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Physiological Integrity Reduction of Risk Physiological Integrity

Physiological Integrity Reduction of Risk Physiological Integrity. Concorde - Garden Grove. Physiological Integrity. Reduction of Risk Potential. Changes/Abnormalities in VS. Monitor VS Compare to baseline Reinforce client teaching about normal/ abnormals (i.e. hypertension, fever, etc.).

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Physiological Integrity Reduction of Risk Physiological Integrity

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  1. Physiological IntegrityReduction of RiskPhysiological Integrity Concorde - Garden Grove

  2. Physiological Integrity Reduction of Risk Potential

  3. Changes/Abnormalities in VS • Monitor VS • Compare to baseline • Reinforce client teaching about normal/abnormals (i.e. hypertension, fever, etc.)

  4. Diagnostic Tests • Performing/collecting • EKG http://www.youtube.com/watch?v=YX_7j8HUrpA • blood glucose • O2 saturation • occult blood • Specimen (blood, urine, stool, sputum • Reinforce teaching about diagnostic testing

  5. Assist With Invasive Procedures • Call time out • Assist with bronchoscopy, needle biopsy, etc.

  6. Lab Values • ABGs • BUN/creatinine • Cholesterol • Glucose • Hemoglobin/hematocrit • Hemoglobin A1C • Platelets • Potassium, sodium • PT/PTT & APTT • INR • WBC

  7. Follow Up • Maintain central venous catheter • http://www.youtube.com/watch?v=uhfu6wG_BSk • Reinforce teaching on purpose of laboratory tests • Monitor diagnostic/laboratory tests • Notify provider of results

  8. Basic Alterations • Signs and symptoms of infection • Identify/intervene hypo or hyperglycemia • Recognize basic abnormalities on EKG • Care for wound drain (i.e Jackson Pratt) • Care for Central Line • Cooling/warming measures to control body temperature • Care of tracheostomy • Care of ostomy (i.e. colostomy, ileostomy, etc) • Care of client on ventilator

  9. Potential Alterations in Body Systems • Identify clients at risk for/exhibit: • Insufficient blood circulation • Change in LOC • Change from baseline • Urinary retention • Implement ways to prevent

  10. Potential for Complications • Identify client response to dx tests/procedures/treatment • Complete incident report when unusual occurrence or variance occurs • Monitor continuous/intermittent suction to NG tube • Implement measures to decrease risk (i.e. TCDB)

  11. Potential for Complications • Insert, maintain, remove urinary catheter, NG tube, IV per facility policy • Maintain strict technique • Care of patient with electroconvulsive shock therapy, dialysis, seizures, wounds, burns, a pacemaker, hemorrhage, ostomy • Notify provider of change in condition

  12. Post-op Complications • Respiratory: atelectasis and pneumonia • Signs and symptoms • Cough, dyspnea, shortness of breath • Elevated temperature • Restlessness/anxiety • Adventitious breath sounds • Chest expansion • Pain with respirations • Interventions • Turn, cough, deep breathe • Mobilize secretion (suction prn) • Increase fluids • Assessment (breath sounds, VS, etc.)

  13. Pneumonia Atelectasis

  14. Post-op Complications • Thrombophlebitis • Symptoms • Red, tender calf • Pain • Edema • Elevated temperature • Positive Homan’s sign (do not repeat -> can dislodge clot) • Interventions • Elevate lower extremities • CMS checks • Assessment • Avoid ambulation • TED hose unaffected leg

  15. Post-op Complications • Wound Infections • Symptoms • Elevated temperature • Tachycardia • Pain and tenderness at surgical site • Edema, erythema, warmth around sutures • Purulent drainage • Interventions • Dressing/skin dry • Sterile technique

  16. Post-op Complications • Wound separation • Dehiscence and evisceration • Pre-disposing factors • Infection, altered ability to heal, excess pressure on incision • Assessment • Sensation of “giving way” or pain • Interventions • Position to decrease stress on site • Cover moist, sterile gauze • Notify MD immediately • Prepare for surgery • Provide emotional support

  17. Question • The nurse is contributing to the plan of care for a client with heart failure. Which of the following interventions should the nurse recommend including in the client’s plan of care? Select all that apply. • Obtaining the client’s weight daily • Encouraging the client to increase the daily fluid intake • Monitoring the client’s serum potassium level • Limiting the client’s intake of fresh fruits and vegetables • Checking the client for peripheral edema

  18. Physiological Integrity Physiological Adaptation

  19. Body Fluids • Adults • Women 50-55% body weight in water • Men 60-70% body weight in water • Older adults 47% body weight in water • Infants 75-80% • Note 2.2lb is 1 L fluid

  20. Fluids and Electrolytes • Water • Intracellular (80%) • Extracellular (20%) • Intravascular • Interstitial • Balance • Intake (ingestion and oxidation) • Output (skin, lungs, saliva, stool, secretions, urine)

  21. Dehydration: fluid volume deficit • Loss of skin turgor • Dry mucous membranes • ↑HR & R • Hyperthermia • Cap refill > 3 sec • Weakness • Fatigue • Labs: ↑Hct,/urine spec gravity/osmolarity • Late signs: oliguria, decreased central venous pressure, flattened neck veins

  22. Fluid Overload • Cough, dyspnea, crackles • ↑BP, P, R • Headache • Weight gain • Hemodiluttion electrolytes/Hct • Late: JVD, tachycardia, pitting edema, increased CVP

  23. Electrolytes • Na+ 135-145 mEq/L • Ca+ 8.5-10 mg/dL • Cl- 85-115 mEq/L • HCO3- 22-26 mEq/L • K+ 3.5-5.0 mEq/L • Mg+ 1.8-3.0 mEq/L

  24. Electrolyte Function • Maintain homeostasis • Promote neuromuscular excitability • Maintain fluid balance • Distribute water balance between fluid compartments • Maintain cardiac stability • Regulate acid-base balance

  25. Hypokalemia • From: GI loss, ↓intake, diuretics, aminoglycosides • Signs and symptoms • Muscle weakness, fatigue • N/V • Dysrhythmias • Flat T waves • Interventions • Administer K • EKG monitoring • Teach diet sources • Never give bolus

  26. Hyperkalemia • From: tissue injury, K+ sparing diuretics, renal failure, adrenal insufficiency, ↑intake • Signs and symptoms • Muscle cramps, weakness, paralysis • Bradycardia • Dysrhythmias • Tall T waves • Interventions • Monitor EKG • Kayexelate • 50% glucose with insulin • Calcium gluconate • Loop diuretics • Dialysis

  27. Hyponatremia • From: GI loss, SIADH, diuretics, adrenal insufficiency, diuretics, water intoxication, ↓intake • Signs and symptoms • Weakness • Lethargy • Confusion • Seizures • Coma • Interventions • Daily weight, I&O • CNS changes, seizure precautions • Restrict fluid prn • Teach fluid sources

  28. Hypernatremia • From: water deprivation, GI loss, diabetes insipidus, ↑loss • Signs and symptoms • Thirst • Mucous membranes sticky • Restlessness/Weakness • Orthostatic hypotension • Muscle irritability, seizures • coma • Often overlooked in elderly • Interventions • Daily weight, I&O • Seizure precautions • Teach dietary sources (esp. medications)

  29. Magnesium 1.3-2.1 mEq/L • Affected by kidney function and metabolic disturbances • Elevation can slow cardiac conduction and muscle function = bradycardia, coma, death • Decreases can lead to muscular irritability, paresthesias, tetany, agitation • Check Chvostek’s & Trousseau’s sign

  30. Hypercalcemia • From: hyperparathyroidism, malignant dx, prolonged immobility, Vit D excess, thiazide diuretics, lithium • Signs and symptoms • Cardiac dysrhythmias • Confusion • Muscle weakness • Hypercalciuria/renal stones • Lethargy/coma • Interventions • Increase mobility • Calcitonin • IV Lasix • Glucocorticoids • Biophosphonates • Increased risk of fractures

  31. Acid-Base Balance • pH 7.35-7.45 • CO2 35-45 • HCO3 22-28 • Respiratory • Opposite CO2 and pH opposite directions • Metabolic • Equal HCO3 and pH go same way

  32. Respiratory Diagnostic Tests • Chest X-ray • Pulse oximetry • Pulmonary function tests • Sputum culture • ABG’s • Bronchoscopy • Mantoux Test (PPD) • QuantiFERON-TB Gold In Tube Test (QFT-GIT) and T-SPOT TB – test for immune response to TB bacteria in whole blood • Thoracentesis

  33. Asthma • Chronic intermittent and reversible airflow obstruction of bronchioles • Extrinsic and/or intrinsic • Manifestations: • Sudden severe dyspnea with use accessory muscles • Tripod sitting • Diaphoresis/anxiety • Wheezing/gasping/coughing • Barrel chest

  34. Asthma • Dx: ABG’s, PFT’’s, sputum • Nursing interventions: • Remain with patient during attack • High Fowler’s • Monitor lung sounds • Administer O2 • Maintain IV access • Adminsiter meds= bronchodilators, corticosteroids, leukotriene antagonists, combination drugs/inhalers • Proper use HHN/inhaler

  35. Status Asthmaticus • Life-threatening episode unresponsive to treatment • Manifestations: extreme symptoms • Nursing: • High Fowler’s • Prepare for emergency intubation • Administer oxygen, epinephrine, systemic steroids • Provide emotional support

  36. COPD • General term for anything that affects expiratory air flow. • Emphysema- distention of alveolar sacs which rupture with destruction of capillary beds • Productive cough • Pursed lip breathing • Wheezing, crackles, shallow/rapid respirations • Anorexia/weight loss • Weakness • Chronic bronchitis- inflammation of bronchi/bronchioles due to irritants • S/S: • Productive cough • Thick, tenacious secretions • Hypoxemia • Respiratory acidosis

  37. COPD: Nursing Interventions • Monitor respiratory effort • Monitor cardiac status for signs of right sided failure • Position upright leaning forward • Schedule activities to allow rest periods • Administer low flow O2 • Use incentive spirometer • Encourage fluids to 3L • High calorie diet • Admin meds: bronchodilators, methylxanthines, anti-inflammatories, mucolytics • Chest physiotherapy • Reinforce teaching

  38. CorPulmonale • Right sided heart failure caused by pulmonary disease • Manifestations • Hypoxia • Dyspnea • Cyanotic lips • Dependent edema • Pulmonary hypertension • Interventions • Monitor oxygen status • Ensure adequate rest • Admin diuretics and digoxin • Encourage low sodium diet • May require mechanical ventilation

  39. Tuberculosis • Chronic, progressive infection due to tubercle bacillus • Manifestations: • Cough, hemoptysis • Positive sputum for AFB • Fever with night sweats • Anorexia, weight loss • Malaise, fatigue • Dx tests: Mantoux, sputum culture, smear,, serum analysis, QFT-G, chest x-ray • Medications (INH-isoniazid, rifampin, pyrazidamide, ethambutol, streptomycin, etc.) • Administer on empty stomach at same time each day • Taken for 6-12 months • Monitor for hepatotoxicity/nephrotoxicity • Reinforce client teaching to decrease transmission • Report to health department • Transmission (N-95 mask, low air flow room, etc.)

  40. Cancer of the Lung • Manifestations • Chronic cough, dyspnea • Hemoptysis • Hoarseness • Unilateral wheezing • Fatigue, weight loss, anorexia • Clubbing of fingers • Chest wall pain • Dx: Chest x-ray and CT scan, bronchoscopy with biopsy, TNM for staging

  41. Cancer of the Lung: Nursing • Maintain patent airway • Suction prn • Monitor VS, pulse ox, nutrition, stomatitis • High fowler’s • Provide emotional support • Protect for immunocompromised client • Pain management • Palliative care • Tx: surgery, chemo, radiation • May do pneumonectomy, lobectomy, wedge resection • Use ancillary services

  42. Pulmonary Embolism • Sudden pain in chest particularly after surgery, trauma- suspect PE • Emboli can occur anywhere and the symptoms will be correlated to where the embolism has occurred (brain- CVA) • Provide O2, High Fowler’s, maintain IV access, emotional support, anticoagulants, emergency care

  43. Pneumothorax/Hemothorax • Collection or air/blood in pleural space • Contributing factors: blunt chest trauma, COPD, occluded chest tube, older adults • Manifestations: respiratory distress, tracheal deviation, reduced/absent breath sounds, asymmetrical chest movement, subcutaneous emphysema • Dx: chest x-ray, thoracentesis • Interventions: administer O2, high fowler’s, monitor chest tube, emotional support, • Tx: Chest tube insertion • http://www.youtube.com/watch?v=dhXu9YEx7EY

  44. Pre-op • Review history • Identify risk factors • Check informed consent • Perform baseline assessment • Assess allergies, esp. Latex • Verify NPO status • Coordinate lab, EKG and x-rays • Reinforce client teaching • Exercises, TCDB • Equipment • NPO • Medication, pain mgmnt • Identify anxieties • Early ambulation • Unit routines

  45. Intraoperative Phase • Implement role according to standards • Maintain safety • Ensure asepsis • Apply grounding devices • Ensure correct sponge, needle, instrument count • Position patient • Remain alert for complications • Communicate with surgical team • Coordinate blood transfusions, radiology, biopsy, lab profiles as needed

  46. Post-op • Airway, Oxygen, Gag reflex • Breath sounds, encourage deep breathing • Level of consciousness, monitor reflexes • Vital signs, compare to baseline • Monitor I&O and urine output • Monitor bowel sounds, abd distension • Monitor skin color, wound, drains • Verify equipment • Check dressings • Ensure thermoregulation • Pain management • Maintain NPO until gag reflex returns • IV patency • Prevent complications

  47. Post-op Complications • Atelectasis • Hypostatic Pneumonia • Respiratory Depression • Hypoxia • Nausea • Shock • Urinary Retention/Hesitancy • Decreased Peristalsis • Wound Hemorrhage • Thrombophlebitis • Delayed Wound Healing • Wound Infection • Wound Dehiscence/Evisceration • Urinary Tract Infection

  48. GI Disease Contributing Factors • Alcohol • Autoimmune • Diet History • Genetics • NSAIDs • Older Adult • Obesity • Smoking • Sedentary Lifestyle • Stress

  49. GI Lab Tests • Albumin • Ammonia • Bilirubin • Direct • Indirect • Cholesterol/Trigglycerides/HDL/LDL • SGOT/SGPT • Amylase/lipase • Protime • Stool sample (C&S, O&P, occult blood)

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