-
accreditation agencies such as ____ ____ ____ specify guidelines for documentation
The Joint Commission
-
requires disclosure or requests regarding health information
HIPAA
-
the joint commission requires each client have an assessment (6 steps)
- physical
- pyschosocial
- environment
- self-care
- client education
- discharge planning needs
-
federal and state regulations, state statutes, standards of care, and accreditation agencies......
set nursing documentation standards
-
confidential permanent legal document
records or chart
-
oral, written, audiotaped exchange of information
reports
-
a professional caregiver providing fomal advice to another caregiver
consultations
-
arrangement for services by another care provider
referrals
-
purposes of records
- communication
- financial billing
- research
- legal documentation
- education
- auditing/monitoring
-
guidelines for quality documentation and reporting
- factual
- accurate
- complete
- current organized
-
tradition method of recording
narrative
-
what the patient says
i.e. symptoms
subjective
-
something observable
i.e. signs
objective
-
focuses on documenting deviations....only chart whats not normal
charting by exception
-
incorporates a multidisciplinary approach to care....gets people out as quick as possible
case management plan and critical pathways
-
includes medicare and medicaid legislation for long term care documentation
Omnibus Budget Reconciliation Act of 1987
-
governs the frequency of written nursing records
department of health
-
S
O
A
P
- subjective
- objective
- assessment
- plan
-
not permanent in patients file
advance directive
-
occurs when a microorganism invades the host but does not cause infection
colonization
-
infectious process transmitted from one person to another
communicable
-
chain of infection
- infectious agent or pathogen
- source of pathogen growth
- portal of exit
- mode of transmission
- portal of entry
- susceptible host
-
three stages of the infection process
- incubation period
- prodromal stage
- illness stage
-
most microorganisms preer an environment within a pH range of
5-7
-
do not usually cause disease when residing in their usual area of the body but instead participate in maintaining flora
normal flora
-
fluid and cells that are discharged from cells or blood vessels
pus and serum
exudates
-
process that involves the destruction and absorbtion of bacteria
phagocytosis
-
increase in number of circulating blood cells
leukocytosis
-
-
containing red blood cells
sanguineous
-
contains WBCs and bacteria
purulent
-
not as strong as tissue collagen and assumes the form of scar tissue
granulation tissue
-
type of HAI from a diagnostic or therapeutic procedure
iatrogenic infection
-
post operative infection that is present outside the body
exogenous
-
occur when pard of the clients flora becomes altered and an over growth occurs
endogenous
-
absence of pathogenic microorganisms
asepsis
-
writes guidlines in infection control and prevention
CDC
-
has a thicker cell wall and holds the violet stain
gram +
-
thinner cell wall and does not hold violet stain
gram -
-
bacteria shaped like a rod
bacilli
-
bacteria shaped like a sphere
cocci
-
bacteria shaped like a spiral
spirilla
-
anerobic bacteria infections are usually found where in the body
bladder, GI, blood
-
anti-infectives are broken into what two classes
- chemical-structure
- pharmacologic-how they work
-
bacteriocidal medications are used to
kill bacteria
-
these type of infections interrupt growth
bacteriostatic medications
-
affects bacterial cell wall, gram +
penicillins or cillins
-
affects bacterial cell wall, gram -
cephalosporins...cefs
-
affects bacterial cell wall, both gram + and -
carbapenems....penems
-
two unclassified drugs that affect bacterial cell wall
vancomycin and aztreonam
-
major considerations for medications that affect the bacterial cell wall
- anaphylatic reactions
- photosensitivity
- decrease effects of birth control
- rash and diarrhea most common
- hyperkalemia
- nephrotoxic
-
can cause hypotension and be ototoxic
vancomycin
-
affects bacterial protein synthesis, gram + and -
tetracyclines....clines
-
affects bacterial protein sythesis, gram +
macrolides
-
affects bacterial protein synthesis, gram -
aminoglycosides
-
effective against MRSE and VRE
linezolid(Zyvox)
-
major considerations for medications that affect bacterial protein synthesis
- destroy normal flora
- photosensitivity
- rash and diarrhea most common
- hepatoxic
- eliminates vitamin K
-
causes tooth discoloration
tetracycline
-
are ototoxic and nephrotoxic
aminoglycosides
-
interferes with DNA replication, gram + and -
floroquinolones...oxacins
-
effective against c-diff
flagyl
-
effective against TB
rifampin
-
commonly used antibiotic ointment
bacitracin
-
major considerations for medications that interfere with DNA replication
- photosensitivity
- rash and diarrhea most common
- hepatoxic
-
most common medications used to interfere with DNA replication
ciprofloxacin, levofloxacin
-
new and effective against anarobes
avelox
-
the awareness of the postion of the body and its parts
proprioception
-
fit closely together and are fixed
fibrous joints
-
removal of waste products
excretion
-
one day of full bed rest takes how many days to recover
3-5
-
what are the three factors that contribute to venous thrombus formation
- damage to the vessel wall
- alterations of blood flow
- alterations of blood constituents
-
muscles break down into _____
protein
-
contractor can start as soon as ___ hours and is not reversable
8
-
atelectasis means
collapsed lung
-
immobitiliy affects the cardio system in what way compared to the other systems
it makes the cardio system work harder, while the other systems being to shut down
-
changes in mobility alter what changes to the metabolic changes
- endocrine metabolism
- calcium resorbtion
- functioning of the GI system
-
when the client is immoble, the clients body often excretes more nitrogen then it ingests in proteins, resulting in _____ ______ _______
negative nitrogen balance
-
inflammation of the lung from stasis or pooling of secretions
hypostatic pneumonia
-
the most common respitory complications from immobility are ______ and ______
- atelectasis
- hypostatic pneumonia
-
accumulation of platelates, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery
thrombus
-
what are the changes on the musculoskeletal due to immobility
- loss of endurance and muscle mass
- decresed stability and balance
-
effects on the muscles due to immobility
- loss of muscle mass
- muscle atrophy
-
what are the effects on the skeletal system due to immobility
- impaired calcium absorbtion
- joint abnormalities
-
what are the effects on urinary elimination due to immobility
- urinary stasis
- renal calculi
-
effects on the integumentary system due to immobility
-
whats the acute care implementation for metabolic immobility
- provide high protein diet
- high caloric diet
- vitamin B and C supplements
-
implementation of acute care for the respiratory system due to immobilty
- cough and deep breathe every 1-2 hours
- chest physiotherapy
-
-
-
stored in bronchi trees, GI tract and skin
histimine
-
reduces prostaglandin synthesis
lowers body temperature
causes centrally mediated peripheral vasodilation and sweating
asprin
-
this class of drug can increase blood sugars
NSAIDS
-
assess the prothrombin time and international normalized ratio with concurrent anticoagulant use
asprin
-
report ringing in the ears, impaired hearing, dizziness, unusual bruising or bleeding that is slow to stop with this medication
asprin
-
analgesic
anti-inflammatory
antipyretic
IBU
-
this NSAID blocks cox-2 but not cox-1; causes less GI bleeding and ulcer formation;anti-inflammatory
celebrex
-
this medications serious adverse effects include MI that can be fatal and stroke
celebrex
-
used to reduce fever and relieve pain but is not a NSAID of anti-inflammatory
acetaminophen
-
which medicine do you take for tylenol poisoning?
acetadote (acetylcysteine)
-
used to treat transplant rejection
inhibit immune response bia several different mechanisms
immunosuppressants
-
what is the specific drug of choice for transplant rejection
diminishes the activity of T cells and B cells and suppresses the immune response
cyclosporine
-
when on this immunosuppressant avoid direct sunlight, and causes renal impairment and hepatic impairment
cyclosproins
-
this immunosuppressant causes reduced urine flow, hypertension, tremor, hair growth in women, elevated hepatic enzymes, infections, anaphylaxis
cyclosporins
-
on this immunosuppressant avoid crowds
take the same time everyday
see dentist before to ensure good dental hygeine
cyclosporins
-
immunosuppressant that inhibits DNA synthesis and is metabolized in the liver
Imuran;azathioprine
-
immunosuppressant side effects:
bone marrow suppression
serious infections
hepatotoxicity
skin and lymphoid malignancies
Imuran
-
when on this immunosupp. nursing respons. include:
obtain baseline lab tests and perform CBCs
monitor kidney and liver function, input/output ratio, and characteristics of urine, abnormal bleeding signs, use protective isolation to reduce infections
Imuran
-
used to prevent transplant rejection, autoimmune disorders, malignancies....harvested from antibodies produced by a single B cell, very specific targeting a single type of target cell or receptor
antibodies
-
drug of choice for short term therapy of severe inflammation
corticosteroids
-
corticosteroids lymphocyte effect
reduces circulating lymphocytes
-
corticosteroids monocyte effect
depletes body of monocytes and macrophages
-
corticosteroids neutrophil effect
causes neutrophil to moce from bone marrow to general circulation
-
what are the other effects of cortiocosteroids
blocks production of protaglandins and ILs
-
the four types of immunosuppessants
- calcineurin inhibitors
- Imuran
- Antibodies
- Corticosteroids
-
the skin has a ____ pH and receives approximately _____ of the blood supply
-
what are the four functions of the skin
- protection
- thermoregulation
- sensation
- communication
-
what are the four assessment steps for the skin
- visual inspection of the skin
- check bony prominences
- skin risk assessment
- stage any pressure ulcers
-
helps indentify patients at risk, has been known to decrease pressure ulcer rates, pt. assessed in 6 areas of functions and scored, the lower the number the higher the risk
Braden scale
-
the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues
stage 1 pressure ulcer
-
partial thickness loss of skin layers involving epidermis and possibly penetrating into, but not thru the dermis...may appear to be blistering with erythema; wound base is moist and pink
stage II pressure ulcer
-
full thickness tissue loss extending thru the dermis to involve subQ tissue...presents as shallow crater unless covered by eschar...may include necrotic tissue, exudate or infection
stage III pressure ulcer
-
full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound..often undermining and tunneling
stage IV pressure ulcer
-
skin intact, discoloration of skin, deep red to purple color, may have recesed area, may be dark blister
deep tissue injury
-
full thickness tissue loss in which the base of the ulcer is covered by yellow, tan, gray, green, or brown tissue and eschar in the wound bed
unstageable
-
factors that impact wound healing include (6)
- nutrition
- infection
- diabetes
- steroids
- immunosupp.
- age
-
transparent dressing that is used to reduce friction, and protect small areas
tegaderm
-
only insulates and protects wound...stages 1-3...agressive skin sealant..can stay on up to 7 days...NOT to be used on infection
hydrocolloid...duoderm
-
provides and maintains moisture to the wound bed, easy to apply, requires external dressing
hydrogels...saf-gel
-
tolerates minimal damage, very comforting on wounds, insulates wounds....used for burns
hydrogels...nu-gel
-
can be used on most wounds, moderate to heavy drainage, can be left in place for 3 or more days, requires outer dressing, made from seaweed, high absorbancy
hydrofiber--aquacel (ag)
-
made from seaweed
used for heavy drainage
turns into gel when moistened
alginate
-
large dressings
heavy draining wounds
non-stick layer
exudry
-
adaptic
non-stick layer
used for skin tears
layer on wound vac
non adherent dressing
-
alldress
wound covering
gentle tape
non-stick dressing
island dressing
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