Foundations Midterm Study Guide

CHAPTER 1 Introduction to Nursing

Describe the historic background of nursing Early civilizations – illness had supernatural causes

o Theory of Animism – cause of mysterious changes in bodily functions – everything in nature was alive with invisible forces and endowed with power.

Good spirits brought health; evil spirits brought sickness and death.

o Physician was medicine man who treated diseases by chanting, inspiring fear, or opening the skull to release evil spirits. Nurse was the mother who cared for her family during sickness by providing physical care and herbal remedies. [nurse as nurturing and caring]

Temples became centers of medical care because of the belief that illnesses were caused by sin and gods’ displeasure.

o Priests were regarded as physicians.o Nurse was viewed as slave, carrying out small tasks based on the orders of

the priest-physician. Christian period – nursing began to have a formal and clearly defined role.

o Women called deaconesses made the first visits to sick people. o During Crusades (11th – 13th) hospitals were built for the pilgrims needing

healthcare and nursing became respectable. By end of Middle Ages – nursing had developed purpose, direction, and leadership. Beg. Of 16th – emphasis from religion to warfare, exploration, and expansion of

knowledge.o There was a shortage of people. Women who had committed crimes were

recruited into nursing to serve jail time. Nurses received low pay and worked long hours.

Middle of 18th – 19th - Nightingale:o Established training school for nurseso Identified needs of patient and roles of nurse to meet those needs.o Established standards for hospital management, occupation for women,

nursing educationo Recognized 2 parts of nursing: health and illnesso Believed nursing as separate and distinct from medicineo Recognized nutrition is important to healtho Stressed need for continuing ed. For nurseso Instituted occupational and recreational therapy for sick peopleo Maintained accurate records, recognized as the beginnings of nursing

research 19th – 21st : Battle casualties during Civil War focused attention on the need for

educating nurses in the US. o Schools in connection with hospitalso Lead to lack of educational standards (no boundary between nursing service

and nursing education), male dominance in healthcare, and idea that women depended on men

WWII – women worked outside of homeo More independent and assertiveo Lead to emphasis on educationo War resulted in knowledge explosion in medicine and technologyo Schools of nursing were based on educational objectives and were

increasingly developed in university and college settingso Lead to degrees in nursing for men, women, and minorities

Nursing broadened in all areaso practice in a wide variety of healthcare settingso Development of a specific body of knowledgeo Conduct and publication of nursing researcho Recognition of the role of nursing in promoting healtho Increased emphasis on nursing knowledge as the base for EB has led to the

growth of nursing as a professional discipline

Definitions of nursing Nurse: nutrix – “to nourish”

o Nursing: person who nourishes, fosters, and protects and who is prepared to take care of sick, injured, and aged people.

International Council of Nurses (2002): “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”

American Nurses Association (ANA): describes values and social responsibility for nursing, provides a definition and scope of practice for nursing, discusses nursing’s knowledge base, and describes the methods by which nursing is regulated within its Nursing’s Social Policy Statement

o Nurses focus on human experiences and responses to birth, health, illness, and death within the context of individuals, families, groups, and communities.

o Knowledge base for nursing practice includes diagnosis, interventions, and evaluation of outcomes from an establish plan of care.

o Nurse integrates objective data with knowledge gained from an understanding of the patient’s or groups subjective experiences, applies scientific knowledge in the nursing process, and provides a caring relationship that facilitates health and healing.

Focus in all definitions of nursing is patient and includes physical, emotional, social, and spiritual dimensions of that person.

o Nursing concepts now include prevention of illness and promotion and maintenance of health for individuals, families, and communications.

Status of nursing as a profession and as a discipline. Nursing uses existing and new knowledge to solve problems creatively and meet human

needs within ever-changing boundaries. Nursing recognized as a profession:

o Well-defined body of specific and unique knowledgeo Strong service orientationo Recognized authority by a professional groupo Code of ethicso Professional organization that sets standardso Ongoing researcho Autonomy

Nursing involves/is:o Specialized skills and application of knowledge based on an education that

has both theory and clinical practiceo Guided by standards set forth by professional organizations and an establish

code of ethics

o Focuses on human responses to health probs and is focused on wellness, an area of caring that includes nurse’s knowledge and abilities.

o Recognized as scholarly, with academic qualifications, research, and publications.

o Nursing interventions are focused on EBP

CHAPTER 5 Theory, Research, and Evidence-Based Practice

Outline the steps in implementing evidence-based practice. Step 1. Ask a question about a clinical area of interest or an intervention:

o Most common PICO: P – Patient, population, or problem at interest (Need for explicit

description; may include setting, limiting to subgroups such as age) I – Intervention of interest (More defined, more focused search of

literature will be; may include exposure, treatment, patient perception, diagnostic test or predicting factor)

C – Comparison of interest (usually to another treatment or standard of care)

O – Outcome of interest (Identifying outcome to enable a literature search to find evidence that examined the same outcome in different ways)

Step 2. Collect the most relevant and best evidence. o Level of strength: 1 strongest and 7 lowesto Strongest evidence found from systematic reviews, EBP guidelines, and

meta-analyis Systematic reviews: summarize finding from many studies of a

specific clinical practice question or topic, and recommend practice changes and future directions for research.

Evidence-based practice guidelines: synthesize info from multiple studies and recommend best practices to treat patients with a disease, a symptom or a disability

Meta-analysis: uses statistical analysis of the effect of a specific intervention across multiple studies, providing stronger evidence than results from a single study.

If these aren’t available, collect reviews of descriptive or qualitative studies or articles of original quantitative studies in databased from MEDLINE and CINAHL

Step 3. Critically appraise the evidenceo Ask 3 questions:

What were the results of the study? Are the results valid (did the investigator measure what was

intended to be measured) and reliable (were the measurements consistent across time)

Will the results of the study improve patient care? Step 4. Integrate the evidence with clinical expertise, patient preferences, and values in

making a decision to change.o If patient doesn’t want change or if it’s too costly or risky, it shouldn’t occur.

X-rays allow one to see but are more riskier b/c of exposure to radiation.

Step 5. Evaluate the practice decision or change. o Essential to determine if the change is effective for a particular patient or

setting and if the expected outcomes resulted from the change.

CHAPTER 6 Values, Ethics, and Advocacy

Compare and contrast the principle-based and care-based approaches to bioethics.Principle based approach includes: Utilitarian (rightness or wrongness of an action depends on the consequences of the

action) Deontologic (action is right or wrong independent of its consequences)

o It identifies 4 key principles: Autonomy - respect the rights of patients or their surrogates to

make healthcare decisions (provide info to patients and families to make the decision that is right for them; might need to collaborate with other professionals)

Nonmaleficience - avoid causing harm (seek not to inflict harm; seek to prevent harm or risk of harm whenever possible)

Beneficence – benefit the patient, and balance benefits against risks and harms (commit yourself to actively promote the patient’s benefit (health and wellbeing or good dying)

Justice – give each his or her due; act fairly (always seek to distribute the benefits, risks, and costs justly)o Many nurses add fidelity - keep promises (never abandon a

patient), veracity (truthfulness), accountability (responsible), privacy, and confidentiality.

Be aware: people identify benefits and harms differentlyo Ethical dilemmas – arise when an attempt to adhere to basic ethical

principles results in two conflicting courses of action. No way to identify which is most important. There are 2 or more correct courses of action where both cannot

be followed You are doing something right and something wrong Most involve ethical conduct or conflicting traits of character

Care based approach – care as foundation for nursing’s ethnical obligations. Directs attention to the specific situations of individual patients viewed within the

context of their life narrative.o How you chose to be and act each time you encounter a patient or colleague

is a matter of ethnical significance. Characteristics:

o Centrality of the caring relationshipo Promotion of the dignity and respect of patients as peopleo Attention to the particulars of individual patientso Cultivations of responsiveness to others and professional responsibilityo Redefinition of fundamental moral skills to include kindness, attentiveness,

empathy, compassion, and reliability.

Use an ethical framework and decision-making process to resolve ethical problems. Ethnical distress: nurse knows right thing to do but either personal or institutional

factors make if difficult to follow the correct course of action. There is a barrier keeping you from doing something that’s right

There is a barrier because something is wrong, but you are not sure what it is

Use nursing process:o 1. Assess the situation (gather data):

Involves the people involved, overall nursing, medical, and social situation, and relevant legal, administrative, and staff considerations.

o 2. Diagnose (identify) the ethical problem: Clarify that the issue is ethical – is there a conflict at the personal,

interpersonal, institutional, or societal level? Is there a question that arises either at the level of thought or

feeling? Does the question have a moral or ethical component (does it raise

issues of rights or moral character?)? State problem, identify your relationship to the decision. Identify

time parameters. o 3. Plan: identify options and short/long term consequences:

Use ethical reasoning to decide on a course of action that you can justify equally.

Identify your personal and professional moral positions and those of other involved individuals.

Apply pertinent ethical theories and principles. Apply codes of conduct and ethics, professional position

statements or guides as applicable. Consider consultation with a respected and wise colleague or an

institutional ethics committee. Decide on the course of action you are best able to support.

o 4. Implement your decision: And compare your action outcome with what you considered and

hoped for in advance.o 5. Evaluate your decision:

What have you learned from this process that will help you in the future?

How can you improve your reasoning and decision making in the future?

In what ways does your institutional culture need to chance to prevent similar conflicts in the future?

8 ethical considerations in patient care:o Balance between benefits and harms in the care of patientso Disclosure, informed consent, and shared decision making

3 models Paternalistic: clinicians act to benefit the patient and

decide what should be done and inform the patient and patient has to comply

Patient sovereignty: patients or their surrogates express their right to be autonomous, tell the clinican what they want, and clinician’s role is to comply.

Most clinicians believe in shared decision making. Objective for all clinical decision making is decisions that

secure the health and well being of the patient and that honor and respect the integrity of all participants in the decision making process.

o Norms of family life

Sensitivity of how a patient’s injury or illness influences family members

Relationship between clinicians and patientso Professional integrity of clinicians

While patient is main focus, nurses owe integrity to other professionals – sacrificing personal integrity to meet the needs of others.

o Cost-effectiveness and allocation Needs of patients and their families and the limited resources

available to professional caregivers. Justice – distributes benefits and burdens of healthcare delivery

fairly.o Issue of cultural and/or religious variation

Conflicts among religionso Considerations of power

Clinicians who believe that they lack power to influence care settings and delivery may also experience ethical conflict and distress

Examples of ethical problems/dilemmaso Paternalism

Does preventing harm justify violating the patient’s right to autonomy and make it acceptable for the nurse to act as a parent and choose an action the patient doesn’t want b/c the nurse believes it to be in the patient’s best interest?

o Deception New student – in order to decrease patient’s anxiety, should student

say, no I’ve given this before?o Confidentiality

If the nurse believes anxiety is interfering with the patient’s ability to obtain needed healthcare, would it be ethical to break the woman’s confidence to obtain help for her?

o Allocation of scare nursing resources You know you cannot meet everyone’s needs well; how do you

distribute your nursing care?o Advocacy in marker-driven environment

Woman has to be discharged but you know she would be better off staying b/c no family but she has no money to pay for more days… What do you do?

o Valid consent or refusal Should you administer the medication knowing the patient no

longer consents to this procedure?o Conflicts between the patient’s and nurse’s interests

Homeless man… nurse pregnant… is a nurse ever justified in refusing to provide care to a patient assigned to his or her care?

o Conflicts concerning new technologies In vitro fertilization

Examples of physician/nurse problemso Disagreements about the proposed medical regimen

Patient wants to die and doesn’t want to go through tests but dr. tells you to do it… do you prepare the patient for the tests? Are there grounds to refuse participation?

o Conflicts regarding the scope of the nurse’s role

Even if dr. says no is nurse obligated to make a recommendation for the patient?

o Unprofessional, incompetent, unethical, or illegal physician practice Is the nurse obligated to report the slacking physician?

Examples of nurse/nurse problemso Claims of loyalty

Patient dies while nurse is sleeping; do you report it?o Unprofessional, incompetent, unethical or illegal nurse practice

Patient reported nurse touching her inappropriately – what should you do?

CHAPTER 21 CommunicatorList at least eight ways in which people communicate nonverbally

o Aka body language – helps nurse to understand subtle and hidden meanings in what is being said verbally.

Toucho Means different things for different people – based on family, religion, classo One of the most effective nonverbal ways to express feelings of comfort,

love, affection, security Eye contact

o Glance – attention-getting method to open convoo Some cultures – respect & willingness to listen while others as invasion to

privacy or inferiorityo Eyes fix in a stare = anger, narrow = disgust, open wide = fearo Blank stare = daydreaming

Facial expressionso Most expressive part of the body

Postureo People in good health hold their bodies well; depressed = slouch; rigid, stiff

= tension/pain Gait

o Bouncy, purposeful walk carries a message of well-beingo Shuffling = sad/discouraged; bent over = recovery from surgery

Gestureso Thumps up = victory, kicking an object = anger, waving = come overo Used when two people speaking in different languages attempt to

communicate with each other General physical appearance

o Dry skin = dehydration; radiate = good health Mode of dress and grooming

o Dress well = high self-esteem Sounds

o Crying, moaning, gasping, sighing Silence

o Complete understanding of each other, thinking, or angry with each other

Describe the interrelation between communication and the nursing process Assessing

o Gather info from verbal & nonverbal communication formso Written word – used to obtain data concerning patients and when reading a

patient’s records or charts before meeting themo Spoke word – give and receive reports to and from other health providers

o Data collected verbally and nonverbally is analyzed to others through oral and written communication

Diagnosingo Communicate with other nurses through writing and wordo Written diagnosis becomes permanent part of patient’s recordo Outcome identification and planningo Planning – requires communication among patient, nurse, and others as

outcomes are developed and interventions are determinedo Need to inform others on what needs to be done

Implementingo Teach, counsel, and support patients/familieso Nursing order requires many messages between nurse and patient

Evaluatingo Rely on verbal and nonverbal cues from patient to see whether objectives or

goals have been achievedo Negative messages facilitates revision of parts of the care plan

Documenting communicationo Assessment of patient’s needs and conditions requires accurate

documentation.

Describe how each type of ineffective communication hinders communication Failure to perceive patient as human being

o Address patient by formal name – Mr. Mrs. Dr. vs slang – honey, sweetieo Focus on whole person not simply on illness

Failure to listeno Closed mind or focusing on own needso Nurses who lack confidence may become defensiveo Defensiveness = barrier to open and trusting communication

Inappropriate comments or questions Cliches

o Cliché – sterotypes, trite, or pat answer “everything will be all right.”o Generalizations “men tolerate pain poorly.”

Using questions requiring only yes or no answero Did you have a good day?o Are you ready to get out of bed?

Using questions containing the words why and howo Why were you not tired? How did you ever go on a crash diet?o Seem intimidating

Using questions that probe for informationo May become resentful, stop talking, and try to avoid further conversationo “let’s get to the bottom of this”

Using leading questionso Produce answers that might please the nurse but are unlikely to encourage

the patient to respond honestly without feelings intimidatedo “You aren’t going to smoke that are you?”

Using comments that give adviceo Implies that the nurse knows what is best for the patient and denies him or

her the right to make decisions and have feelings.o Increases patient’s dependence on caregivers.o Can be good when requested and if nurse is an expert

Using judgmental commentso “You aren’t acting very grown up.”

Changing the subjecto Patient may be ready to discuss something and can be frustrated if put off

by a change in topico Nurse may feel uncomfortable and change subject (death, suicide, abortion)

– ex. of ignoring the patient and worrying about own needs Giving false assurance

o Impression that nurse isn’t interested in their problems Gossip and rumor

o Can be used to inform, influence others, entertain, or vento Can damage reps of individuals who are the subject of the info

Aggressive interpersonal behavioro With physicians, horizontal violence – nurse to nurseo Angry patients – remain with patient, be calm/assertive, restraints as a last

resort

CHAPTER 24 Vital SignsIdentify sites for assessing temperature, pulse, and blood pressure, assess temperature, pulse, respirations, and blood pressure accurately, and demonstrate knowledge of the normal ranges for temperature, pulse, respirations, and blood pressure across the lifespan Temperature

Factors affecting site are age, state of consciousness, amount of pain

o Tympanic membrane: core temp Should not be used with patient who has drainage from ear or

scarso Oral

Patient must close mouth around probe If patient drank hot or cold fluids or smoked or chewed gum, wait

15-30 minutes to allow oral tissue to return to normal temp. Should not be taken in people with diseases of oral cavity and

those who had surgery in nose and mouth or in person with O2 (can drop).

o Rectal: core temp When oral cannot be used Not used in newborns, children with diarrhea Stimulates vagus nerve – decreases BP Can’t use with person low WBC or spinal cord injury

o Axillary Newborns

o Normal temps: >98.6 F = pyrexia (fever) Older adults at risk for an extreme; lose body temp Infants & children respond more to changes in body temp

o Steps to assess temp: Hand hygiene & PPE Identify patient Close curtains around bed – privacy and discuss procedure Make sure thermometer is working Put on gloves it dealing with body fluid

Tympanic: turn on, put disposable probe, insert in ear towards jawline, pull pinna up and back to straighten ear canal, then activate (2 sec)

Oral: place probe under patient’s tongue in posterior sublingual pocket – in contact with blood vessels lying close to surface

Rectal: adjust bed to elbow of caregiver, side-lying position, expose only buttocks, lubricate probe 1 inch with water-soluble lubricant, insert in anus 1.5 in. in adult & 1 in. in child, use toilet tissue to remove feces, place bed in lowest position

Axillary: place end of probe in center of axilla and bring arm down close to body

Temporal artery: like a remote, press on and hold, and spread through forehead, midline, hairline

NORMAL TEMPERATURES IN ADULTSORAL RECTAL AXILLARY TYMPANIC FOREHEAD98.6 F 99.5 F 97.7 F 99.5 F 94.0 F37.0 C 37.5 C 36.5 C 37.5 C 34.4 C

Pulseo Peripheral arterial pulses

Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

Radial most common Carotid – emergency – people in shock or cardiac arrest Brachial – infants

o Apical pulse If peripheral is weak, irregular, very rapid Assessed when giving meds that alter heart rate or rhythm 5th and 6th intercoastal space, 3inc left of the median line and

slightly below nippleo Apical-radial pulse

When radial pulse irregular, count pulse at apex and radial artery together

Difference between the rates – pulse deficit – indicates that all of the heart beats are not reaching the peripheral arteries or are too weak to be palpated

o Normal rates: Adults/adolescents 60-100 beats/min Decrease w/ age

o Assessing peripheral pulse by palpitation Check medical order Perform hygiene Identify patient Close curtains and explain procedure Lightly compress artery so pulsations can be felt and counted If normal, count 30 sec and multiply by 2; if abnormal count

whole min Note rhythm & amplitude (+2 normal)

Respirations o Involves ventilation, diffusion, and perfusion

Ventilation (breathing)- movement of gases in and out of lungs Ventilation has both autonomic and voluntary control

Inspiration (inhalation) – act of breathing in Expiration (exhalation) – act of breathing out Diffusion – exchange of oxygen and carbon dioxide between the

alveoli of the lungs and the circulation blood Perfusion – exchange of oxygen and carbon dioxide between the

circulating blood and tissue cellso Assess respiratory rate (breaths/min), depth (deep or shallow), and rhythm

(regular or irregular) by inspection (observing and listening) or by listening with stethoscope

Can also monitor arterial blood gas results and pulse oximeter to determine oxygenation of blood

o Normal respirations: Adults 12-20/min Infants/young children breathe more rapidly

o Assessing respiration while fingers on pulse measurement, count respirations for 30 sec

and x2 for respiratory rate/min Blood pressure

o Force of the moving blood against arterial walls Max BP – when exerted on the walls of the arteries when the LV of

the heart contracts & pushes blood thru aortic valve into the aorta at the beginning of systole

Pressure rises as ventricle contracts (systole) and falls as heart relaxes (diastole)

o Assessing blood pressure Sphyhmomanometer Cuff & manometer Bladder inside cuff should enclose at least 2/3 of the adult limb

and all of a child’s limb If cuff too narrow = too high reading If cuff too wide = too low reading Length should be 80% of arm circumference and

width 40% of arm circumference Bladder inflated enough to obstruct flow of blood through artery &

needle valve allows cuff to be deflated while pressure is being read

Automated blood pressure monitors May have PR, puse oximetry, or temp

o Doppler ultrasound Amplifies sound

Used if sounds are indistinct or inaudible o Direct electronic measurement

Insert thin catheter into artery; tip senses pressure and transmits it to display waves of systolic and diastolic

Used in intensive careo Assessing brachial artery BP

Should not be taken on arm with IV line or AV fistula or shunt Should be avoided in the arm on the side of an axillary node

dissectiono Assessing politeal artery BP

Systolic = normally 10-40 mm Hg higher; diastolic same Prone position

Palpatiing the BP

Cuff inflated 30 mm Hg above point at which artery disappearso Normal BP

120/80 Rise or fall of 20-30 mm Hg is significant Older people – higher BP Lowest in the am Women lower BP until menopause BP incr. with food, exercise, contraceptives, emotions, weight, and

when sitting (as compared to lying)o Assessing BP

Forearm should be supported at level of heart and palm of hang upward

Palpate brachial artery – center bladder of cuff over brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 – 5 cm (1-2 in.) above inner aspect of the elbow

Line artery marking on the cuff up with the patient’s brachial artery

Wrap cuff around arm smoothly and snugly, don’t allow any clothing to interfere with proper placement of cuff

Palpate radial artery, inflate cuff and note when pulse disappears

Pump pressure 30 mm HG above systolic Note when first faint, but clear sound appears that slowly

increase in intensity – systolic Note when sound completely disappears - diastolic

AGE-RELATED VARIATIONS IN NORMAL VITAL SIGNSAGE TEMPERATURE

(F)PULSE (BEATS/MIN)

RESPIRATIONS (BREATHS/MIN)

BLOOD PRESSURE (MM HG)

Newborn 36.8 (axillary) 80 – 180 30 – 80 73/551 – 3 yrs 37.7 (rectal) 80 – 140 20 – 40 90/556 – 8 yrs 37 (oral) 75 – 120 15 – 25 95/7510 yr 37 (oral) 75 – 110 15 – 25 102/62Teens 37 (oral) 60 – 100 15 – 20 102/80Adults 37 (oral) 60 – 100 12 – 20 120/80>70 yrs 36 (oral) 60 – 100 15 – 20 120/80

CHAPTER 27 Asepsis and Infection Control

Explain the infection cycle

Infection - disease state that results from the presence of pathogens (disease-producing microorganisms)

Infectious agento Bacteria – most significant and most commonly observed infection-causing

agents

Sperical (cocci), rod-shaped (bacilli), or corkscrew shaped (spirochetes)

Gram + : thick cell wall that resists decolorization and are stained violet

Gram - : decolorized by alcohol & do not staino Virus – smallest of all organisms, seen only in EM

Given antiviral meds during prodromal stage to shorten full stage of the illness

o Fungi – plant-like & present in air, soil, water Organism’s ability to produced disease in a person depends on:

o Number of organismso Virulence of organism, or its ability to cause diseaseo Competence of the person’s immune systemo Length and intimacy of the contact between the person and the

microorganism Reservoir

o Growth and multiplication of microorganismo Is natural habitat of the organismo People, animals, soil, food, water, milk, other people

Portal of exito Point of escape for organism from reservoiro Respiratory, gastrointestinal and genitourinary tracts, blood tissues, and

breaks in skin Means of transmission

o Direct or indirect, vectors, airborne, and droplets Portal of entry

o Organism enters new host; usually same as entrance Susceptible host

o Microorganisms can continue to exist only in a source that is acceptable host and only if they overcome any resistance by the host’s defenses

o Susceptibility – degree of resistance the potential host has to be the pathogen

Describe nursing interventions used to break the chain of infection Assessing

o Early detection and surveillance techniqueso Ask about patient’s immunizations and previous/recurring infectionso Observe signs/symptoms of a local or system infectiono Lab results

Diagnosingo Nursing dx : Risk for Infection related to… Impaired ... related to…o Reflects patient’s condition

Outcome identification and planningo Review assessment data, cycle of events leading to infection, and incorporate

principles of infection controlo Plan outcomes that prevent infectiono Good hand hygiene, identify signs of infection, nutritional intake, disposal of

soiled articles, disinfect, reduce stress Implementing

o Asepsis – all activites to prevent infection or break the chain of infectiono Medical asepsis – clean technique involves procedures and practices that

reduce the number and transfer of pathogens

Hang hygiene & wearing gloveso Surgical asepsis – sterile technique, includes practices used to render and

keep objects and areas free from microorganisms Insert indwelling urinary catheter, or IV catheter

Medical asepsiso Contaminated if they bear or are suspected of bearing pathogenso Hand hygiene most effective way to help prevent spread of infectious agents

Hand washing with plain soap and water, use of antiseptic hand rubs (waterless alcohol based products or surgical hand antisepsis)

Clean hands when they are soiled, after each contact with contaiminated materials, and after removing gloves

Use alcohol base rubs before and after direct contact with patients, gloves, before invasive devices that do not require surgical placement, and contact with objects

Rub 15 sec or until dry Wash hands 1 inch above area of contamination

Sterilizing and disinfectingo Disinfection – destroys all pathogenic organisms except spores

Used when preparing skin for a procedure or cleaning a piece of equipment that does not enter a sterile body part

o Sterilization destroys all microorganisms, including spores On equipment that is entering a sterile portion of the body

Techniques to clean equipmento Wear waterproof gloveso Rinse articles with cold water firsto Wash articles with warm water that has detergent or soapo Use a brush with stiff bristles to clean thoroughlyo Rinse and dry articleo Prepare cleansed equipment for sterilization or disinfectiono Discard gloves, brush

PPE – personal protective equipment: gloves, gowns, masks, and eye gearo Gloves – contact with fluido Gowns – patient’s blood and body fluidso Masks – prevent wearer from inhaling large particle aerosols

High-efficiency particulate air HEPA filter respirator or N95 respirator certified by NIOSH must be worn when entering a room of a patient with known or suspected TB

They filter inspired airo Eyewear

Goggles or face shield worn when risk of contaminating mucous membranes of the eyes

Suctioning a tracheostamy or assisting with invasive procedure that results in splattering of blood or other body fluids requires protection for the caregiver

Surgical asepsiso Used in OR, labor, delivery areas, and diagnostic testingo Insert urinary catheter, sterile dressing changes, or preparing injectable

medicationo Areas are contaminated if they are touched by an object that is not sterileo Most solutions are unsterile after 24 hrs after they’re openedo Grasp bottle so label is on palm of your hand – prevents any liquid froom

running over the label and making it illegible

o Sterile drape

List the stages of an infection Incubation period

o Interval between the pathogen’s invasion of the body and the appearance of symptoms of infection

o Organisms are growing and multiplying Prodromal stage

o Person is most infectious hereo Early signs and symptoms of disease are present, but these are often vague

and nonspecific, ranging from fatigue and malaise to a low-grade fevero Patient does not realize that he or she is contagious

Full stage of illnesso Presence of specific signs and symptoms indicates full stage of illnesso Type of infection determines length of illness and severity of the

manifestationso Systemic or local symptoms

Convalescent periodo Recovery period from infectiono Signs/symptoms disappear and person returns to healthy state

Identify factors that reduce the incidence of healthcare-associated infection Instituting constant surveillance by infection-control committeees and nurse

epidemiologistso Their work can reduce infections when aggressive control measures are

initiated based on their findings Having written infection-prevention practices for all agency personnel

o Adhere to hand hygiene recommendations and infection-control precaution techniques can prevent HAI

Use practices to promote and keep patients in the best physical conditiono Measures include meeting the patient’s needs for nutrition, fluids, rest,

oxygen, and physical and psychological comfort and security. Staffing

Identify situations in which hand hygiene is indicated (see above)

Describe strategies for implementing CDC guidelines for standard and transmission-based precautions when caring for patients

Standard precautionso Used in the care of all hospitalized individuals regardless of their diagnosis or

possible infection statuso Apply to blood, all body fluids, secretions, and excretions except sweat

(whether or not blood is present or visible), nonintact skin, and mucous membranes

o Respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk procedures involving spinal cord punctures

o Clean nonsterile gloves, PPE, cough on tissue, 3 foot separation, don’t recap needles (needlestick), safe injection – single dose vials, face mask

Transmission-based precautions

o Used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes

TRANSMISSION BASED PRECAUTIONSAIRBORNE DROPLET CONTACT

TB, chicken pox, measles, SARS

Private room, keep door closed and patient in room

Monitored negative air pressure in relation to surrounding areas, 6-12 air changes/hr, and appropriate d/c of air outside or monitored filtration if air is recirculated

Wear mask or respiratory when entering room unless immune to disease

Transport patient out only if necessary and place surgical mask on patient

Rubella, mumps, diphtheria

Private room, door may be open

PPE upon entry into room for all interactions

Transport patient out of room only when necessary and place surgical mask on patient

Keep visitors 3 feet from infected person

MDRO Private room PPE whenever you enter

room Change gloves after

contact with infective material

Remove PPE before leaving patient environment and wash hands with antimicrobial or waterless antiseptic agent

Limit movement of patient out of room

Avoid sharing patient-care equipment

Implement recommended techniques for medical and surgical asepsis (see above)

CHAPTER 31 Hygiene

Assess the condition of the patient’s skin, oral cavity, hair, and nails using appropriate interview and physical assessment skills Assessing/interviewing

o Daily/weekly bathing habits Skin

o Rashes, lumps, itching, dryness, lesionso How long have you had this problem? Does it bother you? How does it bother

you? o Document patient’s typical hygiene practices and any complaints (use of

creams, soaps) Oral cavity

o History of teeth, tongue, salivary glandso Identify variables that cause oral problems – deficient self-care, poor nutrition,

or excess of sugars, family history Eyes, ears, nose

o Glasses, contacts, hearing aids Hair

o Texture, amount of hair, treatments, malnutrition Nails & feet

o Type of footwear worn, foot problems, history of biting nailso Perineal and vaginal areas

o Foley cath, childbirth, surgery, UTI, diabetes Physical assessment Skin

o Cleanliness, color, texture, temperature, turgor, moisture, sensation, lesionso Lesion – type, color, size, distribution & grouping, location, and consistencyo Dry skin, acne, rashes

Oral cavityo Odorso Lips: color, moisture, lumps, ulcers, lesions, edemao Buccal mucosa: color, moisture, lesions, nodules, bleeding

Color of gums and surface of gums: lesions, bleeding, edema, exudates

o Teeth: loose, missing, decayed teeth; dentures or other orthodontic deviceso Tongue: color, symmetry, movement, texture, lesionso Hard and soft palates: intactness, color, patches, lesionso Oropharynx: movement of uvula and condition of tonsils if presento Caries: decay of teeth wit the formation of cavitieso Plaque: invisible, destructive, bacterial film that builds up and leads to

destruction of tooth enamelo Gingivitis: inflammation of gingival, the tissue surrounding the teetho Periodontitis: inflammation of gums that also involves degeneration of the

dental periosteum (tissues) and boneo Halitosis: strong mouth odor

Eyes, ears, and noseo Check position, alignment, and appearance of eye

Check eyelashes are equally distributed and curl outward Note lesions nodules, redness, swelling, crusting, flaking, tearing

or discharge of eyelids Check color of conjunctiva and test blink reflex

o Ear: position, alighment and appearance Buildup of wax in canal, dryness, crusting, or presence of any d/c

or foreign bodyo Nose: position and appearance, nostrils, check tenderness, dryness, edema,

bleeding, discharge or secretions Hair

o Texture, cleanliness, and oilinesso Scaling, lesions, infections on scalpo Dandruff, hair loss, infestationso Pediculosis: infestation with lice

Nails and feeto Observe nail base for redness, swelling, bleeding, d/c, tendernesso Cleanliness and intactness

Describe the priorities of scheduled hygiene care Early morning

o After patient wakes up, assist with toiletingo Prepare for breakfast or diagnostic testso Wash face, hands, and mouth care

Morning care (AM care)o After breakfast, assist with oral care, bathing, back massage, skin care

measures (pressure ulcers), hair care (shaving), cosmetics, dressing, and positioning for comfort

Afternoon care (PM care)o Toileting, handwashing, oral careo Straighten bed linens

Hour of sleep care (HS care)o Change any soiled linens

As needed care (PRN care)o Oral care every 2 hourso Change bed linens if soiled

Demonstrate techniques for assisting patients with hygiene measures, including those used when administering various types of baths and those used in cleaning each part of the body. (also oral care unconscious patient) Shower & tub baths

o Shower preferred method in patients who can moveo Gather soap, washcloth, towel, gowno Provide place to sit – stool or chairo Temperature – 110F – 115Fo Lower temp for kids and older peopleo Keep door unlockedo Bed bathso Use emollient agents – moisturizes which can be applies as location, cream,

gel, or ointment They seal water into skin and replace lipids in skin, hydrating skin and

recreating waterproof barrier Backrubs – 4-6 minutes Keep oral mouth moist 1-2 hours

CHAPTER 32 Skin Integrity and Wound Care1. Discuss the processes involved in wound healing Hemostasis

o Immediately after tissue injuryo Involved blood vessels constrict and blood clotting begins through platelet

activation and clusteringo These same blood vessels then dilate and capillary permeability increases,

allowing plasma and blood parts to leak out into the area that is injured, forming a liquid exudates

o Accumulation of exudates leads to swelling and paino Increased perfusion results in heat and rednesso If wound is small, clot loses fluid and a hard scab is formed to protect the

injuryo Platelets release substances that stimulate other cells to migrate to the injury

Inflammatory phaseo Lasts 4-6 dayso WBC, leukocytes, and macrophages move to the woundo Leukocytes arrive 1st to ingest bacteria and cellular debriso 24 hrs after injury, macrophages enter wound area and remain o They release growth factors that attract fibroblasts that help to fill wound

Proliferation phaseo Aka fibroblastic, regenerative, or connective tissue phaseo Lasts several weekso New tissue built to fill wound space, mainly through action of fibroblasts

o Fibroblasts are CT cells that synthesize & secret collagen, produced GF responsible for inducing BV formation & incr. # and movement of endothelial cells

o Capillaries grow around wound – bring O2 & nutrientso Fibrin – cloto Granulation tissue forms scar tissue

Maturation phaseo 3 weeks after injuryo Collagen remodeled to become stronger – scar tissue

2. Identify factors that affect wound healing Pressure

o Interferes with blood flow & tissue and delays healing Desiccation

o Process of drying upo Cells dehydrate & die in dry environmento causes crust to formo Moist wounds = enhanced epithelial cell migration

Macerationo Overhydration – urinary & fecal incontinence impaired skin integrityo Traumao Edemao Insufficient O2 and nutrients to tissue

Infectiono Bacteria inc. stress requires inc. energy to deal with invaderso Toxins released when bacteria die interfere with wound healing & cause cell

death Necrosis

o Death of tissue slough, moist, yellow stringy tissueo Eschar dry, black, leathery

Ageo Small infants & children at increaseo Older adults longer to heal

Circulation & oxygenationo Need enough of it to remove toxins & bacteriao Fat people delay healing

Nutritional statuso Vit A & C epithelization and collagen synthesiso Zinc proliferation of cells

Wound conditiono Large contaminated infected wounds or wounds with foreign bodies heal

slowly Medications and health status

o Corticosteroid drugs (dec. inflam process) & postop radation therapy (depress bone marrow dec. WBC) delay healing

o Chemotherapy impair proliferation of growing cellso ABT secondary infection & superinfection

Immunosupression o AIDS, lupus

Identify patients at risk for pressure ulcer development Immobility

o Long time in bed or seated without shifting body weighto Unconscious, paralyzed, cognitive impairment, fractures and others who

remain in 1 position for a long timeo Emotionally depressed

Nutrition and hydrationo Protein & calorie malnutritiono Leads to neg N2 balance, electrolyte imbalance & skin injury

Moistureo Reduces resistance to traumao Urinary & fecal incontinence incr. risk for skin damage due to chem..

irritation from ammonia in urine Mental status

o Apathy, confused, and comatose state dec. Age

o Older people

Describe the method of staging of pressure ulcers Blanching (pale/white) of skin under pressure ulcer Ischemia makes skin look paler Hyperemia reddening of skin when pressure removed

o Body floods area w/ blood to nourish & remove wastes from cellso Area appears red & feels warm but blanches when slight pressure appliedo Circulation impaired & pressure ulcer developso Deep-tissue injury purple/maroon localized area or blood-filled blister

Stage I – pressure ulcer = intact skin w/ nonblanchable redness of a localized area usually over a bony prominence

Stage II – partial thickness loss of dermis Stage III – ulcer with full thickness tissue loss

o Subcutaneous fat may be visibleo Undermining and tunneling

Stage IV – full thickness tissue loss w/ exposed bone, tendon, muscleo Slough or eschar may be present & undermining/tunnelingo Unstageableo Base of ulcer covered by slough (yellow, tan, gray, green, or brown) or eschar

(tan, brown, black) in wound bedo Eschar – thick leathery scab or dry crust that is necrotis

Stable (dry, intact) eschar on heel serves as body’s natural biological cover & can’t be removed

5. Accurately assess and document the condition of wounds Skin assessment

o Acute care setting: every 48 hrs; stable patients in icu are daily; unstable every shift

o Long-term care setting: every 48 hrs 1st week, weekly 1st month, then monthly – quarterly

o Home healthcare: every visit Risk assessment (scale w/ qs Braden scale)

o Assess mobility, nutritional status, moisture, & incontinenceo Moisture makes skin more susceptible to injuryo Microorganisms can multiply

Wound assessmento Appearance

o Document size (L x W x D)o Edges (meet), dehiscence, or evisceratono Type of tissue in wound – granulation, slough, eschar

Drainage – serous (clear, watery), sanguine (bloody), serosanguine (serums & RBC; light pink to blood tinged), purulent (WBC, yellow, green)

Assess pain

Provide nursing interventions to prevent pressure ulcers. Reposition pt every 2 hrs Oblique best as alt. to side lying Use pillows, foam wedges under calves raises heels Avoid massage over boney area Air, gel, water mattresses

Apply hot and cold therapy effectively and safely Heat

o Hot water bags – may leak or burno Electronic heating pads – electric shock, don’t place under pto Aquathermia pads (Aqua K) – help with back pain, muscle spasms,

inflammationo Hot packs o Warm moist compressors – promote circulation, healing, and dec. edemao Sitz bath – inc. vasodilation, relaxation

Warm soaks – inc. blood supply, aid in cleaning wounds like burns, improve circulation, apply medication

Sterile technique if on large wound 15-20 min/soak

Coldo Ice bags – 30 mino Cold packso Cold moist compressors used for injured eye, headache, tooth extraction

30 min; change 2-3 hrs

CHAPTER 35 Comfort

Describe specific elements in the pain experience Transduction

o Conversion of painful stimuli into electrical impulses that travel from periphery to spinal cord at dorsal horn

o Nociceptors – peripheral nerve fibers that transmit paino Damaged cell releases histamine, which excited nerve endingso Lactic acid accumulates in tissues injured by lack of blood supply & is believed

to excite/activate nerve endings & cause paino Bradykinin – vasodilator; incr. capillary permeability & constricts smooth

muscle; triggers release of histamine & produces redness, swelling, & pain when inflammation is present

o Prostaglandins – hormone-like that send additional pain stimuli to CNS

o Substance P – sensitizes receptors on nerves to feel pain & also inc. rate of firing of nerves

Transmission of pain stimulio Pain from site of injury or inflammation are conducted along pathways to

spinal cord & to higher centers – transmissiono Free nerve ending pain receptors incl. afferent (fibers carrying impulses from

pain receptors to brain), fast conducting A delta fibers (acute, well-localized pain) and slow-conducting C fibers (diffuse, visceral pain – burning & aching)

o Protective pain reflex Sensory impulses travel over A fibers through dorsal root ganglion

to dorsal horn of spinal cord Sensory nerve impulse synapse with a motor neuron & impulse is

carried along efferent nerve pathways back to the site of the painful stimulus in a reflex arc

results in immediate muscle contraction that removes injured part from source of the pain

Perception of paino Sensory process that occurs when stimulus for pain is presento Person’s interpretation of paino Pain threshold – lowest intensity of stimulus that causes subject to recognize

pain Modulation of pain

o Sensation is inhibited or modified by neuromodulators (endogenous, opioid compounds [naturally presenting] morphine-like chemical regulators in the spinal cord & brain)

o Endorphins - @ neural synapses @ various points along CNS Powerful blocking chemicals that have prolonged analgesic effects & produce euphoria Pain sensation & relief

o 1) Pain’s path begins as a message & is received by nerve endings in a burned finger substance P, bradykinin, prostaglandins r released, sensitizing nerve endings, helping to transmit pain message from injured finger toward brain, & settings stage for healing (inflammatory response) 2) pain signal from burned finger travels as an electrochemical impulse along length of nerve to the dorsal horn on the spinal cord, a region that runs the length of the spine & received signals from all over body 3) message is relayed to thalamus, a sensory center in the brain where sensations such as heat, cold, pain, and touch first become conscious 4) it then travels on to the cortex where the intensity & location of pain are perceived 5) pain relief begins as a signal from the brain & descends by way of spinal cord 6) in dorsal horn, chemicals such as endorphins are released to diminish the pain message from the injured finger

Compare and contrast acute and chronic pain

ACUTE PAIN CHRONIC PAINRapid in onset, varies in intensity from

mild to severeProtective in nature; warns individual of

tissue damage or organic disease

Lasts beyond normal healing period3-6 months

Remission – no symptoms presentExacerbation - symptoms reappear

Often perceived meaningless and leads to withdrawal, depression, anger

Poorly localized

Identify factors that may affect an individual’s pain experience Culture

o Patients in pain may be calm, objective, and uncomplaining approach to paino Be aware of pain tolerance, expressions of pain, and alternative practices used

to manage pain Ethnic variables

o Jewish and Italian men tend to be more vocal and outwardly emotional w/ their experiences of pain

o Difficult to anticipate individual responses to pain b/c nowadays are mixed Family, gender, and age variables

o Spouses may reinforce paino Children in diff families may be braveo Women verbalize moreo Young kids express more pain than older adults – these adults accept it as a

daily norm Religious beliefs

o Pain & suffering as a lack of goodnesso Way of purification

Environment and support peopleo Lights, noise, lack of sleep can influence paino Presence of loved family member is essential to sense of well-being & may

decr. Pain Anxiety & other stressors

o People who were taught preop what to expect postop did not require as much medication for pain as those who did not receive this teaching

Past pain experienceo People who don’t know severe pain have no fear of ito People who received immediate relief don’t fear ito People who experienced extreme pain tend to anticipate more paino Painful memories may provoke a violent response

Administer analgesic agents safely to produce the desired level of analgesia without causing undesirable side effects Analgesic – pharmaceutical agent that relieves pain

o Reduce person’s perception of pain & to alter person’s responses to discomforto If patient sleeps, give naloxoneo When respiratory rate > 9 breaths/min can resume

Physical dependence – body physiologically becomes accustomed to opioid & suffers withdrawal symptoms if opioid is removed or dose is rapidly decr.

Tolerance – body becomes accustomed to opioid & needs larger dose each time for pain relief

Addiction – compulsive opioid use for means other than pain control Craving for substance, compulsive use, lack of control over drug,

and continued use despite harm

OPIOID ANALGESICS NONOPIOID ANALGESICS MODERATE – SEVERE PAIN RELIEVE PAIN OF EVERY TYPE BIND TO RECEPTORS IN BRAIN MORPHINE SIDE EFFECTS: SEDATION, NAUSEA,

ACETAMINOPHEN & NSAIDS MILD-MODERATE OVER THE COUNTER & PRESCRIBED NSAIDS – ANTIIFLAMMATORY POTENTIAL FOR GASTRIC BLEED

CONSTIPATION DEPRESSION 1 = AWAKE & ALERT; NO ACTION NECESSARY 2 – OCCASSIONALLY DROWSY BUT EASY TO AROUNE; REQUIRES NO ACTION 3 – FREQUENTLY DROWSY & DRIFTS OFF TO SLEEP DURING CONVERSATION; DECR. OPIOID DOSE 4 – SOMNOLENT W/ MIN OR NO RESPONSE TO STIMULI; D/C OPIOID & CONSIDER USE OF NALOXONE (ANTAGONIST) CONSIDER: PATIENT’S PAIN RATING, SEDATION LEVEL, COMFORT-FUNCTION GOAL (ALLOWS PATIENT TO DO ACTIVITY)

COX -2 INHBITORS – LOWER RISK OF GI BLEED LOW DOSES FOR SHORT PERIODS OF TIME

ADJUVANT DRUGS ENHANCE EFFECTS OF OPIOIDS BY PROVIDING ADDITIONAL PAIN RELIEFREDUCE SIDE EFFECTS FROM PRESCRIBED OPIOIDS OR LESSEN ANXIETY ABOUT PAIN EXPERIENCE

Applying analgesico Review pain scale of choiceo Discuss benefits of pain scaleo Try pain control measureso Use pain control measures before pain increases in severityo Ask patient what’s been proven effective in the pasto Select and modify pain control measures based on patient’s responso Encourage patient to try pain treatment several times before labeling it

ineffectiveo Be open-minded about alt. pain reliefo Be persistento Be safe

CHAPTER 39 Oxygenation

Describe the principles of respiratory physiology (medulla) Pulmonary ventilation (breathing) movement of air into and out of the lungs

o Inspiration (inhalation) – active phase – movement of muscles & the thorax to bring air into lungs

o Expiration (exhalation) – passive phase – movement of air out of the lungso Inspiration

Diaphragm contracts & descends, lengthening thoracic cavity External intercostal muscles contract, lifting ribs up & out Sternum pushed forward, enlarging chest from front to back

Incr. lung volume & decr. Intrapulmonic pressure allows atm air to move form area of greater pressure (outside air) into area of lower pressure (within lungs)

o Relaxation/recoil expiration Diaphragm relaxes & moves up; ribs move down, & sternum drops back

into position Causes decr. Volume in lungs & incr. In intrapulmonic pressure Air moves from high pressure to low & air expired

Respiration

o Gas exchange at terminal alveolar capillary systemo Gases exchanged b/w air & blood thru dense network of capillaries in the

respiratory portion of the lungs & think alveolar walls Via diffusion – O2 & CO2 between air (alveoli) and blood (capillaries)

O2 in alveoli moves to capillaries containing unoxygenated venous blood

CO2 diffuses across capillary into alveoli & exhaledo Diffusion dependent on 4 factors

Change in surface area available (atelectasis – incomplete lung expansion or collapse of alveoli)

Thickening of alveolar-capillary membrane Partial pressure (less O2 = less available for diffusion) Solubility & molecular weight of gas

CO2 greater solubility & faster – able to release thru exhalation Perfusion

o Oxygenated capillary blood passes thru tissues of bodyo Greater activity inc. bloodo Dependent on position, activity level, & blood supplyo Hypoxia – inadequate amount of oxygen available to cellso Dyspnea – difficulty breathingo Hypoventilation - decreased rate or depth of air movement into lungs

Leads to small PP, incr. BP, restlessness, anxiety, confusion, clubbing, decr. Urinary output, weakness of extremity muscles & muscle pain

Describe age-related differences that influence the care of patients with respiratory problems

RESPIRATORY VARIATIONS IN THE LIFE CYCLEINFANT (<1 YEAR)

EARLY CHILD (1-5)

LATE CHILD (6-12)

AGED ADULT (65>)

RR 30-60 breaths/min

20-40 breaths/min

15-25 breaths/min

16-20 breaths/min

RESPIRATORY PATTERN

Abdominal breathing, irregular in rate & depth

Abdominal breathing; irregular

Thoracic breathing; regular

Thoracic; regular

CHEST WALL Thin, little muscle, ribs & sternum visible

Same as infants but more fat

Further subcut. Fat & structures less prominent

Thin, structures prominent

BREATH Loud, harsh Loud harsh Clear Clear

SOUNDS crackles at end of deep inspiration

expiration longer than inspiration

inspiration is longer than expiration

SHAPE OF THORAX

Round Elliptical Elliptical Barrel shaped or elliptical

MISC. Lungs go from fluid filled to air filled organs Surfactant formed 34-36 weeks

Eustachian tubs, bronchi & bronchioles are enlarged routine colds & infections decr. Until child enters school

Airways are less elastic Diaphragm moves less efficiently Chest can’t stretch as much Airways collapse

Perform a respiratory assessment using appropriate interview questions and physical assessment skills Assessing

o Health historyo Ask patient, labs figure out what problems can be treated independently by

nursing Nursing history

o Why patient needs nursing care & what kind of care is required to maintain a sufficient intake of air

o Interview qs help identify current or potential health deviations, actions performed by patient for meeting respiratory needs * effects of such actions, contributing factors, the use of any aids to improve intake of air & effects on patient’s lifestyle & relationships with others

Usual patterns of respiration – how would you describe your breathing & do you have allergens?

Medications – are you taking any for breathing? Health history – do you have heart, lung, or breathing conditions? Recent changes – do you have chest pain, respiratory infections? Lifestyle & environment – do you smoke? Cough – do you wheeze, where do you work? Sputum – do you ever spit out mucus? What color? Chest pain – where is the pain, how long?

Physical assessment Inspection

o Adult chest – slightly convex w/ no sternal depression Front-back diameter < transverse

o Infant’s chest wall thin ribs, sternum & xiphoid process seen Front-back = transverse

o Bony landmarks prominent b/c loss of fato Contour of intercoastal space should be flat & depressedo Movement of chest – symmetrical

Skin – warm, dry, even in color Normal respirations – quiet & nonlabored

o Tachypnea – rapid breathingo Bradypnea – slow breathing

Palpationo Palpate trachea – equidistant from each clavicleo Measure thoracic excursion by placing hands on patient’s posterior thorax @

10th rib with both thumbs almost touching vertebrae

Ask pt to take few deep breaths & watch movement of hands Thumbs usually move 5 – 8 cm at max inspiration

o Tactile fremitus Capacity to feel sound on chest wall Place palm to patient’s chest wall, avoiding bony areas (scapula) Ask patient to repeat multi-syllable words and feel vibration Greatest intensity – anterior & posterior base of neck & along trachea &

large bronchi Pneumonia – incr. & COPD – decr. Sounds [solid tissue conducts better

sounds) Percussion

o Position of lungs, density of lung tissue & identify changes in tissue Auscultation

o Stethoscope – move from apex to base of lungs, comparing 1 side w/ the other side while listening to complete respiratory cycle (inspiration & expiration)

o Normal breath sounds: Vesicular (low pitched, soft sounds heard over peripheral lung fields) Bronchial (loud, high pitched sounds heard over trachea & larynx) Bronchovesicular (medium pitched blowing sounds heard over major

bronchi)o Breathe through open mouth

Record location, changed in breath sounds after coughing, & phase of respiration in which abnormal sound is heard (wheezing on expiration)

Adventitious – abnormal lung sounds – discontinuous or continuous

Crackles – heard on inspiration, soft high pitched d/c popping sounds

o Produced by fluid in airways or alveoli & delayed reopening of collapsed alveoli

o Occur due to inflammation or congestion (pneumonia, COPD)

o Crackles – fine or coarse Fine – brief (hair rubbing) Coarse – louder, moist, bubbling

Wheezes – continuous, musical sounds, produced as air passes thru airways constricted by swelling, narrowing, secretions, or tumors

o Sibilant or sonorous Sibilant – high pitched & whistling Sonorous – wheezes heard over larger airways like a

snore Asthma, tumors or buildup of secretions

Common diagnostic testso Pulmonary function studies

Evaluates patients with respiratory disorders & are performed routinely to evaluate pulmonary status & detect abnormalities

Inert gas dilution, nitrogen washout & body plethysmography measure lung volumes

Diffusion capacity estimates patient’s ability to absorb alveolar gases & determines if gas-exchange problem exists

Max respiratory pressures help evaluate neuromuscular cause of respiratory dysfunction

Exercise testing helps evaluate dyspnea during exertion

Spirometry Volume of air in L exhaled or inhaled by a patient over time Evaluates lung function & airway obstruction thru respiratory

mechanics Measures degree of airway obstruction & evaluates response to

inhaled medso Spirometer - measures lung V & airflow

Peak expiratory flow rateo PEFR – pt of highest flow during forced expirationo Reflects changes in size of pulmonary airways & is measured using a peak flow

metero Used for patients with moderate or severe asthma to measure severity of

disease & degree of disease controlo Patient stands straight & takes deep breath & places peak flow meter in

mouth, closing lipso Forcibly exhales into meter & indicator rises to a # (3x done)o Normal values established thru height, age, gendero Used to track disease progression & regulate treatment

Pulse oximetryo Measures arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial bloodo Monitors pts with O2 therapy, titrating O2 therapy, monitoring those at risk for

hypoxia & monitoring postop patientso Desat indicates gas exchange abnormalitieso 95% - 100% normalo <90% are abnormal, indicate that oxygenation to tissues is inadequate &

should be investigates for potential hypoxia or technical error Thoracentesis

o Procedure of puncturing the chest wall & aspirating pleural fluido Patient sits on chair, arms folded & resting on pillowo Fluid removed with syringeo Monitor patient’s color, pulse, RRo Large amt of fluid removed decr. In RR

Describe nursing strategies to promote adequate respiratory functioning & identify their rationale Promoting optimal function Teaching about pollution-free environments

o Involve job change, protective equipmento Dusting & vaccuming 2x/weeko Pollution alerts stay home or reduce activitieso Stop smoking

Reducing anxietyo Listen & don’t judge

Maintaining good nutritiono Measure H, W, proteino Intake vitaminso 6 small meals vs 3

Promoting comfort Positioning

Fowler’s position (tilted 45-60 deg)Prone position (lie on abdoment)

Maintaining adequate fluid intake

2-3 qts/dayProviding humidified air

Dry air removes normal moisture in passages that protect against irritation & infection

Steam vaporizerCool mist can be medium for pathogen if not cleaned properly

Promoting proper breathingEfficient ventilations, decr. Work of breathing

Deep breathingOvercome hypoventilation (decr. Amt of air enters & leaves lungs)

Using incentive spirometryVisual reinforcement for deep breathing by the patientAssists pt to breathe slowly & deeply & to sustain max inspiration

Pursed-lip breathingFor pts with dyspnea or panicExhaling thru pursed lips allows slow & prolonged expirationPrevents collapse of small airways, improves air exchangeRelaxationSitting upright, inhales thru nose while counting to 3 & exhales slowlyDuring exhalation, pt counts to 8

Abdominal or diaphragmatic breathingDec. RR, incr. tidal V, reduced functional residual capacityPlace 1 hand on stomach & other on middle of chestBreathe in slow thru nose, letting abdomen protrude outBreathe thru pursed lips while contracting abdominal muscles, w/ 1 hand pressing

inward & upward on abdomenRepeats for 1 min & rest for 2 min

Promoting & controlling coughingo Dry – nonproductive

Sputum – clearing throato Most effective when sitting upright with feet on floor

Voluntary coughingo Improves oxygenation, taste of food, removes secretionso Assisted cough – pressure placed on abdomen below diaphragm in rhythm w/

exhalationo Similar to Heimlich but less force

Involuntary cougho Respiratory tract infections & irritations

Cough meds Expectorants

o Remove secretionso Liquifies thick mucuso Taking fluids aid

Cough suppressantso Depress a body function – cough reflexo Codeineo Drowsiness – side effecto Dexromethorphan

Lozengeso Relieve mild, nonproductive cough in people w/o congestiono In mouth until dissolves

Chest physiotherapyo Loosen & mobilize secretions, incr. mucus clearance

o Dome-shaped rythym strike area of lung 30-60 sec several times a dayo Hold hands plat on chest wall as patient exhales

Postural drainageo Fowler’s (head of bed elevated 45 – 60 deg) apical secretions of upper lobes

of lungo Lying position posterior sections of lungso Lying on left side w/ pillow drain rt lobe of lungo Trendelenburg (lie pillow b/w butt & back knees bent) drain lower lobes of

lung Suctioning

o Remove secretions sterilyo Irritates mucosa & can lead to hypoxemia - insuffient O2 in bloodo Pre-ox pt b4 suctioningo Incr. ox or take breathes b4o Relieves respiratory distress

Oxygeno Flow rate amt of O2 delivered to patient

Maskso Simple – connected to oxygen tubing, humidifier, & flow meter

Has vents on its sides that allow room air to leak in at many places dilutes source of O2

Incr. delivery needed for <12 hourso Partial rebreather – same as simple except has reservoir bag for collection of

1st part of pt’s exhalation Rest of exhaled air exists thru vents Patient rebreathes 1/3 of expired air from reserved bag Can inhale room temp O2 if supply in mask is interrupted

o Nonbreather – highest concentration of O2 2 1way valves prevent patient from rebreathing exhaled air Reservoir bag filled with O2 that enters mask on inspiration Exhaled air escapes thru side vents

o Venturi - allows mask to deliver most precise concentrations of O2 Large tube with O2 inlet As tube narrows, pressure drops, causing air to be pulled in thru

side ports Ports are adjusted according to prescription

Oxyen tent – like a fridge

Plan, implement, and evaluate nursing care related to select nursing diagnoses involving respiratory problems Planning

o Improved gas exchange in lungs by absences of cyanosis or chest pain & pulse oximetry >95%

o Relate causative factors if known & demonstrate a method of coping with these factors

o Preserve pulmonary function by maintaining an optimal level of activityo Demonstrate self-care behaviors that provide relief from symptoms & prevent

further pulmonary probs o (By March 15 patient will be able to walk one flight of stairs without

dyspnea) Implementing

o Suctioning, chest physiotherapy, meds, oxygen, CPR, etc.

Evaluatingo Examine patient’s projected progress in meeting outcomes planned