to establish and carry out a care plan to meet those needs and to evaluate the effectiveness of the plan to meet the established outcomes.
Trends in nursing
Cost
Research
InterDISciplinary education
Shortage, nursing
Population based care
Globalization- economy
Diversity
Educated consumer
Policy, health
Technology
CRISP G DEPT
What is health
complete state of physical, mental, social well being
Passive state
What is wellness
State of being healthy including living a lifestyle that promotes good physical mental and emotional health.
Active state
What is disease
Diagnosed and treated as prescribed by a HCP
What is illness
The response of a person to a disease
<6 months
Stages of illness
Stage 1 - experiencing symptoms
Stage 2 - Assuming sick role
Stage 3 - Assuming dependent role
Stage 4 - Achieving recovery and rehabilitation
Illness behaviors
- Experiencing symptoms
- Sick role
- Dependent role
- Achieving recovery and rehab
Health disparities
Poverty
Race
Insurance
Mental health
Education
Disabilities
Age/ access to health
Gender
Sexual orientation
PRIME DAGS
FACTORS affecting health and illness
Environment
Living conditions
Family
Lifestyle
Work
Sex
Age
Genetics
Education/Experience
Elf lifestyle work & sage
Maslows hierarchy
Self Actualization
Self Esteem
Love & belonging
Safety & security
Physiologic needs
Physiologic needs
Oxygen, water, food, elimination, temperature, sexuality, physical activity and rest.
They are the most basic in hierarchy of needs. Most essential to life and have highest priority.
Oxygen is the most essential of all needs.
ABCs ( Air, Breathing, & Circulation)
Safety & security
Safety and security needs come next in priority and have both physical and emotional components
Physical - Protected from potential or actual harm.
Emotional- involves trusting others and being free of fear, anxiety and apprehension.
Love & belonging
Often called a higher level need.
They include understanding and acceptance of others in both giving and receiving love. Feeling of belonging to groups such as families, peers, friends, a neighborhood and community.
If unmet, a patient feels isolated and lonely
Self Esteem
Includes the need for a person to feel good about themselves.
To feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.
Nurses can help meet patients’ self esteem needs by respecting values and beliefs.
Self Actualization
Highest level of hierarchy includes the need for people to meet their full potential.
3 levels of health promotion and preventative care
Primary
Secondary
Tertiary
immunization clinics
Primary
physical exams
Secondary
teaching pts w/ diabetes how to recognize & prevent complications
Tertiary
using PT to prevent contractures in a stroke pt
Tertiary
assess normal growth for children
Secondary
dental/eye/medical exams
Secondary
family planning services
Primary
poison control info
Primary
safe sex education
Primary
BP screening
Secondary
referring a woman to a support group after breast removal from cancer
Tertiary
provide case management for disaster victims.
Tertiary
nutrition/fitness activites
Primary
exercise programs for frail adults
Secondary
early detection & treatment of diabetes
Secondary
Child car seat education
Primary
Prevention of pressure injuries as a
complication of spinal cord injury
Tertiary
Promoting independence for patients
with traumatic brain injury
Tertiary
Communicable disease screening and
case finding
Secondary
Health education in schools
Primary
Heath risk assessments
Primary
Self breast or testicular exams
Primary
Seat belts
Primary
Family counseling
Secondary
Pap smears and mammograms
Secondary
Teaching about healthy diet
Primary
Safety in industry and farms
Primary
Teaching about the importance of regular exercise
Primary
Family planning services
Primary
Accident prevention education
Primary
Birth control
Primary
Occupational therapy
Tertiary
Job training
Tertiary
Surgical treatment
Tertiary
Support groups
Tertiary
Water treatment
Primary
Smoking cessation
Primary
Weight loss
Primary
PT
Tertiary
Primary prevention
addresses the needs of healthy patients to promote health and prevent disease with specific protections
Secondary prevention
focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent a worsening health status
Tertiary prevention
aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning
Nursing theory
developed to describe nursing, the purpose of describing, explaining , predicting, and controlling desired outcomes of nursing care practices.
What is research
to examine carefully or to check/search again
What is Nursing research
encompasses research to improve the care of people in the clinical setting as well as the broader study of people and the nursing profession, including studies of education, policy development, ethics and nursing history.
What is EBP
a problem-solving approach to making clinical decisions, using the best evidence available
5 steps of implementing EBP
1: Ask a question about a clinical area of interest or an intervention use PICOT format
2- Collect the most relevant and best evidence to answer the question.
3-Critically evaluate the evidence
4: Integrate the evidence- with clinical expertise, pt preferences and values in making a decision to change
5: Evaluate the practice decision or change
ACE IE
Parts of a research article
Dunn model
Being - recognizing oneself as separate and individual
Belonging - being part of a whole
Becoming - growing and developing
Befitting - making personal choices to befit oneself for the future
Nursing care:
physiologic
Nurses evaluate oxygenation (skin color, VS, anxiety levels)
Assess nutritional status through weight, muscle mass, lab values, and strength
Monitor intake and elimination of fluids.
Nursing care:
Physical safety and security
Proper hand hygiene and admin medications knowledgeably
Nursing care:
Emotional safety and security
Encouraging spiritual practices to provide strength and support
Allowing as much decision making and control as possible.
Nursing care:
Love and belonging
Nursing interventions include family and friends visiting patient
Establishing a nurse patient relationship based on understanding and trust
Referring patients to specific support groups
Nursing care:
Self esteem
Respecting their values and beliefs
Encouraging patient to set attainable goals
Facilitating support from fam
Nursing care:
Self actualizations
Focusing on patient strengths and possibilities rather than problems
Providing sense of direction and hope
Provide teaching that is aimed at maximizing potentials.
Tasks/ health risk factors
Table 4-2 pg 74
Community aspects that affect individual and family health
Social support system
Community healthcare structure
Environmental factor
Economic resources
SCEE
Community:
Social support system
made up of all the people who will help meet financial, personal, physical and emotional needs. (Family, friends, and neighbors provide the best social support within a community) (additionally: church and organizations)
Community:
Community healthcare structure
the size and location of the community often determine what services are available; aswell as county and state funding
Rural residents may need to travel further distances to receive care.
Urban residents have access to public transportation and a variety of healthcare options.
Community:
Economic resources
personal finances and healthcare insurance
Community:
Environmental factor
the community environment in which a person lives and works can either have helpful or harmful effects on health.
- Air and water quality differs across communities
- Large urban areas are often affected by air pollution
- Smaller communities are at risk for water pollution from run-off of chemicals or livestock waste.
- Lack of transportation; distance to services; location of services
List the Competencies
Blended
QSEN
What are blended competencies
Nurses aim to design and manage each patient’s care scientifically, holistically, and creatively.
To do this nurses need many cognitive, technical, interpersonal, and ethical/ legal competencies. (In most instances, nurse actions require all 4 competencies)
Cognitive and technical competencies equip nurses to manage clinical problems stemming from the patients changing health or illness state
Interpersonal and ethical skills are essential for nurses concerned about the patients broader well being.
Explain cognitive
critical thinking- a systematic way to form and shape one’s thinking.
Not accepting information at face value
Examine assumptions, evaluate evidence, and uncover underlying values and reason
Explain technical
Good with their hands”. Familiarize yourself with new equipment. Practice necessary skills until you feel confident in your ability, before performing it on a patient.
Explain interpersonal
Interpersonal: promoting the dignity and respect of patients as people and establishing a caring relationship.
-“you are a person of worth, and i care about you”
-Be sensitive about what your looks, speech and touch to communicate to patients and colleagues
-Direct the conversation
Explain ethical/legal
examining one’s sense of accountability
being attentive and responsive to the healthcare needs of patients.
This earns the patients trust that “all will be well”
What are QSEN competencies
The QSEN project is to meet the challenge of preparing future nurses, who will have the knowledge, skills, and attitudes (KSAs), necessary to continuously improve the quality and safety of the health care systems within which they work.
What is clinical reasoning
ways of thinking about patient care issues (determining, preventing, and managing patient problems)
What is clinical judgement
refers to the result (outcome) of critical thinking or clinical reasoning
the conclusion, decision, or opinion you make
5 characteristics of the nursing processs
Interpersonal
Dynamic
Outcome-oriented
Universally applied
Systematic
IDOUS
INITIAL ASSESMENT
is performed shortly after the patient is admitted to a healthcare facility or service.
Purpose: to establish a complete database for problem identification and care planning
FOCUSED ASSESMENT
the nurse gathers data about a specific problem that has already been identified.
Purpose: routinely part of ongoing data collection/ to identify new or overlooked problems.
Quick priority assessments (QPAs): short, focused, prioritized assessments you do to gain the most important information you need to have first. (These are important because they can “flag” existing problems and risks
EMERGENCY ASSESMENT
performed to identify life-threatening problems when a patient presents with a physiologic or psychological crisis.
Examples: assessing the source of a choking hazard, blood loss from a stab wound, ABCs on an unresponsive patient, the potential for immediate harm from an individual threatening violence.
Time-Lapsed Assessment:
is scheduled to compare a patient’s current status to a baseline data obtained earlier.
Examples: Reassessments
Comprehensive Assessment
baseline data. Allows to make judgment about persons health status.
Ex. health history
OBJECTIVE DATA
observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them.
What you can measure.
SUBJECTIVE DATA
information perceived only by the affected person (patient). Cannot be perceived or verified by another person. What the patient tells you.
NURSING DIAGNOSIS
Actual or potential health problems that can be prevented or resolved by independent nursing intervention
Written to describe patient problems or issues that nurses can treat independently within the nurses scope. I.e: activity, pain and comfort, and tissue integrity/ percussion problems
Medical Diagnoses:
identify diseases; where as nursing diagnosis focus on unhealthy responses to health and illness
Describe problems for which the physician or advanced practice nurse directs the primary treatment;
Remains the same for as long as the disease is present; where as nursing diagnosis may change day to day
Collaborative Problems
certain physiologic complications that nurses monitor to detect onset or changes in status
DIAGNOSTIC STATEMENT
PROBLEM (NANDA nursing diagnosis) “related to” ETIOLOGY “as evidenced by” DESCRIBING CHARACTERISTICS”
INITIAL PLANNING
performed by the nurse with the admission nursing history and the physical assessment
ONGOING PLANNING
carried out by any nurse who interacts with the patient
Discharge planning
best carried out by the nurse who has worked most closely with the patient and family
8 IMPLEMENTATION GUIDELINES
-Reassessing the Patient and Reviewing the Plan of Care
-Using Patient Boards or Whiteboards
-Clarifying Prerequisite Nursing Competencies
-Planning Ahead and Organizing Resources
-Anticipating Unexpected Outcomes and Situations
-Ensuring Quality and Patient Safety: Preventing Errors and Omissions
-Promoting Self-Care: Teaching, Counseling, and Advocacy
-Assisting Patients to Meet Health Outcomes
A PURE CAP
4 TYPES OF OUTCOME
COGNITIVE
PSYCHOMOTOR
AFFECTIVE
PSYIOLOGIC
COGNITIVE OUTCOME
EXAMPLE
Outcome met. Parents discussed some infant problems related to feeding, elimination, and illness and reported appropriate community resources to contact.
The parents understand & have knowledge of the infants problems
PSYCHOMOTOR OUTCOME
EXAMPLE
Outcome partially met. Both parents correctly demonstrated safe techniques for holding, dressing and bathing baby. Mother is still concerned that the baby is not getting enough milk.
Revision: Continue to spend time with mother and infant during feeding — provide positive reinforcement
AFFECTIVE OUTCOME
EXAMPLE
Outcome partially met. Except for concern about breastfeeding, both parents expressed feeling comfortable and eager to care for their son at home.
PHYSIOLOGIC OUTCOME
EXAMPLE
Outcome met. Parents’ report of baby’s weight gain and behavior indicates good parenting skills.
CYCLIC PROCESS
Infectious agent
Reservoir
Portal of exit
Means of transmission – directly or indirectly
Portal of entry
Susceptible host
DIRECT - means of transmission
Kissing, touching, sexual intercourse
INDIRECT- means of transmission
Vector (insect), fomite (inanimate object), respiratory droplets that adhere to dust particles
50% drop in contamination generally when fomites have been cleaned within the week, depending on cleaning method
Droplet, contact, & airborne
Portal of entry examples
Respiratory / gastrointestinal & genitourinary tracts / pustules in skin / blood/tissue/exretions / open wounds / ALL mucous membranes (eyes/nose/lungs/etc)
Reservoir examples
Humans / animals / soil / food / water / milk / fomites
HUMANS & ANIMALS can be asymptomatic OR symptomatic to spread
Some people do not exhibit s/s of disease (carriers) (ex. AIDS s/s do not occur for years)
Ex. rabies: reservoir are animals. West nile virus: reservoir is birds & mosquitos feed on birds & transfer it to humans
Examples of infectious agents
Bacteria (most significant): antibiotics ONLY effective against gram positive bacteria. Aerobic (need air) & anaerobic (no air)
Viruses: smallest microorganism.
Antibiotics have no effect (ex. Hep B & C, cold, AIDS)
Fungi: plant like organisms (mold & yeast)
athletes foot, ringworm, yeast infections
Parasites: live on host & rely on it for nourishment
Portal of exit examples
Respiratory / gastrointestinal & genitourinary tracts / pustules in skin / blood/tissue/exretions
STAGES OF INFECTION
Incubation Period
Prodromal stage
Full stage of illness
Convalescent Period
Incubation period
Interval between ‘pathogenic invasion’ of body and appearance of infection.
Period of intense growing & multiplying of pathogen inside host
Length varies from illness (ex. Cold incubation period 1-2 days, tetanus 2-21 days)
Prodromal stage
Person / host is most infectious during this stage
Early signs & symptoms begin: fatigue, malaise, low grade fever (s/s nonspecific)
Lasts Hours- days & person unaware of being contagious
Infection spread to other hosts
Full stage of illness
Presence of infection specific signs & symptoms indicates the full stage of illness
Localized symptoms: limited or occur only in one body area (ex. Sore throat)
Systematic symptoms: throughout the entire body (ex. Chills, fever)
Convalescent Period
Recovery from infection, symptoms begin to fade
Body’s defense against infection
Skin and mucous membranes
Microbiome / Flora (skin, nose, mouth, throat, large intestine, and genitals)
Inflammatory response (injuries or breaches in skin) & immune response (B-cells/T-cells) systems
Medical asepsis
CLEAN TECHNIQUE” - does NOT try to make the environment pathogen free. It’s used in and out of medical facilities and is based on the assumption that pathogens are present everywhere
procedure/practice used to reduce # of transfer of pathogens
Surgical asepsis
STERILE TECHNIQUE” - sole purpose is to completely ELIMINATE PATHOGENS from the environment!!
HAND HYGIENE, levels of PPE, isolation, education, responsible behavior by nurses, safe practices – at the heart of implementation
Used in the OR, labor and delivery areas, certain diagnostic testing areas, nurses use surgical asepsis at patient’s bedside (IV’s, catheters, etc)
5 moments for hand hygiene
Before touching patient
Before a “clean” or aseptic procedures
After body fluid exposure risk
After touching patient
After touching patient surroundings
MRSA
Methicillin-resistant Staph (S.aureas)
VISA
Vanco. Intermediate-resistant S.aureas
VRSA
Vanco. Resistant s.aureas
VRE
Vanco. Resistant enterococci
CRE
carbapenem-resistant Enterobacteriaceae
– the “NIGHTMARE bacteria”
Acinetobactor baummanii (A.baummanii)
found in hospitals in war zones - Iraq / Afghanistan - soldiers were contracting it
Clostridium difficile (C.diff)
feces of immune people with C.dificile
Healthcare Associated Infection (HAI)
formerly called “Nosocomial” (term being phased out, per book)
Reflects emergence of new pathogens, methods to prevent transmission of multidrug-resistant organism and CDC’s concern over bioterrorism
Tier 1 STANDARD PRECAUTIONS:
Precautions used in care of all hospitalized patients regardless of diagnosis of possible infection status
PPE: masks, eye protection, face shield, fluid repellent gowns during procedures with splashes
TIER 2 – TRANSMISSION-BASED PRECAUTIONS
Airborne
Droplet
Contact
Airborne precautions
Pertains to tuberculosis, chickenpox, rubeola/ measles
(N95)
Place patient in private room with monitored negative air pressure, wear respirator when entering room, transport patient out of room ONLY when necessary, patient should wear surgical mask for transport, CDC for more specific precautions
Droplet precautions
Pertains to rubella (German measles), mumps, diphtheria, adenovirus
(Mask)
Private room if available but pts door can be open, PPE upon entry and all interactions involving contact, transport patient only when necessary and with surgical mask per patient, keep visitors 3 feet from patient
Contact precautions:
For patients who are infected or colonized by a multidrug-resistant organism
- c. diff, scabies, MRSA
(Mask & Gown)
Private patient room if available, wear PPE when entering room and for all interactions that may involve contact in contaminated areas, change gloves after contact with infected materials, remove PPE before leaving patient’s environment and wash hands, limited movement of patient out of their room, avoid sharing patient equipment!
Factors affecting personal hygiene
Personal Preferences
Health State
Developmental Level
Culture
Socioeconomic Class
Spiritual practices
PHD CSS
Interview:
Skin
Question patient about:
-Any past or current skin problems and changes in their skin. (e.g. rashes, lumps, itching, dryness, lesions)
Recent surgeries, wounds, tattoos, or piercings
When skin problems are present, ask the patient:
How long have you had this problem?
Does it bother you?
How does it bother you?
Does it itch?
Have you found anything that helps relieve these symptoms?
Interview:
Oral cavity
Note history of any oral problems and related treatments
Identify any variables known to cause oral problems
e.g. deficient self-care abilities, poor nutrition or excessive intake of refined sugars, family history of periodontal disease, ingestion of chemotherapeutic agents that produce oral lesions
Patients at risk for oral problems include those who:
- are seriously ill, comatose, dehydrated , confused, depressed, or paralyzed
- have mental health problems
- are mouth breathers
-have no oral intake of nutrition or foods (have NG tubes or oral airways in place)
-Have had oral surgery
Interview
Hair
identify patients usual hair and scalp care practices, including styling preference
note any history of hair or scalp problems + possible causes of changes in distribution, texture, or amount of hair
Be alert for any factors known to cause hair or scalp problems or that requires special care
e.g. deficient self-care abilities, immobility, malnutrition, and treatments (chemotherapy)
Interview:
Nails and Feet
Gather info about patients normal nail and foot care practices
include type of footwear worn + any history of nail or foot problems and their treatments
Foot problems are common in people with diabetes and peripheral vascular disease
a proactive educational approach can prevent many serious complications
Identify variables known to cause nail and foot problems
e.g. ulcers, lower extremity amputations
Identify variables known to cause nail and foot problems
e.g. deficient self-care abilities, vascular disease, arthritis, diabetes, nail biting, improper trimming , prolonged exposure to chemicals or water, trauma, ill-fitting shoes, obesity
Interview:
Perineal and Vaginal Areas
Know history of perineal or vaginal problems and related treatments
Identify variables known to cause perineal or vaginal problems or to create a need for special care
e.g. urinary or fecal incontinence an indwelling Foley catheter, childbirth, douching, rectal or genital surgery,
e.g. diseases such as UTI’s, diabetes, certain STI’s
Assessment
Musculoskeletal system
Impairment of musculoskeletal system can interfere with patients ability to perform hygiene
e.g. muscle weakness, decreased ROM, impaired balance, fatigue, lack of coordination
Assessment
Skin
Assisting patients with basic hygiene provides opportunity for examining patients skin
Pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and any lesions
Follow These general guidelines for assessing the skin:
-incorporate assessment of skin during assessment of other body systems
-use a good source of light, preferably daylight
-Compare bilateral parts for symmetry
-use standard terminology to report and record findings
-allow data obtained in nursing history to direct skin assessment
-identify any variables known to cause skin problems
e.g. self-care abilities, immobility, malnutrition, decreased hydration, decreased sensation, skin exposure, vascular problems , or presence of irritants
Assessment
Oral cavity
Inspect oral cavity and surrounding structures with attention to any unusual odors
While performing physical assessment of oral cavity, examine:
-Lips: lumps, ulcers, lesions, edema
-Buccal Mucosa: lesions, nodules, bleeding
Color and surface of gums: Lesions come up bleeding, edema
-Teeth: Any loose, missing, or carious teeth + note presence and condition of dentures or other orthodontic devices
-Tongue: symmetry, movement, texture, and lesions
Hard and Soft Palate: intactness , color, patches, lesions, and petechiae
-Oropharynx: movement of uvula and condition of tonsils
Dental Caries:
Decay of teeth with formation of cavities
result from failure to remove
plaque
invisible, destructive, bacterial film that builds up on everyone’s teeth and eventually leads to destruction of tooth enamel
Periodontal Disease (Peridontitis)
a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone
Symptoms include: bleeding gums; swollen, red, painful gum tissues; Receding gum lines with formation of pockets between teeth and gums; pus that appears when gums are pressed; loose teeth
halitosis
an offensive breath odor that is usually system in nature
Gingivitis
an inflammation of the gingiva tissue that surrounds the teeth
Tartar
Hard deposits at the gumline from build-up of plaque and dead bacteria
Attacks fibers that fasten teeth to gums and eventually attacks bone – teeth then loosen fall out
Stomatitis
inflammation of the oral mucosa
Glossitis
inflammation of the tongue
Cheilosis
an alteration and dry scaling of the lips with fishers at the angles of the mouth
Dry oral mucosa
May be due to dehydration, mouth breathing, alteration in salivary function, medications
Oral malignancies
appearing as bumps or ulcers
Assesment
Eyes
During eye examination, note position, alignment, and general appearance of eye
eyelashes should be equally distributed and curl outward
no presence of lesions, nodules, redness, swelling, crusting, flaking, excessive tearing, or discharge of eyelids
check color of conjuctiva and test patients blank reflex
Assessment
Ear
note position, alignment, general appearance of the ear
Pay particular attention to build up of cerumen (earwax), Dryness, crusting, or presence of any discharge or form body in canal
can cause impaired hearing
Assessment
Nose
note position and general appearance, patency of nostrils, and presence of tenderness, dryness, edema, bleeding, discharge , or secretions
Assessment
Hair
Inspect texture, cleanliness , and oiliness
inspect scalp for scaling, lesions, inflammation, or infection
Note abnormalities such as dandruff, hair loss, or infestations
Dandruff
A condition characterized by itching and flaking of the scalp
Dandruff Tx
Daily brushing and shampooing with medicated shampoo
severe cases require medical attention
Hair loss
Becomes potential problem when it exceeds hair growth
Alopecia
a partial or complete, local or generalized, absence or loss of hair (more common in men than women)
Excessive generalized hair loss may occur with infection, nutritional deficiencies, hormonal disorders, childbirth, general anesthesia, drug toxicity, chemotherapy, thyroid disease, liver disease, hepatic and renal failure, and radiation
Pediculosis
infestation with lice
Pediculus humanus capitis
hair and scalp infestation
Pediculus humanus corporis
body infestation
Pidiculosis pubis
infestation of shorter hairs on the body – usually pubic or axillary
Nits
Lice eggs that are laid on her shafts
- White or light Gray and look like dandruff but cannot be brushed or shaken off the hair
-frequent scratch marks on body and scalp
-easily spread by contact
-Two treatments usually necessary before Nets are destroyed
-infested hermae be shaved – especially when Pete Barker or axe Larry hair is infested
-partners of patients with pubic infestation must be notified
-Patients must finish lice tx – Failure to complete treatment has produced lice that are now resistant to pediculosides
Ticks
Can transmit Lyme disease, Rocky Mountain spotted fever, and Colorado tick fever
Once on a person, takes move to warm and moist location – e.g. hairline, armpit, groin
disease risk is decreased if removed within 24 hours
Assessment
Nails and Feet
Examine nails and feet for intactness and cleanliness
assess capillary refill and contour of nail bed
inspect nail base for redness, swelling, bleeding, discharge, and tenderness
inspect feet for swelling, inflammation, lesions, tenderness, or orthopedic problems
Assessment
Perineal and Vaginal Areas
Examine both male and female genitalia for color, lesions, masses, swelling, inflammation, excoriation (compulsive picking), tenderness, and discharge (Amount, color, odor, source)
Inspect anal area for cracks, nodules, distended veins, masses, or polyps
Note perennial odors
Hygiene diagnosis
Bathing self-care deficit-related to post operative weakness
Impaired oral mucous membrane-related to dehydration and altered nutrition
Impaired Social interaction- related to negative body image: acne
Readiness for Enhanced Self-Care-related to oral hygiene practices
FACTORS AFFECTING BODY ALIGNMENT AND MOBILITY
mental health
exercise
lifestyle variables
fatigue and stress
physical health
attitude and values
growth and development
external factors
MELF-PAGE
LOCK UP EFFECTS OF IMMOBILITY AND EXERCISE
Isotonic exercise
Involves muscle shortening and active movement. Potential benefits include increased muscle mass, tone, and strength, improved joint mobility, increased cardiac and respiratory function, increased circulation, and increased osteoblastic or bone-building activity.
Ex.
-Carrying out ADLs
-independently performing ROM exercises
-swimming, walking, jogging, and bicycling
Isometric exercise
Involves muscle contraction without shortening (i.e., there is no movement or only minimum shortening of muscle fibers).
Potential benefits are increased muscle mass, tone, strength, increased circulation to the exercise body part, and increased osteoblastic activity.
Contractions of quadriceps and gluteal muscles, such as occur when holding a yoga position.
Isokinetic exercise
Involves muscle contractions with resistance. The resistance is provided by a constant rate by an external device that has a capacity for variable resistance.
Ex.
Rehabilitative exercises for knee and elbow increase and lifting weights.
A continuous passive motion CPM, a device used postoperatively after joint surgery (knee replacement anterior cruciate ligament repair)
FOCUSED ASSESSMENT
daily activity level
Describe the activities you normally carry out during a routine day and types of physical exercise that are part of your daily lifestyle.
-ADLs
-type, frequency, duration of physical exercise
-past history of activity and exercise; recent changes
FOCUSED ASSESSMENT
endurance
Describe how much and what type of activity makes you tired.
History of business, dyspnea, frequent pauses in activity to rest, pounding heart, or marked increase in respiratory rate after moderate activity
FOCUSED ASSESSMENT
exercise/ fitness goals
What exercise are fitness goals are you currently working on?
-Attitudes about exercise and physical fitness
-Knowledge of the benefits of exercise
-Motivation to exercise
FOCUSED ASSESSMENT
mobility problems
Do you experience any problems with movement or with more vigorous activity or exercise? If yes, please describe these problems.
-Nature of problem including symptoms
-Onset of disturbance and frequency
-Known causes
-Effect of problem on everyday function
-Interventions attempted and results
FOCUSED ASSESMENT
physical or mental health alterations
Are there any physical or mental health problems that may be affecting your Mobility?
-Decrease of strength or endurance (e.g., MI, CHF, COPD, Cancer, GI disorders)
-Neuromuscular impairment (MS, Parkinson’s disease, spinal injuries)
-Musculoskeletal impairment (arthritis, fractures, muscular dystrophy)
-Perceptual or cognitive impairment (CVA, brain tumor or trauma, vision disorders, dementia)
-Pain or discomfort (Burns, RA, chronic pain syndrome, postoperative pain)
-Depression or severe anxiety (neurosis, schizophrenia)
FOCUSED ASSESMENT
external factors affecting mobility
Is there anything else you can think of that limits your ability to get around?
-Environmental factors ( stairs, lack of railings are other assistive devices, poor lighting, unsafe neighborhood)
-Financial Resources
safe patient handling and movement techniques and equipment when positioning, moving, lifting, and ambulating patients.
Safe patient handling and transfers involve the use of patient assessment criteria, algorithms for patient handling decisions, and proper use of patient handling equipment. Keep the patient in good body alignment and protect the patient from injury while being moved.
Equipment for safe patient transfer:
Gait belt
Stand-assist and repositioning AIDS
Lateral assistive devices
Mechanical lateral assistive devices
Transfer chairs
Power stand-assist and repositioning list
Powered full body lifts
Trapeze bar
LOOK UP OLDER ADULT TABELS
SELF KNOWLEDGE
Who am I?
Global self: is a term used to describe the composite of all the basic facts, qualities, traits, images, and feelings people hold about themselves.
A person’s self knowledge includes:
-Basic facts (sex, age, race, occupation, cultural background, sexual orientation)
-The person’s position within social groups
-Qualities or traits that describe typical behaviors, feelings, moods, or other characteristics (e.g. generous, hot-headed, ambitious, intelligent, sexy)
SELF EXPECTATIONS
Who or what do I want to be?
The ideal self constitutes the ideal self one wants to be, and develops early in childhood
A false self may develop in people who have an emotional need to respond to the needs and ambitions significant people, such as parents, have for them
SELF EVALUATION
How well do I like myself?
Self esteem is the evaluative and affective component of the self concept
Sometimes termed: self-respect, self-approval, or self-worth
2 subsets of self esteem need
Self esteem needs: strength, achievement, mastery and competence, confidence, independence, and freedom
Self respect needs (need for esteem from others): status, dominance, recognition, attention, importance, and appreciation
4 bases of self esteem:
Significance:
the way people feel they are loved and approved by the people important to them
Competence:
the way tasks that are considered important are performed
Virtue:
The attainment of moral-ethical standards
Power:
The extent to which people influence their own or others lives
Positive self concept
People with positive self concept usually have greater self knowledge, more realistic perceptions and expectations, and a higher evaluation of themselves or higher self esteem
Negative self concept
People with negative self concept tend to exhibit poorer self knowledge, less realistic perceptions and expectations and lower self esteem
People with deficient self concept may lack motivation to learn self-care behaviors in response to illness, injury, or trauma.
The experience of aging, illness diagnostic testing, and treatment can severely threaten a person’s self concept
Nursing efforts aimed at teaching new health behaviors may fail until the patient values him or herself enough to want to invest energy in self-care.
