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.
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.
Together, these interventions form a core component of aspiration precautions to protect patients with dysphagia or impaired swallowing reflexes.
This type of insulin typically starts working 30 minutes to 4 hours after injection, depending on the type. The effects of usually last between 16 and 24 hours, depending on the type and dose. It does not have a peak time, which differentiates it from other types of insulin.
What is long acting insulin?
Rapid-acting insulin begins to work within 5 to 20 minutes after injection and peaks in about 30 minutes. Its effects can last up to 5 hours
The onset of action of the intermediate-acting type of insulin after injection is 2 to 4 hours.
Long-acting insulin typically starts working 30 minutes to 4 hours after injection, depending on the type. The effects of long-acting insulin usually last between 16 and 24 hours, depending on the type and dose. Long-acting insulin does not have a peak time, while rapid and short-acting insulins peak around 1–3 hours after injection.
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 is an autoimmune disorder where a patient may present with polyuria, polydipsia, fatigue, weight loss, and polyphagia.
What is Diabetes Mellitus?
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 is a visual deficit condition that is high risk for landscapers because they work outdoors and have high UV exposure, particularly if they also smoke.
What are cataracts?
This common eye condition causes the lens of the eye to become cloudy, leading to blurry vision, and is often associated with aging or prolonged exposure to UV light.
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?
When recording this item in a patient's intake, nurses must document only half of the original volume since it contains approximately 50% air.
What are ice chips?
Additionally, don't forget to add the unit on measure in all medication or intake and output calculations.
When evaluating a patients skin, the nurse knows that this stage of skin injury caused by prolonged pressure, characterized by redness that doesn't blanch but with no skin breakage.
Stage 1: Redness that does not resolve even when the pressure has been relieved for 30 mins, but the skin is intact
Stage 2: The epidermis is broken, but the dermis of the skin is intact
Stage 3: The full thickness of the skin is open, exposing subcutaneous tissue under the skin
Stage 4: The wound extends to muscle / tendon / bone.
To assess this anatomical sound, I would place my stethoscope on the left sternal border at the 5th intercostal space.
What is the sound of the mitral valve closing?
Don't forget to review the assessment details that you learn in NURS371!
Derived from Greek words meaning "old eye," this age-related condition typically affects patients over 40 and makes reading small print increasingly difficult without corrective lenses.
What is presbyopia?
Presbyopia is a normal age-related change where the lens of the eye gradually loses elasticity, making it difficult to focus on close objects. It's important to understand this condition when assessing older adults, as it's a common physiological change rather than a pathological process, and helps explain why many older patients require reading glasses or bifocals.
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 will implement this type of precautions when a patient develops C-diff due to multiple antibiotics that were given during their recent admission.
What are contact precautions?
The nurse evaluating the patients understanding of this condition as being ineffective when the patient makes the following statement about their condition:
"I have a gastrointestinal infection that is often caused by the use of antibiotics, and is then treated with different antibiotics, so my visitors should use hand sanitizer when they come in and when they leave my room"
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 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.
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.
Think about how you may have multiple goals for your patient, for example: free of infection, pain gone, wound healed, emotionally adjust to clinical condition, but your priority goal me be more basic - breathe, stabilize VS, pick up spoon by themselves.
This is the term describing delaying the wound closure, and is a combination of the types of wound healing interventions. After a period of dressing changes, the wound is sutured up later.
It is used when a wound is contaminated or “dirty” (potentially infected) or when the edges of the skin cannot be pulled together, for example if there is missing tissue or internal swelling.
What is Tertiary wound healing?
Initially, the wound can heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together, and the wound edges are sutured closed
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, also called regeneration or healing, occurs from days 5 to 21. Cells develop to fill the wound defect and resurface the skin. Fibroblasts (connective tissue cells) migrate to the wound where they form collagen, a protein substance that adds strength to the healing wound. Where New blood and lymph vessels sprout from the existing capillaries at the edge of the wound. The result is the formation of granulation tissue, a beefy red tissue that bleeds readily and is easily damaged. As the clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound (epithelialization).
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.
This condition, often linked to trauma like being hit in the eye with a baseball, is characterized by symptoms including eye swelling and the sudden appearance of visual floaters, or the feeling that they are looking through cobwebs.
What are signs of a retinal detachment?
Remember: to prevent further tear you want to stop the eye from moving, and since your eyes both move in synchronicity, the patient should either keep their eyes closed, or apply eye patches to BOTH eyes.
One eye patch would be appropriate if your goal is to prevent exposure to UV light, but it would not prevent the eye from moving back and forth.
This bacterial skin infection, often marked by redness, swelling, warmth, and pain, can occur anywhere on the body but commonly affects the legs. To reduce swelling and the pain that swelling can cause, the affected area should be elevated.
What is cellulitis?
Unlike airborne or droplet precautions, people on this type of precautions would not be required to wear a face mask during patient transport outside of their room.
What are contact precautions?
Contact precautions focus on preventing transmission through direct or indirect contact with the patient or environment.
When transporting a patient on contact precautions the primary focus is on proper gowning and gloves for staff, and a mask is not needed if the patient is the patient does not have a condition that involves respiratory transmission.
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.
When evaluating the patients wound, the nurse understands that this transparent pink drainage is a normal part of the healing process and does not represent infection.
What is serosanguinous exudate?