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Wednesday, April 30, 2008

NLE Review: Common Psychiatric Terms

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Affect
The outward manifestation of a persons feelings, tone or mood. Affect and emotions are commonly used interchangeable.

Agitation
Excessive motor activity, usually purposeless and associated with internal tension. Examples: inability to sit still, pacing, wringing of hands, or pulling of clothing.

Akathisia
Motor restlessness ranging from a feeling of inner disquiet, often localized in the muscles, to inability to sit still or lie quietly, a side effect of some antipsychotic drugs.

Akinesia
A side effect of the antipsychotic drugs characterized by a general lack of motor movement in the patient, as well as a slowing down of speech and responsiveness.

Ambivalence
The coexistence of contradictory emotions, attitudes, ideas, or desires with respect to a particular person, object, or situation. Suggests psychopathology only when present in an extreme form.

Anhedonia
Loss of interest and/or pleasure in usual activities associated with depression.

Anxiety
Apprehension, tension or uneasiness that stems from the anticipation of a danger, whose source is largely unknown. Primarily of intrapsychic origin. (top)

Catatonia
Immobility with muscular rigidity or inflexibility and at times excitability most often seen in schizophrenia.

Circumstantiality
In conversation, the use of excessive and irrelevant detail in describing simple events, the speaker eventually reaching his goal only after many digressions.

Clang Association
In thinking, the association of words by sound rather than meaning, after resulting in nonsensical rhymes and puns.

Cognitive
Refers to the mental process of comprehension, judgement, memory, and reasoning, as contrasted with emotional and volitional processes.

Compulsion
An insistent, repetitive, intrusive and unwanted urge to perform an act that is contrary to one's ordinary wishes and standard.

Confabulation
Fabrication of facts or events in response to questions about events that are not recalled because of memory impairment.

Conflict
A mental struggle that arises from the simultaneous operation of opposing impulses, drives external or internal demands (intra psychic when the conflict is between internal forces - extra psychic when the conflict is between self and the environment.

Confusion
Disturbed orientation in respect to time, place or person.

Countertransference
The therapist's partly unconscious or conscious emotional reactions to the patient. (top)

Defense Mechanisms
Patterns of feelings, thoughts, or behaviors that arc relatively involuntary and arise in response to perceptions of psychic danger to alleviate the conflicts or stressors that give rise to anxiety. May be either maladaptive or adaptive, depending on their severity, their inflexibility, arid the context in which they occur. Some common defense mechanisms arc compensation, conversion, denial, displacement, dissociation, intellectualization, repression, projection, somatization, suppression, undoing, splitting, idealization, reaction formation.

Delirium
A clouding of consciousness, marked by reduced ability to focus on and sustain attention to environmental stimuli. Usually of abrupt onset, the syndrome develops over a short period of time with symptoms fluctuating in severity over the course of a day. Perceptual disturbance, incoherent speech, sleep-wake disturbance, emotional liability, disorientation and memory impairment may be present. Condition is reversible except when followed by dementia or death.

Delirium tremors
An acute and sometimes fatal brain disorder caused by total or partial withdrawal from excessive alcohol intake. Usually develops in 24 to 96 hours after cessation of drinking. Symptoms include fever, tremors, ataxia, and sometimes convulsions, frightening illusions, delusions, and hallucinations.

Delusion
A firm, fixed idea not amenable to rational explanation and maintained despite objective evidence to the contrary. Some types of common delusions are delusions of being controlled, delusions of grandeur, delusions or persecution and somatic delusions.

Dementia
A deterioration of intellectual abilities of sufficient severity to interfere with social or occupational functioning. Dementia may follow a progressive, static, or remitting course depending on the underlying etiology. Memory disturbance is the most prominent symptom. In addition there is impairment of abstract thinking, judgement, impulse control, and/or personality change.

Depersonalization
An alteration in the perception or experience of the self so that the feelings of one's own reality is temporarily lost; a sense of unreality.

Dystonia
Acute tonic muscular spasms, often of the tongue, jaw, eyes and neck but sometimes of the whole body. Reactions may come on quickly and dramatically, A treatable side effect of antipsychotic drugs.

Echolalia
Repetition (echoing) of words or phrases of others.

Echopraxia
The pathological repetition by imitation of the movements of another person.

Flight of Ideas
A nearly continuous flow or accelerated speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words.

Grandiosity
An inflated appraisal of one's worth, power knowledge, importance, or identity.

Hallucinations
A sensory impression in the absence of any external stimuli; can arise in respect to any sensory modality - visual, auditory, olfactory, tactile or gustatory.

Hypomania
Abnormality of mood but even normal euphoria and mania. Characterized by optimism, pressure of speech and activity, and decreased need for sleep. Some people have increased creativity while others demonstrate poor judgment and irritability.

Ideas of influence
The conviction that one's behavior, including one's thoughts is being influenced in some way by an external agency, when in fact it is not.

Ideas of reference
The interpretation of external events, especially the actions and statements of other people, as having reference to one's self when in fact they do not.

Loose Associations
Thinking that is overgeneralized, diffuse, and vague with only a tenuous connection between one thought and the next.

Mania
A mood disorder characterized by excessive elation, hyperactivity, agitation,- and accelerated thinking and speaking - sometimes manifested as flight of ideas. Mania is seen in major affective disorders and in some organic mental disorders.

Mood
A pervasive and sustained emotion that in the extreme markedly colors one's perception of the world. ' Examples of mood include depression, elation, and anger.

Obsession
A persistent, unwanted idea or impulse that can not be eliminated by logic or reasoning. (top)

Panic Attacks
: Sudden onset of intense apprehension, fearfulness, or terror - is accompanied by physiological changes.

Paranoid Ideation
Suspiciousness or nondelusional belief that one is being harassed, persecuted, or unfairly treated.
Parkinson's Syndrome
A treatable syndrome of side effects from antipsychotic medication which appear after one or two weeks and that is characterized by resting tremor, muscle rigidity, including a mask-like face; slow motor movement, and a stooped, shuffling gait.

Preservation
The emission of the same verbal or motor response again and again to varied stimuli, despite the parson's effort to move on.

Phobia
An obsessive, persistent, unrealistic intense fear of an object or situation.

Posturing
Maintaining an unusual or awkward posture for a considerable amount of time.

Poverty of Thought
Few verbal communications or ones that convey little information because of vagueness, empty repetitions, or stereotyped or obscure phrases.

Pseudodementia
Clinical features resembling a dementia that are not due to organic brain dysfunction or disease.

Psychomotor Agitation
Excessive motor activity associated with a feeling of inner tension, the activity is usually non productive and repetitious.

Psychomotor Retardation
Visible generalized slowing down of physical reactions, movements, and speech.

Psychosis
A major mental disorder of organic or emotional origin in which a person's ability to think, respond emotionally, remember, communicate, interpret reality, and behave appropriately is sufficiently impaired so as to interfere grossly with the capacity to meet the ordinary demands of life. Often characterized by regressive behavior, inappropriate mood, diminished impulse control, and such abnormal mental content as delusions and hallucinations.

Psychosomatic
The constant and inseparable interaction of the psyche (mind) and the soma (body). Commonly used to refer to illnesses in which the manifestations are primarily physical with at least a partial emotional etiology. (top)

Tangential
In conversation, digressions that divert the speaker from his goal, which he never reaches; to be distinguished from circumstantial in which the goal is eventually reached.

Tardive Dyskinesia
Literally 'late appearing abnormal movements;' a variable complex of choreiform or athetoid movements developing in patients exposed to antipsychotic drugs. Typical movements include tongue-writhing or protrusion, chewing, lip-puckcring, choreiform finger movements, toe and ankle movements, leg-jiggling, or movements of neck, trunk, and pelvis.

Thought Blocking
A sudden obstruction or interruption in the train of thought or speech, which the person is unable to complete.

Thought Broadcasting
A symptom of psychosis in which the patient believes that thoughts are broadcast outside the head so that other persons can actually hear them.

Thought insertion
The patient's belief that thoughts that are not the patient's own Can be inserted into his mind.

Thought Withdrawal
An interruption in the train of thought perceived by tile person as someone removing or taking away his thoughts.

Transference
The unconscious assignment to others of feelings and attitudes that were originally associated with important figures (parents, siblings, etc.) in one's early life. The transference may be negative or positive.

References: American Journal of Nursing/August 1981.


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Tuesday, April 29, 2008

Exercise Transfers & Ambulation Nursing Resource

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Exercise Transfers & Ambulation Nursing Resource Slide Transcript
Slide 1: Exercise, Transfers & Ambulation Nursing 125

Slide 2: Mobility Mobility refers to a person’s ability to move about freely. Immobility refers to a person’s inability to move about freely. Mobility & immobility are the endpoints of a continuum with many degrees of partial immobility in between. mobility immobility Some clients move back and forth, some clients remain absolute.

Slide 3: Ability to Move The ability to move & function is a function most people take for granted. The level of mobility has a significant impact on an ind.’s physiological, psychosocial, & developmental well-being (Hamilton & Lyon, 1995). When there is an alteration in mobility, many body systems are at risk for impairment.  Cardiovascular functioning – orthostatic hypotension  Pulmonary complications – pneumonia  Promote skin breakdown, muscle atrophy etc Such changes can lead to altered self-concept & lowered self- esteem.

Slide 4: Medical Conditions that can Alter Mobility Fractures/sprains Neurological conditions – spinal cord injury, head injury Degenerative neurological conditions – Myasthenia gravis, Huntington’s chorea

Slide 5: Nursing Measures Attempt to maintain and/or restore optimal mobility as well as to decrease the hazards assoc. with immobility.  DB & C exercises  Muscle & joint exercises  Frequent repositioning – q 2 hrs  fluid intake/fiber intake Guidelines: Check activity order  Know client’s past medical history & limitations  Baseline vital signs are necessary  Become familiar with assistive devices 

Slide 6: Major concern during transfer = Safety of both the client and the nurse

Slide 7: Range of Motion Exercise (ROM) ROM exercises, in which a body part is moved through a range of motion, are carried out to promote circulation, maintain muscle tone & promote flexibility. In doing this, joint stiffness & debilitating contractures are prevented. Active ROM is range of motion carried out by the patient. It is a form of isotonic exercise & as such, it maintains strength, tone & flexibility. In patients unable to move body parts due to paralysis or extreme illness, ROM is performed by someone else. This is called passive ROM exercise. Passive exercise helps to maintain joint flexibility & prevent stiffness & contractures. Because this type of exercise involves no active movement on the part of the muscles, it does not contribute to muscle tone or strength.

Slide 8: ROM(cont.) ROM exercises are planned as a regular part of nursing activities. During a bath, for example, the nurse has an excellent opportunity to move the patient’s limbs through their full range of motion. The patient is encouraged to exercise actively those muscles that can be used. However, in certain cases, the nurse may need to assist the patient in performing ROM (active assisted ROM), or to perform passive ROM.

Slide 9: ROM (cont.) The maximum movement that is possible for a joint is it’s range of motion. If a joint is not moved sufficiently it begins to stiffen within 24 hrs & eventually becomes inflexible, flexor muscles contract & pull tight causing contractures or fixed joint flexion. To prevent joint contractures & muscle atrophy (wasting or decrease in size of a normally developed organ or tissue), exercise must be performed – ROM exercise. Contracture – abnormal flexion & fixation of joints caused by the disuse, shortening & atrophy of muscle fibers. Correcting contractures requires intensive therapy over a prolonged period of time, and may be impossible. Prevention is the key.

Slide 10: Two Purposes of ROM  Maintain joint function  Restore joint function Do not exercise joints beyond the point of resistance or to the point of fatigue or pain

Slide 11: Contraindications to ROM ROM requires energy & increased circulation, any illness/disorder where increased use of energy or increased circulation is hazardous is contraindicated; puts strain/stress in soft tissues of the joint & bony structures, therefore not done with swollen, inflamed joints.

Slide 12: Perform Exercises in Head to Toe Format Start with the head and move down, always do bilaterally Do not grasp the joint directly Cup the joint gently (prevents pressure) Do not grasp fingernail or toenail Important joints – thumb, hip, knee, ankle Return to correct anatomic position Move joint through movement 5 times/session

Slide 13: Start at the Neck P&P p. 830 Neck Flexion – look @ the toes Extension – look straight ahead Hyperextension – look up @ ceiling Lateral flexion – look straight ahead, tilt head to shoulder Shoulder Flexion – raise arm forward & overhead Extension – return arm to side of body Abduction – raise arm to side to position above head with palm away from head. Adduction – return arm & bring across chest Internal rotation – elbow flexed, rotate the shoulder by moving arm til thumb is turned inward & toward the back (fingers to the floor) External rotation – elbow flexed, move arm until thumb is upward & lateral to head. (fingers point up) Circumduction – move arm in full circle (arm straight out, move hand as if to draw a circle.

Slide 14: Elbow Elbow Flexion – bend elbow Extension – straighten elbow Hyperextension – bend lower arm back as far as possible Forearm Supination – turn lower hand so palm is up Pronation - turn lower hand so palm is down Wrist Flexion – bend wrist forward Extension – straighten wrist (fingers, wrist & arm in same plane) Hyperextension – bring dorsal surface of hand as far back as possible Abduction (radial flexion) – bring wrist medially towards the thumb Adduction (ulnar flexion) – bend wrist laterally towards 5th finger

Slide 15: Fingers & Thumb Fingers & thumb Flexion – bend fingers & thumb into palm make a fist Extension – straighten fingers & thumb Hyperextension – bend fingers as far back as possible Abduction – spread fingers apart / extend thumb laterally Adduction – bring fingers together/ thumb back to hand Circumduction – move finger/thumb in circular motion Opposition – touch thumb to each finger of same hand

Slide 16: Hip Hip Flexion – move leg forward (ROM 90-120 deg) Extension – move leg back beside other leg Hyperextension – move leg backwards (ROM 30-50 deg) Abduction – move leg laterally away from body (ROM 30-50 deg) Adduction – move leg back to medial position & beyond if possible (ROM 30-50 deg) Knee Flexion – bring heel toward back of thigh (120-130 deg) Extension – return leg to floor

Slide 17: Ankle Ankle Dorsiflexion – move foot so toes are pointed upward Plantarflexion – move foot so toes are pointed downward Foot Inversion – turn sole of foot medially (ROM 10 deg) Eversion – turn sole of foot laterally (ROM 10 deg) Flexion – curl toes downward (ROM 30-60 deg) Extension – straighten toes (ROM 30-60 deg) Abduction – spread toes apart Adduction – bring toes together

Slide 18: Spine Spine Flexion – when standing – bend forward from the waist Extension – straighten up Hyperextension – bend backward Lateral flexion – bend to the side Rotation – twist from the waist

Slide 19: Types of ROM exercises Active – exercises the client is able to perform independently. Passive – exercises performed for the client by someone else. Active assisted – performed by a client with some assistance – client can move a limb partially through its ROM, but needs help completing the ROM.

Slide 20: Isometric/Isotonic Exercises In addition to ROM exercises, some immobilized clients may be able to perform muscle-strengthening exercises.  Isotonic – cause muscle contraction & change in muscle length – walking, aerobics, moving arms & legs against light resistance.  Isometric – tightening or tensing of muscles without moving body parts. This increases muscle tension but do not change the length of muscle fibers. Isometric exercises are easily performed by an immobilized patient in bed. Isotonic and isometric exercises help to prevent muscular atrophy  and combat osteoporosis.

Slide 21: Applying Antiembolism Stockings (Elastic) P&P p. 842 Thromobophlebitis – the development of a thrombus or clot along with the inflammation of the vein & may be classified as superficial or deep. Three elements contribute to the development of a clot. 1. Hypercoagulability of the bld – clotting disorders, dehydration, pregnancy & 1st 6 weeks postpartum if the woman was confined to bed, oral contraceptives. 2. Venous wall damage – local trauma, orthopedic surgeries, major abdominal surgery, varicose veins, arteriosclerosis 3. Blood stasis – immobility, obesity, pregnancy

Slide 22: Antiembolism stockings Promote venous return by maintaining pressure on superficial veins to prevent venous pooling. Prevent passive dilation of veins Application of antiembolism stockings (refer to p. 845 P&P)

Slide 23: Orthostatic hypotension A drop in blood pressure that occurs when the client rises from lying to sitting or from sitting to standing. (A decrease in systolic pressure >15 mmHg or decrease diastolic pressure >10 mmHg.) At risk clients  Immobilized clients  Prolonged bed red Measures to minimized Orthostatic Hypotension  Maintain muscle tone  Increase venous return to the heart  Decrease stasis of bld in the lower extremities  ROM/isometric exercises/TED’s  Mobilize ASAP

Slide 24: Therapeutic Positions Chair – feet flat on floor, footrest if unable to reach floor, knees & hips flexed 90-100 degrees. Buttocks at back of the chair, spine straight, pillows at side to prevent leaning. Fowlers – supine, HOB elevated 45 deg. Promotes lung expansion, decrease ICP, comfortable for eating. High fowlers – same as above, with HOB elevated 45-90 deg. Utilized for clients experiencing difficulty breathing. Semi fowlers – as above with HOB elevated less than 45 deg. Orthopneic – sit on side of bed with over bed table across lap, pillow on table, lean forward & rest head & arms on table. Utilized for patients with extreme difficulty breathing – promotes lung expansion.

Slide 25: Therapeutic positions cont. Lithotomy – supine flex both knees so that feet are close to hips, separate legs, feet in stirrups. Utilized for perineal & vaginal examinations Trendelenburg – supine, entire bed frame tilted down with head 30 deg below horizontal.  Postural drainage  Increase venous return in case of shock

Slide 26: Benefits of Proper Positioning Maintains body alignment & comfort Prevents injury to musculoskeletal system, prevents strain Provides sensory, motor & cognitive stimulation Prevents pressure sore (decubitus ulcer) & joint contractures

Slide 27: Transfers Transferring is a nursing skill that helps the client with restricted mobility attain/maintain mobility & independence. Benefits of transfers  Maintains & improves joint motion  Increases strength  Promotes circulation  Relieves pressure on the skin  Improves urinary/respiratory function  Increases social activity  Increased mental stimulation

Slide 28: Transfers - Safety Safety is a major concern when transferring. Falls are a common hazard. If a patient starts to fall – do not try to stop the fall, instead assist the patient to the floor while protecting the head from injury. This will reduce the risk of patient as well as staff injury. Complete a thorough nursing assessment before you move the patient to determine if she/he has suffered any injuries. Prevention of injury is the key, be aware of the client’s motor deficit, ability to support their body weight and use effective body mechanics & lifting techniques. When in doubt regarding the patient’s ability-GET ASSISTANCE

Slide 29: Nursing Process - Transfers Assessment Activity orders Client capabilities Planning Decide appropriate transfer technique Explain procedure to the patient Implementation Wash hands Position chair 45 deg angle to bed on clients stronger side Lock bed brakes, lower bed, raise HOB as high as patient tolerates Lower side rail Assist to sitting (lift upper body & swing legs around) Assist with robe & slippers Position feet on floor Take wide stance, bend knees, grasp patient “1 2 3 stand” Pivot to chair

Slide 30: Nursing Process (cont.) Evaluation Body in alignment, patient comfortable, no injuries Nurse maintains good body alignment Two person lift (same as above) except one Of note: nurse is on each side of the patient Never lift under the axilla – can damage nerves Mechanical lifts – enables you to lift heavy patients, or those unable to help. (Use 2 people)

Slide 31: Ambulation Clients who have been immobile even for a short time may require assistance A client may require the use of an assistive device to aid in ambulation. Assistive devices  Increase stability  Support a weak extremity  Reduce the load on weight bearing structures; hip, knees

Slide 32: Assisting the patient Simple assist Place arm near patient under the arm & at the elbow & 1. grasp pt’s hand, synchronize walking with the pt (move inside foot forward at same time as pt’s inside foot) Grasp pt’s left hand in nurses’ left hand & encircle pt’s 2. waist with the rt hand & synchronize walking as above Using a transfer belt (held at the waist from the rear by 3. the belt – helps maintain balance)  Nurse to stand on the pt’s weak side. The nurse provides support with his/her leg to the pt’s weakened one if necessary. Do not allow the pt. to place their arm around your shoulder.  Walk slowly, even gait, synchronize your steps.

Slide 33: Cane Helps maintain balance by widening the base of support increases a pt’s security. Should be held on stronger side  Should have rubber tip – prevent slipping  Height (from greater trochanter to the floor allowing 15-30 deg of elbow flexion. Gait – place cane 6-10 inches ahead, move affected leg ahead to cane, place weight on affected leg and cane, move unaffected leg ahead of cane. Stand from sitting  Cane in hand opposite affected leg, grasp arm of chair & cane in other, push to stand, gain balance

Slide 34: Walker Wide base of support, provides great stability & security. Used for clients who are weak or who has problems with balance.  Patient should have at least one weight bearing leg and arm  Pick up walker is more stable, walker with wheels easier for pt’s who have difficulty with lifting or balance, however can roll forward when weight is applied.  Height – upper bar of walker should be slightly below the client’s waist with arms flexed 15-30 deg

Slide 35: Walker (cont.) To stand – walker in front of seat, push up off arms of chair (walker is less stable, chair is lower pt. can push with more force. Hands move to walker one at a time. To sit – back up to chair, reach back with one arm to arm of chair, then with the other arm and lower to chair. Gait – walker ahead 6-8 inches, weight on arms. Partial weight on affected leg first.

Slide 36: Crutches Wooden or metal staff that reaches from the ground to 11/2 – 2 inches below the axilla. When standing tip of crutch rests 4-6 inches in front & 4-6 inches to side of foot. Do not rest on top of crutches – pressure on axilla nerves – can lead to paralysis called crutch paralysis (numbness, tingling, muscle weakness)

Slide 37: Crutches (cont.) P&P p.859 3 point gait – able to wt. bear on one foot, full wt. on unaffected leg then on both crutches – begin in tripod position, move crutches & affected leg ahead, move stronger leg forward and repeat. 4 point gait – (most stable crutch walk) weight on both legs and both crutches – muscular weakness, improves balance by providing a wide base of support, lack of coordination, move each independently – rt crutch-lt foot-lt crutch-rt leg



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Monday, April 28, 2008

Nclex Review Materials: Resource Bullets 1

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The bullets below can also be seen in the DID YOU KNOW section of the site (Top Most)

  • Odynophagia is painful swallowing, in the mouth (oropharynx) or esophagus. It can occur with or without dysphagia, or difficult swallowing
  • Halitosis, oral malodor (scientific term), breath odor, foul breath, fetor oris, fetor ex ore, or most commonly bad breath are terms used to describe
  • Pyloroplasty is surgery to widen the opening of the end of the pylorus, which is found in the lower portion of the stomach,
  • Billroth I = gastroduodenal reconstruction
  • Billroth II = gastrojejunal reconstruction
  • ISOTONIC = the muscle shortens to produce contraction
  • ISOMETRIC = NO CHANGE in muscle length
  • ISOKINETIC = Involves muscle contraction or tension against a resistance
  • Measure correct crutch length
    LYING DOWN
    Measure from the Anterior Axillary Fold to the HEEL of the foot then:
    Add 1 inch (Kozier)
    Add 2 inches (Brunner and Suddarth)
  • Hyperalgesia—excessive sensitivity to pain
  • Bruxism- commonly called night teeth-grinding occurring during stage 2 sleep
  • Somnambulism- “sleepwalking"
  • POLYSOMNOGRAPHY is the only method that can confirm sleep apnea.
  • Urticaria - (or hives) is a skin condition, commonly caused by an allergic reaction, that is characterized by raised red skin wheals
  • Pruritus- is an itch or a sensation that makes a person want to scratch.
  • CAUTION ---- Mnemonics for early detection for CANCER
    C- Change in bowel/bladder habits
    A- A sore that does not heal
    U- Unusual bleeding
    T- Thickening or lump in the breast
    I- Indigestion
    O- Obvious change in warts
    N- Nagging cough and hoarseness
  • Alopecia begins within 2 weeks of therapy. Regrowth within 8 weeks of termination
  • Tenesmus is a feeling of incomplete defecation. It is experienced as an inability or difficulty to empty the bowel at defecation.
  • The CONDUCTING SYSTEM OF THE HEART
    Consists of the
    1. SA node- the pacemaker
    2. AV node- slowest conduction
    3. Bundle of His – branches into the Right and the Left bundle branch
    4. Purkinje fibers- fastest conduction
  • The Heart sounds
    1. S1- due to closure of the AV valves
    2. S2- due to the closure of the semi-lunar valves
    3. S3- due to increased ventricular filling
    4. S4- due to forceful atrial contraction
  • The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated fluid from the tissues and returns it to the blood
  • CARDIAC Proteins and enzymes
    CK- MB ( creatine kinase). Elevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days
  • Troponin I and T
    Troponin I is usually utilized for MI. Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks!
    Normal value for Troponin I is less than 0.6 ng/mL
  • Cholesterol= 200 mg/dL
  • Triglycerides- 40- 150 mg/dL
  • Ischemic changes may show ST depression and T wave inversion
  • Nitrates- to dilate the coronary arteries
  • Aspirin- to prevent thrombus formation
  • Beta-blockers- to reduce BP and HR
  • Calcium-channel blockers- to dilate coronary artery and reduce vasospasm
  • After MI, Patients who are able to walk 3-4 mph are usually ready to resume sexual activities
  • Infective endocarditis >> Osler’s nodes- painful nodules on fingerpads
  • Infective endocarditis >> Roth’s spots- pale hemorrhages in the retina
  • LEFT SIDED CHF
    1. Dyspnea on exertion
    2. PND
    3. Orthopnea
    4. Pulmonary crackles/rales
    5. cough with Pinkish, frothy sputum
    6. Tachycardia
    7. Cool extremities
    8. Cyanosis
    9. decreased peripheral pulses
    10. Fatigue
    11. Oliguria
    12. signs of cerebral anoxia
  • RIGHT SIDED CHF
    1. Peripheral dependent, pitting edema
    2. Weight gain
    3. Distended neck vein
    4. hepatomegaly
    5. Ascites
    6. Body weakness
    7. Anorexia, nausea
    8. Pulsus alternans
  • CARDIOGENIC SHOCK
    1. HYPOTENSION
    2. oliguria (less than 30 ml/hour)
    3. tachycardia
    4. narrow pulse pressure
    5. weak peripheral pulses
    6. cold clammy skin
    7. changes in sensorium/LOC
    8. pulmonary congestion
  • CARDIAC TAMPONADE
    A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial effusion)
  • BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound
  • ANEURYSM - Dilation involving an artery formed at a weak point in the vessel wall
    Saccular= when one side of the vessel is affected
    Fusiform= when the entire segment becomes dilated

    RISK FACTORS
    Atherosclerosis
    Infection= syphilis
    Connective tissue disorder
    Genetic disorder= Marfan’s Syndrome
  • PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD) - Refers to arterial insufficiency of the extremities usually secondary to peripheral atherosclerosis
  • INTERMITTENT CLAUDICATION- the hallmark of PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD)
    Intermittent claudication is a clinical diagnosis given for muscle pain (ache, cramp, numbness or sense of fatigue), classically calf muscle
  • RAYNAUD’S DISEASE - A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor of the fingertips or toes
  • Cheilosis (also called cheilitis) is a painful inflammation and cracking of the corners of the mouth. It sometimes occurs on only one side of the mouth
  • APLASTIC ANEMIA - A condition characterized by decreased number of RBC as well as WBC and platelets
  • Pernicious Anemia - Beefy, red, swollen tongue (Schilling’s test)
  • Progesterone - maintains the uterine lining for implantation and relaxes all smooth muscles
  • Relaxin - is the hormone that softens the muscles and joints of the pelvis
  • Thyroxine - increases basal metabolic rates
  • Buck's Traction - Skin traction
  • Skeletal Traction - with Pins
  • Vit. B2 (riboflavin) deficiency - scaly skin
  • Vit. A deficiency - Night blindness
  • Vit. D deficiency - Skeletal Pain
  • Zinc deficiency - slow wound healing
  • Selenium deficiency - heart damage
  • Toxoplasmosis parasite - infection from inadequately cooked meat, eggs, or milk, ingestion or inhaling the oocyst excreted in feline feces
  • Sclerotherapy - injecttion of a sclerosing agent into a varicosity. The agent damages the vessels and causes aseptic thrombosis, which result in vein closure.
  • Deep Tendon Reflex Test
    1+ - diminished
    2+ - normal
    3+ - increased, brisker-than-average
    4+ very brisk, hyperactive
  • Involution is a progressive descent of the uterus into the pelvic cavity that occurse at approx. 1cm per day.
  • FHR can be first heard with fetoscope at 18 to 20 weeks gestation. 10 weeks with a doppler ultrasound.
  • Folic acid rich food are peanuts, sunflower seeds and raisins
  • Variable deceleration = cord compression
  • Early deceleration = pressure on the fetal head during a contraction
  • Later deceleration = uteroplacental insufficiency
  • Cystitis is inflammation of the urinary bladder.
  • Pyelonephritis is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek).
  • Partial weightbearing - 30% to 50% of the body weight on the affected limb
  • Touch-down weight bearing allows the client to let the limb touch the floor but not bear weight.
  • Thyroid supplements for hypothyroidism should be taken in the morning to avoid insomia.
  • Croup - dont administer cough syrup and cold medicines because they will dry and thicken secretions. Sips of warm fluid will relax the vocal cords and thin the mucos.
  • Koplik spots - small bluish-white spots with a red base found on the buccal mucosa
  • German measles - pinkish-rose maculopapular rash on the face, neck and scalp. Reddish and pinpoint petechiae spots found on the soft palate
  • Erythema infectiosum (fifth disease) [slapped cheek] - an intense, fiery-red, edematous rash on the cheeks.
  • Rocky Mountain Spotted Fever (RMSF) - rash on the palm and soles of the feed and on the remainder of the body. Fever, headache, anorexia and restlessness. Meds given is Tetracycline hydrochloride (achromycin)
  • Thioguanine and thiotepa are antineoplastic medications
  • Ticlopidine hydrochloride (Ticlid) is a platelet aggregation inhibitor
  • Erythema marginatum is characterized by red skin lesions that start as flat or slightly raised macules, usually over the trunk and that spread peripherally.
  • Atrial fibrillation - Auscultating the apical pulse for an irregular rate while palpating the radial pulse for pulse deficit
  • Triple dye is used for initial cord care because it minimizes bateria and promotes drying.
  • A low cardiac output will cause the increased build-up of blood in the heart and pulmonary system, causing crackles to be heard in the lung fields.
  • S3 heart sounds = ventricular gallop
  • Trachoesophageal fistual = abdominal distension
  • 3 stages of separation anxiety are PROTEST, DESPAIR AND DETACHMENT
  • Anaphylactic shock = fatal allergic reaction
  • Cardiac Tamponade - assessment findings include tachycardia, distant or muffled heart sounds, jugular vein distention and falling blood pressure accompanied by pulsus paradoxus ( a drop in inspiratory BY by > 10 mmhg)
  • Spironolactone (Aldactone) > pt. may experience body image changes due to threatened sexual identity. These body image changes are related to decreased libido, gynecomastia in males, and hirsutism in females.
  • Diabetic ketoacidosis (DKA) - fruity odor to the client's breath
  • Rhonchi - occur as a result of the passing of air through fluid-filled narrow passages. Rhonchi are sometimes referred to as "gurgles". Diseases with excess mucous product, such as pnemonia are associated with rhonchi. Rhonchi are usually heard on expiration and may clear with a cough.
  • Urolithiasis is a condition in which crystals in the urine combine to form stones, also called calculi or uroliths
  • Hodgkin's disease is a type of lymphoma distinguished by the presence of a particular kind of cancer cell called a Reed-Sternberg cell.
  • Cardiogenic shock (left-sided heart failure) - includes altered sensorium, tachycardia, hypotension, tachypnea, oliguria, and cold, clammy, cyanotic skin
  • Ovarian cancer symptoms include abdominal discomfort, irreg. menses, flatulence, fullness after a light mean and increase abdominal girth.
  • Myocardial infarction:
    -ST segment elevation usually occurs immediately or during the early stages of MI.
    -The CK-MB isoenzyme begins to rise 3 to 6 hourse after MI.
    -T wave depression and abnormal Q wave changes occur within several hours to several days after the MI.
  • Abdominal aortic aneurysm (AAA) symptoms are "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be ausculated over the mass.
  • Neuroleptic Malignant syndrome experiences an elevated in temperature ( sometimes up to 107 F) and parkinsonian symptoms
  • Intermittent claudication usually refers to cramplike pains in the legs (usually the calf muscles, but may be in the thigh.
  • Cholinergic effect includes increase in salivation, lacrimation, urination and defecation, bradycardia, hypotension and increaes muscle weakness
  • Ventricular tachycardia is characterized by the absense of P waves, wide QRS complexes (usually greater then 0.14 second) and a rate between 100 and 250 impulses per minute.
  • Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. There are no measurable rate and no visible P waves or QRS complexes.
  • Inguinal hernia is a common defect that appears as a painless inguinal swelling when the child cries or strains.
  • Partial obstruction of the herniated loop of intestine - difficulty in defecating
  • Phimosis - a dribbling stream, indicating an obstruction in the flow of urine
  • Cryptorchidism - absense of the testes within the scrotum.
  • Triamterene (Dyrenium) is a potassium-sparing diuretic. Side effects include frequent urination and polyuria.
  • Erythroblastosis fetalis is a hemolytic disease of the fetus or newborn resulting in excessive destruction of red blood cells (RBCs) and stimulation of immature erythrocytes.
  • Glycosylated hemoglobin values of 8% or less are acceptable.

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Eyes

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Eyes Slide Transcript
Slide 1: Eyes

Slide 2: External Anatomy  Sensory Organ for vision -Situated in bony, orbital cavity for protection – Eyelids= shades that add protection form injury, strong light , dust – Eyelashes= hairs to filter dust & dirt

Slide 3: External External Anatomy Anatomy

Slide 4:  Limbus – border b/t the cornea & sclera  Palpebral fissures – elliptical open space b/t lids  Canthus- corners of the eye where the lids meet, inner & outer  Caruncle – sm. Fleshy mass containing sebaceous glands at inner canthus

Slide 5:  Within the upper eyelid – Tarsal plates, connective tissue gives upper lid shape – Meibomian glands, in the plates, lubricate the lids, stops overflow of tears, airtight seal when lids closed

Slide 6:  Exposed part of the eye – Conjunctiva, folded envelope b/t eyelids & eyeball  thin mucous membrane, transparent protective covering of the exposed part of the eye.  Palpebral conjunctiva lines the lids, is clear but has sm .bld. Vessels  Bulbar conjunctiva is over eyeball, white sclera show through, merges at limbus with cornea

Slide 7:  Cornea – clear, covers & protects iris & pupil

Slide 9:  Lacrimal apparatus – irrigates conjunctiva & cornea – 3 parts A. Lacrimal gland, upper, outer corner of eye = tears B. Puncta= inner canthus, tear drainage C. Nasolacrimal duct= allows tears to drain from puncta to nasolacrimal sac. Tears then empty into the inferior meatus of the nose

Slide 11: Extraoccular muscles  6 muscles – Attach eyeball to orbit – Straight and rotary movement – Four straight muscles 1. Superior rectus 2. Inferior rectus 3. Lateral rectus 4. Medial rectus

Slide 12:  Two slanting/ oblique muscles 1. Superior 2. Inferior Humans have a Binocular, single – image visual system – Eyes normally move as a pair

Slide 13: • Eye movement stimulated by Cranial Nerves • III Oculomotor • IV Trochlear • VI Abducens

Slide 16: Internal Anatomy  The eye has 3 layers, the outer & inner layer can be viewed using opthalmascope 1. Sclera (outer layer) tough, protective, white covering connects with the -  Cornea – transparent, protects pupil & iris – helps focus light on retina

Slide 17: 1. Middle layer  Choroid – dark pigmentation to prevent internal light reflection, supplies bld. to retina  Pupil – PERRLA  Lens – biconvex disc, transparent, thickness controlled by ciliary body, bulges = near; flattens = distant  Anterior chamber – posterior to cornea, anterior to iris & lens, has aqueous humor supplies nutrients & drains wastes

Slide 18: 1. Inner layer – Retina – visual receptive layer – light waves changed to nerve impulses  Retinal structures  Optic disc – retinal fibers meet & form optic nerve, nasal side of retina, creamy yellow orange to pink, round or oval shape, physiologic cup inside the disc for bld.vessels to enter & exit  Retina vessels – paired arteries & veins

Slide 19:  Macula – temporal side of fundus, darker pigmented region, surround the fovea centralis  Fovea Centralis- area of sharpest & keenest vision, Very sensitive to light

Slide 21: Visual Pathways & Fields  Objects reflect light  Rays refracted by cornea, aqueous humor, lens, vitreous body and onto retina.  Light stimulus is changed to nerve impulses, travel thru optic nerve to visual cortex in occipital lobe  Image on retina is upside down & reversed. At the optic chiasm retinal fibers cross over. Right side of brain looks at left side of world.

Slide 23: Visual reflexes  Pupillary light reflex – bright light = constriction – Direct light reflex – Consensual light reflex  Fixation – ability to track an object & keep image on the fovea, can be impaired by drugs, alcohol, fatigue & inattention  Accomodation – for near vision = pupil constriction & convergence of eyes

Slide 26: Subjective data  Vision difficulty  Pain  Strabismus, diplopia  Redness, swelling  Watering, discharge  Past history ocular problems  Glaucoma

Slide 27:  Glasses/ contacts  Medications  Vision loss- coping mechanisms  Self–care behaviors

Slide 28: Objective data The Physical Exam  Preparation – Position- sitting, head at eye level  Equipment – Snellen eye chart- visual acuity – Handheld visual screener-near vision – Opaque card – Penlight – Applicator stick – Ophthalmoscope

Slide 29: Test visual acuity Snellen eye chart  Stand 20 ft. from chart  Glasses / contacts (Document )  Remove eye wear, retest  Normal visual acuity is 20/20 – top # is distance person is standing from the chart  Vision 20/30 refer to opthalmologist or optometrist  If unable to see largest letters, move to 10 feet – record as 10/200

Slide 30: Test for near vision  Vision screener  People > 40yrs or difficulty reading  Test each eye with glasses  Hold card 14in. from eyes  Normal result 14 / 14  Test using any available reading material if no card available

Slide 31:  Presbyopia is a normal physiological change in near vision occurs with aging = note if the person moves the card farther away

Slide 32: Test visual fields Confrontation test  Compares peripheral vision with a tester who has normal peripheral vision  2 ft. apart, eye level  Tester & client cover opposite eyes  Tester advances finger in the periphery – Superiorly ( 50 degrees ) – Inferiorly ( 70 degrees ) – Temporally ( 90 degrees )

Slide 34: Inspect Extraoccular Muscle Function  Corneal light reflex  Cover test  Diagnostic positions test – 6 Cardinal Positions of Gaze

Slide 35: Inspect Extraocular Muscle Function  Corneal Light Reflex ( The Hirschberg Test) assesses parallel eye alignment – Shine light toward person’s eyes – Tell to stare directly ahead – Hold light 12 in. away – Light should reflect on both corneas in same spot

Slide 36:  Cover Test- detects deviated alignment – Stare straight at examiner’s nose – Cover 1 eye of the person being examined with opaque card – Normally the uncovered eye should maintain a steady, fixed gaze – Covered eye- should stare straight ahead when covered & then uncovered. If muscle weakness exists the covered eye will relax and then jump to fixed position when uncovered..

Slide 37: Diagnostic Positions Test  6 cardinal positions of gaze – – Determines muscle weakness during movement – Person must hold head steady – Follow movement of object (examiner’s finger, pen etc) only with eyes – Hold object 12 in. from person – Move thru each position, clockwise, hold , then back to center – Normal response= parallel tracking with both eyes

Slide 39:  During this test be aware of Nystagmus-fine jerky movement seen around the iris  Mild nystagmus in extreme lateral gaze is normal but not normal in any other position

Slide 40: Inspect External Structures  General – movement & facial expression (squinting?)  Eyebrows – 2(bilateral), symmetrical (look the same; move the same)  Eyelids & Lashes – present, approximate when closed, no redness, swelling, discharge, lesions?  Eyeballs- alignment, ? Protrusion? Sunken?  Conjunctiva & Sclera – moist, glossy, clear, white sclera

Slide 41:  Eversion of the upper eyelid FYI – we will not do this examine in lab see pg. 312 for technique – usually done for complaint of eye pain due to foreign body

Slide 44:  Lacrimal Apparatus – Person looks down – Using thumbs, slide outer part of upper lid along bony orbit – Note redness or swelling – Press index finger against lacrimal sac at inner canthus – Normal response is slight eversion of lower lid, no tearing or discharge

Slide 46: Anterior Eyeball Structures  Cornea & lens  Iris & pupil – Size & shape – Pupillary light reflex – Accommodation

Slide 47: Cornea & Lens  Shine light from side across cornea  Check smoothness, clarity  Normally no opacities

Slide 48: Iris and Pupil  Iris = flat, round, regular, even color bilaterally.  Pupils = PERRLA – Resting size norm = 3-5mm – 5% population have pupils of 2 diff. Sizes called Anisocoria

Slide 49:  Pupillary Light Reflex – Darken room – Person gazes straight ahead – Advance light from the side  Direct light reflex  Consensual light reflex – Measure pupil size before & after light reflex – Measurement R3/1 L3/1 =both pupils measure 3mm in resting state & 1mm with light

Slide 50:  Accomodation – focus on distant object -dilatation of pupils – Shift gaze to near object – pupils constrict & converge  Record the normal response to these tests as  PERRLA = Pupils Equal, Round, React to Light and Accomodation

Slide 51: Ocular Fundus (internal surface of retina)  Use Opthalmoscope- try keeping both eyes open- practice looking at a ring on your finger. Become familiar with the instrument before you examine your partner’s eyes

Slide 52:  Diopter of opthalmoscope – Black numbers = +diopter, focus on near objects – Red numbers = - diopter, focus on further objects  Use ophthalmoscope in darkened room = dilates pupils

Slide 53:  Remove examiner’s and person’s eyeglasses but contact lenses may be left in.  Select lg. White aperture light  Person should focus on a distant object and try & remain still  Examiner hold ophthalmoscope in Right hand to right eye to eamine person’s right eye

Slide 54:  Begin 10in away at 150 lateral angle & advance  Keep sight of red reflex  Adjust lens to +6 as you advance till your foreheads almost touch. Adjust diopter to focus. – Normal vision set at 0. Nearsighted use red #s. Farsighted use black.

Slide 56: Retinal background  Light – dark red normally  Note Lesions – Size, shape, color, distribution

Slide 57: Macula & Fovea Centralis  Last in Funduscopic exam – 1 DD in size – Darker than rest of fundus – Foveal light reflex – Exam last

Slide 59: Retinal Vessels Arteries Veins COLOR Light red Dark red SIZE Smaller 2/3 to Larger 4/5 diam. Of veins LIGHT Bright Inconspicuous REFLEX absent

Slide 60: Read Aging & Developmental Considerations Review Abnormalities of the Eyes

Slide 61: 3 most common causes of decreased visual functioning in the older adult  Cataract (lens opacity)  Glaucoma (increased ocular pressure) = loss of peripheral vision  Macular degeneration (breakdown of cells in the macula lutea) = loss of central vision



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Sunday, April 27, 2008

NLE Review: Vital Signs, Pulse, Respiration

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Normal Temperature: 37 degrees Celsius or 98.6 degrees Fahrenheit.

Hypothalamus is the temperature center.

When taking temperature (Rectal 2-3 mins; Oral 3-5 mins; axillary 6-9 mins)

Remittent fever means temperature fluctuates and is non-normal between fluctuation.

Relapsing fever means short febrile periods of a few days.

Intermittent fever means that temperature fluctuates and is normal on fluctuation.


Factors affecting heat production

1. Radiation - transfer of heat from surface to surface without contact.
2. Conduction - transfer of heat from surface to surface through contact.
3. Convection - dispersion of heat by air currents
4. Vaporation - evaporation of moisture.

Convertion from Celsius to Fahreheit
F = (Temperature in Celsius) x 1.8 + 32

Convertion from Fahreheit to Celsius
C = (Temperature in Fahrenheit) -32 / 1.8

Where to elicit PULSE
1. Temporal pulse
2. Carotid pulse
3. Brachial pulse
4. Radial pulse
5. Femoral pulse
6. Popliteal pulse
7. Posterior Tibial pulse
8. Dorsalis Pedis pulse

Pulse Deficit - is the difference between the apical and the peripheral pulse. Two nurses need to take this.

Pulse Pressure - is the difference between the systolic and diastolic pressure in the blood pressure.

Korotkoff's sound is the sound heard when taking blood pressure.

Factors Affecting Blood Pressure:
1. Pumping action of the heart
2. Peripheral vacualr Resistance
3. Blood volume
4. Blood Viscosity

Repiratory center is the Medulla and the Pons

Cheyne-Stokes breathing- from very slow to very deep breathing floowed by period of apnea

Kussmual breathing - rapid, deep and labored breathing found in diabetic ketoacidosis and in renal failure.

Orthopnea - can breath in upright position

Stridor - a shrill, harse sound heard on inspiration

Wheeze - high pitched musical sound on expiration

Intercostals retraction - indrawing between ribs

Substernal retration - indrawing between breastbone

Suprasternal retraction - indrawing above the clavicle







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Head Neck Regional Lymphatics

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Head Neck Regional Lymphatics Slide Transcript
Slide 1: Head, Neck, Regional Lymphatics

Slide 2:  Focuses on – Cranium – Face – Thyroid Gland – Lymph node structures within the head & neck

Slide 3: Skull  Size & shape – 8 bones • 1 frontal • 2 parietal • 2 temporal • 1 occipital • 1 ethmoid • 1 sphenoid – Protects the brain & sensory organs

Slide 5: Face  Structures  Expression

Slide 6: Neck  Symmetry  ROM  Muscles  Lymph nodes (10) – Preauricular – Post auricular – Occipital – Submental – Submandibular

Slide 7: – Jugulodigastric – Superficial cervical – Deep cervical chain – Posterior cervical Supraclavicular

Slide 9: Trachea  Inspect  Palpate; anterior, posterior  Auscultate

Slide 10: Trachea

Slide 11: Thyroid  Inspect (drink of water). Thyroid tissue moves up.  Palpate. – Posterior approach – Anterior approach  Usually not palpable  Auscultate if enlarged





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Ears Nose Throat Mouth Nursing

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Ears Nose Throat Mouth Nursing Slide Transcript
Slide 1: Ears, Nose, Mouth, Throat

Slide 2: Ears

Slide 3: Summary of any symptom should include PQRSTU  P= provocative or palliative  Q= quality or quantity  R= region or radiation  S= severity scale  T= timing (onset, duration, frequency)  U= understand client’s perception

Slide 4: Anatomy  The ear is responsible for hearing and balance  Consists of 3 regions  External ear  Middle ear  Inner ear

Slide 5: Structure and Function  External Ear – auricle/pinna movable cartilage and skin Mastoid process= important Landmark  External Auditory Canal – the opening in the external ear; cul-de-sac 2.5 to 3 cm. Long in adult and ends at the eardrum.  Lined with glands that secrete cerumen

Slide 9: External Ear  2 types of cerumen  Whites and blacks – wet, sticky, and honey colored  Asians and Native Americans – dry and flaky Lubricates & protects Moves to meatus with chewing & talking  Outer 1/3 of canal is cartilage, inner 2/3 consists of bone covered with skin

Slide 11: External Ear  Tympanic membrane (eardrum) separates external and middle ear.  Translucent membrane  Pearly, gray color  Cone of light reflection when using otoscope  Oval and slightly concave shape, pulled in at center by malleus

Slide 13: External Ear  Malleus (hammer) – one of the middle ear ossicles  3 parts  Umbo, manubrium short process, may show through the drum  Lymphatic drainage of the external ear flows into  Parotid, mastoid, superficial cervical nodes

Slide 14: Middle ear  Tiny air–filled cavity in the temporal bone contains: Auditory ossicles (bones) Malleus Incus Stapes Openings to Outer ear covered by tympanic membrane Inner ear = oval and round windows Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)

Slide 15: Middle ear has 3 functions 1. Conducts sound vibration from outer ear to inner ear 2. Protects the inner ear by reducing the amplitude of loud sounds 3. Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes)

Slide 16: Inner Ear  Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium 1. Vestibule 2. Semicircular canals 3. Cochlea (contains the central hearing apparatus)

Slide 17: Function of hearing  3 levels 1. Peripheral – ear transmits sound and converts its vibrations into electrical impulses that can be analyzed by the brain. The electrical impulses are conducted by the auditory process of cranial nerve VIII (Acoustic) to the brain stem 1. Amplitude=loudness 2. Frequency=pitch

Slide 18:  Sound waves cause the eardrum to vibrate  Vibrations travel via the ossicles thru the oval window, the cochlea and are scattered against the round window  The basilar membrane of the cochlea contain the organ of Corti receptor hair cells that translate the vibrations to electric impulses  The impulses go to the brainstem via Acoustic nerve (VIII)

Slide 19: 1. Brain stem – function is binaural interaction – permits identification of sound and locating the direction of a sound in space. The acoustic nerve (Cranial nerve VIII) sends signals from each ear to both sides of the brain stem. Brainstem is sensitive to intensity & timing from the ears depending on head position

Slide 20: 1. Cerebral cortex – interprets the meaning of the sound and begins the appropriate response

Slide 21: Pathways of hearing 1. Air conduction (AC)– normal pathway of hearing, the most efficient 2. Bone conduction (BC)– bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve

Slide 23: Hearing loss 1. Conductive – mechanical dysfunction of the external or middle ear resulting in partial hearing loss (if ↑ amplitude to reach nerve elements in inner ear, person can hear) 1. Causes= impacted cerumen, FB, perforated eardrum, pus/bld in the middle ear, otosclerosis

Slide 24: Hearing loss 1. Sensorineural ( perceptive) – pathology of the inner ear, acoustic nerve or auditory areas of the cerebral cortex. ↑ amplitude may not help 1. Causes= Presbycusis, a nerve degeneration due to aging (50yrs) or ototoxic drugs 2. Equilibrium – labyrinth feeds info to the brain about the body’s position in space, inflammation causes vertigo.

Slide 25: Subjective data  Earaches  Infections- otitis media  Discharge  Hearing loss  Environmental noise  Tinnitus- ototoxic: ASA, Aminoglycosides (gentamicin) etc.  Vertigo  Self care behaviors

Slide 26: Objective data  External ear = Inspect and Palpate  Size and shape  Skin condition  Tenderness- pinna & tragus; mastoid process  External auditory meatus- cerumen

Slide 27: Inspect using Otoscope  Pull pinna up & back for adult/older child  Pinna down for infant & ↓ 3yrs. Maintain hold on pinna until exam is complete.  Avoid inner, bony section of canal= sensitive to pain  Can angle otoscope towards nose

Slide 28: Inspect using Otoscope  External canal  Color  Swelling  Lesions  Discharge ; color and odor. Clean or change speculum before examining other ear.

Slide 30:  Perform the otoscope exam prior to hearing tests.

Slide 31:  The following slide show a furuncle which is an infected hair follicle

Slide 33: Tympanic membrane  Color – normal is shiny, translucent, pearl-grey  Characteristics – landmarks; umbro, manubrium, and short process  Position – flat, slightly pulled in at the center and flutters when person holds nose and swallows  Integrity of membrane – intact? Scarring = dense white patch

Slide 34: Hearing tests  Begins with the history-Conversational tone  The following tests may indicate the presence of hearing loss but not the degree.

Slide 35: Hearing tests  Voice– place a finger on the tragus of one ear and while rapidly pushing it in and out of the meatus, place your head 1 –2 feet from your client’s other ear, shield your lips and whisper a 2 syllable word. Repeat on the opposite ear using another word, have the client identify the words (Used to detect high-tone loss)

Slide 36:  Normal Response to Voice test  Correct identification of whispered words bilaterally

Slide 37:  Tuning fork tests- measure hearing by AC and BC  To activate the tuning fork, hold it by the stem and strike the tines softly on the back of the hand 2. Weber test – used when hearing is reported as better in one ear than other (bone conduction)

Slide 38:  Normal finding for the Weber test is  Tone heard = loud bilaterally If sound lateralizes to one ear it indicates conductive or sensorineural loss.

Slide 39: 1. Rinne test – compares bone conduction and air conduction 1. Normally sound is heard 2X as long by air conduction as by bone conduction 2. Normal response ; positive Rinne Test = AC>BC Bilaterally Sound is heard longer by BC with a conductive loss.

Slide 40: Weber test Rinne test

Slide 41: Nose, Throat and Mouth

Slide 42: Nose  First segment of the respiratory system  Warms, moistens and filters inhaled air  Sensory organ for smell

Slide 43: External parts  Bridge  Tip  Nares  Vestibule -nares widen in to vestibule  Columella divides the nares  Ala –lateral outside wing of the nose bilaterally  Upper 1/3 nose is bone; rest is cartilage

Slide 44: Internal  Nasal cavity, extends back over the roof of the mouth  Nasal hair, ciliated mucous membrane – red due to ↑ bld supply  Septum-divides cavity into 2 passages

Slide 45: Internal  Superior, middle, inferior turbinates- 3 parallel bony projections on lateral walls of each cavity  Meatus- cleft underlying each turbinate. The sinuses drain into the middle, tears from the nasolacrimal duct drain into the inferior

Slide 47: Internal  Olfactory receptors- in roof of the nasal cavity & upper part of septum. Merge into the olfactory nerve (I) goes to the temporal lobe of the brain

Slide 49: Foreign Body

Slide 51:  Paranasal sinuses- air- filled pockets in the cranium  Purpose  ↓ wt. of the skull  Serve as resonators for sound  Provide mucous for the nasal cavity Sinus openings are narrow = susceptible to occlusion resulting in inflammation/sinusitis

Slide 52: 1. Frontal sinuses 2. Maxillary sinuses 3. Ethnoid sinuses 4. Sphenoid sinuses Frontal & Maxillary sinuses are accessible to examination

Slide 55: Mouth  First segment of the digestive system  Airway for the respiratory system  ORAL CAVITY  Lips  Palate 1. Hard 2. Soft 3. Uvula – hangs down from the soft palate

Slide 56:  Cheeks- side walls of cavity  Tongue 1. Papillae- rough, bumpy elevations on dorsal 2. Frenulum 3. Taste buds  Teeth – 32 permanent

Slide 58:  Salivary glands 1. Parotid- largest of the glands, located in the cheeks, front of the ear. Stenson’s duct opens in buccal mucosa 2. Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum 3. Sublingual –smallest, almond shape, under tongue

Slide 60: Throat  Area behind the mouth & nose  Oropharynx – separated from the mouth by a fold of tissue on each side called anterior tonsillar pillars  Tonsils – lymphoid tissue behind pillars

Slide 61:  Posterior pharyngeal wall located behind the tonsils  Nasopharynx continues from the oropharynx but it is above it and behind the nasal cavity. It holds the adenoids and the eustachian tube openings.

Slide 62: Subjective data Nose  Discharge  Frequent colds  Sinus pain  Trauma  Epistaxis  Allergies  Altered smell

Slide 63: Subjective data Mouth and Nose  Sores, lesions  Sore throat  Bleeding gums  Toothache  Hoarseness  Dysphagia  Altered taste

Slide 64:  Smoking  Alcohol intake  Self care behaviors

Slide 65: Objective behavior  Nose – Inspect and palpate  INSPECT for:  Symmetry, deformity  Inflammation  Skin lesions  Color  If injury – palpate gently

Slide 66:  Test for Patency  Test for Sense of Smell – Cranial nerve I (olfactory)

Slide 67:  Inspect nasal cavity/ septum  Deviated septum?  Can see middle & inferior turbinates

Slide 68:  Inspect and palpate Paranasal Sinuses  Press thumbs over frontal & maxillary sinuses  Transillumination for sinus inflammation  Frontal & Maxillary sinuses  Darken room

Slide 71: Mouth - Inspect Use gloves, tongue depressor, light  Lips  Teeth  Gums  Tongue  Buccal mucosa –Stenson’s duct (parotid)  Palate

Slide 74: Throat - Inspect  Tonsils  Grade size 1+ visible  …………….2+ ½ way b/t tonsillar pillars and uvula  …………….3+ touching the uvula  …………….4+ touching each other  Posterior pharyngeal wall  Gag reflex cranial nerves IX = glossopharyngeal and X = Vagus  Cranial nerve XII = hypoglossal- stick out tongue  Halitosis – Due to ????





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Monday, April 21, 2008

Elimination Nursing Lecture

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Elimination Nursing Lecture Slide Transcript
Slide 1: Elimination

Slide 2: Basic Principles  Wash Hands & Wear Gloves  Infection control, your protection & your client’s protection  Privacy  Embarrassing  Positions for urination  Independence

Slide 3: Functions of Urinary System  Remove wastes from blood to form urine  Remove nitrogenous waste products of cellular metabolism  Regulates fluid and electrolyte balance The nephron = functional unit of the kidney and forms the urine

Slide 4: Goal of Urinary System  To maintain chemical homeostasis of the blood.  Filtration by the Nephrons  H2O, glucose, amino acids, urea, creatinine, major electrolytes  Not normally large proteins or blood cells  Proteinuria is a sign of glomerular injury  Normal adult 24hr output = 1500-1600ml.

Slide 5: Overview of Urinary System  Kidneys  Bean shaped organs  Either side of vertebral columns T12 – L3  Right kidney lower due to liver  Urine produced with filtration of blood through nephrons  Major role in fluid & electrolyte balance

Slide 6:  Ureters  Connect kidneys to bladder  10 -12 in length, ½ in diameter in adult  Peristaltic waves  Renal colic  Micturition

Slide 7:  Bladder  Distensible, muscular sac  Reservoir for urine ( approx. capacity = 600mls )  Organ of excretion ( norm. voiding= 300mls)  Lies in pelvic cavity behind symphysis pubis

Slide 8:  Urethra  Short, muscular tube  Urine from bladder to meatus and from the body  Female 4-6.5cm (1 ½ - 2 ½ in.) length  Male 20cms ( 8 in.)  Urinary and reproductive systems

Slide 9:  Meatus  External opening of the urethra, male & female  The need to void is a conscious awareness

Slide 10: Life Cycle Changes  Infants & children  Unable to concentrate urine b/c kidneys are immature  Urine is light yellow  Void frequently  Voluntary control @ 24mos. when neuromuscular structures develop

Slide 11:  Adult  1500 – 1600 mls urine/24hrs  Concentrates urine – normal is amber colored  Nocturia  Not usually  Decreased renal blood flow during rest  Ability to concentrate urine

Slide 12:  Elderly  Micturition impaired  mobility  Diseases, alzheimer’s, CVA  Physiological age related changes  Bladder loses muscle tone and capacity  Kidneys lose ability to concentrate urine  Bladder loses muscle strength

Slide 13: Common Problems  Urinary Retention  Accumulation of urine in the bladder  Inability to empty  Pressure, discomfort and tenderness  Residual Urine = urine retained in the bladder after voiding

Slide 14:  Incontinence  Loss of voluntary control to void  Infection, nerve damage to bladder or brain, spinal cord injury, or aging process  Total incontinence = no control  Stress incontinence = sm. amts. Urine excreted involuntarily with coughing or laughing At risk for skin breakdown related to acid urine next to skin. Adult Diapers or Attends

Slide 15:  Frequency & Urgency  Nocturia  Enuresis – involuntary discharge of urine  Nocturnal Enuresis  During sleep  Bed-wetting children 5yrs and older  Oliguria  30mls/hr or 720 mls/24hrs

Slide 16:  Renal anuria  cessation of urine production 100mls/24h

Slide 17: Promoting Healthy Urinary Elimination  Urinate as soon as the urge is felt  Avoids stasis and distention  Prevents urgency, infection, and incontinence  Drink about 2liters fluid/day  Limit Na, caffeine, and alcohol

Slide 18:  For people with Nocturia  fld. Intake in the p.m.  caffiene and alcohol  Void before bedtime  For Women  Wipe perineum front to back  Void soon after intercourse  Wash hands  Pelvic – floor strengthening exercises (Kegel Exercises)

Slide 19: Client Education  S & S of infection  Fluid intake ( if no restrictions 2-5 L/day )  Perineal hygiene  Meds. & side effects on urination, color, and volume

Slide 20: Facilitating Micturition  Nursing Measures to promote voiding in people who are having difficulty: 1. Privacy and natural position 2. Providing commode or bathroom 3. Running water 4. Warm water to dangle fingers 5. Warm water over perineum ( measure if on In/Out )

Slide 21: 1. Gently stroking inner thighs or pressure to symphysis pubis 2. Pain relief Warmth to the bladder & perineum relaxes muscles & facilitates voiding. ( Sitz bath or warm tub ) If unsuccessful- urinary catheterization may be indicated

Slide 22:  Promoting complete bladder emptying  Prevention of infection  Good perineal hygiene  Adequate fld. Intake  Dilutes urine & flushes urethra  Acidifying urine ( inhibits microorganisms)  Cranberry juice, whole grain breads, meats, eggs, prunes and plums.

Slide 23: Indwelling Catheter Care  Goal- prevent infection & maintain unobstructed flow of urine. Monitor for problems.  Perineal hygiene @ least 2x/day and prn  Do not advance catheter further into urethra during perineal care

Slide 24: Catheter Care  Fld intake (3L/day )  Handwashing and Gloves  Positioning  Urine bag  Tubing

Slide 25: Bowel Elimination  Function- excrete/eliminate waste products of digestion.  Maintaining normal bowel elimination is essential to health and efficient body functions.

Slide 26: GI System  Small Intestine  Absorption nutrients & electrolytes  20 ft length, 1 in. diameter  3 sections  Duodenum  Jejunum  Ileum

Slide 27: GI  Large Intestine  Absorbs H2O and electrolytes  Temporarily stores waste products  Main function is elimination  5 – 6 ft. length, 6 – 7 cm. diameter  Cecum  Ascending colon ( Right side )  Transverse colon  Descending colon

Slide 28: Patterns through life cycle  Babies: 3 – 6 BM’s/day  Children:  Neuromuscular structures not developed until 15 – 18 mos.  Voluntary control 2 – 3 yrs.  Pregnant women prone to constipation  Pressure on abd. Organs  Iron supplements

Slide 29:  Elderly prone to constipation  Slowing of peristalsis

Slide 30: Determinants affecting elimination  Dietary patterns & fld. Intake  6 – 8 glasses H2O/day ( 1400- 2000mls )  fld. Liquifies stool  Dietary fiber stimulates peristalsis  Soft stool

Slide 31: Factors affecting elimination  Fiber ( undigestible residue ) provides bulk  Absorbs fluid  Increases stool mass  Bowel wall stretches  Peristalsis stimulated  Defecation results

Slide 32: Factors affecting elimination  Personal habits  Busy schedule, postpone BM, constipation  Activity & exercise  Immobile activity in colon  Medications  Laxatives  Narcotics with codiene

Slide 33: Factors affecting elimination  Emotions  Anxiety peristalsis & diarrhea  Depression  Pain  Surgery  Anaesthetic causes temporary cessation of peristalsis  Direct manipulation of the bowel stops peristalsis

Slide 34: Common Problems 1. Constipation – difficult passage of hard, dry stool; infrequent movements 2. Fecal Impaction – unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops 3. Diarrhea- # liquid stool 4. Flatulence – abd. Distention & pain

Slide 35: Common Problems  Incontinence – inability to control passage of stool  Hemorrhoids  Dilated engorged veins  Increased pressure when straining  Internal / external  Bleeding

Slide 36:  Daily BM Not essential.   2 / week a concern  Defecation pattern  BM, Stool, Feces, Defecate – all mean waste products expelled via the bowel

Slide 37: Promoting Healthy Bowel Elimination  Privacy  Squatting position  Bedpan position  Cathartics & laxatives  Anti- diarrheal agents  Enemas  disimpaction

Slide 38:  Bowel routine Daily time clock Hot drinks Stool softeners Privavy Position and abdominal pressure Bearing down

Slide 39: Assissting with Elimination  Embarrassing & stressful  Usually urge to defecate 1hr. Pc  Bedpans  Metal or plastic  Regular or fracture pan  Cleanliness  Urinals  Commode

Slide 40: Procedure  Privacy- close door,  Side rail as needed  Recumbent with HOB  Tissue  Call bell  Leave alone if possible  Gloves  Clean genitals

Slide 41: Procedure  Remove pan and cover  In & Out  Specimens  Clean pan  Wash hands yours and client’s  Lower bed  Client comfort

Slide 42: Peri - Care  Cleaning of genitals , routine part of complete/ partial bed bath  Incontinence

Slide 43: Procedure for Peri Care  Regular patient  Simple explanation- layman’s terms  Privacy  Gloves  Dorsal recumbent position  Incontinent pad under buttocks  Warm soap and water  Female – separate labia

Slide 44: Procedure for Peri Care  Male – begin penile head move down along shaft, retract foreskin, rinse and dry.

Slide 45: Procedure for Peri Care  Catheter –  Q 8 hrs.  Clean perineum & 2in. Of catheter  No powders / lotions  Avoid advancing catheter  Keep urine drainage bag off floor but below level of bladder  Empty bag Q8 – 12hrs or when bag is full, remember to mark amt. Emptied on In/Out sheet

Slide 46:  Avoid use of baby powder/ cornstarch  No medicinal purpose  Can form clumps or will cake in creases  Use vaseline/ zincoxide as skin barrier for incontinent clients

Slide 47: Suppository Administration  Check physician’s order, protocol  Left Lateral position  Gloves  Lubication  Hold with thumb and index finger  Insert with index finger (3 – 4”) never force  Deep breath = relaxes anal sphincter

Slide 48:  Caution  Vagus nerve stimulation can cause heart rate to slow – avoid excess manipulation

Slide 49: Enema Administration  Main purpose  Promotion of defecation, stimulate peristalsis  The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex

Slide 50: Types of Enemas

Slide 51: Cleansing Enemas  Tap Water  Hypotonic  Used only once  Electrolyte imbalance  Water toxicity  Circulatory overload ( concentration gradient)

Slide 52:  Normal Saline  Used when more than one enema is needed  Safest  Isotonic  Large volume to distend bowel

Slide 53:  Hypertonic Solution  Smaller volume of fluid  Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis  Fleets – sodium phosphate  Low volume, concentrated solution

Slide 54:  Soap suds  Less common  Soap irritates the bowel  5 – 15 mls. Castile soap in 1000mls warm water

Slide 55:  Oil Retention  Oil based solution  Lubricates the rectum and colon  Softens stool, easier to pass  Retain 1 –2 hrs if possible  Follow with cleansing enema

Slide 56:  Medicated  Instill meds.  Rectal mucosa absorption  Ex. – Kayexalate to K (potassium). Absorbs K from the intestinal tract

Slide 57: Volumes for Enemas  Large Volume  500 – 1000mls.  Container 12 – 18 in. above the bowel  Lg. Volume stimulates & causes evacuation of stool  Small Volume  500 mls.  Container 12 in.above bowel

Slide 58: Volumes for Enemas  Pre packaged  Fleet 150mls  Microlax 5mls  Hypertonic solution  User friendly  Hold for 5min.  Oral Fleet

Slide 59:  Prepackaged used more than large volume because:  Works  Less risk for electrolyte imbalance  Rapid administration  Less discomfort and distention  Convenient and quick

Slide 60:  Physician’s order reads “ enemas to clear”  No more than 3 total given  Return solution will be highly colored but no solid stool  Isotonic solution (normal saline) Excess enema use seriously depletes fluid and electrolytes

Slide 61: Procedure for Enema Administration  Confirm Dr’s order, prepare client, verbal consent, equipment, privacy  Left lateral position ( fld. Flows by gravity)  Drape, pad under buttocks  Warm solution- stimulates peristalsis  Hot sol’n burns mucosa  Cold sol’n causes cramping

Slide 62: Procedure for Enema Administration  Prime tube  Lubricate tip  Glove  Insert 7 – 10 cm.(3-4in) adult  Do not force  Deep breath  Guide toward umbilicus

Slide 63: Procedure for Enema Administration  Container at appropriate height  Lg. = 12 – 18in  Sm. = 12in  1000mls takes ~ 10 min to instill  Higher the bag – greater the pressure  C/O discomfort, lower bag, slow infusion, stop, then start again  Remain side lying to retain 5 – 10 min. or as long as possible

Slide 64: Procedure for Enema Administration  Assist to bathroom or give bedpan  Evaluate results  Document  Type & volume of enema  Color, amount, consistency of fecal return  Hygienic measures for client  Wash Hands

Slide 65: Ostomy Care

Slide 66:  Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination  Enterostomy – the surgical procedure performed to produce the artificial stoma.

Slide 67: Definitions  Ostomy = opening made to allow passage of urine or stool  Piece of intestine is brought out onto the client’s abd.  Lacks nerve endings  Doesn’t hurt to touch but has other implications  Stoma = mouth like opening in the abdominal wall to drain urine or stool

Slide 68:  Effluent – drainage from stoma  Bowel ostomies  Cancer ( Ca)  Drain fecal material  Consistency depends on location  Higher up = more liquid  Greater risk skin irritation b/c concentration of digestive enzymes

Slide 69:  Ileostomy  End of small intestine  By passes lg. Intestine = freq. Liquid stools  Colostomy  Large intestine  More solid stool

Slide 70:  Ostomies may be permanent  More common  temporary  Rest the bowel  Crohn’s

Slide 71: Urinary Ostomies  Provide drainage of urine that bypasses the bladder = Urinary Diversion  Ureterostomy  Ureter to abd. Wall  Lt., Rt., Bilateral

Slide 72: Ileal Conduit  6 – 8 in. ileum  1 end for external opening  Other end closed off  Ureters implanted into this piece of bowel  Pouch  Urine will have shred of mucus b/c bowel still produces same

Slide 73: Concerns  Infection  Sterile ureters provide opening into system  Skin Breakdown  Continuous drainage  Moisture on skin  Replace urinary pouch q 2-3 days

Slide 74: Pouching an Enterostomy  Effluent ( drainage ) may begin immediately  Collects all effluent  Protects the skin  Stoma should be moist and reddish pink (same as other mucus membranes)  Flush to skin or bud-like protrusion  Black, purple, dry = inadequate circulation

Slide 75: Pouch with Skin Barrier  Comfortable fit  Cover skin surrounding stoma  Good seal  Post-op pouch should allow for visibility of stoma

Slide 76: Types of pouches and skin barriers  One Piece Pouching System  Skin barriers preattached, precut, custom fit  Two Piece System  Skin barrier with flange ( plastic ring)  Corresponding size pouch  Assess stoma  Measure correct size  Change q 3-7 days  Empty 1/3 to ½ full, expel flatus prn

Slide 77: Steps to Care for Ostomies  Supine position  Wash hands, glove  Remove pouch & skin barrier, push skin away from barrier  Cleanse peristomal skin gently with warm tap water and clean cloth  Do not scrub, Avoid soap ( residue- pouch won’t adher)

Slide 78: Steps to Care for Ostomies  Correct sizing  Cut opening 1/16 – 1/8 larger than stoma  Remove backing  Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application)

Slide 79: Steps to Care for Ostomies  Pouch should point to client’s knees  Maintain gentle finger pressure around barrier for 1-2 min.  Picture frame flange with non allergic paper tape  Ostomy deodorant for pouch  Tub bath or shower

Slide 80: Steps to Care for Ostomies  Normal stoma oozes blood if rubbed  Actual bleeding into pouch is abnormal  Pouch covers are available  The client will be watching the nurse during ostomy care to gage reaction.  Be conscious of facial expression & nonverbal cues

Slide 81: Steps to Care for Ostomies  Education  Counseling  Body image  Self care  Fear of rejection  Sexual function  Powerlessness over bowel regulation





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Sunday, April 20, 2008

Texas Senator John Cornyn Files Bill for U.S. Global Competitiveness;Recapturing 61,000 Schedule A Visas for RNs and PTs Among Others

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WASHINGTON—On the heels of Tuesday's announcement by U.S. Citizenship and Immigration Services (USCIS) that it received enough petitions, in just 24 hours, to meet the congressionally-mandated cap of 65,000 H-1B visas available for next year, U.S. Sen. John Cornyn, R-Texas, announced today that he and several Senate colleagues are re-introducing legislation to address this urgent problem by promoting competitiveness, innovation, and employer access to skilled employees.

Specifically, Senator Cornyn, along with Senators Judd Gregg, Joe Lieberman, and Chuck Hagel, today introduced the "Global Competitiveness Act of 2008" (S. 2839) which would give United States employers access to previously unused H-1B temporary worker visas and permanent employment-based visas from prior fiscal years. The bill also temporarily increases the level of H-1B visas in a timely manner while including reasonable targeted enforcement provisions to combat and investigate fraud and abuse of the H-1B program. Importantly, under the Cornyn legislation, H-1B visa holders are only allowed to work in areas where there is a demonstrated shortage of American workers and are not allowed to act as "labor for hire" at different job sites, potentially displacing American workers. Furthermore, participating employers must agree to not rely exclusively on H-1Bs for their labor needs or advertise solely for H-1B workers, and make a concerted effort to hire Americans workers first.

"Tuesday's announcement highlights the critical nature of this irresponsible cap. For businesses in Texas, and across the country, to continue to grow, prosper, and create more jobs here at home, they must have the resources necessary to remain competitive in an increasingly global economy. Just last month, Microsoft Chairman Bill Gates testified before the House Science Committee on the issue of American competitiveness. He stated that the U.S. economy 'depends on the ability of innovative companies to attract and retain the very best talent, regardless of nationality or citizenship.' I agree and we need to do something about it," Sen. Cornyn said today.

"Well-educated, highly skilled workers are key to our country's competitiveness. Our outdated system has limited the ability of many American companies to recruit and retain top-quality talent. We must address the H-1B visa crisis to ensure that America remains the world leader in innovation," Sen. Lieberman said.

"Congress must pass critical visa legislation for our small and seasonal businesses, as well as for companies that fuel economic growth for all Americans. The unreasonably low caps on H-1B and H-2B visas have made it difficult, if not impossible, for businesses to augment their U.S. workforce with foreign labor. Hotels, landscapers, restaurants, and other businesses in New Hampshire have been hit hard by losing access to the H-2B program, and some will be forced to reduce operations, lay off U.S. workers, or close their doors. Moreover, the lack of H-1B visas undermines our nation's economy," Sen. Gregg said. "Talent is a nation's most important resource in today's information age, and the lack of immigration opportunities for highly skilled labor undermines our competitive edge and forces companies to move their operations overseas, which hurts all Americans."

"Clearly, the top priority for the Congress must be passage of a comprehensive immigration reform bill. But the unfortunate delay we have seen on that effort should not harm the high-tech companies and other employers who truly need to strengthen their U.S. workforce now and have played by the rules. This legislation creates interim relief for American businesses, large and small, to help maintain our competitiveness in a global market, while at the same time instituting certain enforcement measures temporarily until we can return to comprehensive immigration reform. This issue has the support of Senators in both political parties and I hope the Senate will soon address it," Sen. Cornyn concluded.

OUTLINE OF GLOBAL COMPETITIVENES ACT OF 2008

H-2B Temporary Worker Program



• Extends the H-2B Returning Worker provisions for 3 fiscal years

H-1B Temporary Worker Program

• Recaptures 150,000 unused H-1B visas which will be distributed over a 3 year period
• Imposes a H-1B recapture fee of $1,500
• Increases H-1B visa levels from 65,000 to 115,000 for fiscal years 2009 through 2011
• Increases the advanced degree cap for H-1B workers with masters degrees or higher from 20k to 30k for fiscal years 2009 to 2011
• Increases the H-1B petition fee from $1,500 to $2,250

Employment Based Visas

• Recaptures approximately 218,000 unused employment-based visas
• Distributes 61,000 of the recaptured EB visas to nurses and physical therapists (and spouses and children accompanying or following to join)
• Imposes an EB visa recapture fee of $1,500
• Exempts health care facilities in underserved areas from paying the additional EB recapture fee

Prohibitions on Outsourcing and H-1B Only Recruiting

• Requires U.S. employers to provide prospective H-1B applications with a copy of their approved H-1B petition
• Requires all U.S. employers to agree not to advertise the jobs solely to H-1B or indicate that H-1B workers will be given priority
• Prohibits U.S. employers from outsourcing the labor of an H-1B worker by requiring that the alien work only at the worksite of the employer or its affiliates and subsidiaries in the United States
• Bars U.S. employers who have an employee total that includes more than 50% H-1B workers from filing more than 1,000 H-1B petitions in a given fiscal year
• Sunsets advertising and outsourcing provisions in 3 years

Early Adjustment Provisions

• Authorizes aliens who are seeking permanent employment-based visas to file for adjustment of status early if the visa number availability date shown on the State Department Visa bulletin is no more than 24 months out from the date of filing
• Imposes an additional $500 fee for early adjustment filing
• Revises distribution of fees to increase funding of STEM scholarship programs

H and L Enforcement Provisions

• Authorizing DHS and DOL to investigate H and L visa fraud
• Revising the conditions that will result in finding a violation of the provisions of a labor condition application
• Requires information and document sharing between DHS and DOL for H and L fraud investigations and noncompliance
• Increases frequencies of H and L program audits
• Doubles the penalties for violations of the labor condition application provisions
• Adds whistleblower protections for L workers, including requiring back-pay for those harmed by an employer violation
• Limits eligibility for L intra-company transferee status for aliens working with start-up companies

Miscellaneous Provisions

• Extends E-Verify authorization
• Modifies the H and L fraud account provisions to allow USCIS flexibility in terms of use of funds for benefit fraud investigations







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