Assessment
This is blood test can be drawn at any time of day without regard for when the patient last ate and is used to diagnose the condition and monitor the patients compliance with therapy and the result can be affected if the patient has anemia or renal disease.
If the result comes back at 5.4 this indicates that the patient has done a good job at managing their long term health condition.
What is a HgA1c test?
Greater than or equal to 6.5% - diabetic
5.7% to 6.4% - prediabetic
Remember: Co-morbidities such as anemia and renal disease can affect A1c results.
Bonus question: If a person has an insulin pump, do they still need to check and document their blood glucose?
In this condition that is commonly seen as a complication of diabetes, the nurse may find numbness, tingling, or pain in their lower extremities during assessment.
What is Diabetic Peripheral Neuropathy?
Remember: This is a tertiary prevention issue. Restricted blood flow and vascular disease can lead to nerve damage.
The lack of pain means that patients can have significant injuries and not be aware of it, which is why foot inspections are so important for people who have diabetes.
When they do get an injury, the same poor vasculature means that the patient's poor blood flow delays healing and increases their risk for infection.
These critical nursing interventions are essential protective measures for patients who have weakness or delayed control of their glottic muscles
What are aspiration precautions?
Interventions like upright positioning (typically 90 degrees during meals and 30-45 degrees at other times) uses gravity to help direct food/liquid away from the airway.
Thickening agents added to thin liquids slow their transit time, giving patients better control of the bolus.
Avoiding straws prevents the rapid posterior propulsion of liquids that can bypass protective mechanisms.
Use the chin tuck and inspect the mouth for pocketed food after each bite.
Together, these interventions form a core component of aspiration precautions to protect patients with dysphagia or impaired swallowing reflexes.
For this inflammatory condition of the stomach lining, patients should follow a bland diet avoiding spicy foods and caffeine, may use antacids for symptom relief, but must avoid aspirin and NSAIDs which can worsen the condition.
What is gastritis?
THINK: We want to lessen irritation to the gastric mucosal lining that protects the gastric muscle from exposure to acid.
While acute pain typically serves as a protective warning signal and resolves with tissue healing, this type of pain persists beyond normal healing time and may become a disease state itself rather than just a symptom.
Acute pain typically lasts less than 3-6 months while chronic pain continues beyond expected healing time
Acute pain has an identifiable cause and purpose, while chronic pain may persist after the original cause is resolved
Treatment approaches differ significantly, with chronic pain often requiring multimodal strategies beyond just medication
Chronic pain frequently involves central sensitization and neuroplastic changes that aren't present in acute pain
This condition causes shakiness, sweating, confusion, and blurred vision that improves with glucose administration, unlike its counterpart which causes fruity breath, polyuria, polydipsia, fatigue, weight loss, and polyphagia.
What is Hypoglycemia?
Type 1 typically happens fast and is more common in younger people and treatment is with insulin
Type 2 is slower in onset, and can often be managed with oral hypoglycemics and lifestyle modification, but may progress to needing insulin too.
This diet allows items like apple juice, broth, and gelatin, black coffee and coca-cola, but would not allow consumption of milk, cream soups, or ice cream, or apple sauce.
What is a clear liquid diet?
Think: Is it transparent?
Jello will melt to a clear liquid in the mouth/stomach
How do you count ice-chips?
* It is not about color, but the substance that the GI tract would need to process.
These evidence-based interventions can be implemented without physician orders, and as with all nursing interventions they should begin with least to most invasive, and they can help support the coping mechanisms for the family and the patient.
What are integrative therapies?
IH interventions must be evidence based and includes techniques like deep breathing, therapeutic communication, guided imagery, and therapeutic touch.
Nursing interventions for this condition include elevating the head of bed 30 degrees, eating multiple small meals per day and not eating for 3 hours before bed, and teaching patients to avoid trigger foods like citrus and caffeine. This condition occurs when the lower esophageal sphincter (the muscle between the esophagus and stomach) fails to close properly, often worsened by increased abdominal pressure from obesity or pregnancy, leading to stomach acid backing up into the esophagus.
What is Gastroesophageal reflux disease (GERD)?
THINK about how bigger meals, or anything that puts pressure on the abdomen will impact the change of stomach contents refluxing into the esophagus.
What about gravity? Should the person lie down after eating? Why?
When providing care, this age group benefits from having limited, age-appropriate choices such as "Would you like the medicine in a cup or with a spoon?" to promote autonomy and cooperation, while infants require no choices as caregivers make all decisions for them.
What are school-age children?
THINK: How do you address differently the family who are caring for a sick infant, older child, or grandparent?
How do you evaluate if there is caregiver stress if a disproportionate amount of the care is assumed by one person?
How will you assist in the establishment of boundaries and communication expectations so that the family unit can adapt to change and collaborate to problem solve together?
When performing an abdominal assessment, you must complete this step before palpation or percussion to avoid altering bowel sounds, and you should listen for a full 5 minutes in each quadrant before documenting their absence.
What is auscultation?
(or What is listening to bowel sounds)?
Inspect, Auscultate, Percuss, Palpate
Don't forget to review the assessment details that you learn in NURS371 for the specifics of HOW to properly complete each step!
A 108 lb Caucasian female is at greater risk of developing the first condition, but a 260 lb male marathon runner is at higher risk of developing the second condition.
What are osteoporosis and osteoarthritis?
THINK: Bone density and regrowth are triggered by the body stimulating the need for retaining and rebuilding the internal honeycomb of bone. An underweight, malnourished, postmenopausal female is at higher risk of developing osteoporosis. Osteoarthritis is caused by wear and tear on specific joints, so a heavier person who runs marathons will incur more pressure on their knees than a person who is smaller.
We treat osteoporosis with calcium and Vitamin D, and weight bearing exercises to stimulate bone retention.
This conditions differs from Dementia/Alzheimer's disease because it is a temporary acute reversible condition that can be caused by illness, sleep deprivation, or overstimulation which is common in hospitals, and it resolves when the factors that caused it are reversed.
What is delirium?
THINK: Can a patient who has dementia also have delirium?
How would you know?
The nurse providing education to younger women would advise them to void after sex and wipe from front to back after toileting to lessen their risk of developing this condition.
What is a UTI?
Young sexually active females are at high risk for this infection because their urethras are only 1-2 inches long compared to males' 8 inches, making bacterial ascension from the perineal area more likely.
THINK: What about older people with incontinence?
Would a foley catheter be a good preventative measure?
When caring for patients in these family structures that include grandparents, parents, and children living together, nurses must assess communication patterns, decision-making hierarchies, cultural values, and potential role conflicts that can impact patient care and treatment compliance.
What are multigenerational families?
THINK: How do you provide support for each member of the family?
Who do you address if only one person is responding to your questions?
In this situation, I would expect assessment finding of Hyperthermia, Tachypnea, Tachycardia, and Hypotension, and Hyperglycemia?
What are signs and symptoms of an infection? OR
What are signs and symptoms of an immune response?________________________________________
In assessing a patient that has an infection we expect to see clinical manifestations because of the body mounting an immune response to fight the infection.
Hyperthermia is anticipated as part of the immune response to an infection to kill the bacteria or virus.
When out temp increases, our blood vessels dilate and become more permeable, but this causes blood
Hypotension is anticipated due to vasodilation
Tachycardia is anticipated as a compensatory mechanism due to the lower blood pressure
Tachypnea is expected to compensate for an imbalance in metabolic needs versus supply. The work of fighting infection, plus the work of cardiac contractility (increased heartrate) mean that the body needs more oxygen to provide tissue perfusion, so RR increases to provide more oxygen.
Hyperglycemia occurs as part of the inflammatory response to infection or injury. Even when a person does not have diabetes, they may have elevated blood sugar levels requiring treatment after surgery, injury, or infection, so increased testing of blood sugar is very important, particularly if they do have diabetes.
This is a condition that presents with hemoptysis, weight loss, and night sweats, and I would put this patient on airborne precautions, NOT droplet precautions.
What is tuberculosis?
Airborne: TB - We would also want to use a negative pressure airflow room to protect the tiny particles floating in the air from drifting out of the room where it could cause infection in patients outside the room.
Droplet: Influenza - Flu droplets are larger than TB, and do not typically float around on currents of air.
Hemoptysis, or rust-colored sputum, means that the patient is coughing up blood. This can occur in TB and is very different from purulent, yellow, or green sputum that is seen in other bacterial infections such as pneumonia.
I would plan to keep my patient NPO and consult the provider if I note absent bowel sounds in a patient because I may have a concern that the patient has developed this condition.
What is bowel obstruction? or
What is a gastrointestinal perforation?
THINK: What is a penetration vs a perforation?
Which is worse? Why do you anticipate the patient should be NPO?
What are the possible secondary conditions that the patient could develop?
These precautions should be implemented for high-risk patients including those taking multiple different medications, those who have visual impairments, and any condition causing muscle weakness or gait instability such as Parkinson's disease, or cognitive issues affecting their judjement.
What are fall risk precautions?
Think: Can't see - more likely to trip, can't react quickly more likely to fall rather than catch themselves, lots of meds can affect vital signs and mental acuity.
This degenerative joint disease is characterized by the formation of osteophytes (bone spurs), and decreased synovial fluid, while a similar sounding autoimmune disorder involves increased synovial fluid production and inflammatory changes, with characteristic bilateral presentation that may include swan neck or Boutonniere's deformity, or ulnar deviation.
What is osteoarthritis?
THINK: OA is a disease caused by repetitive use leading to wear and tear that erodes the bone.
Who is more at risk for this?
This age-related condition presents with blurry or wavy vision that progresses to central vision loss, and it is caused by a breakdown of a component of the retina due to gradual capillary blockage to the eye.
What is macular degeneration?
For Patient safety, how would you plan to treat this condition? Are all types of blood vessels involved?
This condition is most commonly caused by H. Pylori infection, and the pain worsens with food intake, and is not alleviated by antacids.
What is a Gastric ulcer?
or What is a stomach Ulcer?
THINK: Duodenal vs Gastric - The acid is causing the pain, so gastric ulcers have worse pain when acid production is stimulated by putting anything into the stomach (food or meds, including antacids).
For Duodenal ulcers the opposite is true - pain is relieved by food and antacids do help.
(You are looking for 3 things here)
This pancreatic hormone promotes glucose movement into cells, while this alternative fuel from fat metabolism can be used when glucose stores are depleted. Additionally, this protein marker helps assess nutritional status in malnourished patients.
What are insulin, ketones, and prealbumin?
THINK: What is your primary source of energy for cellular metabolism?
Glycogen in the liver - Glucose.
In diabetes, a person may have plenty glucose but the insulin is not there to allow movement of the glucose from the bloodstream into the cells.
Next - Fats are broken down to Keytones (fruity breath) as an energy source.
Muscle breakdown can occur after all available sugars and fats are used up - extreme malnutrition.
This type of incontinence may occur when a patient who has SCDs on and is unable to take them off, has the urge to go to the bathroom. The patient has pushed the call light for the assistance to the bathroom, but the patient has has drank 1000cc of fluids in the last hour and really needs to go. Due to this urgency the patient voids in the bed.
What is Functional Incontinence?
Remember - The patient is perfectly capable of normal continence in that they have awareness of a need to go, and the ability to control their bladder, but there is a practical barrier between the patient and the toilet. This is different than if a person has a nerve problem (like MS) and they are unable to control their bladder and may have a deficit in sensation or the ability to voluntarily control the required muscles-They have reflex incontinence.
These four terms involving bleeding describe:
1: Black flecks found in emesis
2: Rust colored streaking that is expectorated in sputum
3: Black tarry stool
4: Bloody vomit
What are coffee-ground vomit, hemoptysis, melena, and hematemesis?
BONUS: Hematochezia is the passage of fresh blood per anus. You may also see BRBPR documented.
THINK: Why are two of these descriptors talking about black colored findings? What causes the blood in the GI tract to look almost black in color?
How do you test stool to differentiate blood from black stool caused by taking iron supplements?