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
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.
I would like to offer limited choices to both of these groups of clients.
What are children or elderly patients, particularly those with dementia?
Remember that people with dementia may not find the words to describe what they want or what they are feeling.
Chicken or beef?
Liquid or pill form?
Before I take your BP or after?
Straws should be avoided for patients with this condition because they can cause liquids to enter the mouth too quickly for this reflex to protect the airway leading to aspiration.
What is Parkinsons disease?
What do they look like? Masklike face, shuffling gait, slow to start moving but hard to stop.
Major safety concerns: Falls and aspiration.
Falls: remove throw rugs, place items in reach, call bell
Aspiration: Avoid straws, thicken liquids, chin tuck before swallowing, look in the mouth for pocketed food, sit at 90 degrees while eating.
Of these items, this is the NUMBER of them that are actually permitted on a clear liquid diet.
Sweet black tea
White coffee
Vanilla pudding
Lemon jello
Ice-chips
Non-fat milk
What are 4 items?
ALLOWED Clear Liquids:
1 Sweet black tea
2 Lemon jello
3 Ice chips
NOT ALLOWED:
White coffee
Vanilla pudding
Non-fat milk
In a person with this type of peptic ulcer, I would expect to find that the condition is worsened by eating, not effectively relieved by antacids, but epigastric pain does not wake the person up during the night.
What is a gastric ulcer?
A gastric ulcer (stomach) is worsened when food triggers an increase in the gastric acid needed for digestion.
Conversely, a duodenal ulcer is worsened during fasting and lessens after it is mixed with gastric contents that leave the stomach. Because duodenal acid builds up between meals, the acid can cause pain during the night, and pts can be woken by severe epigastric pain.
This disease of overuse is characterized by the presence of decreased synovial fluid, eroded cartilage, and the formation of osteophytes.
What is osteoarthritis?
THINK: Over use = wear and tear.
Unlike RA, they have less pain after a rest. Bone spurs (osteophytes) form as damaged bone regenerates. Worse in people who are overweight, but the key is overuse, so marathon runners are at high risk despite not being overweight.
This autoimmune condition that presents with symmetrical bilateral symptoms is most problematic in the morning, so the nurse will plan activities later in the day.
What is rheumatoid arthritis?
THINK: How does this differ from osteoarthritis?
What are the defining characteristics of each disorder? How does that affect your plan of care?
RA=bilateral joints are affected, and they get super stiff in the morning, so give them time to wake up and stretch before expecting them to participate in activities.
Classic signs: Ulnar deviation; Swan neck deformity; Ulnar deviation; increased synovial fluid in joint, smooth thin cartilage that was eroded by the increased pressure.
This term describes the heightened, abnormal skin reaction to sunlight and UV exposure that is common in lupus patients, making sunscreen and protective clothing an essential part of patient teaching to prevent disease flares.
What is photosensitivity?
Malar rash (butterfly rash) is a red, raised rash spanning the cheeks and bridge of the nose while sparing the nasolabial folds, and is a characteristic sign of Lupus (SLE).
Photosensitivity in lupus isn't just a cosmetic concern — UV exposure can actually trigger a systemic disease flare, not just a localized skin reaction. This is why patient education typically includes broad-spectrum sunscreen (SPF 30+), protective clothing, wide-brimmed hats, and avoiding peak sun hours (10am–4pm), rather than just "wear sunscreen if you're going to be in the sun."
This condition occurs when a person has an incompetent lower esophageal sphincter.
What is GERD?
What is the relationship between GERD, abdominal pressure, and meal size/timing?
Lose weight, small meals, do not lay down after eating, no food 3 hrs before bed, risers at the head to elevate the bed at night.
A pressure injury that extends through the epidermis but not through the dermis could be categorized as this.
What is a stage two (or partial-thickness) wound?
Stage 1 - no breakdown of skin
Stage 2 - Partial thickness of skin
Stage 3 - Full thickness of skin
Stage 4 - Down to either bone, tendon, or muscle
Can't see the bottom (slough, necrosis, eschar) - Unstageable
This is the medical term describing black, tarry, foul-smelling stool that indicates digested blood passing through the GI tract.
What is melena?
THINK: What other terms indicate a GI bleed? Hematemesis; coffee-ground.
What are the expected symptoms versus symptoms of a severe complication?
These two conditions can result from intentionally restricting fluids to reduce nocturia, and reduced appetite, particularly in elderly patients.
________ AND ________
What are malnutrition and dehydration?
Why might older people get these?
Less sensitive to hunger/thirst triggers, fear of falling, nocturia, poor dentition, cognitive impairment.
Does BMI correlate with malnutrition?
What lab values indicate low protein/malnutrition?
What is the relationship between BMI, nutrition, and skin breakdown?
This demineralization condition makes people prone to big injuries related to a small event, such as a fractured femur following a ground level fall, and most people have no idea that they have it till they get a fracture, particularly in underweight Caucasian females.
I would recommend strength training and weight bearing exercises like walking in addition to dietary supplements with calcium and vitamin D for people with this condition.
What is osteoporosis?
THINK: How does it manifest itself?
You may not know it's there till you get a fracture that is disproportionate to the injury - ask, does this injury make sense from this event.
Bone is eroded faster than its being rebuilt, so supplement with calcium and vitamin D and complete strength training and weight bearing exercise to stimulate regeneration.
Relate the treatment to the risk reduction!
This gastrointestinal infection that is often caused by the use of antibiotics but is then treated with different antibiotics, and cannot be killed by hand sanitizer.
What is C. Diff infection?
C. Diff is not killed by hand sanitizer and the spores should be washed off vigorously using soap and water instead.
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/inflammatory response? ________________________________________
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. THINK: HOW DOES THIS AFFECT DM MANAGEMENT?
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 the type of precautions that I would anticipate implementing for a patient who presents with hemoptysis, weight loss, and night sweats.
What are airborne precautions?
THINK - how is the infection spread?
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.
Hemoptysis can present as rust-colored sputum or blood-streaked sputum. It means 'coughing up blood' and occurs in TB, which is very different from purulent, yellow, or green sputum that is seen in other bacterial infections such as pneumonia.
Droplet: Influenza - Flu droplets are larger than TB, and do not typically float around on currents of air.
Contact: C. Diff / MRSA / MDRO
This is a plan of action that reflects a priority action for the patient, not what the end result will be.
For example, a patient will be able to change their own dressing, but not that the wound will be healed.
What is a short-term goal?
The wound being healed is a great long-term goal, so be sure to read questions carefully to pick the answer that is answering the question.
Remember S.M.A.R.T. goal formulas
Specific
Measurable
Achievable
Relevant
Timely (Time-specific)
When teaching a patient recovering from gastroenteritis, the nurse advises avoiding these categories of foods because they can worsen this common symptom of the illness.
What are dairy products, caffeine, high-fat/fried foods, and high-fiber or raw fruits and vegetables?
These are the four stages of wound healing that the nurse would expect to see when evaluation the progression of wound healing.
What are hemostasis, inflammation, proliferation and maturation?
Hemostasis: Stopping bleeding and forming a clot to prevent bacteria from entering the wound
Inflammation: The inflammatory reaction is characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues.
Proliferation: This is when granulation tissue forms, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin. The result is the formation of granulation tissue, a beefy red tissue that bleeds readily and is easily damaged.
Maturation: Epithelialization is the final stage of the healing process. Also known as remodeling, this phase begins in the second or third week and continues even after the wound has closed. During the next 3 to 6 months, the initial collagen fibers that were laid in the wound bed during the proliferation phase are broken down and remodeled into an organized structure (e.g., scar tissue), increasing the tensile strength of the wound.
Good: Serous exudate, serosanguinous exudate
Bad: Slough, necrotic tissue, Eschar, purulent exudate
When I position my stethoscope placement relating to the flow of effluent through the large bowel, this is the last quadrant that I listen to when assessing bowel sounds.
What is the left lower quadrant?
Remember the assessments that you learned in 371!
Think about the anatomical structure of the bowel, and you listen based on following the flow through the bowel, you start @ the RLQ, and move clockwise, (RLQ, RUQ, LUQ, LLQ) ending at the left lower quadrant.
This type of medication may be used to treat type II diabetes but is never used to treat type I diabetes.
What is an oral hypoglycemic medication?
Type 1 diabetes is an autoimmune disease in which the pancreatic beta cells — the cells that produce insulin — are progressively destroyed. By the time someone is diagnosed, they typically have little to no functional beta cell mass remaining, and insulin production is severely deficient or absent entirely.
Most oral hypoglycemic meds work by stimulating the pancreas to secrete more insulin, but in type 1 diabetes, there's essentially nothing left to stimulate.
This complication of an ulcer creates a hole completely through the stomach wall that allows gastric contents and digestive juices/enzymes to leak out into the abdominal cavity, often causing life threatening peritonitis.
What is gastric perforation?
THINK: How does this differ from gastric penetration?
What symptoms would me MOST concerning to you?
The first is a high risk for a patient presenting with a low BMI, dehydration, low prealbumin, peripheral neuropathy, and limited mobility, and the second is the first nursing action if this condition is found.
Two things! (it is 500 points)
Condition _______ Priority nursing action_______
What is relieving the pressure (repositioning /offloading the area)?
THINK: If you don't first address the pressure that's causing the problem, how will you prevent progression of the pressure injury?
Each of these factors independently undermines skin integrity. Low BMI means less cushioning over bony prominences, dehydration and low protein impair tissue resilience and wound-healing capacity, neuropathy removes the pain signal that would normally prompt a patient to shift position, and immobility removes the ability to act on that signal even if it were present. But regardless of which risk factors are present, relieving pressure always comes first once a pressure injury exists, because continued pressure will undermine any other intervention (nutrition, moisture management, wound dressing) you layer on top of it.
Of the 6 P's of perfusion, this is considered the latest and most ominous sign to appear, since significant neuromuscular damage may have already occurred by the time it's present.
What is pulselessness?
Pulselessness is considered a late and ominous sign in compartment syndrome specifically (i.e. in fractures or 3rd degree sprains) — by the time it's present, significant tissue damage may have already occurred, since compartment syndrome can compromise capillary perfusion well before it affects a palpable pulse. The 6 P's are really assessing if there has been a compromise to blood flow, and if so, has it progressed to the point of affecting sensation and muscle function. They are a range of early to late indicators of compromised tissue perfusion. These findings are never normal.
6 P's" Pain, pressure, paralysis, pallor, paresthesia, and pulselessness.