Download
physiological integrity reduction of risk physiological integrity n.
Skip this Video
Loading SlideShow in 5 Seconds..
Physiological Integrity Reduction of Risk Physiological Integrity PowerPoint Presentation
Download Presentation
Physiological Integrity Reduction of Risk Physiological Integrity

Physiological Integrity Reduction of Risk Physiological Integrity

229 Views Download Presentation
Download Presentation

Physiological Integrity Reduction of Risk Physiological Integrity

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  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)