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MCD I Final Exam Concept Guide Module 1- Hygiene chapter 37 Benefits of Bathing: • Bathe clients to cleanse body, stimulate circulation, provide relaxation, and enhance healing. • Bathe cl... ients whose health problems have exhausted them or limited their mobility • Give a complete bath to clients who can tolerate it and whose hygiene needs warrant it. • Allow rest periods for clients who become tired. • Partial baths are useful when clients cannot tolerate a complete bath, need cleaning of odorous or uncomfortable areas, and can perform part of the bath independently. □ Therapeutic baths are used to promote comfort and provide treatment. Giving a Bed Bath:  Collect supplies, provide privacy, explain procedure, apply gloves.  Lock wheels on the hospital bed and adjust the height to a comfortable working position.  Place a blanket over the client and remove gown.  Obtain warm bath water. Start by washing clients face first & allow client to perform this if able.  Perform the bath systematically by starting with the client’s trunk and upper extremities and continuing to the lower extremities. Keep clean area covered with a blanket or towel.  Wash with long, firm strokes from distal to proximal and light strokes over lower extremities for clients who have a history of deep vein thrombosis.  Apply a lotion and powder (If needed) and a clean gown.  Replace water if he becomes cool and use fresh water for perineal care.  Document skin assessment, type of bath, and the client’s response. • FOOT CARE: prevents skin breakdown, pain, and infection. It is extremely important for clients who have diabetes mellitus, peripheral vascular disease, or immunosuppression to evaluate the feet and prevent injury. a qualified professional must perform it. o Inspect the feet daily, paying specific attention to the area between the toes o Use lukewarm water, and dry the feet thoroughly o Apply moisturizer to the feet, but avoid applying it between the toes o Avoid over the counter products that contain alcohol or other strong chemicals o Wear clean cotton socks daily o Check shoes for any objects, rough seams, or edges that can cause injury o Cut the nail straight across, and use an emery board to file nail edges o Avoid self-treating corns or calluses o Wear comfortable shoes that does not restrict circulation o Contact the provider if any indications of infection or inflammation appear Chapter 38--- sleep and rest • Adequate amounts of sleep and rest promote health. Too little sleep leads to an inability to concentrate, poor judgement, moodiness, irritability, and increased risk for accidents. Chronic sleep loss can increase risks of obesity, depression, hypertension, diabetes mellitus, heart attack, and stroke. Non-rapid Eye Movement (NREM): Muscles begin to relax, light sleep, etc. Rapid Eye Movement (REM): Vivid dreaming, about 90 mins after falling asleep, reoccurring. • Ask about sleep patterns, history, or any recent changes. Client education: Establish a bedtime routine, exercise regularly 2 hours before bedtime, make sleep environment comfortable, limit alcohol, caffeine, and nicotine at least 4 hours before bedtime, limit fluids, and relax. Narcolepsy: sudden attacks of sleep that are often uncontrollable. Often happens at inappropriate times and increases the risk for injury. Chapter 39 Nutrition and oral hygiene. ASSESSMENT: Dietary should include: number of meals per day, fluid intake, food preferences, amounts, food preparation, purchasing practices, access, history of indigestion, heart burn, gas, allergies, taste, chewing, swallowing, appetite, elimination patterns, medication use, Activity levels, religious, cultural food preferences and restrictions, nutritional screening tools. NURSING INTERVENTIONS: Assist in advancing the diet as the provider prescribes, Instruct clients about the appropriate diet regimen Provide interventions to promote appetite - Good oral hygiene - Favorite food - Minimal environmental odors Educate clients about medications that can affect nutritional intake Assist clients with feeding to promote optimal independence Individualize menu plans according to client’s preferences Chapter 41- pain management Medication: ➢ Non-Opioid analgesics: Example is NSAIDS, treating mild to moderate pain. ➢ Opioid Analgesics: Treating moderate to severe pain, such as postoperative pain. ➢ Adjuvant Analgesics: Help alleviate other manifestations that aggravate pain, treating neuropathic pain. ➢ Patient-Controlled Analgesia: Allows clients to self-administer safe doses of opioids. Acute Pain- protective, temporary, usually self-limiting, has a direct cause and results in tissue healing. Chronic Pain: is NOT protective, ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing. Nociceptive Pain- arises from damage to or inflammation of tissue. Usually throbbing, aching, and localized. Neuropathic Pain- arises from abnormal or damaged pain in nerves. Includes phantom limb pain, pain below level of spinal cord injury, and diabetic neuropathy. a. Cutaneous pain: Arises from burning your skin like on a hot iron or from touching a hot pan on the stove. b. Visceral pain: Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. c. Deep Somatic pain: Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains. d. Radiating pain: Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head. e. Referred pain: Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw. f. Phantom pain: Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb. Unlicensed nurse can: do vitals (for stable/Non critical pt), give bath/document task, walking, moving/ambulating pt, bedside glucose monitoring, assist a nurse with IV insertions and catheters. Incident report: tool for improvement Vitals: temperature 96.4 to 99.5, respiratory rate 12-20, BP 120/80, pulse oximetry (saturation) 94-100, pulse 60-100. Complications of Amputations? • Hematomas, infections, necrosis, contractures, stump pain, phantom sensation, stump edema, bone overgrowth, causalgia, etc. Amputation Pain?: Possibility of Phantom Pain. Vital Signs indicating Post-Surgical Pain? ➢ Elevated Heart Rate ➢ Elevated Blood Pressure ➢ Elevated Respiratory Rate (Breathing) What are Complications of Hip Surgery? Blood clots, infection. Chapter 43- bowel elimination Many factors can alter bowel function. Interventions (surgery, immobility, medications, therapeutic diets) can affect bowel elimination. stools specimen are collected both for screening and for diagnostic tests. Fiber requirement: 25-38 g/day. Fluid requirement: 2 L/day for females, 3 L/day for males from fluid and food sources. Laxatives: Soften stool Cathartics: promote peristalsis Diarrhea: Is a bowel pattern of frequent, loose or liquid stools. Causes include- viral or bacterial gastroenteritis, antibiotic therapy, inflammatory bowel disease, irritable bowel disease. Chapter 44 urinary elimination Complications: Urinary Tract Infection (UTI); Most due to Escherichia Coli. And Incontinence. Risk Factors include: In females, close proximity of the urethral meatus to the anal, frequent sexual intercourse, menopause which decrease estrogen levels, uncircumcised clients, use of indwelling catheters. Manifestations: Urinary frequency, urgency, nocturia, flank pain, hematuria, cloudy, foul-smelling urine, and fever. Nursing Actions: Females wipe front to back, cleanse beneath male foreskin, provide catheter care regularly. More Complications: Skin breakdown (from chronic exposure to urine). Nursing Actions: Keep the skin clean and dry, assess for manifestations of breakdown, apply protective barrier creams (Vaseline), implement a bladder-retraining program, assist with measures of conceal urinary leaking (perineal pads, external catheters, adult incontinence garments). Client Education on Urinary Elimination: Maintain regular bowel movements, try to empty bladder completely with each void, keep incontinence diary, perform Kegel exercises, perform bladder compression techniques, avoid caffeine and alcohol consumption, adverse effects of medications can affect urination, and conduct vaginal cone therapy, WIPE FRONT TO BACK, keep perineum clean (proper cleaning). Drink 2 to 3 L of fluid daily, try to hold urine and stay on schedule for bladder retraining, drink cranberry juice to decrease risk of infection, if obese lose weight, intake meds to help resolve incontinence, get a catheter placed. Verbal and nonverbal communication skills 458 Verbal communication is the use of spoken and written words to send a message. It is influenced by such factors as educational background, culture, language, age, and past experiences. Nonverbal Communication: Sometimes called body language, communicates how someone is feeling and gives a more accurate account of an individual’s true sentiment. Personal Distance is 18 inches to 4 feet. Social Distance is 4 to 12 feet. Public Distance is beyond 12 feet. Therapeutic Relationships: Therapeutic communication occurs in the context of a helping relationship. The helping relationship has four phases: pre-interaction, orientation, working phase, and termination. • Pre-Interaction: Before you meet the client. Gathering data, diagnosis, lab work, gathers information, etc. • Orientation: First contact with patient. Introduce each other. Call pt. by preferred name • Working Phase: the bulk of therapeutic com. Occurs (active part). Start care plan. Work on getting patient to end goal. Maintain personal relationship. Shows respect, expresses concerns. • Termination: End at the nurse shift, discharge of patient, making sure they are following all the correct precautions before leaving. Therapeutic communication: is client centered communication directed to achieve the patients’ goal. Key skills to establish a therapeutic relationship include expressing interest, concern, caring, perception, and provide as well as obtain healthcare information. Therapeutic Key Characteristics: Therapeutic communication is the use of communication skills that results in a positive effect on client care; it is the foundation of professional nursing practice. Ex: Empathy: The desire to understand and be sensitive to the feelings, beliefs, and situation of another person. sharing and understanding how the patient feels. Put yourself in their place Sympathy: Feeling bad for someone. To Enhance Communication: Listen actively, establish trust, be assertive, restate messages, clarify and validate messages, interpret body language, share observations, explore issues, use silence, summarize the conversation, and make use of process recordings while you are learning. Barriers to Communication: Include asking too many questions; asking why; fire- hosing information; changing the subject inappropriately; failing to listen; failing to probe; expressing approval or disapproval; offering advice; providing false reassurance; stereotyping; and using patronizing language. • Communication: Has 2 major components, content and process. • Content: describes the actual subject matter, words, gestures, and substance of the message. It is the message that everyone may hear or see. • Process: refers to the act of sending, receiving, interpreting, and reacting to a message. The communication process has five elements: sender, message, receiver, feedback, and channel • Encoding: process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message • Decoding: refers to the relating the message to your past experiences to determine the sender’s meaning. (visual, auditory, tactile sense to decode). How you interpret the message the sender sent you by relating it to your past experience. Feedback can be verbal, non-verbal or both Chapter 24- safety What factors affect safety: developmental factors and individual risk factors. individual factors also influence a person’s risk for unintentional injury. These include lifestyle, cognitive awareness, sensoriperceptual status, ability to communicate, mobility status, physical and emotional health, and awareness of safety measures Safety: is a basic human need, second only to survival needs. Infant/Toddler Drowning is the leading cause of death for children ages 1 to 4, followed by motor vehicle accidents. Preschooler: Motor vehicle injuries are a major cause of accidental death, along with drowning, fires, and poisoning. Falls are the primary cause of nonfatal injuries. After age 3, children are a little less prone to falls be- cause their gross and fine motor skills, coordination, and balance have improved. School-Age Child Motor vehicles continue to be the leading cause of accidental death in this age group. Falls are the leading cause of nonfatal injuries. Adolescent: The leading cause of death in this age group is motor vehicle accidents, followed by homicide— both frequently associated with alcohol and drug use Motor vehicle is leading cause of death for preschool, school age, and adolescent. Sports and recreational injuries, including diving and drowning incidents are also common, especially when drinking and drug use are involved. Adult: Among people 35 to 64 years old, unintentional poisoning causes more deaths than motor vehicle accidents (CDC, 2010a). Workplace injury may also be a significant concern. Other injuries to adults are related to lifestyle (e.g., excessive alcohol use), stress, careless- ness, abuse, and decline in strength and stamina. Poisoning death rates have more than quadrupled in the past 20 years. 35-64 years old The leading causes of death in the home are poisonings, falls, fires and burns, and choking. Older Adult: Falls are the most common cause of accidental death for adults age 65 and older • Falls: primary cause of non-fatal injuries in preschool and school-age SAFE HAZARDS IN THE HOME: home hazards are fire, chocking, poisoning. o Fires • Home fires are the major cause of death and injuries • Older adults & children < 5y/o have the highest risk. • Most common causes of fires: - Cooking fires (number one cause of home fires and home fire injuries). - Smoking. - Heating Equipment. - Home oxygen administration equipment: 75% of home fires involves oxygen, smoking materials are the ignition source. - Remove the client from the area. o RACE (priority when patient is in fire situation) ▪ Rescue – remove patient from danger. ▪ Alarm – pull the alarm. ▪ Contain - close doors. ▪ Extinguish fire (if possible). o PASS (How to use the fire extinguisher) ▪ Pull the pin. Aim at the base of the fire. Squeeze the handles. Sweep FALLS: third leading cause of injury-related deaths—the leading cause for older adults. More than half of all falls occur in the home, and about 80% of home falls involve people age 65 years and older. Risk for falls include poor vision, hypotension, a history of falls, dizziness, pain, alcohol use, cognitive impairment, polypharmacy, arthritis, gait or balance deficits, and age greater than 80 years MFS: (Morse Fall Scale) scale that used to assess patient for fall risk. 1. Does the patient have a history of falling? 2. Does the person have more than one medical diagnosis? 3. Does the person use ambulatory aids, such as crutches or a walker? 4. Does the person have an IV line or a saline lock? 5. Is the person’s gait normal or stooped or otherwise impaired? 6. What is the person’s mental status (e.g., disoriented, forgetful)? When a Client Falls? • 1st Priority is to check the patient for any injuries. • Before you check, guide the patient to the floor Interventions for Fall Risks: • Place client in a room close to the nurse’s station. • Place client with a sitter. • Orient client to room & surroundings & do not reposition furniture. • Keep bed in lowest position. • Remove rugs & keep floors clutter free. • Use proper fitting non-skid footwear. • Keep top 2 bed rails up; maximum 3 bed rails total. • Keep call light within reach. • Ensure proper lighting for patient to see at night. Education for an Elderly Client at Risk for Falls at Home: Physical activity/exercise, weight bearing for bone strength. Home modifications: handrails, slip-proof rugs, adequate lighting, avoid scatter rugs, slippery floors, clutter, encourage use of visual, hearing, ambulatory assistive devices. Prolonged Bedrest Can Result in What Types of Physical Issues? • Atrophy/muscle discomfort. pressure wounds/skin breakdown. immunosuppression (pneumonia). DVT/damage to superficial nerves & blood vessels. Contractures Restraints: last resort. RN may determine the need for restraints, provider must sign the order within the 24 hours. Nursing Interventions: Review medications, provide consistency, encourage family members to interact with patient, use relaxation techniques, reduce noise, frequent assessment, and surveillance communication. RN Responsibilities when using restraints: • Assess the initial restraint placement. • Periodically assess the circulation and skin integrity. • Remove the restraints ASAP when no longer needed • Modify the plan of care to reflect. Unlicensed Professional (UAP) responsibilities when using restraints: o The application of restraints o Period removal of restraints (If UAP is knowledgeable and skilled to.) o Verify the patient’s needs while restrained. • Body mechanics: term used to describe the way we move our bodies. o It includes 4 components: body alignment, balance, coordination, and joint mobility. Alignments Most posture problems result from a combination of the following: o Accidents, injuries, and falls o Careless sitting, standing, or sleeping habits o Excessive weight Foot problems or improper shoes Negative self-image o Occupational stress o Poor sleep support (mattress) o Poorly designed workspace o Visual difficulties o Weak muscles or muscle imbalance o Skeletal misalignment or malformation (e.g., scoliosis, kyphosis) Balance The body achieves balance when it is in alignment. For your body to be balanced, your line of gravity must pass through your center of gravity, and your center of gravity must be close to your base of support. o Line of gravity: imaginary vertical line drawn from the top of the head through the center of gravity. o Center of gravity: the point around which mass is distributed. It is located below the umbilicus at the top of the pelvis. o Base of support is what holds the body up (your feet). Coordination o Voluntary movement is initiated in the cerebral cortex. However, the cerebellum coordinates movements. o basal ganglia, located deep in the cerebrum, assist with coordination of movement. Joint Mobility The key concept mobility refers to a person’s ability to move within the environment. o Baseline activity refers to the light-intensity activities of daily living, such as standing, walking slowly, and lifting lightweight objects. Joints list from least to greatest ROM: Fibrous, cartilaginous, and synovial. Risk associated with exercise Cardiac injury, musculoskeletal injury, dehydration, hypoglycemia, and temperature regulation problems. Benefits of Regular Exercise • Regular exercises reduce the risk for early death, heart disease, stroke, type 2 diabetes, hypertension, hyperlipidemia, metabolic syndrome, colon and breast cancers, and depression. • Weight-bearing exercise reduces loss of bone density in adults and older adults Benefits of regular exercises (cardiovascular) ▪ Improves pumping action of the heart. ▪ Decreases heart rate, heart rate variability, and blood pressure. ▪ Improves circulation by increasing the number of capillaries. ▪ Improves venous return to the heart. ▪ Increases blood volume and hematocrit. ▪ Increases high-density lipoprotein (HDL). ▪ Decreases low-density lipoprotein (LDL) and total cholesterol. ▪ Decreases risk of thrombophlebitis. Benefits of regular exercises (Respiratory) ➢ Improves pulmonary circulation. Improves gas exchange at the alveolar– capillary membrane, and overall aerobic capacity, dilates bronchioles to increase ventilation Benefits of regular exercises (Musculoskeletal) ▪ Improves skeletal development in children. ▪ Increases coordination, muscle mass, strength, power, and endurance. ▪ Helps maintain joint structure and function; reduces risk of osteoarthritis. ▪ Improves flexibility, bone mass and mineral density. ▪ Improves gait speed, stability, and balance ▪ Improves bone mass with aging; reduces risk of osteoporosis. ▪ Reduces risk of falls and helps older adults maintain an independent lifestyle Benefits of regular exercises (Nervous) ➢ Speeds nerve impulse transmission, reduces sympathetic response to exercise, improves reaction time. Benefits of regular exercises (Endocrine) ▪ Increases sensitivity to insulin at the receptor sites. ▪ Increases efficiency of metabolic processes. ▪ Improves temperature regulation Facilitates weight management. ▪ Decreases adipose surrounding organs. Benefits of regular exercises (GI) ➢ Improves appetite, improves abdominal muscle tone, decreases risk of colon cancer. Benefits of regular exercises (Urinary) ➢ Increases efficiency of kidney function. Benefits of regular exercises (Integumentary) ➢ Improves skin tone as a result of improved circulation. Benefits of regular exercises (Immune) ➢ Reduces susceptibility to minor viral illnesses. Reduces systemic inflammation. Benefits of regular exercises (Overall health) ■ Burns calories to achieve and maintain healthy body weight. ■ Leads to reduced abdominal obesity. ■ Improves overall stamina & reduces fatigue. ■ Increases sleep time and improves sleep quality. Osteogenesis imperfecta (OI): is a congenital disorder of bone and connective tissue that is characterized by brittle bones that fracture easily. Infants with OI are often born with fractures and continue to fracture with minimal trauma or even spontaneously. Prompt recognition and treatment of fractures helps prevent deformities. Achondroplasia, or dwarfism: occurs when the bones ossify (harden) prematurely. Paget’s Disease: is a metabolic bone disease in which increased bone loss results in pain, pathological fractures, and deformities. This disorder usually affects the skull, vertebrae, femur, and pelvis. Osteoarthritis: Progressive deterioration & loss of cartilage & bone in one or more joints (crepitus). The most prevalent type of degenerative joint disease is osteoarthritis (OA). OA involves a loss of articular cartilage in the joint, with pain and stiffness as the primary symptoms. Patients may also have decreased ROM and crepitus, a creaking or grating sound, with joint motion. Symptoms are aggravated by weight-bearing and joint use and are relieved by resting the affected joints. OA is more common in women, older adults, and people who are overweight. CAM for osteoarthritis include Topical capsaicin (cream to put on joint) OTC provide burning sensation. Glucosamine and chondroitin Rheumatoid arthritis (RA): is a systemic autoimmune disease involving chronic inflammation of the joints and surrounding connective tissue, frequently resulting in difficulty in performing activities of daily living (ADLs). RA causes joint pain, deformity, and loss of function; patients may also experience fever, fatigue, weakness, and weight loss. RA occurs most frequently in the fingers, wrists, elbows, ankles, and knees. It occurs in 1% to 2% of the population, with a greater incidence in women. The illness usually begins in mid-life, but persons in any age group can be affected. Those in the 30- to 50-year-old range are the most frequently affected age group. Unlike OA, RA does NOT improve with rest. Pain is most intense when the person arises from bed. Pain and joint deformities may so severely affect mobility that patients cannot care for themselves. Non-Pharmacological Interventions for Rheumatoid Arthritis: Proper positioning, heat/cold therapy, hypnosis, imagery, music therapy, adequate nutrition, gradual weight loss. Ankylosing Spondylitis: is a chronic inflammatory joint disease characterized by stiffening and fusion of the spine and sacroiliac joints. The inflammation occurs where the ligaments, tendons, and joint capsule insert into the bone. The disease usually develops in young adults, equally in men and women. Signs and symptoms include low back pain and stiffness and decreased ROM of the spine. The convex lumbar curve is lost, and the upper spine curve increases, causing kyphosis. Gout: is an inflammatory response to high levels of uric acid. Crystals form in the synovial fluid, and small white nodules, or tophi, form in the subcutaneous tissues. Gout produces painful joints and severely limits activity during acute flare-ups. Positioning • Fowler Position: semi sitting position, bed is elevated 45° to 60°. This position promotes respiratory function by lowering the diaphragm and allowing the greatest chest expansion. • Semi-fowlers: bed is elevated only 30° • High fowlers: bed is elevated 90° orthopneic position: head of the bed is elevated 90° & an overbed table with pillow on top is positioned in front of the pt (help w shortness of breath) • Prone: Lying on the abdomen with the head turned to one side. only position that allows full extension of the hips and knees. • Oblique position alternative to the lateral position that places less pressure on the trochanter. • Supine: lies on the back, head and shoulders elevated on a small pillow & the arms and hands comfortably rest at the side. • Sims: semiprone position. lower arm positioned behind and upper arm flexed. upper leg is more flexed than the lower leg. facilitates drainage from the mouth and limits pressure on the trochanter and sacrum (enema, or perineal procedure). • Trendelenburg's Position: Patient is on their back whose lower section is inclined 15-30 degrees so that the head is lower than the body. • Reverse Trendelenburg's Position: Patient is in the supine position with the feet facing downward and head is inclined 15-30 degrees. • Lateral Position: side-lying position with the top hip and knee flexed and placed in front of the rest of the body. it creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from the heels and sacrum. Diagnostic and Imaging Assessment: Imaging studies for patients who report mild nonspecific back pain may not be done, depending on the nature of the pain. Patients with severe or progressive motor or SENSORY PERCEPTION deficits or who are thought to have other underlying conditions (e.g., cancer, infection) require complete diagnostic assessment. To determine the exact cause of the pain, a number of diagnostic tests may be used, including: • Plain X-Rays (show general arthritis changes and bony alignment) • CT Scan (shows spinal bones, nerves, disks, and ligaments) • MRI (provides images of the spinal tissue, bones, spinal cord, nerves, ligaments, musculature, and disks) • Bone Scan (shows bone changes by injecting radioactive tracers, which attach to areas of increased bone production or show increased vascularity associated with tumor or infection) • Myelogram/post-myelogram CT (evaluates nerve root lesions and any other mass, lesion, or infection of the meninges or spinal cord). Electro diagnostic Testing, such as electromyography (EMG) and nerve-conduction studies, may help distinguish motor neuron diseases from peripheral neuropathies and radiculopathies (spinal nerve root involvement). These tests are especially useful in chronic diseases of the spinal cord or associated nerves. TEST NORMAL RANGE FOR ADULTS SIGNIFICANCE OF ABNORMAL FINDINGS Serum calcium 9.0-10.5 mg/dL (2.25- 2.75 mmol/L) Older adults: decreased Hypercalcemia (increased calcium) • Metastatic cancers of the bone • Paget's disease • Bone fractures in healing stage Hypocalcemia (decreased calcium) • Osteoporosis • Osteomalacia 3.0-4.5 mg/dL (0.97- 1.45 mmol/L) Older adults: decreased Hyperphosphatemia (increased Serum phosphorus (phosphate) phosphorus) • Bone fractures in healing stage • Bone tumors • Acromegaly Hypophosphatemia (decreased phosphorus) • Osteomalacia Alkaline phosphatase (ALP) 30-120 units/L Older adults: slightly increased Elevations may indicate: • Metastatic cancers of the bone or liver • Paget's disease • Osteomalacia Serum muscle enzymes Creatine kinase (CK- MM) Total CK: Men: 55-170 units/L Elevations may indicate: • Muscle trauma • Progressive muscular dystrophy TEST NORMAL RANGE FOR ADULTS SIGNIFICANCE OF ABNORMAL FINDINGS Women: 30- • Effects of electromyography 135 units/L CK-MM: 96%- 100% Total LDH: 100- Elevations may indicate: • Skeletal muscle necrosis • Extensive cancer • Progressive muscular dystrophy Lactic dehydrogenase 190 units/L LDH1: 17%- (LDH) 27% LDH2: 27%- 37% LDH3: 18%- 25% LDH4: 3%-8% LDH5: 0%-5% Aspartate aminotransferase (AST) 0-35 units/L Older adults: slightly increased Elevations may indicate: • Skeletal muscle trauma • Progressive muscular dystrophy Aldolase (ALD) 3.0-8.2 units/dL Elevations may indicate: • Polymyositis and dermatomyositis • Muscular dystrophy Effect of immobility The most life-threatening side effects of immobility: Pulmonary Embolus Effect of Immobility on the Heart and Vessels Immobility increases the workload of the heart and promotes venous stasis. Without muscle activity, the force of gravity causes blood to pool in the periphery, which leads to edema. Virchow’s triad: make up of stasis, activation of clotting, and vessel injury (trilogy of symptoms associated with DVT). Effects of Immobility on Metabolism Inactivity increases the level of serum lactic acid and decreases ATP concentrations. In response, metabolic rate drops, protein and glycogen synthesis decrease, and fat stores increase. Together, these effects cause glucose intolerance and reduced muscle mass. Immobility also triggers the release of EPI and NOREPI, ACTH, which is why immobility can be seen as a stressor. Effects of Immobility on the Integument It can cause decreased skin turgor. External pressure from lying in one position compresses capillaries in the skin, obstructing skin circulation. Lack of circulation causes tissue ischemia and possible necrosis (death). Effects of Immobility on the GI System Immobility slows peristalsis, which leads to constipation, gas, and difficulty evacuating stool from the rectum. In extreme circumstances, a paralytic ileus (cessation of peristalsis) may occur. Effects of Immobility on the Genitourinary System It encourages renal calculi formation. Being supine inhibits drainage of urine from the renal pelvis and bladder. Urine becomes stagnant, which creates an ideal environment for infection and kidney stone formation. Psychological Effects of Immobility signs of depression, anxiety, hostility, sleep disturbances, and changes in the ability to perform selfcare activities. Effects of immobility in the respiratory system It can cause atelectasis, Pneumonia and Hypoxemia. • Osteoporosis: is a chronic disease of CELLULAR REGULATION in which bone loss causes significant decreased density and possible fracture. The priority problem for patients with osteoporosis or osteopenia is Potential for fractures due to weak, porous bone tissue. (Fracture is the most common complications). More common at the wrist, spine, and hip bones. Mostly occurs in women ▪ Risk factor: advanced age, low bone mineral density, previous fracture as an adult, Smoking, low calcium and vitamin D intake, excess alcohol use, and sedentary lifestyle. Osteoporosis occurs most often in older, lean-built Euro-American and Asian women, particularly those who do not exercise regularly. However, African Americans are at risk for decreased vitamin D, which is needed for adequate calcium absorption in the small intestines. Education on reducing the risk of Osteoporosis: Prevent obesity, proper nutrition, avoid injuries, weight baring exercises. Active lifestyle, avoid staying (sitting or lying) in one spot for too long, participate in ADL’S Generalized osteoporosis: Primary and secondary • Primary: more common and occurs in postmenopausal women and in men in their seventh or eighth decade of life. caused by a combination of genetic, lifestyle, and environmental factors. • Secondary: result from other medical conditions, such as hyperparathyroidism; long-term drug therapy, such as with corticosteroids; or prolonged immobility, such as that seen with spinal cord injury. Regional osteoporosis, an example of secondary disease, occurs when a limb is immobilized related to a fracture, injury, or paralysis. Physical Assessment: inspect the vertebral column, the classic “dowager's hump,” or kyphosis of the dorsal spine, is often present. Back pain accompanied by tenderness and voluntary restriction of spinal movement suggests one or more compression vertebral fractures. Diagnosis: Osteoporosis is diagnosed in a person who has a T-score at or lower than −2.5 Laboratory Assessment: Serum calcium and vitamin D3 levels should be routinely monitored (at least once a year) for all women and for men older than 50 years. Serum calcium should be between 9.0 and 10.5 mg/dL, or 2.25 and 2.75 mmol/L. Total 25-hydroxy D (vitamins D2 +D3) levels should be between 25 and 80 ng/mL, or 75 and 200 nmol/L Imaging assessment: X-ray show decreased bone density, but only after a large amount of bone loss. Dual X-ray absorptiometry is the most commonly used screening and diagnostic tool for measuring BDM. The most promising imaging test for determining bone quality is MRI- It does not involve radiation. Interventions: Because the patient is predisposed to fractures, nutritional therapy, exercise, lifestyle changes, and drug therapy are used to slow bone resorption and form new bone tissue. Self-management education (SME) can help prevent osteoporosis or slow the progress. • Nutrition therapy: Teach pt about the importance of calcium and vitamin D intake, avoid excessive alcohol and caffeine consumption. the plan of care should emphasize fruits and vegetables, low-fat dairy and protein sources, &increased fiber. • Drug therapy: The health care provider may prescribe calcium and vitamin D3 supplements, bisphosphonates (most commonly used), estrogen agonist/antagonists (formerly called selective estrogen receptor modulators), parathyroid hormone, RANKL inhibitor, or a combination of several drugs to treat or prevent osteoporosis. Treatment: Getting appropriate exercises, having a healthy diet, and increasing calcium and vitamin D intake. Genu valgum: knock knee Genu varum: bowlegged Assessing Risk Factors for Primary Osteoporosis Assess for these nonmodifiable risk factors: • Older age in both genders and all races • Parental history of osteoporosis, especially mother • History of low-trauma fracture after age 50 years Assess for these modifiable risk factors: • Low body weight, thin build • Chronic low calcium and/or vitamin D intake • Estrogen or androgen deficiency • Current smoking (active or passive) • High alcohol intake (three or more drinks a day) • Lack of physical exercise or prolonged immobility Osteomyelitis: Infection of the bone. It is the direct results of bacterial infection. it can be caused by Bacteria (most common), viruses, or fungi) may develop after bone injury or surgery. Treatment: Antibiotics Open fracture: High risk for osteomyelitis • Two major types: acute and chronic ➢ Acute hematogenous infection results from bacteremia, underlying disease, or nonpenetrating trauma. Patients undergoing long-term hemodialysis and IV drug users are also at risk for osteomyelitis. ➢ Chronic osteomyelitis: Occurs if bone is misdiagnosed or inadequately treated. Half cases are caused by gram-negative bacteria. Acute and Chronic Osteomyelitis Signs & Symptoms Acute Osteomyelitis: Fever; temperature usually above 101° F (38.3° C) • Swelling around the affected area • Possible erythema and heat in the affected area • Tenderness of the affected area • Bone pain that is constant, localized, and pulsating; worsens with movement. Chronic Osteomyelitis: Foot ulcer(s) (most commonly) • Sinus tract formation • Localized pain • Drainage from the affected area. Assessment- Bone pain, with or without other signs and symptoms, is a common concern of patients with osteomyelitis. The pain is described as a constant, localized, pulsating sensation that worsens with movement. Interventions (Nonsurgical): 4 to 6 weeks of antimicrobial (e.g., antibiotic) therapy as soon as possible for acute osteomyelitis. For patients with MRSA infection, IV vancomycin or linezolid (IV or oral) is used. Surgical: Surgical techniques include incision and drainage of skin and subcutaneous infection, wound débridement, and bone excision. Bone graft to repair bone defects are also widely used. The most common donor sites are the patient's fibula and iliac crest. Plantar Fasciitis: inflammation of the plantar fascia, which is in the area of the arch of the foot. Often seeing in middle age & older adult, athletes (mostly runners). Obesity is also a contributing factor. Patients report severe pain in the arch of the foot, especially when getting out of bed. The pain is worsened with weight bearing. Best treatment: physical therapy, steroid injections, shoe inserts, surgery. Conservative Management: rest, ice, stretching exercises, strapping of the foot to maintain the arch, shoes with good support, and orthotics. NSAIDs or steroids may be needed to control impaired COMFORT and inflammation. If conservative measures are unsuccessful, endoscopic surgery to remove the inflamed tissue may be required. Fracture: a break or disruption in the continuity of a bone that often affects MOBILITY and causes impaired COMFORT. Complete fracture: The break is across the entire width of the bone in such a way that the bone is divided into two distinct sections. displaced fracture: bone alignment is altered or disrupted. the ends of bone sections of a displaced fracture are more likely to damage surrounding nerves, blood vessels, and other soft tissues. Incomplete fracture: The fracture does not divide the bone into two portions because the break is through only part of the bone. This type of fracture is not typically displaced (greenstick). Open or compound fracture: The skin surface over the broken bone is disrupted, which causes an external wound. These fractures are often graded to define the extent of tissue damage. Close or simple fracture: does not extend through the skin and therefore has no visible wound. Open fractures- Interventions in Reducing Infection: 1. Hand washing or strict infection control. 2. Dressing changes with aseptic technique. 3. Monitor vital signs especially temperature & heart rate. 4. Administer broad spectrum antibiotics if ordered (Clindamycin & Gentamycin) 5. If irrigating open wound may be used using an antibiotic solution. 6. For chronic infections – adherence to antibiotic regimen Stages of Bone Healing: • Stage 1: 24-72 hours after injury hematoma formation. • Stage 2: 3 days-2 weeks granulation tissue invades hematoma forming fibrocartilage. • Stage 3: 3-6 weeks callus formation. • Stage 4: 3-8 weeks callus is gradually reabsorbed and transformed into bone. (ostification) Stage 5: 4-8 weeks to a year consolidation and remodeling of bone to continue to meet mechanical demands Complications of fractures: Acute compartment syndrome • Crush syndrome • Hemorrhage and hypovolemic shock • Fat embolism syndrome • Venous thromboembolism • Infection • Chronic complications, such as ischemic necrosis, delayed union, and complex regional pain syndrome (CRPS). Compartment syndrome (ACS): areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Most common site for this is in the lower leg (tibia) & forearm (emergency). If ACS is suspected, notify the primary health care provider immediately and, if possible, implement interventions to relieve the pressure. (Fasciotomy) Limb threatening complication caused by severe neurovascular impairment manifested by increasing alterations in levels of comfort (pain even after analgesics are given) and paresthesia (painful tingling and numbness). Assess Compartment Syndrome: wiggle their toes, pulse in the surrounding extremities, edema, sensation. Capillary refill, dorsal, extension, flexion. Treatment: remove the cause of the pressure and fasciotomy Connective tissue changes related: loss of bone, thickening of tendons, harden cartilage. 6Ps: paresthesia, pain, pulselessness, pallor, paralysis, Pressure. Fat Embolism: complication in which fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness. Patients with fractured hips have the highest risk, but FES is also common in those with fractures of the pelvis within 24 to 72 hours after injury. Signs and symptoms: low arterial oxygen level (hypoxemia), dyspnea, and tachypnea. Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Nonpalpable, red-brown petechiae—a macular, measles-like rash—may appear over the neck, upper arms, and/or chest. (last sign to develop) Venous thromboembolism: Include DVT and pulmonary embolism (PE). It is the most common complication of lower-extremity surgery or trauma and the most often fatal complication of musculoskeletal surgery. Risk Factors: Cancer or chemotherapy • Surgical procedure longer than 30 minutes • History of smoking • Obesity • Heart disease • Prolonged immobility • Oral contraceptives or hormones • History of VTE complications • Older adults (especially with hip fractures) Traction: application of a pulling force to a part of the body to provide reduction, alignment, and rest. It deceases muscle spasm (thus relieving pain) and prevent or correct deformity and tissue damage ➢ Buck’s extension traction: use for Fractures of the hip or femur before surgery Prevention of hip flexion contractures Hip dislocation ➢ Russell’s traction: (like Buck's traction, but a sling under the knee suspends the leg) use for Fractures of the hip or distal end of the femur ➢ Halo traction: use for Cervical fractures of the spine; muscle spasms. Halo traction and problems with infection. What are priority steps? Follow hospital policy for pin site care which may specify use of solutions such as saline, and Vaseline dressings. Monitor vital signs for indications of possible infection, fever, purulent drainage from pin site. Send cultures prior to the start of an antibiotic. ➢ Pelvic belt: use for Pain, strain, sprain, or muscle spasms in the lower back ➢ Skin traction: involves the use of a Velcro boot (Buck's traction), belt, or halter. primary purpose of skin traction is to decrease painful muscle spasms that accompany hip and proximal femur fractures. (weight 5-10 lb) ➢ Skeletal traction: long bone (femur, tibia) screws are surgically inserted directly into bone. use of longer traction time and heavier weights (15 to 30 lb). aids in bone realignment but impairs the patient's mobility. *Weight should be hanging at all times*. ➢ Bryant’s fracture: congenital hip in children Lordosis- Is defined as an excessive inward curve of the spine. Closer to lower part of the back. Scoliosis- Is a sideways curvature of the spine. Kyphosis: Is a forward rounding of the back. Closer to the neck Carpal Tunnel Syndrome (CTS): is a common condition in which the median nerve in the wrist becomes compressed, causing pain and a numb sensation. Is the most common type of repetitive stress injury (RPI). People whose jobs require repetitive hand activities such as pinching or grasping during wrist flexion (e.g., factory workers, computer operators, jackhammer operators) are predisposed to CTS. It can also result from overuse in sports activities such as golf, tennis, or racquet ball. CTS usually presents as a chronic problem. Rotator Cuf f Injuries:  The musculotendinous, or rotator, cuff of the shoulder functions to stabilize the head of the humerus in the glenoid cavity during shoulder abduction.  Young adults usually sustain a tear of the cuff by substantial trauma, such as may occur during a fall, while throwing a ball, or with heavy lifting. o Older adults tend to have small tears related to aging, repetitive motions, or falls; and the tears are usually painless. o The patient with a torn rotator cuff has shoulder pain and cannot easily abduct the arm at the shoulder. When the arm is abducted, he or she usually drops it because abduction cannot be maintained (drop arm test). Pain is more intense at NIGHT. o Partial-thickness tears are more painful than full-thickness tears, but full-thickness tears result in more weakness and loss of function. o Patients then begin rehabilitation in the ambulatory-care occupational therapy department. Teach them that they may not have full function for several months. Glaucoma: causes increased intraocular pressure. occurs with increased pressure and resulting hypoxia of photoreceptors and their synapsing nerve fibers. Glaucoma: damage the eye optic nerve, possibly create blindness and vision loss. (North America) Glaucoma Risk factor: African American over 40, history of DM, hypothyroid, prolonged corticosteroids individual over the age of 60 (especially Mexican Americans), family hx, high eye pressure, corneal thinness, and abnormality of the optic nerve Glaucoma untreated: can lead to complete loss of visual sensory perception. It is painless Primary open angle glaucoma (POAG): the most common form of primary glaucoma usually affects both eyes and has no signs or symptoms in the early stages. At times, vision is foggy, and the patient has mild eye aching or headaches. Late SS include seeing halos around lights, losing peripheral vision, and having decreased visual SENSORY PERCEPTION that does not improve with eyeglasses. Primary angle closure glaucoma (PACG): has a sudden onset and it is a medical emergency. The problem is a forward displacement of the iris, which presses against the cornea and closes the chamber angle, suddenly preventing outflow of aqueous humor. Systemic osmotic drugs may be given for angle-closure glaucoma to rapidly reduce IOP. These agents include oral glycerin and IV mannitol (Osmitrol). Glaucoma (open and closed angle) which test determines the difference? Gonioscopy is used when IOP is high and can determine whether a patient has open or close angled glaucoma. A special lens eliminates the corneal curve and allows for visualization of where the iris meets the cornea. The procedure is painless. Or ultrasonic imaging. Glaucoma PACG, S/S: sudden, severe pain around the eyes that radiates over the face. Headache or brow pain, nausea, and vomiting may occur. Other symptoms include seeing colored halos around lights and sudden blurred vision with decreased light perception. Sclera reddened and cornea foggy. Ophthalmoscopic examination reveals a shallow anterior chamber, a cloudy aqueous humor, and a moderately dilated, nonreactive pupil. Glaucoma Diagnostic Assessment: In open-angle glaucoma, the tonometry reading is often between 22- and 32-mm Hg (normal is 10 to 21 mm Hg). In angle- closure glaucoma, the tonometry reading may be 30 mm Hg or higher. Common causes of Glaucoma Primary Glaucoma: Aging • Heredity Associated glaucoma: Diabetes mellitus • Hypertension • Severe myopia • Retinal detachment Secondary Glaucoma: Uveitis • Iritis • Neovascular disorders • Trauma • Ocular tumors • Degenerative disease • Eye surgery • Central retinal vein occlusion Glaucoma priority problems: Decreased visual acuity due to glaucoma 2. Need for health teaching due to treatment regimen for glaucoma. Drug therapy: These drugs do not improve lost vision but prevent more damage by decreasing IOP. Glaucoma priority intervention is teaching. Glaucoma surgical management: laser trabeculoplasty and trabeculectomy. ➢ laser trabeculoplasty burns the trabecular meshwork, scarring it and causing the meshwork fibers to tighten. ➢ Trabeculectomy is a surgical procedure that creates a new channel for fluid outflow. Both are ambulatory surgery procedures. ➢ Glaucoma surgery complication: complications of glaucoma surgery include choroidal hemorrhage (immediate loss of vision with sudden, excruciating, throbbing pain) and choroidal detachment (some degree of vision loss but is usually painless). Intraocular Pressure (IOP): normal IOP requires a balance between production and outflow of aqueous humor. If the IOP becomes too high, the extra pressure compresses retinal blood vessels and photoreceptors and their synapsing nerve fibers. This compression results in poorly oxygenated photoreceptors and nerve fibers. These sensitive nerve tissues become ischemic and die. When too many have died, vision is lost permanently. Cataract: is a lens that has lost its transparency. It is a lens opacity that distorts the image Common causes of cataracts Aged related cataracts: most common (70 up) Lens water loss and fiber compaction Traumatic cataracts: Blunt injury to eye or head, penetrating eye injury, intraocular foreign bodies, radiation exposure, therapy. Toxic cataracts: corticosteroids, phenothiazine derivatives, miotic agents. Associated Cataracts: Diabetes mellitus • Hypoparathyroidism • Down syndrome • Chronic sunlight exposure Complicated Cataracts: Retinitis pigmentosa • Glaucoma • Retinal detachment Cataracts early SS: slightly blurred vision and decreased color perception. Without surgical intervention, visual impairment progresses to blindness. No pain or eye redness is associated with age-related cataract formation. Cataracts priority collaborative problems: Decreased visual acuity due to cataracts (reduced visual SENSORY PERCEPTION). Surgery is the only cure for cataract. Blood shot appearance is normal after surgery. Describe Symptoms of Bilateral Cataracts. • Blurred/clouded vision • Double vision • Decreased color perception • Problems with ADLs • Decreased visual acuity, recent in prescription change • Difficulty with night vision and sensitivity to light/glare • Rate and development of cataracts vary in each eye • May think glasses are smudged. • Halos around objects Visual acuity tests measure both distance and near vision. The Snellen eye chart measures distance vision. This chart has letters, numbers, pictures, or a single letter presented in various positions. Assess balance by using the Romberg Test. Refractive Errors: The main types of refractive errors are: Myopia (nearsightedness) The eye over refracts the light and bent images fall in front of, not on the retina causing far away objects to appear blurry. Hyperopia (farsightedness) Presbyopia (loss of near vision with age), and astigmatism. Hearing Loss: Conductive Hearing Loss: Is an alteration in the middle ear that blocks sound waves before they reach the cochlea of the inner ear. Usually a history of middle ear infections and older age. Expected findings- hears better in a noisy environment, speaks softly, packed cerumen, etc. Sensorineural Hearing Loss: Is an alteration in the inner ear, auditory nerve, or hearing center of the brain. Risk factors include; prolonged exposure to loud noise, ototoxic medications, infectious process, and older age. Expected Findings are tinnitus (ringing of the ear), dizziness, hears poorly in a noisy environment, speaks loudly, etc. Cerumen: earwax What is Vertigo: Feeling of a spinning sensation Tinnitus: ringing in the ear How do you apply ear drops? Pull upper ear up and back. Teaching for clients with Meniere’s Disease: teach patients to move head slowly to prevent worsening of the vertigo, reduce sodium intake to help reduce excess retention of endolymphatic fluid, adhere to medications, and reduce or stop smoking, continue medications. Communication with a pt with hearing aid o Position yourself directly in front of the patient. o Ensure that you are not sitting or standing in front of a bright light or window, which can interfere with the patient's ability to see your lips move. o Make sure that the room is well lighted. o Get the patient's attention before you begin to speak. o Move closer to the better-hearing ear. o Speak clearly and slowly. o Do not shout (shouting often makes understanding more difficult). o Keep hands and other objects away from your mouth when talking to the patient. o Have conversations in a quiet room with minimal distractions. o Have the patient repeat your statements, not just indicate assent. o Rephrase sentences and repeat information to aid understanding. o Use appropriate hand motions. o Write messages on paper if the patient is able to read. o Remove distractions like turning off the television Chapter 25: Pressure Injuries (review the pictures on page 454) Pressure Injury: is a loss of TISSUE INTEGRITY caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. Commonly occurs in: sacrum, hips, and ankles, but it can occur on anybody surface. Unrelieved pressure leads to ischemia, inflammation, and tissue necrosis. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and gas exchange, which eventually leads to cell death. Pressure Injury complications: sepsis, kidney failure, infectious arthritis, and osteomyelitis. Friction and shear are mechanical forces that impair skin TISSUE INTEGRITY and cause skin tears, which set the stage for skin breakdown Pressure occurs as a result of gravity. It is determined by the amount and distribution of weight exerted at the point of contact and the density of the contacting surface. If pressure is unrelieved, tissue destruction progresses to full-thickness ulcer. Friction occurs when surfaces rub the skin and irritate or tear fragile epithelial tissue. Shearing forces are generated when the skin itself is stationary and the tissues below the skin (e.g., fat, muscle) shift or move. Shearing leads to soft-tissue ischemia and deep-tissue ulcer. Reducing Shear (Skin) Injury? • Avoid pulling, tugging, and sliding patient against the bed. • Keep head of bed at a slight elevation. • Make sure sheets and blanket DON’T have ripples in then that rub against the patient’s skin. Use others to assist in moving patient to protect from shearing. Positioning to reduce injury to bony prominences? Place pillows under areas and elevate. Change positioning every 2 hours. Elevate calves to protect heels. Preventing Pressure Injuries Positioning • Pad contact surfaces with foam, silicone gel, air pads, or other materials with pressure- redistribution properties. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, position at a 30-degree tilt. • Re-position an immobile patient at a frequency consistent with assessed needs. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles or a heel-suspension device. Nutrition • Ensure a fluid intake between 2000 and 3000 mL/day. • Help the patient maintain an adequate intake of protein and calories. Skin Care • Perform a daily inspection of the patient's entire skin. • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin and apply when skin is damp. • Keep moisture from prolonged contact with skin: • Dry areas where two skin surfaces touch, such as the axillae and under the breasts. • Place absorbent pads under areas where perspiration collects. • Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room. • Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin-barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talc directly on the perineum. • After cleaning, apply a commercial skin barrier to areas in frequent contact with urine or feces. 1. Early identification of high-risk patient 2. Implementation of aggressive intervention for prevention with the use of pressure-relief or pressure-reduction devices. Pressure mapping: Red indicates areas of greater heat production and increased pressure loads. Blue indicates cooler areas under lower pressure Skin risk assessment tool: Braden Scale. Pressure Injury Nutrition Assessment: evaluation of weight and weight change; ability of the patient to consume an adequate diet; and the need for vitamin, mineral, or protein supplementation. Serum prealbumin levels are often used to monitor nutrition status. Nutrition is considered inadequate when the serum prealbumin level is less than 19.5 g/dL, albumin level is less than 3.5 g/dL, or the lymphocyte count is less than 1800/mm3. positive nitrogen balance requires an intake of 30 to 35 Cal/kg of body weight daily with a protein intake of 1.25 to 1.5 g/kg/day. Up to 2 g/kg/day of protein if nutritional deficits are severe or protein loss is ongoing. Capillary closing pressure: pressure needed to occlude skin capillary blood flow and normally ranges from 12 to 32 mm Hg. pressure-redistribution surface or device keeps tissue interface pressure below the capillary closing pressure. Observe skin color, capillary refill, tissue integrity, and temperature directly to determine capillary flow adequacy. Factors to consider when selecting a product redistribute include: • Number and severity of existing pressure injuries • Risk for developing new pressure injuries • Patient's ability to reposition self to relieve pressure-related discomfort • Need for microclimate control to help manage skin temperature and moisture • Need to reduce shearing forces • Compatibility of product with care setting. Support Surfaces nonpowered (static): Static devices use gel, water, foam, or air to increase the body surface area that encounters the surface and reduce interface pressure. Stage 1 and 2 powered (dynamic): comprised of cells that inflate and deflate to continuously alter the area of the body that is bearing the load. Stage 3, 4, and unstageable pressure injury. Suspected Deep Tissue Injury: The intact skin area appears purple or maroon. • Blood-filled blisters may be present. • Before the previously listed changes appeared, the tissue in this area may first have been painful. • Other changes that may have preceded the discoloration include that the area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue. Stage 1 Skin is intact. Nonblanchable erythema with no epidermal tissue loss. • Area, usually over a bony prominence, is red and does not blanch with external pressure. • For patients with darker skin that does not blanch, observe pressure-related alteration of intact skin; changes are compared with an adjacent or opposite area and include one or more of these: • Skin color (darker or lighted than the comparison area) • Skin temperature (warmth or coolness) • Tissue consistency (firm or boggy) • Sensation (pain, itching) • The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage 2 Skin is not intact. • There is partial-thickness skin loss of the epidermis or dermis. • Ulcer is superficial and may be characterized as an abrasion, a blister (open or fluid-filled), or a shallow crater. • Bruising is not present. Stage 3 • Skin loss is full thickness. • Subcutaneous tissues may be damaged or necrotic. • Damage extends down to but not through the underlying fascia; bone, tendon, and muscle are not exposed. • The depth can vary with anatomic location; areas of thin skin (e.g., the bridge of the nose) may show only a shallow crater, whereas thicker tissue areas with larger amounts of subcutaneous fat may show a deep, crater-like appearance. • Undermining and tunneling may or may not be present. Stage 4 • Skin loss is full thickness with exposed or palpable muscle, tendon, or bone. • Often includes undermining and tunneling. • Sinus tracts may develop. • Slough and eschar are often present on at least part of the wound. Unstageable Skin loss is full thickness; and the base is completely covered with slough or eschar, obscuring the true depth of the wound. Pressure Injury history Assessment: • Prolonged bedrest • Immobility • Incontinence • Diabetes mellitus • Inadequate nutrition or hydration • Decreased sensory perception or cognitive problems • Peripheral vascular disease. Wound assessment: Assess wounds for location, size, color, extent of tissue involvement, cell types in the wound base and margins, exudate, condition of surrounding tissue, and presence of foreign bodies. Inspect the wound margins for cellulitis (inflammation of the skin and subcutaneous tissue) extending beyond the area of injury. Client Education for Cellulitis: • Take prescribed antibiotic until gone. • Keep the infected area clean. • Raise the infected area above the level of heart to keep swelling down. • Apply clean bandage as advised. • Take temperature once a day. • Wash your hands often to prevent spreading the infection. • Advise how to apply cool compress for discomfort alternating with warm and moist compress. Eschar: full-thickness pressure injury is often covered by a layer of black, gray, or brown collagen. Types of Wound Exudate Serosanguineous Exudate: Blood-tinged amber fluid consisting of serum and red blood cells o Significance: Normal for first 48 hrs after injury. Sudden increase in amount precedes wound dehiscence in wounds closed by first intention Purulent exudate: Creamy yellow pus (Staphylococcus), Greenish-blue pus causing staining of dressings and accompanied by a “fruity” odor (Pseudomonas), Beige pus with a “fishy” odor (Proteus), Brownish pus with a “fecal” odor (aerobic coliform and Bacteroides (usually occurs after intestinal surgery). Wound infection: is a state of critical colonization with pathogenic organisms to the degree that organism growth and spread cannot be controlled by the body's immune defenses. Signs of wound infection include erythema and swelling, fever, foul odor, severe or increasing pain, large amount of drainage, or warmth of the surrounding soft tissue. Swab cultures: helpful only in identifying the types of bacteria present on the ulcer surface Wound biopsies: allow the numbers of bacteria to be analyzed (time consuming, costly, not always available) Different dressing materials help remove debris by mechanical débridement, topical chemical débridement or natural chemical débridement. Depth of the Wound: Superficial wounds: involve only the epidermal layer of the skin. The injury is usually the result of friction, shearing, or burning. Partial Thickness: wounds extend through the epidermis but not through the dermis. Full thickness: wounds extend into the subcutaneous tissue and beyond. The descriptor penetrating is sometimes added to indicate that the wound involves internal organs. Wound depth is a major determinant of healing time: The deeper the wound, the longer the healing time. Common Dressing Techniques for Wound Débridement Wet-to-damp saline-moistened gauze: As with the wet-to-dry technique, necrotic debris is mechanically removed but with less trauma to healing tissue. Continuous wet gauze: The wound surface is continually bathed with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar. Topical enzyme preparations: Proteolytic action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue. Moisture-retentive dressing: Spontaneous separation of necrotic tissue is promoted by autolysis. Pressure Injury nursing priority: Change synthetic dressings when exudate causes the adhesive seal to break and leakage to occur. Pressure Injury Nutrition: • Well-balanced diet, emphasizing protein, vegetables, fruits, whole grains and vitamins. Increase caloric intake & fats are also needed. Pressure Injury technology-based therapies Electrical stimulation is the application of a low-voltage current to a wound area to increase blood vessel growth and promote granulation. Voltage is delivered in pulses and may cause a tingling sensation. Perform 1hr/day & 5-7 days a week. Do not use on pt with pacemaker, wound over the heart, and or skin cancer. Negative pressure wound therapy (NPWT): reduce or even close chronic injuries by removing fluids or infectious materials from the wound and enhancing granulation. Requires a suction tube and foam dressing is changed every 48 to 72 hours. Pt needs to be monitored q 2hrs for bleeding at or near the wound site. Do not use with pt on anticoagulant. Hyperbaric oxygen therapy (HBOT): administration of oxygen under high pressure, raising the tissue oxygen concentration. usually reserved for life- or limb-threatening wounds such as burns, necrotizing infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers (60-90mnte) Topical growth factors are normal body substances that stimulate cell movement and growth. platelet-derived growth factor (PDGF) stimulates the movement of fibroblasts into the wound space. Skin substitutes are engineered products that aid in the closure of different types of wounds. Ultrasound-assisted wound therapy (USWT) uses energy produced by low frequency (40 kHz) sound waves to cleanse & debride of granulation, and reduced rates of infection. electrical stimulation (ES): promote healing of chronic wounds that are stalled in the healing process. ES works by restoring the natural electric impulses found in healthy tissue and promoting more normal cellular function. benefits include increased fibroblast activity to stimulate granulation, increased epithelial cell migration, enhanced macrophage activity, and reduced pain. Pressure Injury surgical management: removal of necrotic tissue and skin grafting or use of muscle flaps to close wounds that do not heal by re-epithelialization and contraction. Bacteremia: fever, an elevated WBC count, and positive blood cultures. Patient at Risk for Pressure Injuries (Focused assessment) Assess cardiovascular status: • Presence or absence of peripheral edema • Hand-vein filling in the dependent position • Neck-vein filling in the recumbent and sitting positions • Weight gain or loss Assess cognition and mental status: • Level of consciousness • Orientation to time, place, and person • Can the patient accurately read a seven-word sentence containing words of three syllables or fewer? Assess condition of skin: • Assess general skin cleanliness • Observe all skin areas, paying attention to bony prominences and areas in greatest contact with the bed and other firm surface. • Measure and record any areas of redness or loss of integrity • If possible, photograph areas of concern • Note the presence or absence of skin tenting over the sternum or the forehead • Note the moistness of skin and mucous membranes • If wounds are present, remove dressings (noting condition of dressings), cleanse the wound, and compare with previous notations of wound condition: • Presence, amount, and nature of exudate • Use a disposable paper tape measure to measure wound diameter and depth • Amount (%) and type of necrotic tissue • Presence of granulation/epithelium • Presence or absence of cellulitis • Presence or absence of odor • Take patient's temperature to assess for fever Assess the patient's understanding of illness and compliance with treatment: • Signs and symptoms to report to primary health care provider • Drug therapy plan (correct timing and dose) • Ambulation or positioning schedule • Dressing changes/skin care • Nutrition modifications (24-hr diet recall) Assess the patient's nutritional status: • Change in muscle mass • Lackluster nails, sparse hair • Recent weight loss of more than 5% of usual weight • Impaired oral intake • Difficulty swallowing • Generalized edema. Pruritus (itching): distressing and often debilitating condition caused by stimulation of itch- specific nerve fibers. Pruritus can also be caused by too little or too much blood flow to an area (especially the feet and legs). Xerosis: dry skin. Conditions that make itching worse: skin dryness, increased temperature, perspiration, and emotional stress. Urticaria (hives): is a rash of white or red edematous papules or plaques of various sizes. Some common causes of urticaria include drugs, temperature extremes, foods, infection, diseases, cancer, and insect bites. • Management focuses on removal of the triggering substance and relief of symptoms Contact dermatitis is an acute or chronic rash caused by direct contact with either an irritant or an allergen. Atopic dermatitis is a chronic rash that occurs with allergies and atopic skin disease. It is made worse by dry or irritated skin, food allergies, chemicals, or stress. Psoriasis: chronic autoimmune disorder affecting the skin with exacerbations and remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes. (cannot be cured) it is a genetic disposition (always ask about family Hx). Psoriasis vulgaris is the most common type of psoriasis, with thick, reddened papules or plaques covered by silvery white scales. Common sites include the scalp, elbows, trunk, knees, sacrum, and outside surfaces of the limbs. Facial skin is rarely affected. Exfoliative psoriasis (erythrodermic psoriasis) is an explosively eruptive and inflammatory form with generalized erythema and scaling but no obvious lesions. Palmoplantar pustulosis (PPP) is a type of psoriasis that forms pustules on the palms of the hands and soles of the feet along with reddened hyperkeratotic plaques Skin infection can be bacterial, viral, or fungal. Bacterial infections: Bacterial skin lesions usually start at the hair follicle, where bacteria easily collect and grow in the warm, moist environment. Folliculitis (superficial infection involving only the upper part of the follicle and is often caused by Staphylococcus) usually show small pustules. Furuncle (also caused by Staphylococcus, but the infection is much deeper in the follicle). This larger, inflamed, raised bump may or may not have a pustular “head” at its point. Cellulitis (generalized infection with either Staphylococcus or Streptococcus and involves the deeper connective tissue). Viral infections: herpes simplex, herpes zoster (varicella zoster). • Herpes simplex virus (HSV) infection is the most common viral infection of adult skin • Herpes zoster (shingles) is infection caused by reactivation of the varicella-zoster virus (VZV) in patients who have previously had chickenpox. It happens more often in adult or immunosuppressed pt. Fungal infections: dermatophytosis, candidiasis. • Candida albicans, also known as yeast infection, is a common fungal infection of skin and mucous membranes. Risk factors include immunosuppression, long-term antibiotic therapy, diabetes mellitus, and obesity. Cutaneous anthrax is an infection caused by the spores of the bacterium Bacillus anthracis. the most common risk factor is contact with an infected animal. most at risk include farm workers, veterinarians, and tannery and wool workers. Infection laboratory assessment: When pustules are present in bacterial infections, the infecting organism is confirmed by swab culture of the purulent material. Blood cultures may be helpful if fever and malaise are present. Pediculosis is a lice infestation: pediculosis capitis (head lice), pediculosis corporis (body lice), and pediculosis pubis (pubic, or crab, lice). Human lice are oval and 2 to 4 mm long. Most common pediculosis manifestation is itching. Scabies is a contagious skin infection caused by mite infestations. It is transmitted by close contact with an infested person or infested bedding. Phases of wound healing: inflammatory phase, proliferative phase, and maturation phase. Inflammatory Phase- cleansing: Begins at the time of injury or cell death and lasts 3 to 5 days (1-5). And consist of Hemostasis (clotting) and inflammation (phagocytosis). • Immediate responses are vasoconstriction and clot formation (hemostasis). • After 10 minutes, vasodilation occurs with increased capillary permeability and leakage of plasma (and plasma proteins) into the surrounding tissue (hemostasis). • White blood cells (especially macrophages) migrate into the wound. • Signs and symptoms of local edema, pain, erythema, and warmth are present (inflammation). Proliferative Phase- Granulation: Begins about the 4th day after injury and lasts 2 to 4 weeks. Day 5-21 • Fibrin strands form a scaffold or framework. • Mitotic fibroblast cells migrate into the wound, attach to the framework, divide, and stimulate the secretion of collagen. • Collagen, together with ground substance, builds tough and inflexible scar tissue. • Capillaries in areas surrounding the wound form “buds” that grow into new blood vessels. • Capillary buds and collagen deposits form the “granulation” tissue in the wound, and the wound contracts. • Epithelial cells grow over the granulation tissue bed (epithelialization). Maturation Phase- epithelialization: Begins as early as 3 weeks after injury and may continue for a year or longer. • Collagen is reorganized to provide greater tensile strength. • Scar tissue gradually becomes thinner and paler in color. • The mature scar is firm and inelastic when palpated. Mechanism of wound healing: re-epithelialization, granulation, and wound contraction Partial-thickness wounds are superficial with minimal loss of tissue integrity and they are healed by re-epithelialization. 5-7 days. (Full-thickness Wounds) Removal of the damaged tissue results in a defect that must be filled with scar tissue (granulation) for healing to occur. Fibroblasts also begin to pull the wound edges inward along the path of least resistance (contraction). Skin cancer: Overexposure to sunlight is the major cause of skin cancer, although other factors also are associated. The most common precancerous lesions are actinic (solar) keratosis, and the most common skin cancers are squamous cell carcinoma, basal cell carcinoma, and melanoma. Actinic (solar) keratoses are premalignant lesions of the cells of the epidermis. common in adults with chronically sun-damaged skin. If untreated can lead to squamous cell carcinoma. Squamous cell carcinomas are cancers of the epidermis. They can invade locally and are potentially metastatic. Basal cell carcinomas arise from the basal cell layer of the epidermis. Early lesions often go unnoticed. although metastasis is rare, underlying tissue destruction can occur. UV exposure is the most common cause. Melanomas are pigmented cancers arising in the melanin-producing epidermal cells. Risk factors include genetic predisposition, excessive exposure to UV light, and the presence of one or more precursor lesions that resemble unusual moles. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Surgical types for skin cancer include: • Cryosurgery—Cell destruction by the local application of liquid nitrogen (−200° C) to isolated lesions, causing cell death and tissue destruction. • Excisional biopsy—Total surgical removal of small lesions for pathologic examination. • Mohs' surgery—A specialized form of excision usually for basal and squamous cell carcinomas. Tissue is sectioned horizontally in layers, and each layer is examined histologically to determine the presence of residual tumor cells. • Wide excision—Deep skin resection often involving removal of full-thickness skin in the area of the lesion. Depending on tumor depth, subcutaneous tissues and lymph nodes may also be removed. Fundamental Book Chapter 35: how do pressure ulcers develop, Braden & Norton Scale, Analysis Nursing Diagnosis integumentary system consists of the skin, hair, nails, sweat glands, and the subcutaneous tissue. Epidermis: is the outer portion of the skin • stratum corneum: outermost layer, composed of numerous thicknesses of dead cells. Functioning as a barrier, it restricts water loss and prevents fluids, pathogens, and chemicals from entering the body. • stratum germinativum: innermost layer of the epidermis, continually produces new cells, pushing the older cells toward the skin surface. • keratinocytes are protein- containing cells that give the skin strength and elasticity • Langerhans cells are mobile. Their function is to phagocytize (engulf) foreign material and trigger an immune response. Dermis: lies below the epidermis and above the subcutaneous tissue. It is made of irregular fibrous connective tissue that provides strength and elasticity to the skin and is generously supplied with blood vessels. Within the dermis are sweat glands, sebaceous (oil) glands, ceruminous (wax) glands, hair and nail follicles, sensory receptors, elastin, and collagen. subcutaneous layer: composed primarily of connective and adipose tissue. It provides insulation, protection, and a reserve of calories in the event of severe malnutrition. How Do Pressure Ulcers Develop? Patients at risk for developing pressure ulcers are those with immobility, friction and shear, moisture, incontinence, poor nutrition, perfusion, age, skin condition, and altered level of consciousness. Pressure ulcers are caused by unrelieved pressure, or pressure in combination with shearing forces. These compromise blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Tissue ischemia leads to tissue anoxia (lack of oxygen) and cell death. Pressure ulcers can occur in as little time as 2 hours, though they may take as long as 5 days for the full extent of tissue dam- age to be known *Nutrition and hydration* Protein: healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, & preserve intravascular volume. Inadequate intake can lead to edema—skin breakdown Cholesterol: low cholesterol levels predispose patients to skin breakdown and inhibit wound healing. Pt on low-fat tube feedings may experience deficiencies in cholesterol, fatty acids, and linoleic acid. waterproof barrier in the stratum corneum. Calorie Intake: If calorie intake is inadequate, the body uses proteins for energy (catabolism); they are then unavailable for building and maintenance functions (anabolism). untreated malnutrition can lead to weight loss, loss of subcutaneous tissue, & muscle atrophy. As a result, padding between the skin and the bones decreases, predisposing the skin to pressure ulcers. Ascorbic Acid, Zinc, and Copper Vitamin C, or ascorbic acid, is involved in the formation and maintenance of collagen, so a deficiency can delay wound healing. Hydration: skin turgor depends on hydration. Both dry, dehydrated, as well as edematous, overhydrated, skin are prone to injury, especially when exposed to pressure, shearing, friction, and moisture. Impaired arterial circulation restricts activity, produces pain, and leads to muscle atrophy and thin tissue that can lead to ischemia and necrosis. Impaired venous circulation results in engorged tissues containing high levels of metabolic waste products that make the tissue susceptible to edema, ulceration, and breakdown. Both forms of circulatory impairment delay wound healing. Types of wounds Abrasion: a scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces. Open wound involving the skin Abscess: localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen; must be opened and drained to heal Contusion: a closed wound caused by blunt trauma. May be referred to as a bruise or ecchymotic area. Crushing: a wound caused by force leading to compression or disruption of tissues. Often associated with fracture. Usually there is minimal or no break in the skin. Incision: an open, intentional wound caused by a sharp instrument Laceration: the skin or mucous membranes are torn open, resulting in a wound with jagged margins. Penetrating: an open wound in which the agent causing the wound lodges in body tissue Puncture: an open wound caused by a sharp object. Often there is collapse of tissue around the entry point, making this wound prone to infection. FINAL EXAM CONCEPT GUIDE Tunnel: a wound with an entrance and exit site. Clean contaminated wounds are surgical incisions that enter the gastrointestinal GI or GU, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. Contaminated wounds: open, fresh, accidental/surgical wound, sterile tech broken or GI spillage has occured. include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. high risk of infection. Wounds are considered infected when bacteria count in the wound tissues are above 100,000 organisms per gram of tissue. Chronic Wounds Pressure Ulcers: Caused by pressure, resulting in tissue ischemia and injury. Appearance depends on the stage or tissue layers involved. PU tend to be located over bony prominences Arterial Ulcers: Caused by inadequate circulation of oxygenated blood to the tissue, which leads to tissue ischemia and damage. Ulcer appears “punched out,” small and round with smooth borders. Pale, occur in distal part of the leg, especially the ankles, toes, side of the foot, and shin. The surrounding skin appears shiny, thin, and dry and is cool to touch. Can leads to death. Venous stasis ulcer: Caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function, resulting in venous pooling, edema, and impaired microcirculation of the skin. located around the inner ankle, or in the lower part of the calf. skin is reddened or brown & edematous. Wounds are shallow, with irregular wound margins (“ruddy” or “beefy” red and granular). Types of wound healing Regenerative/Epithelial Healing: When a wound affects only the epidermis and dermis. No scar forms and the new (regenerated) epithelial and dermal cells form new skin that cannot be distinguished from the intact skin. Primary Intention Healing: When a wound involves minimal or no tissue loss and has edges that are well approximated (closed). Little scarring is expected. (clean surgical incision). Secondary Intention Healing: occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating, or (2) should not be closed. Wounds that heal by secondary intention heal more slowly, are more prone to infection, and develop more scar tissue. Tertiary Intention Healing: also called delayed primary closure. Wound left open 3-5 days to allow edema/infection to resolve. Close with suture or adhesives. when two surfaces of granulation tissue are brought. This technique may be used when the wound is clean- contaminated or contaminated. creates less scarring than does secondary, but more than primary intention healing. Wound Closures Adhesive Strips: Closing superficial low-tension wounds, such as skin tears or lacerations. Closing the skin on a wound that has been closed subcutaneously to aid in healing and reduce scarring. Giving additional support to a wound after sutures or staples have been removed. Sutures: traditional wound closures are sutures (“stitches”). Suturing leads to small puncture wounds along the track of the laceration or incision. • Absorbent sutures are used deep in the tissues, for ex- ample, to close an organ or anastomose (connect) tissue (no need to remove). • Nonabsorbent sutures are placed in superficial tissues and require removal, usually by the nurse. Surgical Staples: lightweight titanium, surgical staples provide a fast, easy way to close incision. lower risk of infection and tissue reaction than are sutures. most common sites are arms, legs, abdomen, back, scalp, or bowel. Wounds on the hands, feet, neck, or face should not be stapled. Surgical Glue: this is a relatively new method for wound closure. It is safe for use in clean, low- tension wounds. It is an ideal wound closure method for skin tears. *Types of Wound drainage* Serous exudate: Clean wounds typically drain serous exudate. It is watery in consistency and contains very little cellular matter. It consists of serum, the straw-colored fluid that separates out of blood when a clot is formed. Sanguineous Exudate: often seeing with deep/open wounds or wounds in highly vascular areas. It is bloody drainage. It indicates damage to capillaries. Fresh bleeding produces bright red drainage, whereas older, dried blood is a darker, red-brown color. Serosanguineous Drainage: most commonly seeing serosanguineous drainage in new wounds, a combination of bloody and serous drainage. Purulent Exudate: thick, often malodorous, drainage that is seen in infected wounds. It contains pus, a protein-rich fluid filled with WBCs, bacteria, and cellular debris. It is commonly caused by infection from pyogenic (pus- forming) bacteria, such as streptococci or staphylococci. Normally, pus is yellow in color, although it may take on a blue-green color if the bacterium Pseudomonas aeruginosa is present Purosanguineous Exudate: Red-tinged pus. It indicates that small vessels in the wound area have ruptured. Complication of wound healing: hemorrhage, infection, dehiscence, evisceration, and fistulas. Hemorrhage: risk of hemorrhage is higher in the first 48 hours Infection: Microorganisms can be introduced to a wound during an injury, during surgery, or after surgery. Suspect infection if a wound fails to heal. Localized swelling, redness, heat, pain, fever, foul-smelling or purulent drainage, or a change in the color of the drainage. Dehiscence: partial or total Rupture (separation) of one or more layers of a sutured wound. It is most likely to occur in the inflammatory phase of healing. Common causes are poor nutritional status, inadequate closure of the muscles, wound infection, or increased tension on the suture line (obese people). feeling a “pop” or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. o Nursing interventions include maintaining bedrest with the head of the bed elevated at 20° and the knees flexed. To pre- vent evisceration, a binder may be applied. Evisceration: total separation of the layers of a wound with internal viscera protruding through the incision. It is surgical emergency. stay in bed with knees bent to minimize strain do not put a binder on the patient. Fistulas: abnormal passage connecting two body cavities or a cavity and the skin. often result from infection or debris left in the wound. most common sites are gastrointestinal and genitourinary tracts. The Braden Scale: Used to identify persons at risk for developing pressure ulcers. The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. The final score reflects the patient’s risk; the lower the score, the more likely the patient will develop a pressure ulcer. A score of 18 or less for hospitalized patients indicates risk. Interventions should be based on individual risk factors, as well as the total score. You should use this scale to assess the patient on admission to the facility and again in 48 to 72 hours or per facility policy. Studies have shown the second score to be more predictive, probably related to an increased awareness of the patient’s status. The Braden Q is a modified scale used in children. The Norton Scale: Assesses risk based on the patient’s physical condition, mental state, activity, mobility, and incontinence. A low score indicates a high risk. Some have suggested that the Norton scale should be modified by adding categories for skin appearance, medication, and nutrition. Greater than 18 low risk, between 18-14 medium risk, between 14-10 high risk, less than 10 very high risk. Analysis/Nursing Diagnosis for skin breakdown: The following nursing diagnoses are appropriate for patients who are at risk for skin breakdown or for patients who have wounds. • Risk for Impaired Skin Integrity is appropriate for patients who have one or more risk factors for skin breakdown (e.g., immobility, incontinence, extremes of age, impaired circulation, impaired sensation, under nutrition, emaciation). NANDA International (2009) recommends that you use a risk assessment tool (e.g., Norton or Braden scale) to identify these patients. • Impaired Skin Integrity is appropriate for patients who have experienced damage to the epidermis or dermis, for example, patients who have superficial wounds or stage I or II pressure ulcers. • Impaired Tissue Integrity is appropriate for patients with wounds that extend into the subcutaneous tissue, muscle, or bone. Use this diagnosis for patients with deep wounds or stage III or IV pressure ulcers. • Risk for Impaired Tissue Integrity is appropriate for clients with Impaired Skin Integrity who are at risk for delayed healing. • Skin problems and wounds can be the etiology for other nursing diagnoses as well. • Risk for Infection is an appropriate diagnosis if the patient has a traumatic wound or is immunosuppressed, undernourished, or immobile. • Pain is a diagnosis that may be used for patients who are experiencing discomfort from the wound or from the treatments required to heal the wound. • Disturbed Body Image should be used if the patient is experiencing distress about the wound. Consider this diagnosis even if the patient is expected to make a complete recovery. Some patients experience extreme distress about wounds. You will certainly want to consider this diagnosis if the patient experiences an injury that is expected to result in disfigurement. HIV (retrovirus): The cause of HIV infection is a virus—the human immune deficiency virus. This virus, just like all other viruses, is an intracellular parasite because it must use the infected cell's resources to reproduce. The HIV can infect a cell and take over its functions to force the cell to make more copies of the virus (viral particles). These new viral particles are able to infect more cells, repeating the cycle as long as there are new host cells to infect. Effects of HIV infection are related to the new genetic instructions that now direct CD4+ T-cells to change their role in immune system defenses. The new role is to be an “HIV factory,” making up to 10 billion new viral particles daily. For adults who have been transfused with HIV-contaminated blood, AIDS often develops quickly. For those who become HIV positive as a result of a single sexual encounter, progression to AIDS takes much longer. Other personal factors that influence progression to AIDS include frequency of re- exposure to HIV, presence of other sexually transmitted infections (STIs), NUTRITION status, and stress. Everyone who has AIDS has HIV however not everyone who has HIV has AIDS. A healthy adult has around 800-1000 CD4 + T-cells per cubic millimeter of blood. Once they become infected the CD4 + T-cell count keeps diminish because the virus is turning the cells into their own. Once the count gets to 200 cells or less the person is diagnosed with AIDs. Symptoms of this acute HIV infection can be fever, night sweats, chills, headache, and muscle aches, which are similar to those of any viral infection —not just HIV. A sore throat and rash also may be present. Stages of HIV: Stage 0 a patient who develops a first positive HIV test result within 6 months after a negative HIV test result. Stage 1 a patient with a CD4+ T-cell count of greater than 500 cells/mm3 (0.5 × 109/L) or a percentage of 29% or greater. An adult at this stage has no AIDS- defining illnesses. Stage 2 a patient with a CD4+ T-cell count between 200 and 499 cells/mm3 (0.2 to 0.449 × 109/L) a percentage between 14% and 28%. An adult at this stage has no AIDS-defining illnesses. Stage 3 any patient with a CD4+ T-cell count of less than 200 cells/mm3 (0.2 × 109/L) or a percentage of less than 14%. An adult who has higher CD4+ T- cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition. Stage Unknown is used to describe any patient with a confirmed HIV infection but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available. HIV is in the blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, cerebrospinal fluid, lymph nodes, cervical cells, corneal tissue, and brain tissue of infected patients. The fluids with the highest concentrations of HIV are semen, blood, breast milk, and vaginal secretions. Contact with tears, saliva, and sweat is considered low risk for transmission unless obvious blood is present. HIV is transmitted most often in these three ways: • Sexual: genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions • Parenteral: sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products • Perinatal: from the placenta, from contact with maternal blood and body fluids during birth, or from breast milk from an infected mother to child Way to stop transmission: Safer sex methods of A, abstinence; B, be faithful (monogamous); and C, condom use can reduce HIV transmission Occupational exposure is defined as contact between blood, tissue, or selected body fluids (e.g., blood, cerebrospinal fluid [CSF], pleural fluid, synovial fluid, peritoneal fluid, pericardial fluid, breast milk, amniotic fluid, semen, and vaginal secretions) from a patient who is positive for HIV (source patient) and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances not considered infectious for HIV unless obviously bloody (e.g., feces, nasal secretions, sputum, saliva, sweat, tears, urine, vomit) do not require prophylaxis. Enhancing Nutrition HIV: Many patients with AIDS have difficulty maintaining their weight and NUTRITION status, and a registered dietitian is part of the inter-professional health care team. This problem may be caused by fatigue, anorexia, nausea and vomiting, difficult or painful swallowing, diarrhea, intestinal malabsorption, or wasting syndrome. Opportunistic Infections: Opportunistic Infections are those caused by overgrowth of the patient's microbiome (normal flora). Only when IMMUNITY is depressed are such organisms capable of causing infection. Opportunistic Infections occur because of the profound reduced IMMUNITY of the adult with HIV disease. Opportunistic Infections account for many of the signs and symptoms observed in HIV/AIDS t 8and can be protozoan, fungal, bacterial, or viral. These infections can result in death if appropriate treatment is not started quickly. - Priority nursing actions when caring for a patient who is HIV positive are continually assessing for and documenting the presence of an opportunistic infection and monitoring the patient's response to therapy. - Report to the primary health care provider any signs and symptoms that may indicate an infection. - Bacterial infection: are acquired from other people or sources and as overgrowth of skin flora. That invade tissue. Occur after minor cuts or scrapes. Ex: UTI, strep throat. - Viral Infection: is a proliferation of a harmful virus inside the - body. Viruses cannot reproduce without the assistance of a host. Viruses infect a host by introducing their genetic material into the cells and hijacking the cell's internal machinery to make more virus particles. Ex: Chicken pox, measles, herpes. - Fungal Infection: A fungus that invades the tissue can cause a disease that's confined to the skin, spreads into tissue, bones, and organs, or affects the whole body. Ex: athletes foot, jock itch, ringworms, pneumonia. OSHA: prevent work related injuries, illness, and deaths. Healthcare-Associated Infections: The term healthcare- associated infections (HAIs) refers to infections associated with healthcare given in any setting (e.g., hospitals, home care, long- term care, and ambulatory settings). Healthcare-associated infections aggravate existing illness and lengthen hospital stay and recovery time. HAIs are the leading complication of hospital care and one of the 10 leading causes of death in the United States and are preventable. Approximately 1 out of every 20 hospitalized patients will contract an HAI. Ill patients are vulnerable to infection, and they are a source of infection for others. In addition, they undergo invasive procedures (e.g., injections), which can introduce infectious organisms into their body • What is Nosocomial Infection? - Hospital-Acquired Infection. Mode of Transmission: Contact, either direct or indirect, is the most frequent mode of transmission of infection. Direct contact between two people usually involves touching, kissing, or sexual intercourse. Animals commonly transmit infection via scratching and biting as well. Indirect contact involves contact with a fomite, a contaminated object that transfers a pathogen. For example, suppose that while you are charting you begin to sneeze or cough. If you cover your nose and mouth with your hand and then resume charting, you may transmit pathogens to the pen, paper, and chart. Droplet Transmission Infection: is passed when the pathogen travels in water droplets expelled as an infected person exhales; coughs, sneezes, or talks. Airborne Transmission: Microorganisms that float considerable distances on air currents can pass infection to vulnerable hosts. Airborne pathogens can travel through heating and air- conditioning systems to infect large numbers of people. Sweeping a floor or shaking out contaminated bed linens can stir up airborne microorganisms and launch them on air currents. Muso, varicella Vector Transmission: This is an organism that carries a pathogen to a susceptible host, typically by biting or stinging, creating another portal of entry into the body. The mosquito is a common vector for diseases. Methicillin-Resistant Staphylococcus aureus (MRSA): Staphylococcus aureus lives on the skin and in the nose, usually without causing problems. If a person does have a “staph” infection it is normally treated with methicillin, but methicillin-resistant S. aureus (MRSA) can’t be killed by this drug. More than a million hospitalized patients acquire MRSA infection each year in the United States; it can be fatal. The organism is spread by skin-to-skin contact, and by living in crowded conditions. Control of MRSA has become a national priority. PPE for MRSA: Healthcare institutions are targeting MRSA with staff education, aggressive handwashing and use of alcohol- based hand rubs for 20 to 30 seconds for hand hygiene before touching a patient, increased use of protective gloves and gowns, and targeted screening. • Virulence: power of the agent to cause a disease Interventions In Reducing Infection: Proper dental care. Maintaining clean & intact skin. Proper hand hygiene. Not leaving catheters in long term. Understanding who is at risk. Using proper standard and contact precautions. Reduce caffeine and stop smoking Sterile Techniques in Nursing Care: Healthcare providers use sterile technique to perform a variety of procedures. Some of the procedures require full surgical attire; others do not. The following procedures, for example, use both sterile technique and principles of medical asepsis: administering an injection, starting an IV line, and performing a sterile dressing change. Administering an injection: you prepare the patient, cleanse the injection site, and remove the needle cap using standard precautions. You do not don sterile gloves, but for the rest of the procedure you observe sterile technique by taking care not to touch or otherwise contaminate the exposed needle. Before performing a sterile procedure, determine what supplies you will need and whether you will need assistance. If the patient is unable to maintain a position required for the procedure, you will need a helper to hold the patient during the procedure. • Wash your hands before gathering materials from the sterile supply area • gather the other required supplies and equipment. • Check the expiration date on each package. • Check the package to make sure it is intact. If it has paper or cloth wrapping, be sure there are no indications that it has ever been wet. BODY’S DEFENSE AGAINST INFECTION Primary Defenses— The “soldiers” in the first line of defense are the structural barriers of the human body. These primary defenses prevent organisms from entering the body. The normal flora of the body provides one such defense. Ex: Skin, eyes, mouth, respiratory tree. Secondary Defenses— Protective biochemical processes fight pathogens that do enter. Pathogens that dodge the primary defenses and gain entry into the body begin to release wastes and secretions and to cause the breakdown of cells and tissues. The presence of such chemicals activates a set of secondary defenses. Ex: Inflammation, fever. Tertiary Defenses— The presence of pathogens activates immune responses against specific, recognized invaders. Immunity against an infection is achieved through the presence of antibodies that neutralize or destroy toxins or disease- producing organisms. Lupus Erythematosus: Lupus is thought to be an autoimmune process. Antinuclear antibodies (ANAs) primarily affect the DNA, ribonucleic acid (RNA), and other components within the cell nuclei Immune complexes form in the serum and organ tissues, which cause inflammation, damage, and destruction. These complexes invade organs directly or cause vasculitis (vessel inflammation), which deprives the organs of arterial blood and oxygen. Like RA, lupus is probably caused by a complex combination of genetic and environmental factors. The two main classifications of lupus are: Discoid Lupus Erythematosus (DLE): A small percentage of patients with lupus have the DLE type, which affects only the skin. is a chronic skin condition of sores with inflammation and scarring favoring the face, ears, and scalp and at times on other body areas. These lesions develop as a red, inflamed patch with a scaling and crusty appearance. Lab: skin biopsy Systemic Lupus Erythematosus (SLE): is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Like RA, it is characterized by spontaneous remissions and exacerbations (“flare-ups-fever”), and the onset may be acute or insidious (slow). is an autoimmune disease. In this disease, the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. “Immune system attacks its own tissues”. Autoimmune complexes in SLE tend to be most attracted to the glomeruli of the kidneys. Therefore, many of these patients have some degree of kidney involvement, called lupus nephritis—the leading cause of death from the disease. Other causes of death are cardiac and central nervous system involvement. polyarthritis occurs in most patients with SLE. LAB: RF, ANA, ESR, serum protein electrophoresis, serum complement (C3 and C4), and immunoglobulins. false-positive Venereal Disease Research Laboratory (VDRL) syphilis test is common with lupus Topical cortisone preparations help reduce inflammation and promote fading of the skin lesions. Acetaminophen (Tylenol) or NSAIDs may be used to treat joint and muscle pain and inflammation. For renal or central nervous system lupus, he or she may also prescribe immunosuppressive agents such as methotrexate (Rheumatrex) or azathioprine (Imuran). first drug approved for SLE in 60 years is belimumab (Benlysta). Teach them not to receive live vaccines for 30 days before treatment. Skin Protection in Patients with Lupus Erythematosus • Cleanse your skin with a mild soap such as Ivory. • Dry your skin thoroughly by patting rather than rubbing. • Apply lotion liberally to dry skin areas. • Avoid powder and other drying agents such as rubbing alcohol. • Use cosmetics that contain moisturizers. • Avoid direct sunlight and any other type of ultraviolet lighting, including tanning beds. • Wear a large-brimmed hat, long sleeves, and long pants when in the sun. • Use a sun-blocking agent with a sun protection factor (SPF) of at least 30. • Inspect your skin daily for open areas and rashes. Pregnancy is not recommended for those with cardiac, renal, or central nervous system involvement. The major skin manifestation of DLE and SLE is a dry, scaly, raised rash on the face (“butterfly” rash) Systemic Sclerosis:: Systemic sclerosis (SSc), also called scleroderma, is another chronic, inflammatory, autoimmune connective tissue disease, Chronic hardening and tightening of the skin and connective tissues. The onset of the disease is usually between 25 and 55 years of age, with most women getting it in their 40s. Scleroderma means hardening of the skin, which is only one sign of the problem. Some patients, often children, have only skin involvement, or localized scleroderma (also called linear scleroderma). However, adults usually have skin and other body system involvement. Diffuse: almost every where Limited: limited to face, neck and distal. People with limited often experience the CREST syndrome. Education for a Client Who Has Scleroderma Receiving an Organ Transplant Should Take What Precautions? • Teach patients that the drug increases their risk for serious infections. • Teach them not to receive live vaccines for 30 days before treatment. • Do not receive live flowers, do not visit ill people, wear a mask when visiting others. What is Crest Syndrome? • • Calcinosis (calcium deposits) • • Raynaud's phenomenon (first symptom that occurs) • • Esophageal dysmotility • • Sclerodactyly (scleroderma of the digits) • • Telangiectasia (spider-like hemangiomas) Explain the Typical Assessment Findings of Systemic Sclerosis/Lupus? Physical Assessment: Alopecia Mouth ulcers, Polyarthritis, Hardened skin- scleroderma Signs and Symptoms: • Inflamed red rash across the nose (butterfly rash). Nephritis, Pericarditis, Raynaud’s phenomenon, Pleural effusions Pneumonia Abdominal pain, joint inflammation, Fever, Fatigue, Anorexia, Weight loss, Generalized weakness Lab Assessment: • Same as for RA, Other test, Anti-SS-a, Anti-SS-b, Anti-smith, Anti-DNA and extractable nuclear antigens, CBC Psychosocial Assessment: • Altered body image, decreased activity-social isolation, Assess support system Caring for A Patient With Dementia, Specific Nursing Interventions • Promote patient orientation, use simple communication, decrease anxiety, keep the patient safe, and provide continuity of care. As for assistance with procedures such as indwelling catheters or IV insertions. Interventions For A Patient With Deep Vein Thrombosis (DVT)? • Patient education, Leg exercises, Early ambulation • Adequate hydration • Graduated compression stockings • Intermittent pneumatic compression, such as sequential compression devices (SCDs) • Venous plexus foot pump, Anticoagulant therapy What Types of Clients Are at Greatest Risk for A DVT? • Decreased mobility or immobility • Older adults (40 years or older) • Family history or history of DVT, VTE, PE varicose veins, or edema • Oral contraceptives use • Smoking • Decreased cardiac output • Hip fracture or total hip or total knee surgery • Obesity • Cancer • Spinal cord injury • Heart disease Negative Effects of Immobility? Osteoarthritis, Rheumatoid Arthritis, Loss of muscle strength, Impaired balance, altered join mobility, decreased stability, Osteoporosis, Depression, isolation, anxiety, and mood change, can cause decreased peristalsis, DVT. Interventions to Reduce the risk of Contractures: • Gently straighten out contracted extremity, fingers. • Mobility: Encouraging interventions such as passive ROM, and rotation. Flexion and extension exercises, these interventions should be performed about every 2hrs and as needed if the contractures are present. • How Does a Nurse Perform a Neurovascular Assessment? If Negative Findings Occur, What Should the Nurse Do Next? Assessment of the extremities to evaluate sensory & motor function (neuro) & peripheral circulation (vascular). Components: (bilateral comparison) pulses, capillary refill, skin color, temperature, sensation, & motor function (movement). Pain & edema are also assessed. (5 P’s: Pain, Pulse, Pallor, Paresthesia, & Paralysis) Explain the Differences Between Acquired, Adaptive, Innate, and Specific Immunity: • Acquired- Antibody-mediated immunity, acquired by infection (active) or by the transfer of antibody or lymphocytes from an immune donor (passive). • Adaptive- A person's body learns to make as an adaptive response to invasion by organisms or foreign proteins, occurs either naturally or artificially through lymphocyte responses and can be either active or passive. • Innate- Nonspecific defense mechanisms that come into play immediately or within hours of an antigen's appearance in the body, already present in the body. • Specific- Acquired during the organism's lifetime and involves the activation of white blood cells (B and T lymphocytes), which distinguish and react to foreign substances. B lymphocytes (or B cells) operate by producing antibodies, proteins that neutralize foreign molecules. • Think of Maslow’s Hierarchy) • • Maslow’s hierarchy CPM machine: Check cycle every 8 hrs, ensure the joint is placed properly Do not store the machine on the floor, assess patient's response to machine Turn the machine off when patient is eating, If patient is confused, move the control out of reach The priority collaborative problems for patients with AIDS are: 1. Potential for infection due to reduced IMMUNITY 2. Inadequate GAS EXCHANGE due to anemia, respiratory infection (P. jiroveci pneumonia [PCP], cytomegalovirus [CMV] pneumonitis), pulmonary Kaposi's sarcoma (KS), or anemia 3. Pain due to neuropathy, myelopathy, cancer, or infection 4. Inadequate NUTRITION due to increased metabolic need, nausea, vomiting, diarrhea, difficulty chewing or swallowing, or anorexia 5. Diarrhea due to infection, food intolerance, or drugs 6. Potential for reduced TISSUE INTEGRITY due to KS, infection, reduced NUTRITION, incontinence, immobility, hyperthermia, or cancer 7. Cognitive decline due to AIDS dementia complex (ADC), central nervous system infection, or cancer 8. Potential for psychosocial distress due to living with a life-threatening chronic disease that affects all aspects of life 1. Fibromyalgia - A chronic pain syndrome usually affiliated with arthritis and other comorbidities. Treatment focuses on management of the symptoms of the disease process. Clients are encouraged to exercise and maintain daily routines as much as possible. 2. Pain, stiffness, and tenderness are located at specific sites in the back of the neck, upper chest, trunk, low back, and extremities. These tender points are also known as trigger points and can typically be palpated to elicit pain in a predictable, reproducible pattern 3. Cast care- Handle with palms of hands, have pt. report “hot spots”, instruct pt. not to put anything down the cast, encourage pt/family to smell cast After- remove dry skin w/ lotion, expect decr. Size and ROM, support with pillows, exercise slow, wear support hose to prevent edema 1. Benefits of activity a. Improve circulation b. Promote health c. Promote independence d. Decrease pain and other joint stiffness Posture- places body in neutral position, everything is in line and works better. POOR- accidents/trauma/falls, careless sitting/standing/sleeping, excessive weight, foot probs or improper shoes, negative self image, occu. Stress, poor sleep support, poor designed workspace, visual difficulties, weak muscle or imbalance, skeletal misalignment/malformation. GOOD- avoid standing in1 position for long time, don’t lock knees, keep core tight, don’t bend forward at waist/neck, sit @ comfy height @ desk, don’t slump, sit close to work, use back support, sit w/ feet flat on floor and knees below hips, sleep on firm mattress. NEVER EVENTS: ■ Foreign object (such as a sponge) left in patients after surgery. ■ Air embolism ■ Administering the wrong type of blood. ■ Severe pressure ulcers ■ Falls and trauma ■ Injuries from burns, restraints, or bedrails ■ Infections associated with urinary catheters ■ Infections associated with intravenous catheters ■ Symptoms resulting from poorly controlled blood sugar levels ■ Surgical site infections following certain elective procedures (e.g., certain orthopedic surgeries, bariatric surgery for obesity ■ Deep vein thrombosis or pulmonary embolism following total knee and total hip replacement procedures. 24-2 Joint Commission 2013 Patient Safety Goals Goal 1. Improve the accuracy of patient identification. Goal 2. Improve effectiveness of communication among caregivers. Goal 3. Improve the safety of using medications (including anticoagulants) Goal 7. Reduce the risk of healthcare associated infections (including hand hygiene, multidrug-resistant organisms, central-line bloodstream infections, catheter associated urinary tract infections and surgical site infections). Goal 8. Accurately and completely reconcile medications across the continuum of care. Goal 15.The organization identifies safety risks inherent in its patient population Health Disparities : Health status. Quality of care. Access to care Stress incontinence: loss of small urine from increased abdominal pressure without bladder muscle contraction with laughing, sneezing, and lifting. Urge incont: inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increase bladder pressure. Overflow incont: urinary retention from bladder overdistention and frequent loss of small amount of urine due to obstruction of urine outlet or an impaired detrusor muscles. Reflex incont: involuntary loss of moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle usually from spinal cord disfunction Functional incont: loss of urine due to factors interfere with responding to the need to urinate (cognitive, mobility, and environmental barriers) Transient incont: reversible incontinence due inflammation or irritation (UTI) temporary cognitive impairment, disease process (hyperglycemia) medications (diuretics, anticholinergics, sedatives) a) Identify negative effects of immobility on musculoskeletal system • Osteoarthritis • Rheumatoid Arthritis • Loss of muscle strength • Impaired balance • Altered join mobility • Decreased stability • Osteoporosis • Depression, isolation, anxiety, and mood change • Can cause decreased peristalsis b) Explain ways to maintain proper posture for a client • Place the spine in a neutral position(Resting) FINAL EXAM CONCEPT GUIDE • This allows the bones to be aligned, reduce stress and fatigue & muscle joints, and ligament can work efficiently • Avoid standing in 1 position for a long period of time • Do not lock your knees when standing • Keep core tight and don’t bend at the waist or neck • No slumping when sitting • Sit close to your work and use back support • Sit with feet flat on floor • Sleep on firm mattress • Do not wear high heels for a prolonged time, do not slump, and use a chair that supports your back. a) Identify assessment of a client with rheumatoid arthritis • Physical assessment i) Early signs and symptoms – Inflammation; low-grade fever, fatigue, weakness, anorexia, paresthesia ii) Late signs – deformities, moderate to severe pain & morning stiffness; osteoporosis, severe fatigue, anemia, weight loss, subcutaneous nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung disease, Sjogren’s syndrome, kidney disease, Felty’s syndrome, chronic pain, redness and swelling of affected joints. Symptoms are bilateral and symmetric a) Special care patients taking Timolol eye drops • Timolol is a beta-blocker eye drop used to treat glaucoma. Timolol lower the pressure in the eye by decreasing the amount of fluid within the eye. This drug induces hypoglycemia and also mask the hypoglycemic symptoms. Therefore, special care may include monitoring patient’s glucose level. Take vital signs. • Other side effects of Timolol are slow heart rate, hives, difficult breathing, swelling of face, lips, tongue, or throat. Therefore, when caring for patient taking Timolol eye drops, assess breathing, swelling of face, lips, tongue, and throat. In addition, asses skin for hives. a) Main causes of accidental poisoning • Young Children exposure is mainly due to improper storage of household chemicals, medicines, vitamins & cosmetics • Older children and adolescents cause is due to suicide attempt, accidental experiment with recreational or prescription drugs. Adults poisoning occurs by misuse or abuse or prescription drugs, especially narcotics, tranquilizers and antidepressants b) Interventions for a patient with a DVT • Patient education • Leg exercises • Early ambulation • Adequate hydration • Graduated compression stockings • Intermittent pneumatic compression, such as sequential compression devices (SCDs) • Venous plexus foot pump Anticoagulant therapy a) Appropriate nursing interventions for a client with a lowered immunity. • Reduce exposure to pathogens through the use of aseptic technique • Maintain skin integrity and support natural defenses against infection. • Reduce stress. • Promote immune function through collaborative care. • Provide supportive measures to decrease the length of time that invasive devices, such as intravenous lines and urinary catheters, are needed by a patient • For clients who have had surgery and general anesthesia or who are at risk for pneumonia, promote coughing and deep breathing on a regular basis. • For clients being mechanically ventilated, provide special oral care designed to prevent ventilator-associated pneumonia. • For older adults, especially those who or frail or in a debilitated state and those living in a group residence, encourage immunizations that can help them to acquire immunity from some communicable diseases, such as influenza. • For clients who have breaks in the skin or incision sites, provide regular assessment for infection status and follow appropriate medical or surgical asepsis guidelines. • For all clients at risk for infection, provide care that is based on principles of medical asepsis lab values for Rheumatoid arthritis, p.320 • Rheumatoid factor: Positive or increase indicative of possible RA or other CTD; may also be elevated in leukemia, liver disease, and kidney disease • ANA: Elevations common in SLE, SSc, RA, and other inflammatory CTDs (5% of healthy adults have positive ANA results) • Erythrocyte sedimentation rate (ESR): Increased in inflammatory diseases such as RA, SLE, PMR, temporal arteritis; also elevated in patients with bacterial infections or severe anemias • Alpha1 globulin: (>0.3 g/dL; >3 g/L) Increased level possible in RA Early Signs and Symptoms Joint • Inflammation Systemic • Low-grade fever • Fatigue • Weakness • Anorexia • Paresthesias Late Signs and Symptoms Joint • Deformities (e.g., swan neck or ulnar deviation) • Moderate-to-severe pain and morning stiffness Systemic • Osteoporosis • Severe fatigue • Anemia • Weight loss • Subcutaneous nodules • Peripheral neuropathy • Vasculitis • Pericarditis • Fibrotic lung disease • Sjögren's syndrome • Kidney disease • Felty's syndrome Osteoarthritis is the progressive deterioration and loss of cartilage and bone in one or more joints. Articular cartilage, also known as hyaline cartilage, contains water and a matrix of: • Proteoglycans (glycoproteins containing chondroitin, keratin sulfate, and other substances) • Collagen (elastic substance) • Chondrocytes (cartilage-forming cells) primary OA, the disease is caused by aging and genetic secondary OA occurs less often than primary disease and results from joint injury and obesity. Priority problems: 1. Chronic pain due to joint swelling and deterioration 2. Potential for decreased MOBILITY due to joint pain and muscle atrophy Sjögren's syndrome, which includes a triad of: • Dry eyes (keratoconjunctivitis sicca [KCS], or the sicca syndrome) • Dry mouth (xerostomia) • Dry vagina (in some cases The antinuclear antibody (ANA) test measures the titer of a group of antibodies that destroy the nuclei of cells and cause tissue death in patients with autoimmune disease. [Show More]

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