How do you identify your patient?
name and date of birth
What are some factors that may influence hygiene?
culture/religion, level of development, personal preference, economics/living environment, knowledge and cognitive level
Hourly rounding
seeing patient every hour on a schedule; improves patient safety and reduces call light usage; identify 3 P's: pain, position, potty
Early morning care
upon awakening; toileting, wash face and hands, oral care
A.M. (morning) care
After breakfast; toileting, bathing, hair, skin, oral care, dressing, positioning, change or straighten linens
PM care
afternoon - toileting, hand washing, oral care, readying for visitors
H.S. (hour of sleep, bedtime) care
prior to sleep; relaxation activities (back massage especially for the bed bound patient), readying environment to facilitate sleep (water, urinal, call light within reach, etc.)
What should you do prior to delegating your patient?
assess
When delegating patient to a CNA, inform them of
clients limitations, amt. of assistance needed, use of assistance devices, specific safety precautions, presence and care of tubes, observations to make during hygiene care
Epidermis
thicker, outer layer of skin; stratified squamous epithelial tissue; waterproof; sheds; contains melanin
Dermis
Thinner, second layer of skin; blood and lymphatic vessels; nerves; bases of hair follicles; sebaceous and sweat glands
What are the functions of the skin?
protection, sensation, regulation, secretion/excretion, vitamin D formation (sunlight)
What to look for during a skin inspection?
color (pallor, erythema, jaundice, cyanosis), maceration, pruritus, acne, dryness, excoriation, abrasions, pressure ulcers, burns
Jaundice
yellowing of skin; first occurs in eyes and is caused by the liver
Erythema
inflammation and redness of the skin
Cyanosis
bluish coloring of the skin; low oxygenation; toes, fingers, lips
Pruritus
itching of the skin
Maceration
soft skin (usually wet)
Excoriation
loss of superficial layers of the skin
Abrasion
deeper tear of the skin
What are common types of baths?
unassisted, assit, complete/total, partial
Unassisted bath
patient does everything themselves
Assist bath
nurse helps with hard to reach areas
Complete/total bath
nurse cleans patients entire body without assistance from patient
Partial bath
bathe only those areas that may cause odor or discomfort
Bed bath
used for bed bound patients or for patients who can't bathe themselves
Basin and water bath
a type of bed bath; water must be warm; each part of body is cleansed with a fresh wash cloth
Therapeutic baths
must be ordered by physician; oatmeal or ritz
What might an oatmeal bath be used for?
skin irritation, rash, abrasions
What might a sitz bath be used for?
for the perineal area
What order should the patient be washed?
Face neck and ears, arms, chest, abdomen, legs and feet, back and buttocks; apply new gloves then provide perineal care
Perineal care for females
wash from front to back, labia majora (outer), labia minora (inner), meatus, catheter
Perineal care for males
Use clean portion of wipe for each stroke, cleanse head of penis, shaft, scrotum, catheter
How to assess the feet:
assess, inspect, palpate
Foot care for a diabetic
they have impaired circulation and increased risk for infection which leads to high risk for problems on the feet; inspect daily
How to assess the mouth for oral care
inspect lips, condition of teeth and gums, conditions affecting the mouth (bad breath, cavities, gingivitis, periodontal disease, oral malignancies
What are some common problems with hair?
dandruff, pediculosis (lice), alopecia (hair loss)
How to care for hair:
brush daily with a stiff bristle brush, comb tightly curled hair with wide toothed comb
How to care for unconscious patient's eyes:
give frequent care every 2-4 hours, use lubricant, use protective shield to keep eye(s) closed if necessary
How to care for patient's ears:
assess for drainage, excess cerumen, and hearing loss during bath
What are the functions of the kidneys?
filter metabolic wastes, toxins, excess ions, and water from the blood and excrete them as urine
What is the anatomy of the kidneys?
Location: retroperitoneal
Weight: avg 5 oz
Layers: Cortex (outer layer), Medulla (inner layer), renal pelvis (innermost layer)
How does urine form?
Nephron: glomerular filtration, tubular reabsorption, tubular secretion
How is urine transported?
renal pelvis --> ureter --> urinary bladder
How is urine stored?
the bladder holds urine until discharged from the body
How long is the urethra in males and females?
Females: 3-4 cm
Males: 20 cm (8 in)
How does urinary elimination occur?
1. Filling of the bladder (200-450 mL)
2. Activation of stretch receptors in bladder wall
3. Signaling to voiding reflex center
4. Contraction of detrusor muscle
5. Conscious relaxation of external urethral sphincter
How much urine do the kidneys produce per hour/day
- 50-60 mL per hour
- 1000-2000 mL per day
Oliguria
Decreased urine output
Dysuria
painful or difficult urination
Polyuria
frequent urination and increased amt of urine
Specific gravity
1.002 - 1.030; dissolves solutes
If there is an increase in solutes there is a ___ in specific gravity.
increase
If there is a decrease in solutes there is a ___ in specific gravity.
decrease
Urinary Elimination: Infants
- 15-60 mL per day
- 8-10 wet diapers per day
- No voluntary control
- Normal s.g.: 1.008
Urinary Elimination: Children
- Toilet training requires: mature neuromuscular system, adequate communication skills, and ability to remove clothing
Enuresis
occasional involuntary passage of urine
Nocturnal enuresis
nighttime bedwetting
Urinary Elimination: Older adults
- Kidney function decreases (50 yr. old)
- Urgency and frequency
- Loss of bladder elasticity and muscle tone (nocturia and incomplete emptying)
- Confusion may occur @ first symptoms of UTI
Analgesics
Pyridium; treats bladder and urethral pain, burning, increased urination, and increased urge to urinate; turns urine a deep orange-red color
Diuretics
- "Water pills"
- treats blood pressure, fluid retention, and edema by increasing elimination of urine
- classified as thiazide, potassium-sparing, or loop-acting diuretics
Anticholinergics
-promotes urine retention
-inhibits involuntary contractions of the bladder, increase bladder capacity, and delaying the urge to void for people with urge incontinence
Antidepressants
-reduce stress incontinence by relaxing bladder muscles
-some work by stimulating the nerve controlling urethral sphincter
Antispasmodics
help stop bladder muscle contractions and prevent urge incontinence
Muscarinic receptors
block nerve receptors in smooth muscle of bladder; control bladder contraction and reduce urinary frequency for people with overactive bladder and urge incontinence
Estrogen
used to improve blood flow to urethral tissues and increase thickness of mucosal and urethral tissues; not approved bu FDA for treatment of stress incontinence
Diuretics: Thiazide
used to treat high blood pressure by reducing the amount of sodium and water in the body and dilating blood vessels
Diuretics: Potassium-sparing
reduce the amount of water in the body; do not cause potassium loss
Diuretics: Loop-acting
Cause kidneys to reabsorb less water; increase urine excretion reduce amount of water in the body and lowers blood pressure
Diuretics: Common side effects
weakness, muscle cramps, skin rash, increase sensitivity to sunlight, dizziness, light-headedness, joint pain
Pathological conditions affecting urinary elimination
bladder/kidney infections, kidney stones, hypertrophy in the prostate (males), mobility problems, decreased blood flow through glomeruli, neurological conditions, communication problems, alteration in cognition
UTI
infection in any part of the urinary system
UTI: Transmission
Microorganisms (usually E. coli)
UTI Types: Urethritis
infection limited to urethra
UTI Types: Cystitis
bladder infection caused by microbes within urethra
UTI Types: Pyelonephritis
infection that progresses upward to the ureters or kidneys
Catheter associated UTI
often asymptomatic and likely to resolve spontaneously with the removal of the catheter
UTI risk factors
sexual activity, spermicidal gels, older women, pregnant women, enlarged prostate, kidney stones, indwelling catheter
Treatment of UTI: Cystitis
oral antibiotics for 5 days
Treatment of UTI: Pyelonephritis
IV antibiotics followed by oral antibiotics
Treatment of UTI: Pyridium
relieves burning and urgency
Treatment of UTI: Liberal liquids
flush out bacteria
Blood urea nitrogen (BUN)
8-20 mg/dL
Creatinine
0.5-1.1 mg/dL
Urine Specimens: Freshly voided
when collecting urine sample, pour urine into specimen container labeled with patient's name, date, and time of collection
Urine Specimens: Clean catch
client cleanses genitalia before voiding and collects sample midstream (free of organisms from urethra and perineum
Urine Specimens: Steril
insert catheter into bladder; aids in determining presence of UTI
Urine Specimens: 24 hr. collection
may be prescribed to evaluate renal disorders by showing kidney function at different times of day/night
Urine Studies: Urinalysis (UA)
overall screening test and an aid to diagnose renal, hepatic, and other diseases
Urine Studies: Dipstick
can determine pH and specific gravity and the presence of protein, glucose, ketones, and occult blood in urine
Urine Studies: Specific gravity
-indicator of urine concentration
-refractometer: precise measurement; measures extent to which a beam of light changes direction when it passes through urine
Direct Visualization Studies: Cystoscopy
direct view of urethra, bladder, and urethral offices by scope
Direct Visualization Studies: Cystometry
-determines whether a muscle/nerve problem is causing problems with how well the bladder holds/releases urine
-catheter is inserted into bladder and pressure probe into rectum
-measures how much the bladder can hold and pressure in bladder
Indirect Visual Studies: IVP
IV radiopaque contrast medium to visualize kidneys, bladder, and ureter
The female client says to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as __.
Stress incontinence
How do you promote normal urination?
-Provide privacy: Curtains, doors
-Assist with positioning
-Facilitate toileting routines: Client's pattern
-Promote adequate fluids and nutrition
-Assist with hygeine
Straight catheter
single-lumen tube that is inserted for immediate drainage of the bladder; catheter is removed after the bladder is empty
Indwelling (Foley) catheter
used for continuous bladder drainage
Suprapubic catheter
continuous urine drainage when urethra must be bypassed
The nurse prepares to insert an indwelling urinary catheter. Which statement least explains the reason for this intervention?
A. Empty your bladder prior to your procedure.
B. Treat your problem of leaking urine.
C. Obtain a sterile urine specimen for cul
B. Treat your problem of leaking urine
Urge incontinence
involuntary loss of urine with a strong urge to void
Stress incontinence
Involuntary loss of urine with increased intra-abdominal pressure in the absence of an overactive bladder (childbirth, exercise, laughing, sneezing, coughing, lifting)
Mixed incontinence
combination of urge and stress incontinence
Unconscious (reflex) incontinence
Loss of urine when the person does not realize the bladder is full and has no urge to void
Functional incontinence
Untimely loss of urine with no urinary or neurological cause
Transient incontinence
short-term incontinence expected to resolve spontaneously
Overflow incontinence
Leakage of urine with a distended bladder
There is a 24-hr urine collection in process for a client. The nursing assistive personnel (NAP) inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should
A. Continue with the collection of urine until the 24-hr
D. Dispose of the urine already collected and begin an entirely new 24-hr collection.
What is a urinary diversion?
surgically created opening for elimination of urine
Cutaneous ureterostomy
routes the ureter(s) directly to the surface of the abdomen, forming a small stoma
Conventional urostomy
-Most common type of urinary diversion; simplest to perform surgically and eliminates the need for intermittent catheterization
-ureters are implanted into a loop of the ileum where urine drains freely into the stoma bag
Goals to care for a patient with an indwelling catheter:
1: Prevent Urinary Tract Infection
2: Maintain free flow of Urine
3: Prevent Transmission of infection
4: Promote normal urine production
5: Maintain skin and mucosal integrity
How to insert an intermittent urinary catheter:
1. Work at right side if right handed
2. Places patient into supine
3. Don clean gloves
4. Drape the patient
5. Cleanse the perineal area
6. Remove and discard gloves
7. Organize work area
8. Place sterile underpad
9. Cleanse meatus
10. Prepare urine rece
How to insert an Indwelling catheter
1. Place patient supine
2. Stand on right side
3. Drape patient
4. Don clean gloves
5. If using, insert topical anesthetic gel
6. Remove and discard gloves
7. Organize area
8. Place sterile waterproof underpad
9. Cleanse meatus
10. Lubricate
11. Insert ca
How to insert an external (condom) catheter:
1. Determine size
2. Wash hands and use gloves
3. Organize supplies
4. Position supine
5. Flod down bed linen
6. Gently cleanse penis
7. Change gloves
8. Apply skin prep
9. Hold penis in non dominant hand
10. Secure catheter
Mobility
body movement
FItness
ability to carry out activities of daily living
Physical activity
bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above baseline level
Skeletal system
bones, cartilage, ligaments and tendons
Muscles
skeletal, smooth, cardiac
Skeletal muscles
moved the skeleton
Smooth muscle
occurs in digestive tract and other hollow structures such as the bladder and blood vessels
Cardiac muscles
can contract spontaneously
Motor nervous system
autonomic (involuntary) and somatic (voluntary)
Body mechanics
the way we move our body
Body alignment
-posture
-places the spine in a neutral position
Balance
-line of gravity must pass through your center of gravity and the center of gravity must be close to your base of support
Coordination
-smooth movement requires coorination between the nervous and musculoskeletal system
Cerebral cortex initiates ___
voluntary movement
Cerebellum
coordinates movements; largely responsible for controlling the awareness of posture, movement, and position sense
Basal ganglia
located deep in cerebrum and assists with coordination of movement
Joint mobility
range of motion (ROM), active ROM (AROM), and passive ROM
ROM
maximum movement possible at a joint
AROM
movement of the joint performed by the individual without assistance
PROM
involves moving joints through their ROM when the patient is unable to do so for himself
Principles of body mechanics
rules that allow you to move your body while reducing your risk for injury
To maintain proper posture, it is important to __.
Avoid arching shoulders forward when sitting
Baseline activity
light-intensity activities of daily living; standing, walking, lifting
Exercise
more than baseline to produce health-enhancing benefits
Isometric exercise
-muscle contraction without motion
-usually performed against an immovable surface or object
-Each position is held for 6 to 8 seconds and repeated 5 to 10 times
-patients who are bed bound
Isotonic exercise
-movement of the joint during the muscle contraction
-weight training with free weights
Calisthenics
pull-ups, push-ups, and planks, all of which use body weight as the resistance force, are also isotonic exercises
Isokinetic exercise
-performed with specialized apparatuses that provide variable resistance to movement
-both isometrics and weight training
-use of machines
Aerobic exercise
-occurs when the amount of oxygen takin into the body meets or exceeds the amount oxygen required to perform the activity
-increases heart and respiratory rates
-exercises cardiovascular system and skeletal muscles
-jogging, brisk walking, cycling
Anaerobic exercising
-occurs when the amount of oxygen taken into the body does not meet the amount of oxygen required to perform the activity
-lifiting heavy objects, sprinting
Steps in planning a fitness program:
1. Medical evaluation
2. Type of activity, duration, intensity, and frequency determined by health
Flexibility training
-stretch before/after exercising
-helps maintain mobility
Aerobic conditioning
-Improves fitness and body composition
-Components: intensity, duration, frequency, and mode
Resistance training
-movement against resistance increases muscular strength and endurance
Risks of exercise
cardiac injury, musculoskeletal injury, dehydration, temperature regulation
Cardiac injury
fear of triggering a cardiac event deters some people from exercising
Musculoskeletal injury
-high-impact exercises may pose a risk for injury to bones, joints, muscles
-prevent by proper body alignment
Dehydration
fluid and electrolyte loss
Hypertermia
-can occur when one exercises in hot climate
-often accompanied by dehydration
Heat exhaustion
-potentially life threatening
-signs: light-headedness, nausea, headache, fatigue, hyperventilation, abdominal cramps, high temp., cold, clammy skin
Hypothermia
-can occur when one does not wear proper clothing or is exposed to cold water for an extended time
Syndactylism
fusion of two or more fingers/toes
Developmental dysplasia of the hip
-congenital abnormality of the development of the femur, acetabulum, or both that shows as a hip dislocation
Foot deformities
clubfoot
Scoliosis
a lateral curvature of the spine
Osterogenesis imperfecta (OI)
congenital disorder of bone and connective tissue that is characterized by brittle bones that fracture easily
Achondroplasia
dwarfism; when bones ossify (harden) prematurely
Paget's disease
increased bone loss results in pain, pathological fractures, and deformities; skull, vertebrae, femur, and pelvis
Osteoarthritis (OA)
loss of articular cartilage in the joint, with pain and stiffness as the primary symptom
Rheumatoid arthritis (RA)
autoimmune disease involving chronic inflammation of the joints and surrounding connective tissue, frequently resulting in difficulty performing ADLs
Ankylosing spondylitis
chronic inflammatory joint disease; stiffening and fusion of the spine and sacroiliac joints
Gout
inflammatory response to high levels of uric acid; crystals form in synovial fluid, and small white nodules form in subcutaneous tissues
Osteoporosis
decrease in total bone density
Osteomyelitis
infection of the bone
Fractures
-breaking of bone
-one of most common forms of trauma
Sprains and strains
-more common than fractures
Sprain
a stretch injury of a ligament that causes the ligament to tear; a partial tear can usually heal with rest, but a complete tear often requires surgery
Strain
injury to a muscle caused bu excessive stress on the muscle
CNS Disorder: Cerebrovascular accident
stroke
CNS Disorder: Multiple sclerosis
disorder affecting nerve transmission
CNS Disorder: Myasthenia gravis
disease caused by antibodies to the acetylcholine receptors at the neuromuscular junction
Respiratory disorders
-affects oxygenation
-asthma, pneumonia
Circulatory disorder
impaired arterial circulation limits oxygen delivery to tissue
Fatigue
acute illnesses that produces fatigue; influenza, anemia, anorexia nervosa, cancer, depression, and grief
Activity intolerance
state in which a patient has insufficient physical or psychological energy to carry out daily activities.
Impaired physical mobility
limitation of independent purposeful movement of the body
risk for disuse syndrome
when a patient's prescribed or unavoidable inactivity creates the risk for deterioration of other body systems
Sedentary lifestyle
habit of life that is characterized by a low physical activity level
Semi-Fowler's Position
the head of the bed is raised 30 degrees
High Fowler's Position
head of the bed is raised 90 degrees
orthopneic position
head of bed is elevated 90 degrees and an overbid table with a pillow on top is positioned in front of the patient
Lateral position
side-lying position with the top hip and knee flexed and placed in front of the rest of the body
Prone position
-patient lies on his abdomen with his head turned to one side
-allows full extension of the hips and knees
-allows secretions to drain freely from mouth
Sims position
-The lower arm is positioned behind the patient, and the upper arm is flexed. The upper leg is more flexed than the lower leg
-drainage from the mouth and limits pressure on trochanter and sacrum
Supine position
-patient lies on his back with head and shoulders elevated on a small pillow
-spine is aligned and the arms and hands comfortably rest at the side
Logrolling
used when the patient's spine must be kept in straight alignment
Of the following interventions for the client who is immobile, the nurse will give priority to
having the client use the incentive spirometer q2hr; helps to
prevent atelectasis, which improves
oxygenation�a priority need.
Oblique position
alternative to the lateral position that places less pressure on trochanter
lying on side with top hip and knee flexed with top leg placed behind body
Transfer board
a wood or plastic device designed to assist with moving patients
mechanical lift
a hydraulic device used to transfer patients; a fabric sling with chains or straps attaches to the lifting device
Transfer belt
a heavy belt several inches wide that is used to facilitate transfer or provide a secure mechanism to hold the patient when ambulating
How to assist patient to walk:
1. Assess patient
2. Promote safety non-skid socks, remove rugs/equipment, make sure floor is clean
What do you do if a patient begins to fall?
Gently guid one to a seated or lying position; create a wide base support, project forward the him and slide patient down your leg
How to assist an older adult to ambulate:
1. Observe constantly for weakness and fatigue
2. Move patient gradually
3. Assess for fall risk factors
4. Use assistive devices as needed
5. Be cautions when using transfer belt
Single-ended cane with half circle handle
ideal for patient who needs minimal support and can negotiate stairs
Single-ended cane with a straight handle
ideal for patient with hand weakness who has good balance
Multiprong canes
most have 3 or 4 prongs; all types have a straight handle; provide a wide base of support for patients with balance problems
Walkers
A lightweight metal frame divide with 4 legs that provides a wide base of support as a patient ambulates; best for patients whose mobility problems are related to fatigue or shortness of breath rather than gait instability
Braces
support joints and muscles that cannot independently support the body's weight
Crutches
commonly used for rehabilitation of an injured lower etremity; limit weight bearing on leg(s)
forearm support crutch
likely used by a patient with permanent limitations
Axiallary crutches
for both short and long term use; support the body weight in the hands and arms
How to use a cane:
1. pt should hold cane on the stronger side of the body
2. Distribute weight evenly b/t feet and cane
3. Move his weaker leg and cane simultaneously
4. Avoid leaning over or on cane
How to use a walker:
1. Stand between back legs of walker
2. Pick it up and advance it as you step ahead
3. If one leg is weaker, move it forward as the walker moves forward
4. Pick up, rather than slide, the walker
How to use crutches:
Tripod position - place crutches 6 in. in front of feet, with crutch point 6 in. from patients center (triangle form)
How to turn a patient in bed:
1. Lock bed wheels
2. Position pt for turning
3. Place pt's near leg and foot across the far one
4. Place pt's near arm across chest
5. Nurses position wide base of support
6. Instruct pt turn will occur on count of 3
7. On 3, flex knees and hips and shif
How to logroll a patient:
1. Lock bed wheels
2. Place drawsheet with underlying friction-reducing device
3. Position one staff member at patient's head and shoulders
4. Nurse position feet as wide base of support
5. Use drawsheet to move pt to side of bed
6. Instruct pt to fold ar
How to move patient up in bed:
1. Lock bed wheels
2. Place friction-reducing device
3. Remove pillow
4. Instruct pt to fold arms over chest
5. Instruct pt to flex his neck
6. With nurses on both sides, grasp and roll drawsheet close to pt
7. Instruct pt, on count of 3, to lift truck an
Dangling how to:
1. Lock bed wheels
2. Apply a gait transfer belt
3. Place bed in low position
4. Instruct pt to bend his knees and turn the pt onto side keeping knees flexed
5. Stand at side of bed with wider BOS
6. Position hands on each side of gait belt
7. Rock onto b
Assisting with ambulation (one nurse)
1. Put nonskid footwear on pt
2. Place bed in low position
3. Apply transfer belt
4. Assist pt to dangle
5. Face pt
6. Instruct pt to place arms around you between shoulders and waist
7. Ask pt to stand and allow to pt to steady
8. Stand at pt's side with
Assisting with ambulation (two nurses)
1. Put nonskid footwear on pt
2. Place bed in low position
3. Apply transfer belt
4. Assist pt to dangle
5. Each nurse face pt
6. Instruct pt to place arms around each of you between shoulders and waist
7. Ask pt to stand and allow pt to steady
8. Nurses
Identify the true statement about devices used when assisting clients to ambulate.
a. The client should stand a foot back from the back legs of a walker.
b. A cane should be used by the client to support the weakest side of the body.
c. A transfer belt sh
d. Each crutch-walking "gait" begins with the client in the tripod position.