Week 1 Flashcards
You can never delegate a take that the RN must EAT, what does EAT stand for?
Evaluate, assess, teach
what is a primary, independent nursing responsibility?
Health education
Tips for educating elderly patients:
Treat as they are capable of learning include in setting goals ID and accomodate any disability Gear rate of teaching to person's disability Break into small parts
Guideslines for developing patient education materials:
- visuals
- 3-5 grade level
- short and concise
- key points or must know bullets
- explain measurements
- clearly ID when to call doctor
- plan language
- teach back
- find advocate for someone with low literacy to ensure compliance
Chronic illness:
persistent and recurring health problems, non-self limiting, duration of months and years or forever
Trajectory model of chronic illness:
- pretrajectory
- trajectory onset
- stable
- unstable
- acute
- crisis
- comback
- downward
- dying
Palliative care
Relieve suffering; initiate at any time through patient care; encourage physical support
Hospice is the same BUT is only utilized when the patient is told they have less than 6 months to live
Goal setting in palliative care → comfort vs. aggressive disease focused treatment
hospice care
End of life
Focus: QOL
Eligibility criteria
Services covered by CMS
Pre-death what should patient expect and what should nurse do
The dying person needs to know what is happening and talked about its reality
be allowed to experience the pain of a feeling bad instead of hiding their feelings
participate in decision-making regarding how they will spend their final days
nurse primary responsibility is to develop a relationship with the dying person
Death
primary responsibility is to anticipate problems such as distressing symptoms or family disruptions before they interfere with a dying person’s wishes
Bereavement
Time after death, nurse should be in position to listen
Ethical decision making in end of life care
nurses must educate patients about possibilities and probabilities regarding their illness and live with the illness
Advanced directives
durable power of attorney for health care
Living Will
Symptom management for end-of-life care
physical, psychological, social, spiritual
Pain should be treated; even as death approaches those receiving pain medication should continue as the level of Consciousness changes. even if the patient is unresponsive pain medication should be continued
Anorexia is expected at the end of life; can use appetite stimulants; not important to make sure the dying person is eating if they do not want to eat. educate the family that this is a normal part of the dying process
Cachexia
muscle waisting
Measures to manage anorexia in dying patient
Utilize anti-emetics Encourage to each when effects of meds subside modify environment to eliminate odors remove items that may decrease appetite manage anxiety and depression position to enhace gastric emptying assess bowels oral care ensure dentures fit treat pain
Changes in consciousness and delirium in dying patient:
Hypo/hyper active; can treat with benzo’s like ativan; focus on cause
teach family, ensure safety, monitor medications, confusion May mask needs and fears about dying, acknowledge family concern
Dyspnea – end of life
treatment varies; subjective and objective should be treated, assess, intervene if needed
Secretions in end of life
Related to oropharyngeal relaxation and diminished awareness
suctioning generally does not help
repositioning is most helpful
Oral Care
Atropine (SL/IV/SQ/IM) reduces production of oral secretions
Glycopyrrolate (PO/rectal/SL)
Scopolamine patch
Palliative sedation at end of life
Used for people close to death who are not responding to conventional treatment
Goal: reduce symptoms
This is different from euthanasia or PAS as this is to cause death (nurses in iowa can not do this)
Nursing care of patients and families in final hours of life
Expected physiological changes
a. s/s of near death, focus on patient, pt. will sleep longer, encourage family to continue to speak to client
After death care
body becomes dusky, blood pools, skin waxy
Describe grief mourning and bereavement
Grief is a person’s feelings that accompany an anticipated or actual loss
mourning refers to expressions of grief
Bereavement is the period of time that the mourning takes place
Anatomy of skin: Epidermis
Keratin (live, continuously dividing cells)
Melanocytes (pigment)
Merkel cells (transmit stimuli to the axon through a chemical synapse
Langerhans cells (play a big role in cutaneous immune system reactions)
Rete ridges (hold epidermis and dermis together and permits the free exchange of essential nutrients between two layers)
Anatomy of skin: Dermis
Strength and structure in the form of collagen and elastic fibers
Anatomy of skin: hypodermis
subcutaneus
What are the 3 types of sweat glands
Eccrine: all areas of skin
Apocrine: larger glands and eccrine found in axilla, anus, scrotum and labia majora
Sebaceous glands: sebum on to the space between the hair follice and hair shaft
piloerection
tiny hairs standing related to chill or fear
Hirsutism
abnormal hair growth related to endocrine issue; Cushing increase hair growth; hypothyroidism causes a change in hair texture
Alopecia
General loss caused from chemotherapy, radiation, or immune disorders
petechiae
pinpoint spots from blood leaking into skin
Striae
stetch marks or Cushing’s syndrom sign
What may brown/tan spots indicate on the skin
endocrine (adrenal) function
What should nurse assess for rash
border, size, shape, primary/secondary condition, pruritus
What should nurse assess for lesions
Color, redness/pain/swelling, size, location, pattern of eruption (macule, papular, scaling, oozing, discreet, confluent), distribution, wound bed, edges, size, surrounding skin, vascularity, hydration (turgor)
What is the first thing nurse should assess when assessing lesions
vascularity (capillary refill around border)
Primary vs. secondary lesion
What you have (macule, papule, nodule, wheal, pustule, cyst)
Characteristic of the primary; what is on top or within that lesion (erosion, ulcer, fissure, scales, crust, scar, keloid, atrophy, lichenification)
What are macules, papules, nodules, vesicles, wheals, pustules, cyst
macule = patch papule = plaque nodule = tumor vesicle = bulla wheal = evanescent rounded or flat-topped elevation in the skin that is edematous, and often erythematous pustule = containing pus cyst = sac-like pocket of membranous tissue that contains fluid, air, or other substances
Examples of topical medications
Lotion, powder, cream and emulsions, gels, pastes, ointments, sprays and aerosols, corticosteroids, intralesional therapy, systemic medications
It is important for the nurse to consider that penetration of a topical steroid depends on the Skins site, which varies based upon the denseness of the stratum corneum, blood supply and tissue Integrity of the involved area. penetration of topical steroids applied to the eyelids or scrotum is 4 times greater for the forehead and 36 times greater than the palms and Soles. stop Center in less intact skin has a higher absorption and poses a higher risk for side effects
It is important to know what you are putting on a patient’s skin because some topical medications are debriders and they will eat away at the wound; if it is put on the healthy skin it will also eat away at the healthy skin
How can nurses care for wounds
- Dressings
Primary dressings are usually considered passive and provide protection to the wound, whereas interactive dressings create a moist wound environment and interact with the wound bed components to further enhance wound healing. interactive dressings May reduce colonization count, reduce the level of exudate, improve wound bad moisture retention, improve wound collagen Matrix, remove cellular products, or provide protection for the epithelialing bed - Debridement (getting rid of slough and dead tissue)
- Negative pressure wound therapy (wound vac → suction to wound → gets rid of slough and sucks up vascular delivery which increases O2 to that area
- Hyperbaric oxygen therapy (increasing O2 to that wound so it can heal)
- Pharmacological therapy
Braden scale
Assessment toolTo determine the risk a patient has for developing pressure ulcers
measures sensory perception, moisture, activity, mobility and friction / shear
should be completed on every patient you take care of
the lower the score the higher the problem / risk for ulcers
Describe the stating of ulcers
Stage 1: Non blanchable redness; no break in thermos when you push on skin it does not turn white
Stage 2: break in dermis (just the first layer); blister
Stage 3: subcutaneous fat
Stage 4: ligament, tendon, bone
unstageable: covered in eschar or slough; You cannot see under this which means you can’t see how deep the wound goes which means you can’t stage it; requires debridement
Staging of pressure ulcer is dependent on what?
tissues exposed, not depth
How do pressure ulcers heal?
secondary intention → they granulate (heal) from the inside out and create a large scar
Seborrheic Dermatitis
Excessive production of sebum
topical steroids can heal this
may develop secondary candidiasis and require topical anti-fungal
anti-dandruff shampoo (zinc-based)
Herpes Zoster
Viral infection
a. shingles
b. pain management (post herpatic neuralgia)
c. Eyes or close to eye/ ear is emergency (blind or deaf)
d. Common in older people
Tinea
Viral skin infection
Ringworm, corporis (body), cruris (groin), pedis (foot), ungulum (nails)
Scabies
Viral skin infection Infestation of skin by mite Usually found in unstandard conditions Long term care facilities at risk Warm bath and prescribed lotions Burrow under skin and track mark you see is feces Ammonia based cream
Contact dermatitis
Viral skin infection
- Epidermis is damaged by repeated physical and chemical irritation
- Non allergen or allergen causing
- Management → avoid trigger, non-fragrant soaps, avoid topical lotions unless prescriber given
- Usually allergic reaction to whatever caused it
Psoriasis
Non-infectious inflammatory dermatitis
a. chronic non inflammatory disease
b. overproduction of keratin
c. current research supports immune
d. silver scales called plaque
e. arthritis or erythrodermic psoriasis
f. topical or systemic treatment
g. Non-contagious
Exfoliative dermatitis
Non-infectious inflammatory dermatitis
- progressive inflammation with erythema and shedding up the skin
Pemphigus
Blistering disorder
a. Autoimmune illness involving IgG
b. high-dose corticosteroids and or plasmapheresis
Bullous pemphogoid
Blistering disorder
- acquired disease of flaccid blisters
- Corticosteroids
- common in elderly
- risk for sepsis and F&E imbalance
Toxic epidermal necrolysis & Steven Johnson syndrome
Blistering disorder
a. potentially fatal triggered by a medication reaction
b. immunocompromised our most highly affected
c. treatment aimed at F&E, prevent sepsis and
d. ophthalmic complication
e. Skin peels off
Cysts
Benign skin lesion
contains fluid or solid material
Seborrheic keratosis
beneign skin lesion
wart-lie lesions, light tan to black in color
Actinic Keratosis
Benign skin lesion
a. premalignant; similar to seborrheic keratosis
Verrucae
benign skin lesion
warts - infection by HPV
Angioma
Benign skin lesion
a. benign vascular tumor of the skin; read and look like spider; vascular tumor but not can
Pigmentsed nevi
Benign skin lesion
moles - monitor for changing colors or a regular borders; should be removed related to malignancy risk
Keloids
Benign skin lesion
a. overgrowth of fibrous tissue at the sight of Scar or trauma
b. African-Americans are more prone to this
c. can be removed from surgery
Assessing moles ABCDE
asymmetry border (irregular is bad) color (variegated) diameter elevation, enlargement, evolution
Basal cell
Malignant skin tumor
a. face
b. waxy nodule, may have vessel visible, make row and crust
Squamous cell
Malignant skin tumor
a. arises from epidermis
b. metastesizes into blood and lymphatics
c. need to get rid of lesion with surgery
Malignant melanoma
Malignant skin tumor
a. atypical melanocytes are present in the epidermis and the dermis; maybe present in subcutaneous cells
b. curable if caught early
c. superficial spreading melanoma
d. lentigo maligna melanoma
e. nodular melanoma
f. Acrall lentiginous melanoma
Medical management of melanoma
depends on depth and invasion of lesion
skin grafting, Sentinel node, does metastasize to organs, 3% of all cancer deaths
kaposi sarcoma
malignancy of cells that line the small blood vessels
–> skin, oral cavity, GI tract, and lungs
Immunosuppressed (organ transplant AIDS) → opportunistic cancer
