1. Tracheostomies
1.1. Background
1.1.1. Causes of obstruction
1.1.1.1. Disease
1.1.1.2. Bronchoconstriction
1.1.1.3. Foreign body
1.1.1.4. Secretions
1.1.2. Methods of assessment
1.1.2.1. Inspection
1.1.2.2. Palpation
1.1.2.3. Auscultation
1.2. Characteristics
1.2.1. Surgical opening (stoma)
1.2.1.1. Includes indwelling tube
1.2.1.2. Temporary or permanent
1.2.2. Indications
1.2.2.1. Bypass URT obstruction
1.2.2.2. Facilitate removal of secretions
1.2.2.3. Long-term mechanical ventilation
1.2.2.4. Prevent aspiration
1.2.2.5. Replace ET tube
1.2.3. Advantages
1.2.3.1. Less direct laryngeal injury
1.2.3.2. Facilitate oral care
1.2.3.3. Increase mobility & comfort
1.2.3.4. Allow for speech
1.2.3.5. Facilitate oral feedings
1.2.4. Types
1.2.4.1. Cuffed
1.2.4.1.1. Inflated cuff on tube
1.2.4.1.2. Reduces aspiration risk
1.2.4.1.3. Used in mechanical ventilation
1.2.4.2. Uncuffed
1.2.4.2.1. When client can protect their airway
1.2.4.2.2. Not paired with mechanical ventilation
1.2.5. Complications
1.2.5.1. Early
1.2.5.1.1. Bleeding
1.2.5.1.2. Pneumothorax
1.2.5.1.3. Air embolism
1.2.5.1.4. Aspiration
1.2.5.1.5. SQ or mediastinal emphysema
1.2.5.1.6. Laryngeal nerve damage
1.2.5.1.7. Tracheal wall penetration
1.2.5.2. Long-term
1.2.5.2.1. Accumulation of secretions
1.2.5.2.2. Cuff protrusion
1.2.5.2.3. Infection
1.2.5.2.4. Innominate artery rupture
1.2.5.2.5. Dysphagia
1.2.5.2.6. Tracheoesophageal fistula
1.2.5.2.7. Treacheal ischemia >> necrosis
1.2.5.3. Prevention
1.2.5.3.1. Warmed humidity
1.2.5.3.2. Maintain cuff's pressure
1.2.5.3.3. Auscultate & suction PRN
1.2.5.3.4. Skin integrity
1.2.5.3.5. S/S of infection
1.2.5.3.6. Hydration
1.2.5.3.7. Sterility
1.3. Tracheostomy care
1.3.1. Components
1.3.1.1. Changing or cleaning inner cannula
1.3.1.2. Changing dressing
1.3.1.3. Inspecting skin
1.3.1.4. Suctioning PRN
1.3.2. Assessment
1.3.2.1. Breath sounds
1.3.2.2. Vital signs
1.3.2.3. Oxygen saturation
1.3.2.4. Coughing ability
1.3.2.5. Visible secretions
1.3.2.6. WOB
1.3.3. Diagnoses
1.3.3.1. Ineffective airway clearance
1.3.3.2. Disturbed body image
1.3.3.3. Risk for aspiration, bleeding, infection
1.3.3.4. Deficient knowledge
1.3.3.5. Anxiety
1.3.3.6. Impaired verbal communication
1.3.4. Care plan
1.3.4.1. On-going assessment
1.3.4.1.1. Maintaining airway
1.3.4.1.2. Preventing complications
1.3.4.2. Management
1.3.4.2.1. Suctioning while maintaining oxygenation
1.3.4.2.2. Site care
1.3.4.3. Other objectives
1.3.4.3.1. Alleviate apprehension
1.3.4.3.2. Provide effective communication
1.4. Suctioning
1.4.1. Indications
1.4.1.1. Coughing
1.4.1.2. Secretions
1.4.1.3. Respiratory distress
1.4.1.4. Decreasing oxygen saturation
1.4.2. Monitoring
1.4.2.1. Hypoxemia
1.4.2.1.1. HTN
1.4.2.1.2. Dysrhythmias
1.4.2.1.3. Decreased oxygen saturation
1.4.2.2. Bronchospasms
1.4.2.3. Atelectasis
1.4.2.4. Increased ICP
1.4.3. Documentation
1.4.3.1. Client's response
1.4.3.2. Vital signs
1.4.3.3. Breath sounds
1.4.3.4. Cardiac rhythm
1.4.3.5. Oxygen saturation
1.4.3.6. Amount & consistency of secretions
1.4.4. Gerontological differences
1.4.4.1. Assess lung sounds before & after
1.4.4.2. Fragile skin during stoma care
1.5. Patient education
1.5.1. Daily care
1.5.2. Emergency measures
1.5.3. Community resources
1.5.4. Home-health nursing
2. IV Medications
2.1. Nurse's role in IVs
2.1.1. Insert peripheral catheter
2.1.2. Monitor site
2.1.3. Administer & maintain therapy
2.1.3.1. Instill fluid into a vein
2.1.3.2. Technically a medication
2.1.4. Know therapeutic action of therapy
2.1.4.1. Replace lost fluid
2.1.4.2. Maintain fluid/electrolyte balance
2.1.4.3. Give IV medications
2.1.4.4. Nutrition
2.1.4.5. Blood products
2.1.5. Assess response to IV
2.2. Appropriate IV sites
2.2.1. Arms & hands
2.2.2. Avoid certain areas
2.2.2.1. Legs/feet
2.2.2.2. Sites distal to infiltration
2.2.2.3. Sclerosed or thrombosed veins
2.2.2.4. Arms wtih shunts/fistula (renal pts)
2.2.2.5. Edema
2.2.2.6. Infection
2.2.2.7. Clots
2.2.2.8. Scarring
2.2.2.9. Skin breakdown
2.2.2.10. Arm on side of mastectomy
2.3. IV catheters
2.3.1. Plastic catheter
2.3.1.1. Flexible
2.3.1.2. Less likely to puncture wall
2.3.1.3. Long-lasting (72 hours)
2.3.1.4. 14-24 gauge
2.3.1.4.1. 24 - Pediatric/elderly
2.3.1.4.2. 14 - Cardiac patients or large volume
2.3.2. Needle (butterfly)
2.3.2.1. Shorter
2.3.2.2. Little to no "threading"
2.3.2.3. Less trauma or pain
2.3.2.4. Inflexible
2.3.2.5. Easily punctures wall
2.3.2.6. Increased risk of infiltration
2.4. Central lines
2.4.1. Types
2.4.1.1. PICC
2.4.1.1.1. Peripherally inserted central catheter
2.4.1.1.2. Can be inserted by nurse w/special training
2.4.1.2. Chemport
2.4.1.2.1. Chest
2.4.1.2.2. Arms
2.4.1.2.3. Abdomen
2.4.1.3. TLC
2.4.1.3.1. Subclavian or internal jugular vein
2.4.1.3.2. By MD only
2.4.1.4. Broviac-Hickman
2.4.1.5. Tunneled vs. non-tunneled catheters
2.4.2. Advantages
2.4.2.1. Less frequent sticking
2.4.2.2. Can give vesicants
2.4.3. Disadvantages
2.4.3.1. Must be placed by MD*
2.4.3.2. High risk for complications
2.5. IV maintenance
2.5.1. Tubing
2.5.1.1. 72-96 hours*
2.5.1.2. Exceptions to rule
2.5.1.2.1. Changing tubing with new IV site
2.5.1.2.2. Blood or TPN
2.5.2. Sites
2.5.2.1. 72-96 hours
2.5.2.2. Infiltration
2.5.2.3. Dislodged catheter
2.5.2.4. Pain reported
2.6. Potassium infusions
2.6.1. Never given direct IV push
2.6.2. Infusion pump only
2.6.3. Must be diluted
2.6.4. No faster than 10-20 mEq/hr through peripheral IVs
2.7. Complications of IVs
2.7.1. Infiltration
2.7.2. Phlebitis
2.7.2.1. Pain or burning
2.7.2.2. At catheter site
2.7.3. Thrombus
2.7.4. Site infection
2.7.5. Fluid volume excess
2.7.5.1. SOB
2.7.5.2. Crackles
2.7.5.3. Tachycardia
2.7.6. Bleeding
2.7.7. Sepsis
2.8. Venipuncture
2.8.1. For blood specimens
2.8.2. Slightly greater angle (15-30 degrees)
2.8.3. Specific tubes
2.8.3.1. Lavender
2.8.3.1.1. CBC
2.8.3.1.2. Blood typing
2.8.3.2. Red or yellow
2.8.3.2.1. Chemistries
2.8.3.2.2. Often the red top**
2.8.3.3. Blue
2.8.3.3.1. Coags - PT/PTT/INR
2.8.3.4. Green
2.8.3.4.1. Cardiac enzymes
2.8.3.5. Light or dark blue
2.8.3.5.1. Additional coags
2.8.3.5.2. DIC panels
2.8.3.5.3. FDP
2.8.4. Assessment
2.8.4.1. Type of test ordered
2.8.4.2. Timing or client preparation
2.8.4.3. Ability to cooperate
2.9. Blood cultures
2.9.1. Process
2.9.1.1. Collect 10-15 mL of blood
2.9.1.2. Inoculate anaerobic, then aerobic cultures
2.9.1.3. Mix gently
2.9.1.4. Label and transfer
2.9.1.4.1. Date/time/initials
2.9.1.4.2. Site***
2.9.2. Should be negative
2.9.3. Positive = bacteremia
2.9.4. May have false-positive if contaminated
3. Blood & TPN
3.1. Blood
3.1.1. Increased safety
3.1.2. AB (receiver) & O (donor)
3.1.3. Ordered by HCP
3.1.3.1. "Type and screen"
3.1.3.2. "Type and match"
3.1.3.3. "Type, match & hold X units"
3.1.4. Many varieties
3.1.4.1. Whole blood
3.1.4.1.1. All parts
3.1.4.1.2. For hemorrhage >20% of circulating volume
3.1.4.1.3. Restores oxygen-carrying capacity + volume
3.1.4.1.4. Given over 2-4 hours
3.1.4.2. Packed RBCs
3.1.4.2.1. No plasma!
3.1.4.2.2. Same mass of RBCs as whole, but less volume (-250 mL)
3.1.4.2.3. Decreased risk of overload
3.1.4.2.4. For restoring oxygen-carrying capacity
3.1.4.2.5. Given over 2-4 hours
3.1.4.3. Washed RBCs
3.1.4.3.1. Removed foreign proteins
3.1.4.3.2. For patients w/anaphylactic reactions
3.1.4.3.3. Expires after 24 hours
3.1.4.3.4. Give over 2-4 hours
3.1.4.4. Platelets
3.1.4.4.1. Donor types
3.1.4.4.2. Forms
3.1.5. Transfusion
3.1.5.1. Pre-procedure
3.1.5.1.1. Check orders
3.1.5.1.2. T&M to lab
3.1.5.1.3. Explain procedure; get consent
3.1.5.1.4. Get blood <30 min before transfusion
3.1.5.1.5. Hang w/i first 30 min
3.1.5.2. Procedure
3.1.5.2.1. Baseline vital signs
3.1.5.2.2. May use blood wormer
3.1.5.2.3. Flush with NS
3.1.5.2.4. Check the site (18*-20 GA)
3.1.5.2.5. Give slowly during first 15 min***
3.1.5.2.6. Observe for adverse effects
3.1.5.2.7. Increase rate if all clear
3.1.5.2.8. Observe per policy
3.1.5.2.9. Document
3.1.5.2.10. Never add meds to blood!!!
3.1.6. Central lines
3.1.6.1. Ends in SVC or IVC
3.1.6.2. 10-24 inches long
3.1.6.3. Must verify placement by X-Ray
3.1.6.4. Complications
3.1.6.4.1. Air embolism
3.1.6.4.2. Clot or occlusion
3.1.6.4.3. Infection
3.1.6.4.4. Hemothorax
3.1.6.4.5. Pneumothorax
3.1.6.4.6. Brachial plexus injury
3.1.6.4.7. Malposition
3.1.6.4.8. Migration or external damage
3.1.6.5. Management
3.2. TPN
3.2.1. IV infusions of nutrition
3.2.1.1. Pump only
3.2.1.2. Check flow rate q1hr
3.2.1.3. VS q4
3.2.1.4. I&Os
3.2.1.5. Daily weights
3.2.1.6. Chems q3 days*
3.2.1.7. Have to wean off
3.2.2. Maintain or improve status over long-term
3.2.3. May be given with lipid (fat emulsion)
3.2.3.1. Supplemental kCals
3.2.3.2. Gives good fatty acids
3.2.3.3. Infuse slow! (Over 12 hours!)
3.2.4. Goal is to move towards use of GI tract
3.2.5. Complications
3.2.5.1. Embolism, occlusion, sepsis
3.2.5.2. Electrolyte imbalance
3.2.5.3. Hypercapnia
3.2.5.4. hGLY or HGLY
3.2.5.5. HHNK/coma
3.2.5.6. Pneumothorax
3.2.5.7. Thrombosis
3.2.6. May require CVC (>10% dextrose)
3.2.6.1. Hypertonic
3.2.6.2. Irritating solution
3.2.7. Change q24
3.2.7.1. Remove from refrigerator 1 hour early
3.2.7.2. Change tubing q12
3.2.8. May hang bag of dextrose if new TPN hasn't arrived
3.2.8.1. Prevents rebound hGLY
4. Older Adults
4.1. Theories of aging
4.1.1. Chronological
4.1.2. Subjectively
4.1.3. Functional
4.1.4. Many, many, others!
4.2. Leading CODs
4.2.1. Heart disease
4.2.2. Malignant neoplasms
4.2.3. Cerebrovascular diseases
4.2.4. COPDs
4.2.5. Alzheimer's
4.2.6. Diabetes
4.2.7. Pneumonia/influenza
4.2.8. Kidney-related disorders
4.2.9. Accidents
4.2.10. Sepsis
4.3. Health promotion
4.3.1. Cholesterol
4.3.2. Colonoscopy
4.3.3. Fasting blood glucose
4.3.4. Fecal occult blood
4.3.5. Pap smear
4.3.6. PSA
4.3.7. Mammogram
4.3.8. ASA prophylaxis
4.3.9. AAA screen (65+)
4.3.10. Vaccinations
4.3.10.1. Herpes zoster @ 60 yo
4.3.10.2. Influenza
4.3.10.3. Pneumococcal @ 65 yo
4.3.10.4. TDAP booster q. 10yrs
4.4. Age-related changes
4.4.1. Cardiovascular
4.4.1.1. Decreased CO
4.4.1.2. Poor stress response
4.4.1.3. Too consistent HR and SV
4.4.1.4. Slower recovery
4.4.1.5. Increased BP
4.4.2. Respiratory
4.4.2.1. Increased RLV
4.4.2.2. Decreased muscle strength
4.4.2.3. Decreased endurance
4.4.2.4. Decreased vital capacity
4.4.2.5. Decreased gas exchange/diffusing
4.4.2.6. Poor cough efficiency
4.4.3. Integumentary
4.4.3.1. Decreased protective substances
4.4.3.2. Decreased glandular activity
4.4.3.3. Capillary fragility
4.4.4. Musculoskeletal
4.4.4.1. Loss of bone density, muscle strength/size
4.4.4.2. Degenerated joint cartilage
4.4.5. Gastrointestinal
4.4.5.1. Decreased senses
4.4.5.2. Decreased salivation
4.4.5.3. Dysphagia
4.4.5.4. Delayed emptying
4.4.5.5. Reduced motility
4.4.6. Nervous
4.4.6.1. Reduced speed of conduction
4.4.6.2. Increased confusion w/illness
4.4.6.3. Loss of environmental cues
4.4.6.4. Reduced cerebral circulation (syncope)
4.4.7. GU & Reproductive
4.4.7.1. Slower response
4.4.7.2. Female differences
4.4.7.2.1. Vaginal narrowing
4.4.7.2.2. Decreased elasticity
4.4.7.2.3. Decreased secretions
4.4.7.2.4. Relaxed perineal muscles
4.4.7.2.5. Detrusor instability
4.4.7.2.6. Urethral dysfunction
4.4.7.3. Male differences
4.4.7.3.1. Less firm testes
4.4.7.3.2. Decreased sperm production
4.4.7.3.3. BPH
4.5. Pharmacological changes
4.5.1. Polypharmacy
4.5.2. Altered response to drugs
4.5.3. "Start low, go slow"
4.5.4. Noncompliance
4.6. Mental health issues
4.6.1. Depression (most common)
4.6.2. Delirium (acute)
4.6.2.1. Disorientation >>
4.6.2.2. Altered LOC, brain damage >>
4.6.2.3. Death
4.6.3. Dementia
4.6.3.1. Decline in reasoning
4.6.3.2. Reduced ability to perform ADLs
4.7. Nursing care for elders
4.7.1. Cognitive function
4.7.2. Safety
4.7.3. Independence
4.7.4. Good mood
4.7.5. Communication
4.7.6. Intimacy
4.7.7. Nutrition/Activity/Rest
4.7.8. Home care
4.8. Geriatric syndromes
4.8.1. Altered mobility
4.8.2. Dizziness/falls
4.8.3. Urinary incontinence
4.8.4. Susceptibility to infection
4.8.5. Altered pain/fever responses
4.8.6. Altered emotional impact
4.8.7. Altered systemic responses
4.9. "Atypical presentations"
4.9.1. 3 types
4.9.1.1. Vague presentation
4.9.1.2. Altered presentation
4.9.1.3. Non-presentation
4.9.2. Often signaled by behavioral change
4.9.3. Other presentations
4.9.3.1. Failure to eat/drink
4.9.3.2. Failure to develop a fever r/t increased WBCs
4.9.3.3. Lack of appropriate pain response
4.9.4. At-risk groups
4.9.4.1. 85+ yo
4.9.4.2. Many comorbidities/meds
4.9.4.3. Cognitive/functional impairment
4.9.5. Best screening
4.9.5.1. Comprehensive, but problem-focused
4.9.5.2. Focused physical exam
4.9.5.3. Does an ATP exist??
4.10. Elder neglect/abuse
4.10.1. Neglect**
4.10.1.1. Caregiver strain?
4.10.2. Physical
4.10.3. Emotional
4.10.4. Sexual
4.10.5. Financial
5. Chronic Disease
5.1. Characteristics
5.1.1. Over phases
5.1.2. Adaptation
5.1.3. Adherence!
5.1.4. Leads to more disorders
5.1.5. Entire family affected
5.1.6. Collaboration required
5.2. Management
5.2.1. Prevention first!
5.2.2. Then, manage S/S
5.2.3. Avoid complications, acute Sx
5.2.4. Health promotion
5.2.5. Functionality
5.3. Nursing care
5.4. Diabetes in elderly
5.4.1. 15-20% of 65+ yo
5.4.2. Very common
5.4.3. More prevalent in non-whites
5.4.4. Reduces life-expectancy by 10 yo
5.4.5. Doubled mortality rate & risk of complications
5.4.6. Increased risk of geriatric syndromes
5.5. Disabilities
5.5.1. Impairment that seriously limits 1+ major life activities
5.5.2. Remember, "people first"!
5.5.3. Types of disabilities
5.5.3.1. Developmental
5.5.3.2. Acquired
5.5.3.3. Age-related
5.5.4. Models of disability
5.5.4.1. Medical
5.5.4.2. Rehab
5.5.4.3. Biopsychosocial
5.5.4.4. Interface
5.6. Chronic Pain
5.6.1. Over 3 or more months
5.6.2. Suffering + sleepless + sad
5.6.3. Similar treatment r/t acute pain
5.6.3.1. Prevention/management of ADRs
5.6.3.2. Enhance QOL
5.6.3.3. Realistic goals
5.7. Rehabilitation
5.7.1. Comprehensive
5.7.2. Long-term
5.7.3. Multidisciplinary
5.7.4. Can use FIMTM tool for functional assessment