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Assessment: deliberate systematic collection of data to determine current and past health
status, including patient’s ability to function and cope. Identification actual or
potential health problems, needed to formulate a nursing diagnosis. Collection and
verification of data
Data Collection:
Subjective data: Information given directly from the patient ( i.e. pts perception
understanding and interpretation of what is happening.
Methods of collection: Health Hx, Interviewing using open ended questioning, Physical exam,
vital signs, diagnostic testing
Purpose
Health Hx
Nursing Dx and care plan
Mange patient problems
Evaluate nursing care
Steps: Collection and verification of data from primary source and secondary
source the analysis of all data as a basis for developing a nursing diagnosis
identifying collaborative problems and developing a plan if pt centered care.
Critical thinking:
Decision making steps
- Interpret & analyze data
- cluster findings
- Group signs
- Group behaviors
Outcomes:
S: specific
M: measurable
A: Attainable
R: Realistic
T: Timed
Focus on the set outcomes and goals, continuous assessment of outcomes and goals
Documentation: DAR
D: Data
A: Action (intervention)
R: Response (pt’s response to interventions)
Ethics in Nursing
Preventative ethics:
Advance directives: decisions made by competent individual about their future health care
Living Will: Identifies treatments a person wants or does not want or wants should he or
she become unable to make their own decisions – enforceable by law
Durable power of attorney for health care: A person legally designated to make health care
decisions for an individual who is no longer able to make decisions for themselves
Infection control:
Infective agent
Reservoir
Portal of exit
Means of transmission
Portal of entry
Susceptible host
Inflammation:
Vascular and cellular response
Inflammatory exudate
Tissue repair
Inflammatory response:
Always present with infection
Causes: Heat, Radiation, Trauma, Allergens, Infection
Local response: redness, heat, pain, swelling, loss of infection
Clinical Manifestations: Increased WBC, malaise, Nausea, anorexia, increased pulse,
and respiration, fever
HAIs
Factors:
Rate of contact: # of times a person comes in contact with health care worker
Invasive procedures
Therapy
Length of stay
MRSA:
death caused by sepsis
Occurs from: skin-skin, contact with personal items, contact with infected surface
Risk Factors: immunocompromised, invasive procedures, carrier
Risk factors:
Antibiotic exposure
GI surgery
Immunocompromised
Potential complications
Hypovolemia
Renal failure
Peritonitis: bowel perforation, toxic megacolon
Death
Infection Prevention:
Chain of infection
Asepsis:
Hand hygiene
Standard precautions
Disinfect & Sterilize
Patient education:
Hand hygiene
Personal care products
Cough etiquette
Hygiene
Peri-care
Wound Care:
Prevent and manage infection
Cleanse wound
Removable nonviable tissue
Manage exudate
Maintain the wound in a moist environment
Protect the wound
Pressure ulcers : localized area of tissue necrosis caused by unrelieved pressure that
occludes blood flow to the tissue
Influencing factors
Amount of pressure: if pressure is greater on capillary than normal capillary
pressure it will collapse
- ⇑pressure ⇒ occluded blood vessel ⇒ tissue ischemia ⇒ Tissue death
Length of time pressure is exerted
Ability of tissue to tolerate externally applied pressure
Contributing Factors
Shearing force: pressure exerted on the skin when it adheres to the bed and the skin
layers slide in the direction of body movement
Friction
Excessive Moisture
Possible complication:
Recurrence
Cellulitis
Chronic infection
Osteomylitis
Assessment:
Stage
Percentage
Color
Measurement
Exudate: amount, color, consistency, odor
Surrounding skin condition
Treatment:
Document : size, stage, location, exudate, infection, pain, and tissue appearance
Keep ulcer bed moist
Cleanse with nontoxic solutions
Debride
Use adhesive membrane, ointment, or wound dressing
Good nutrition
Self care and signs of breakdown
Initiate specialty services if needed
Musculoskeletal
Risk Factors
Female
Increased aging
Family Hx
White or Asian
Small structure
Early menopause
Excess alcohol intake
Cigarette smoking
Anorexia
Oophorectomy
Sedentary lifestyle
Insufficient calcium intake
Low testosterone levels in men
Diagnostics
Hx and physical
Bone mineral density
Change in height is # 1 indicator
Osteopenia is more than normal bone loss but not yet at the level of osteoporosis
Supplement Vitamin D
Delirium: State of temporary but acute mental confusion, common in older adults who have a
short term illness
Early manifestations
Inability to concentrate
Irritability
Insomnia
Loss of appetite
Restlessness
Confusion
Later Manifestations
Agitation
Misperception
Misinterpretation
Hallucinations
Dementia:
Can manifestations ….
Personality changes
Behavioral problems: agitation, delusions, hallucinations
Age is most important risk factor, family Hx, more common in women
Late stages
Long-term memory loss
Unable to communicate
Can’t perform ADLs
Pt may become unresponsive, incontinent, and require total care
Diagnostics
Dx of exclusion
Comprehensive Pt evaluation
Brain imaging
Definitive dx can only be made at autopsy
SLEEP
Purpose of sleep
Remains unclear
Physiological and psychological
Maintenance of biological function
Dreams
Occur in NREM and REM
Important for learning, memory, and adaptive to stress
Rest contributes
Mental relaxation
Freedom from anxiety
State of mental, physical and spiritual activity
Sensory
Cataract: cloudy or opaque lens interferes with passage of light causing glare or blurred
vision, 3rd leading cause of blindness
Senile cataract
Most common
Altered metabolic processes cause
- accumulation of water
- Altered lens fiber structure
Clinical Manifestations
Decreased vision
Abnormal color perception
Glaring of vision
Diagnostic studies
Past medical Hx
Physical examination
Visual acuity
Ophthalmosocy
Slit lamp microscopy
Glare Testing
Glaucoma
A group of disorders characterized by
Increased IOP against optic nerve
Optic nerve atrophy
Peripheral visual field loss
Balance between aqueous production and reabsorption needed for normal level of IOP
Communication
Verbal Communication
Nonverbal communication
Body language
Voice quality
Manner, directness, and sincerity
Dress and attire
Visual aids
Personal space
Eye contact
Emotional content
Setting time place
Rhythm and pacing
Attitude and confidence
Agenda
Silence
Therapeutic communication
Active listening
Sharing observations
Sharing empathy
Sharing feelings
Using touch
Using silence
Providing information
Clarifying
Focusing
Paraphrasing
Asking questions
Summarizing self-disclosure
Confrontation
Nontherapeutic communication
Asking personal questions
Giving personal opinions
Changing the subject
Automatic responses
False reassurances
Sympathy
Asking for explanations
Approval or disapproval
Defensive responses
Arguing
Respiratory
Physiology of Respiration
Ventilation
Compliance
Diffusion
Oxygen-hemoglobin dissociation
Atrial blood gases
Mixed venous blood gases
Oximetry (finger, nose, toes)
Oxygen delivery
Control of respirations
Chemoreceptors
- central: respond to co2 increase
- Peripheral: respond to decrease O2 levels
Pneumonia: Acute inflammation of the lungs caused by microbial organism, leading cause
of death in the US from infectious disease
Etiology:
Likely results when defense mechanisms become incompetent or overwhelmed
Mucociliary mechanism impairment
Alteration of leukocytes from malnutrition
Immunosuppression from other disease processes
Three ways organisms can reach the lungs: Aspiration, inhalation, and hematogenous
spread
Types of pneumonia:
Community-Acquired Pneumonia: is defined as a lower respiratory tract infection of
the lung parenchyma with onset in the community or during the first 2 days of
hospitalization
Hospital-Acquired pneumonia: occurs after the first 48 hours of admission and not
incubated at the time of hospitalization
Cardiovascular system
The right ventricle loses it’s ability to contract, causing blood to back up into
the body, causing congestion. Blood backs up into the liver, the gastrointestinal tract,
and extremities. the right ventricle becomes to damaged and is unable to pump blood
efficiently to the lungs and left ventricle.
The left side of the heart receives oxygenated blood from the lungs and pumps it
into systemic circulation. As the ability to pump blood out of the left ventricle is
decreased, the body does not receive enough oxygen, causing fatigue. the pressure in the
veins of the lung increases causing fluid accumulation in the lungs. Resulting in
shortness of breath and pulmonary edema.
Alcohol abuse
MI
Cardiac infection
Hypertension
Hypothyroidism
Leaking/narrowing valves
Clinical Manifestations
Abnormal heart sounds (murmur)
Abnormal lung sounds
Edema
Distended neck veins
Hypotrophy of liver
Dysrhythmias
Weight gain
Hypervolemia: fluid volume excess: compromised regulatory mechanism, such as renal failure,
heart failure, cirrhosis, over consumption of sodium containing fluids, fluid shift
(treatment of burns), prolonged corticosteroid treatment, sever stress, and
hyperaldosteronism contribute to fluid volume excess.
Excess: Hypernatremia
Thirst
CNS deterioration
Increased interstitial fluid
Elevated body temp
Swollen dry tongue and sticky mucus membrane
Hallucinations
Lethargy
Restlessness
Irritability
Seizures
Pulmonary edema
⇑ BP
⇑ pulse
Deficit: Hyponatremia
CNS deterioration
Excess: hyperkalemia
V-fib
ECG changes
CNS changes
Deficit: hypokalemia
Bradycardia
ECG changes
CNS changes
Diabetes
Glucose: energy
Two sources:
Food: absorbed into bloodstream, insulin assists glucose into tissues and cells
Liver: Stores glucose as glycogen and releases it when blood glucose levels are
low (gluconeogensis)
Type 1 Diabetes
Risk factors:
Unknown
Family Hx
Type 2 Diabetes
Risk Factors:
Weight: high amounts of fatty tissue causes insulin resistance
Inactivity: Increased weight, exercise uses up glucose, making tissue and cells
insulin sensitive
Family Hx
Race: African American, Hispanic, Native American, Asians
Age: >45yo
Gestational Diabetes
Polycystic ovarian syndrome
HTN
High LDL/HDL
Diabetes PCs
Acute complications
- diabetic ketoacidosis
- Hyperosmolar hyperglycemic syndrome
- Hyperglycemia
- Hypoglycemia <70 can be fatal because brain needs glucose to function
Chronic complications
- CVD: Atherosclerosis, PVD, cerebrovascular, HTN, dyslipidemia
- Retinopathy: can lead to blindness, also at risk for cataracts and glaucoma
- Neuropathy
- LE complications related to decreased sensation
- Integumentary complications
- Infection
Urinary
24 hour urine specimen collection: Always through away the first urine because you need to
start with an empty bladder, at the end of 24 hours instruct patient to urinate, unsure
that serum creatinine is determined during 24 hour period. keep collected specimen on ice
or refrigerated, 24 hr urine is collected to check clearance of creatinine by the kidneys,
given an estimate of the GFR, Creatinine is a waste product of protein breakdown, primarily
body muscle mass, 12-24 hour urine test may also be done to test for protein in urine, it
is more accurate then dipstick, persistent proteinuria usually indicates Glomeruli renal
disease.
Urinary retention: the inability to empty the bladder completely despite micturition or the
accumulation of urine in the bladder because of inability to urinate. Can be associated
with urinary leakage or post void dribbling, called overflow urinary incontinence.
Acute urinary retention: the complete inability to pass urine via micturition, medical
emergency
Chronic urinary retention: incomplete bladder emptying despite urination.
Normal postvoid residual volume 50-75ml a finding of over 100ml indicates the need to
repeat measurement
Urinary retention is caused by two different dysfunctions of the urinary system: bladder
outlet obstruction and deficient detrusor contraction strength. Obstruction leads to
urinary retention when the blockage is sufficiently severe so that the bladder can no
longer evacuate its contents despite detrusor contraction. Common cause enlarged prostate.
Deficient detrusor contraction strength leads to urinary retention when the muscle strength
is no longer able to contract with enough force or for a sufficient period of time to
completely empty the bladder. Common causes of deficient detrusor contraction strength are
neurological diseases affecting sacral segment 2,3, and 4; long standing DM, over
distention, chronic alcoholism and drugs.
Most common bacterial infection in women, Pregnant women are at increased risk. E. coli
most common cause, primarily in women. There are also fungal and parasitic infections but
they are less common
Classification:
Upper urinary tract infection: involves renal parenchyma, pelvis, ureters, typically causes
fever, chills, and flank pain
Lower urinary tract infection: confined to lower urinary tract and usually has no
systematic manifestation
Urosepsis: UTI that has spread into systemic circulation, a life threatening condition.
Uncomplicated: are infections that occur in otherwise normal urinary tract usually only
involves the bladder
Complicated: are the infections that coexist with obstruction, stones, catheters, diabetes,
neurological disease, pregnancy-induced changes, or an infection that is recurrent.
Patients with complicated UTI’s are at risk for Pyelonephritis, renal damage, and urosepsis
UTI’s can also be classified by their natural history, for example initial infection,
secondary infection, or recurrent
Before menopause , glycogen rich epithelial cells and normal flora keep the vaginal pH
acidic (3.5-4.5). In postmenopausal women, lower estrogen levels cause vaginal atrophy, a
decrease and lactobacillus, and a increase in vaginal pH, increasing the risks for a UTI.
Treatment giving women low dose estrogen replacement to acidify the vagina
After seven days on antibiotic therapy pcp my order a repeat UA to check for nitrates to
make sure UTI has been completely eliminated
Urinary Incontinence : an under diagnosed and underreported problem that can significantly
impact the quality of life and decrease independence, and my lead to compromise of the
upper urinary tract. Causes may include cognitive decline, medication and underlying
physical conditions, including UTI and urinary retention
Types:
Stress Incontinence: Most common type, when combined with urge incontinence is
referred to as mixed incontinence, may be caused by poor pelvic muscle strength
leading to possible leakage when laughing, sneezing, coughing. Education on kegal
exercises.
Urge Incontinence: over active bladder is common cause
Reflux Incontinence: leakage with out warning may be caused by neuro defect
Overflow Incontinence: caused by full bladder, possible in ability to urinate,
distention
Functional Incontinence: is caused by loss of cognitive function, environment,
Latrogenic: is an unknown cause
Mixed Incontinence: combination of Stress and Urge incontinence
Problems with fecal incontinence may signal neurological causes for bladder problems
because of shared nerve pathway. Constipation and impaction can partially obstruct the
urethra, causing inadequate bladder emptying, overflow incontinence and infection.
Fecal incontinence:
Occurs with
Motor and sensory dysfunction
Weakness or disruption of anal sphincters
Nerve Damage
Trauma
Constipation:
Causes:
Insufficient dietary fiber
Inadequate fluid intake
Decreased physical activity
Ignoring the urge to defecate
Medications
Neuro dysfunction
Emotions
Bowel obstruction
When stress overwhelms a person’s existing coping mechanisms, disequilibrium occurs, and a
crisis results. If symptoms of stress persist beyond the duration of the stressor, the
person has experiences a trauma
Interrelationship of
Nervous system:
Cerebral cortex: evaluates and plans course of action, theses functions
are involved in the perception of a stressor
Limbic system: mediator of emotions and behavior. When stimulated
emotions, behaviors, and feelings can occur to ensure survival and self-
preservation.
Reticular formation: contains RAS, which sends impulses contributing to
the alertness to the limbic system and cerebral cortex. When stimulated
the RAS increases its output of impulses leading to wakefulness,
overstimulation due to stress can lead to sleep disturbances.
Hypothalamus / Pituitary: fight or flight, stimulated by limbic system,
secretes neuropeptides that regulate the release of hormones by thee
anterior pituitary , is central to the connection between the nervous
system and endocrine system in response to stress.
Endocrine System:
SNS stimulates the adrenal cortex to release epinephrine and
norepinephrine (catecholamines) , which prepare the body for fight or
flight, Endorphins have an analgesic-like effects and blunt pain
perception during stress situations involving painful stimuli,
Corticosteroids are essential for the stress response, they produce a
number of physiological responses including increased blood glucose,
potentiating the actions of catecholamines on blood vessels, and
inhibiting inflammation response. Corticosteroids play an important role
in turning off the stress response , which if left uncontrolled can
become self-destructive.
Immune system:
Brain is connected to the immune system by neuroanatomic and
neuroendocrine pathways, stressors have the potential to lead to
alterations in immune system function. Both acute and chronic stress can
affect immune function, including decreased number and function of
natural killer cells. Chronic stress induces immunosuppression
Medulla oblongata: Controls heart rate, blood pressure, and respirations. Heart
rate increases in response to impulses from sympathetic
fibers and decreases with impulses from parasympathetic fibers
Reticular formation: Small cluster of neurons in the brain stem and spinal
cord, continuously monitors the physiological status of
the body through connections with sensory and motor tracts
General adaptation Syndrome: When the body encounters a physical demand the pituitary
initiates GAS
Phases of GAS
Alarm - Be Flight or Fight Ready The hypothalamus, adrenal and pituitary glands release
additional hormones into the bloodstream in order for the body to be prepared for action.
Breathing may become rapid and shallow, the liver releases additional glucose into the
blood for energy and your heart rate may rise. The body can activate the alarm stage many
times throughout the day in response to stressful situations.
Exhaustion- Weakening of the Immune System This is the body’s response to continued long
term stress. During the exhaustion stage, the body’s immune system may become
weakened or there may be damage or disease to other internal organs. During
exhaustion there is potential for an individual to experience physical illness as the
immune system breaks down. When stress is excessive or prolonged, physiologic
responses can be maladaptive and lead to harm and disease
Pain
Transduction: Noxious stimuli causes cell damage with the release of sensitizing chemicals,
these substances activate noiciceptors and lead to generation of action potential
Transmission: Action potential continues from site of injury to spinal cord ⇒ brainstem and
thalamus ⇒ thalamus to cortex for processing
Perception: Conscious experience of pain
Modulation: neurons originating in the brainstem descend to the spinal cord and release
substances that inhibit nociceptive impulses
Acute/transient pain
Sudden onset
Less then 3 months or time for normal healing to occur
Mild to sever
Generally can ID a precipitating event or illness
Course of pain decreases over time and goes away as recovery occurs
Can progress to chromic pain
Clinical manifestations: ⇑HR,⇑RR,⇑BP, diaphoresis, anxiety, agitation,
confusion, urinary retention
Chronic Pain
Gradual onset
> 3 months
Does not go away
Treatment goals include: control to the extent possible, enhancing function and
quality of life
Radiating pain: sensation of pain extending from initial site of injury to another part of
the body, pain feels as though it travels down or along body part
Legal
Quasi-intentional tort:
Deformation of character: intentionally harmful
slander (spoken)
Libel (written)
Invasion of privacy
Breach of confidentiality: privileged communication DR. Lawyer, priest
Unintentional Tort:
Negligence: failure to act as a reasonable person would
Malpractice: Professional negligence
1.Adequate Disclosure
Adequate disclosure of the Dx
Nature and purpose of the proposed treatment
Risks and consequences
Probability of success
Availability of alternative treatment
Physical Manifestations: Occurs when all vital organs cease to function: irreversible
cessation of circulatory and respiratory function or all functions of the brain
DNR/DNI require physician’s orders and must be renewed, Transport DNI/DNR is separate
Hospice: six months from death, two admission criteria ( pt wants service, 6mths or less to
live)