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Nursing Fundamentals - Coggle Diagram

- - - - Temperature
        
        Thermal receptors send messages to the hypothalamus
        
        Heat production: by-product of metabolism, shivering, & physical exercise
        
        Heat loss: Mainly lost via skin, then sweat evaporation, warming of air, & elimination of urine/ feces
      - Pulse
        
        Regulated by ANS through the sinoatrial node (pacemaker) of the heart.
      - Respiration
        
        CO2 is the body's drive to breathe.
      - Blood Pressure
        
        The arterial walls are elastic tissue that stretch during ventricular contraction. The pressure keeps the blood flowing continuously. Aged adults have less elastic tissue walls, raising blood pressure.
    - - Respiration
        
        Exercise
        
        Disease/ trauma
        
        Fluid alterations
        
        electrolyte changes
        
        acid-base balances
        
        medications
        
        emotions
      - Temperature
        
        Circadian Rhythm: Low in morning, high in afternoon
        
        Age/ Sex: Lower in aged adults. Changes in body temp occur rapidly in infants & children. Fluctuations common amongst women.
        
        Physical Exercise: Exercise increases temp.
        
        Health: Certain diseases can raise or lower temp. such as MI, cancer, trauma, surgery
        
        Environment
      - Pulse
        
        Age/Sex: Women have higher pulse rates, Aged adults have slower pulse rate (due to decreased metabolic rate)
        
        Physical Exercise: increases with exercise (except athletes)
        
        Stress/ Fever: Both increase pulse
        
        Medications: variable
        
        Disease: Variable. Some examples are COPD, pneumonia, sepsis
      - Blood Pressure
        
        Age/Sex: Aged adults have higher BP, women have lower BP until menopause
        
        Circadian Rhythm: Lowest in morning, highest by afternoon
        
        Eating: increases BP
        
        Physical Exercise: Systolic rises
        
        Weight: increases with weight
        
        Emotions
        
        Body position: Sitting or standing raises BP
        
        Race: HTN more prevalent in African Americans
        
        Medication: oral contraceptives increase BP
    - - Temperature
        
        Ear canal
        
        Forehead (temporal artery)
        
        Oral
        
        Axillary
        
        Rectal
      - Pulse
        
        Femoral
        
        Popliteal
        
        Posterior tibial
        
        Dorsalis pedis
        
        Apical pulse
        
        Radial
        
        Brachial
        
        Carotid
        
        Temporal
      - Blood Pressure
        
        Brachial artery
        
        Radial artery
        
        Popliteal artery
    - - Adults
        
        Temp: 96.4 - 99.5 F
        
        Pulse: 60 - 100
        
        Resp.: 12 - 20
        
        BP: 120/80
      - Child
        
        Temp: 98.2 - 100 F
        
        Pulse: 70 - 115
        
        Resp.: 20 - 26
        
        BP: 95/57
      - Infant
        
        Temp: 98.7 - 100.5 F
        
        Pulse: 80 - 160
        
        Resp.: 20 - 40
        
        BP: 85/37
      - Aged Adult
        
        Temp: 96.4 - 98.3 F
        
        Pulse: 40 - 100
        
        Resp.: 16 - 24
        
        BP.: 120/80
      - Dangerous Temperature: above 106 F, below 95 F
  - - - Portals of entry, susceptible host, means of transmission, portal of exit, reservoir, infectious agent
    - - Incubation period- no sx
        
        Prodromal stage- vague sx
        
        Acute stage- specific sx
        
        Convalescent period- recovery
    - - poor skin integrity
        
        pH levels
        
        low WBC
        
        young or old age
        
        unvaccinated
        
        pre-existing illness
        
        certain medications
        
        increased stress level
        
        indwelling or invasive medical devices
        
        poor nutrition
        
        unsafe sex
        
        IV needle use
    - - hand hygiene
        
        don't let soiled linens touch your clothing
        
        provide patients tissues for cough/ sneezing
        
        avoid raising dust
        
        clean least soiled areas first, then dirtier areas last
        
        wrap moist items in waterproof containers
        
        pour liquids directly into drain
        
        sterilize equipment
        
        groom regularly
    - - Before touching a patient
        
        Before a clean procedure
        
        After body fluid exposure risk
        
        After touching a patient
        
        After touching patient surroundings
      - Use hand soap when:
        
        blood or body fluid exposure
    - - MRSA
        
        VISA
        
        VRSA
        
        VRE
        
        CRE
        
        C. diff
    - - wash hands regularly
        
        clean home with disinfectant
        
        avoid sharing items
        
        oral care
        
        avoid sunburn, cuts, tampons, intercourse
        
        don't handle animal waste
        
        avoid crowds, public pools, recently ill people
        
        disinfect kitchen surfaces
        
        cook food to proper temperature and avoid raw meats
    - - Standard
        
        precautions used in the care of all hospitalized patients regardless of their diagnosis or possible infection status. These precautions apply to blood, all body fluids, secretions, excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes. Additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures.
        
        hand hygiene
        
        clean gloves
        
        PPE: mask, eyewear, face shield, Tyvek
        
        cough etiquette
        
        DONT recap needles
        
        safe injection practices
        
        face masks for catheter or spinal injections
      - Transmission-based:
        
        precautions 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. The 2007 CDC guidelines include a directive to don PPE when entering the room of a patient with transmission-based precautions, and to remove the PPE only when leaving the room. These categories recognize that a disease may have multiple routes of transmission.
        
        Airborne: negative air pressure, respirator, transport only when necessary
        
        Droplet: wear PPE, transport only when necessary
        
        Contact: wear PPE, limit movement out of room
    - - keep sterile objects separate and together
        
        open packages AWAY from you
        
        avoid spilling solution on sterile field
        
        hold sterile objects above the level of the waist
        
        avoid talking, sneezing, coughing over sterile field
        
        outer 1-inch of sterile field contaminated
- - - - Trial and Error - testing solutions until one works, inefficient and potentially dangerous
        
        Scientific - controlled and systematic
        
        Intuitive - based on experience, knowledge, and skill
    - - 5 steps
        
        Systematically collect patient data (assessing)
        
        Clearly identify patient strengths and actual and potential problems (diagnosing)
        
        Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning)
        
        Execute the care plan (implementing)
        
        Evaluate the effectiveness of the care plan in terms of patient goal achievement (evaluating)
    - - Systematic
        
        Dynamic
        
        Interpersonal
        
        Outcome Orientated
        
        Universally Applicable
    - - Patient benefits:
        
        promotes wellness
        
        prevents disease
        
        facilitates coping
        
        Nursing Benefits:
        
        cost-effective
        
        clear and efficient
        
        satisfaction
        
        professional growth
    - - collect patient concerns and problems on a list
        
        Connect and analyze the relationships
        
        Create a diagram
        
        Keep in mind key concepts (holism, safety, advocacy)
  - - - The source sends a message via a channel of communication (visual, auditory, kinesthetic) to a receiver. The receiver provides feedback. Communication is influenced by noise, previous knowledge, past experiences, feelings, or sociocultural influences.
    - - Touch, Eye Contact, Facial Expression, Posture, Gait, Gestures, Physical Appearance, Mode of Dress/ Grooming, Sounds
    - - Do not release identifiable information online, this includes diagnosis, patient name, or room number. Maintain patient-nurse boundaries. Utilize privacy setting. Report content online that could violate patient privacy. Follow institutional policy.
    - - A: what is the preferred language; assistive devices; interpreters
        D: communicate written and verbal diagnosis to team members
        P: Written/ verbal plans improve continuity in care
        I: Communicate importance of treatment; the plan; receive feedback from patient
        E: exchange positive or negative feedback and revise nursing plan as needed.
    - - 1. Orientation: Call nurse by name, describe roles of participants, establish goals, location, frequency, and length of contact, duration of relationship.
        2. Working: active relationship, cooperation, express feelings and concerns
        3. Termination: identify accomplished goals or progress, verbalize feelings about the termination.
  - - - Carbs, protein, and lipids: supply energy
        vitamins, minerals, water: regulate body processes
    - - Age, systemic/ local diseases, psychosocial issues, limited food intake, chewing/swallowing difficulties, GI problems, surgery, low food budget.
    - - Infants: Fast growth increases nutritional needs. Breastfeeding recommended. New foods introduced slowly.
        
        Toddler: Slower growth rate with increased muscle mass and bone density.. Food dislikes and likes develop. Many fruits and vegetables. Uses food as a bribery tool.
        
        Children: Erratic growth pattern with increased energy requirements. Improved appetite. Advertising has a big effect,.
        
        Adolescents: Rapid sexual maturation with growth spurt. Lower quality diet.
        
        Pregnancy: Nutrient needs increase. Breast milk quality determined by diet and nutrition during pregnancy,
        
        Older Adults: Energy expenditure decreases. Caloric needs decrease. Prone to dehydration. Risk for malnutrition,
    - - Sex: Men require more calories and protein. Women require more iron.
        
        Health: Fever, trauma, chronic disorders, and mental health problems change nutritional needs.
        
        Medication: Nutrient absorption may be altered by drugs that (1) change the pH of the GI tract, (2) increase GI motility, (3) damage the intestinal mucosa, or (4) bind with nutrients, rendering them unavailable to the body. Nutrient metabolism can be altered by drugs that (1) act as nutrient antagonists, (2) alter the enzyme systems that metabolize nutrients, or (3) alter nutrient degradation
        
        Megadoses of Supplements: Excess of one nutrient can lead to deficiency of another due to preferential absorption.
      - A: Systematic approach. Medical history including diet, medical, socioeconomic, and physical assessments/ labs. Nutritional screening, assess dietary intake, allergies, food preparation and storage, type of dietary practices, eating disorder patterns, BMI, Clinical observations, laboratory values
        D: biochemical data with nutritional implications
    - - Imbalanced Nutrition: Less Than Body Requirements
        
        Obesity
        
        Risk for Overweight
        
        Fatigue
        
        Constipation
        
        Risk for Impaired Skin Integrity
        
        Readiness for Enhanced Nutrition
    - - screening patients
        
        observing intake and appetite
        
        evaluate patient tolerance
        
        assist with eating
        
        consult dietician
        
        addressing drug-food reactions
        
        obtain food and snacks
        
        monitor food brought by visitors
        
        nutrition education efforts
    - - "passing a tube into the GI tract"
        
        verify correct placement after initial insertion, before feeding, and at regular intervals during continuous feeding.
        
        Radiographic examination
        
        measuring tube length and marking
        
        measuring aspirate pH
        stomach: pH 5.5 or less, Intestines pH 7 or higher, Respiratory tract pH 6 or higher
        
        visual assessment of aspirate
        
        monitoring CO2 levels
        
        Check gastric residual
        
        use sterile water for flushes
        
        Follow guidelines for holding feedings
        
        Assess the abdomen for abnormalities.
        
        Check bowel sounds
        
        keep patient upright
      - Feeding Pumps: automatic tube flush, prevention of free flow of formula, audible and visible alarms.
    - - " nutritional support via IV"
        
        use electronic infusion
        
        make small infusion rate changes
        
        discard used solutions within 24 hours
        
        check vitals every 4 hours
        
        monitor BGL
        
        use aseptic techniques
        
        avoid blood sampling
        
        change site dressings
        
        check that connections are securely taped
        
        monitor fluid intake and output
        
        assess electrolytes for imbalances
- - - - Age; children and aged adults have thinner/weaker skin prone to infection and injury
        
        Health; Very thin and obese people more prone to skin injury. Dehydration/ malnutrition and reduced sensation (diabetes).
        
        Lifestyle; Occupation, body piercings, sexual partners/ drug use (HIV risk)
        
        Therapeutic Risk; bed rest, casts, aquathermia unit, meds, radiation
      - Local Factors: Pressure, Desiccation, Maceration, Trauma, Edema, Infection, Excessive Bleeding, Necrosis, Biofilm
        
        Systemic Factors: Age, Circulation, Oxygenation, Nutritional Status, Medications, Wound etiology, Immunosuppression, Adherence to Treatment Plan.
    - - Aged adults
        
        Aging skin
        
        Chronic illness
        
        Immobility
        
        Malnutrition
        
        Malnutrition
        
        Fecal/ Urinary incontinence
        
        Altered LOC
        
        Spinal cord injuries
        
        TBI
      - Poor skin hygiene
        
        DM
        
        Diminished pain awareness
        
        Fractures
        
        Steroid therapy
        
        Immunosuppression
        
        Increased body temperature
        
        Multiple organ dysfunction syndrome
        
        Microvascular dysfunction
        
        Previous pressure injuries
        
        Obesity or thinness
        Terminal illness/ dying
    - - Stage 1: Intact, Erythema
        
        Stage 2: Partial-thickness, exposed dermis. Intact or ruptured blister
        
        Stage 3: Full-thickness skin loss, wound bed visible in ulcer.
        
        Stage 4: Full- thickness skin and tissue loss, exposed muscle, tendon, ligament, cartilage, or bone in ulcer.
        
        Unstageable: Obscured and cannot be confirmed due to slough and eschar. Stage 3/ 4 ulcer underneath.
        
        Deep Tissue: localized area of deep red/ maroon/ purple discoloration
    - - Appearance of wound, depth, color (red/ yellow/ black)
        
        Drainage- serous, sanguineous, serosanguinous
        
        Sutures/ Staples
      - Red = Protect (proliferative stage of healing)
        Yellow = Cleanse (exudate drainage)
        Black = Debride (eschar, necrosis)
    - - Assess skin daily
        
        Cleanse skin routinely, avoid hot water and mild cleansing agent
        
        Maintain higher humidity, use moisturizer
        
        Avoid massage over bony area
        
        Protect skin from moisture
        
        Minimize skin injury from friction and shearing forces by using pads, protective films, re-positioning
        
        Use support surfaces
        
        Investigate inadequate diet intake (mainly protein and calories)
        
        Attempt to improve mobility and activity where possible
    - - Generally, an ideal dressing should maintain a moist environment, be absorbent, provide thermal insulation, act as a bacterial barrier, reduce or eliminate pain at the wound site, and allow for pain-free removal
      - Dry gauze: wound barrier dressing
        
        Sof-Wick: special gauze around drains
        Abdominal pads, large: placed over smaller gauze dressings
        
        Transparent films: adhesive and waterproof, decreases possibility of contamination
      - Keep wounds moist
        
        Remove foreign material/ debris
        
        Do not use dry gauze directly on wound, use product that promotes moisture.
    - - Proper hand hygiene
        
        Encourage consultation
        
        Easy-to-read instructions
        
        Educate need for nutrition
        
        Teach to use pain medication
      - Methods for obtaining supplies, costs, insurance
        
        Signs and symptoms of infection (increased temp, flu-like symptoms, red or separated wound edges, increased pain, increased drainage that is thick or odorous),
        
        aseptic technique, dressing disposal,
    - - Heat:
        
        pain relief,
        
        accelerate inflammatory response to promote healing
        
        reduces muscle tension
        
        systemic effects of prolonged heat: increased pulse, cardiac output, decreased BP, sweating, hypovolemic shock
      - Cold:
        
        reduces muscle spasms
        
        promotes comfort
        
        reduced edema/ inflammation
        
        increased coagulation at wound site
        
        numbs tissue
        
        systemic effects of prolonged cold: increased BP, shivering, goose bumps
    - - Stages:
        
        Hemostasis
        
        Inflammatory
        
        Proliferation
        
        Maturation
      - Primary intention: well approximated edges.
        ex. surgical wounds
        
        Secondary intention: not well approximated.
        ex. trauma wounds/ burns/ infection
        
        Tertiary intention: Delayed primary closure, wound left open for several days due to edema or infection and need to drain
  - - - Muscular
        
        Motion
        
        Posture
        
        Support
        
        Heat production
      - Nervous
        
        Impulses
        
        Convey information
      - Skeletal
        
        support soft tissues
        
        protect important tissues
        
        surface for attachments
        
        storage of minerals and fat
        
        produce blood cells
    - - Age
        
        Physical Health
        
        inflammation, degeneration, trauma
        
        spinal cord injuries
        
        Pathology of illnesses
        
        Treatment of illness (i.e. bedrest)
        
        Mental Health
        
        Lifestyle
        
        Attitude and Values
        
        Fatigue and Stress
        
        External Factors (ex. weather)
    - - Isotonic: muscle shortening exercises (ex. swimming, walking)
        
        Isometric: muscle contraction w/o shortening, minimal movement (ex. holding a Yoga pose)
        
        Isokinetic: muscle contractions with resistance (ex. lifting weights)
    - - cardiac: increased BP, HH, efficiency
        
        Respiratory: decreased work of breathing, improved ventilation
        -Musco: increased strength, coordination, impulses, reduced bone loss
        
        Metabolic Processes: increased triglyceride breakdown, gastric motility, and body heat
        
        GI: increased appetite, intestinal tone
        Urinary System: increases blood circulation, improves blood flow to kidneys
        
        Skin: nourishes skin
        Psychosocial Outlook: more energy, sleep, body image, self-concept, positivity
    - - Altered response to activity
        
        Physical inability to move purposefully or a reluctance to move
        
        Postural instability
        
        Activity Intolerance related to fatigue, generalized weakness, and exertional discomfort
        
        Impaired Transfer Mobility related to pain and musculoskeletal impairment
        
        Risk for Injury related to altered sensation, unsteady gait, and confusion
    - - Assess patient ability to assist.
        
        Asses ability to understand instructions
        
        Use assistive devices for lifting 35 + lbs.
        
        Utilize multiple staff
        
        Assess for clutter and choose equipment
        
        Safety precautions (lock bed heels)
        
        Use gait belts to transfer or assist with ambulation
        
        Stand assist- minimal assistance
        
        Lateral Assist Device: reduce side to side
        
        Friction reducing sheets: prevent moving in bed
        
        mechanical lateral assist device: eliminate need to slide patient manually
    - - Have an erect posture
        
        Use longest and strongest muscles for strenuous tasks
        
        Use the internal girdle to stabilize the pelvis
        
        Position body close to object being moved
        
        face direction of your movement
        
        Use body weight as a force
        
        Slide roll, push, pull before lifting
        
        Push over pull
        
        Broaden base of support (spread feet)
        
        Make sure surfaces are dry and smooth
        
        Flex knees, lift using legs
        
        Take breaks, recover
        
        Break up heavy loads into small loads
  - - - A stimulus must be present
        
        A receptor must receive the stimulus
        
        A nerve impulse must conduct from the receptor to the sense organ
        
        The brain must translate the impulse into sensation
    - - The RAS mediates arousal. Nerve impulses reach the RAS between the hypothalamus and medulla. The RAS then selects which impulses are perceived and monitors stimuli.
    - - Sensory Overload
        
        Etiology:
        
        increased internal stimuli (ex. pain)
        
        increased external stimuli (ex. lights, noise)
        
        Inability to disregard or ignore some stimuli
        
        Response:
        
        Person feels out of control
      - Sensory Deprivation
        
        Etiology:
        
        monotonous stimuli
        
        impaired ability to receive stimuli (i.e. impaired vision)
        
        Unable to process stimuli (i.e. spinal cord injuries)
        
        Response:
        
        Hallucinations & daydreams to maintain RAS arousal levels
        
        Inaccurate perception of sight/ sound/ taste/ smells/ etc.
        
        Inability to focus, poor attention span
        
        Rapid mood changes, apathy, anxiety/ fear anger, panic, depression
    - - Stimulation
        
        Does your current environment overly, insufficiently, or appropriately stimulate you?”
        
        “Are you bored? Why?”
        
        “Are you able to read? Watch television? Knit? Why not?”
        
        “Are there other people in your home during the day? Do you spend much time together? How do you spend the time?”
        
        “Who visits you while you are in the hospital?”
        
        Note reduction in the patterns or meaningfulness of stimulation in each sensory modality, changes in stimulation other than decreases (e.g., new or unusual stimulation), or developmental appropriateness of stimulation.
      - Reception
        
        “Does anything interfere with the functioning of your senses?”
        “Describe any corrective devices you use for sensory impairments.”
      - Visual Disturbances
        
        “Please read my name tag (or this page of print).”
        
        Note if the patient can correctly identify objects directly in front of the eyes as well as those requiring peripheral vision.
        
        Note eye rubbing, squinting, movements indicating faulty vision (bumping into furniture, overreaching or underreaching for objects), changes in the appearance of the eye (cataracts, swelling), and complaints of eye pain, spots, halos, or other visual disturbances.
    - - Acute Confusion: The abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity level of consciousness, or sleep–wake cycle
        
        Risk for Acute Confusion: A vulnerability to reversible disturbances of consciousness, attention, cognition, and perception that develops over a short period of time, which may compromise health
        
        Chronic Confusion: An irreversible, long-standing, or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought processes and manifested by disturbances of memory, orientation, and behavior
        
        Impaired Memory: The state in which a person experiences the inability to remember or recall bits of information or behavior skills. Impaired memory may be attributed to pathophysiologic or situational causes that are either temporary or permanent.
    - - Vision: Use corrective lenses, medications, good lighting, large print, visit ophthalmologist annually
        
        Hearing: Assistive device, lower tone, speak where patient can see mouth movement
        
        Touch: Protect skin from temperatures, assess for wounds, ensure patient is ambulating
        
        Sensory deprivation: discourage sedatives, provide interaction with children/ pets, encourage exercise class ensure frequent visits from family
        
        Sensory overload: orient to person, place, time, decrease noise, encourage patient to participate in nursing care
    - - live in a stimulating and safe environment
        
        exhibit level of arousal that enables meaningful stimulation
        
        demonstrate intact functioning of the senses
        
        schedule health screening exams
        
        maintain orientation
        
        respond appropriately to sensory stimuli
        
        verbalize acceptance of sensory deficit