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(Hockenberry 623)
What to do prior to surgery? Prepare the child to play with doll and toy medical
equipment ex: stethoscope
Talk about things in aspect of boo boos and ouchies
During hospital stay it is important for child to understand routines and participate
in active treatment ex: keeping track of input and output
5. 5 questions on experienced RN intervening on novice RN
Dont touch patient unless asking
No translating unless translator
Always ABC, safety and Maslows hierarchy of needs
Dont re-assess if they already assessed in question
6. What are the expected outcome and skin characteristics in older adults?
Changes related to the aging process increase the risk of impaired skin integrity.
These changes include a loss of lean muscle mass; decreases in skin thickness,
strength, moisture, and elasticity; decreased arterial and venous blood flow; and a
diminished perception of pain and pressure that may prevent early recognition of
tissue injury.8 Skin changes often associated with aging are a result of sun and
environmental damage over a long period of time, leading to a wrinkled and
leathery appearance. In addition, hair and nail growth slow with aging and a
decrease in sebaceous gland activity can result in rough, dry, and itchy skin
(Giddens 250)
Age-related changes such as reduced skin elasticity, decreased collagen, and
thinning of underlying muscle and tissues cause the older adult's skin to be easily
torn in response to mechanical trauma, especially shearing forces
Concomitant medical conditions and polypharmacy, which are common in the
older adult, are factors that interfere with wound healing.
The attachment between the epidermis and dermis becomes flattened in older
adults, allowing the skin to be easily torn in response to mechanical trauma (e.g.,
tape removal).
Aging causes a diminished inflammatory response, resulting in slow
epithelialization and wound healing
The hypodermis decreases in size with age. Older patients have little
subcutaneous padding over bony prominences; thus they are more prone to skin
breakdown.
An identified risk factor for the development of pressure ulcers is malnutrition
7. What are expected cognitive changes in older adults?
Peaget theory thinking of local and abstract ideas, reasoning deductive, and
future is oriented
Psychoanalytical/psychosocial theories focus on an individual's unconscious
thought and emotions; cognitive theories stress how people learn to think and
make sense of their world. As with personality development, cognitive theorists
have explored both childhood and adulthood. Some of the theories highlight
qualitative changes in thinking; others expand to include social, cultural, and
behavioral dimensions
8. What is poly-pharmacy?
Use of a number of different drugs by a patient who may have one or several
health problems. Takes multiple drugs from multiple doctors.
Increases adverse drug effects, multiple medications is often necessary when
older adult has multiple diseases
Use of a number of different drugs by a patient who may have one or several
health problems.
9. Know appropriate activities in children related to play
children derive pleasure from handling raw materials ,Enjoy playing with paint,
Social effective play- want to play with touching stuff, respond to behavior as
smiling and cooing
Sports, games, playing with other children allows them to accept other peoples
views
Age 1 more complex, 9 months peek a boo and patty cake
P 148 potter --Play of preschool kids becomes more social, shifts from parallel to
associative
By age 4, children play in groups of 2 or 3. 3 year olds, play roles such as mother
and child. By age 5, they are cooperative playing, having leaders.
10. Know Ericksons stages and what they represent.
Potter 132, hockenberry 71, 72, giddens page 5
Trust vs. mistrust (birth 1 year)- Establishing a basic sense of trust is essential
for the development of a healthy personality. The infant's successful resolution of
this stage requires a consistent caregiver who is available to meet his needs. From
this basic trust in parents, the infant is able to trust in himself, in others, and in the
world
Autonomy vs. shame ( 1- 3)- By this stage a growing child is more accomplished
in some basic self-care activities, including walking, feeding, and toileting. This
newfound independence is the result of maturation and imitation. The toddler
develops his or her autonomy by making choices. Choices typical for the toddler
age-group include activities related to relationships, desires, and playthings.
Initiative vs. guilt (3-6)- Children like to pretend and try out new roles. Fantasy
and imagination allow them to further explore their environment. Also at this time
they are developing their superego, or conscience. Conflicts often occur between
the child's desire to explore and the limits placed on his or her behavior. These
conflicts sometimes lead to feelings of frustration and guilt. Guilt also occurs if
the caregiver's responses are too harsh.
Industry vs. inferiority (6-11)- School-age children are eager to apply
themselves to learning socially productive skills and tools. They learn to work and
play with their peers. They thrive on their accomplishments and praise. Without
proper support for learning new skills or if skills are too difficult, they develop a
sense of inadequacy and inferiority. Children at this age need to be able to
experience real achievement to develop a sense of competency
Identity vs. role confusion (puberty)- Dramatic physiological changes
associated with sexual maturation mark this stage. There is a marked
preoccupation with appearance and body image. This stage, in which identity
development begins with the goal of achieving some perspective or direction,
answers the question, Who am I?
Intimacy vs. isolation (young adult)- Young adults, having developed a sense of
identity, deepen their capacity to love others and care for them. They search for
meaningful friendships and an intimate relationship with another person. Erikson
portrayed intimacy as finding the self and then losing the self in another
Generativity vs. self-absorption (middle aged)- Following the development of
an intimate relationship, the adult focuses on supporting future generations. The
ability to expand one's personal and social involvement is critical to this stage of
development. Middle-age adults achieve success in this stage by contributing to
future generations through parenthood, teaching, and community involvement
Integrity vs. despair (old age)- Many older adults review their lives with a sense
of satisfaction, even with their inevitable mistakes. Others see themselves as
failures, with their lives marked by despair and regret. Older adults often engage
in a retrospective appraisal of their lives. They interpret their lives as a
meaningful whole or experience regret because of goals not achieved
11. Know role of pain in promoting wellness.
When managing pain, goals of care promote a patient's optimal function.
Determine, along with the patient, what the pain has prevented the patient from
doing. Then decide on a mutually acceptable level of pain that allows return of
Because pain affects physical and mental functioning, holistic health approaches
are important interventions for maintaining wellness. Holistic health is an ongoing
state of wellness that involves taking care of the physical self, expressing
emotions appropriately and effectively, using the mind constructively, being
creatively involved with others, and becoming aware of higher levels of
consciousness. The concept of holistic health parallels the values of nursing in
maintaining the integrity of the whole person.
(Potter 977)
When a person develops pain, you can offer nonpharmacological and
pharmacological strategies.
(Potter 977)
Focus on mind, body & spirit
18. Know what the side effects are when taking narcotics
Common side effects of opioids include constipation, nausea and vomiting,
sedation, respiratory depression, and pruritus. With continued use, many side
effects diminish; the exception is constipation. Less common side effects include
urinary retention, myoclonus, dizziness, confusion, and hallucinations.
Constipation is the most common side effect of opioids.
(Lewis 126)
981 Potter
Abuse is respiratory depression, cyanosis, constricted pupils
Respiratory depression you give narcan
19. How is peripheral neuropathy related to pain?
Neuropathic pain results from the abnormal processing of sensory input by the
nervous system as a result of damage to the brain, spinal cord, or peripheral
nerves.4 Simply stated, neuropathic pain is pathologic. Examples of neuropathic
pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and
poststroke pain syndrome. Patients with neuropathic pain use very distinctive
words to describe their pain, such as burning, sharp, and shooting.
(Giddens 270)
Symptoms numbness, tingling of affected area, and stumbling gait.
Damage to peripheral system, can be one nerve or group of nerves
Affects patients awareness of and response to pain
20. 4 questions: Understand how a PCA pump works & its process
The concept of PCA recognizes that only the patient can feel the pain and only the
patient knows how much analgesic will relieve it. Patients who use PCA must be
able to understand the relationships between pain, pushing the PCA button, and
pain relief. They must also be able to cognitively and physically use the PCA
equipment. Some of the methods used to manage pain are accomplished via
catheter techniques such as intraspinal analgesia and continuous peripheral nerve
block infusions with or without PCA capability.
(Giddens 275)
It is a drug delivery system that allows patients to self-administer opioids
(morphine, hydromorphone, and fentanyl) with minimal risk of overdose. The
goal is to maintain a constant plasma level of analgesic to avoid the problems of
prn dosing. Systemic PCA traditionally involves IV or subcutaneous drug
administration; however, a controlled analgesia device for oral medications,
Medication on Demand (MOD), is now available. This device allows patients
access to their own oral prn mediations, including opioids and other analgesics,
antiemetics, and anxiolytics, at the bedside
(Potter 983)
To receive a demand dose, the patient pushes a button attached to the PCA device.
Systems are designed to deliver a specified number of doses every 1 to 4 hours
(depending on the pump settings) given every 5 to 15 minutes (programmable) to
avoid overdoses .Most pumps have locked safety systems that prevent tampering
by patients or family members and are generally safe to be managed in the home.
21. Know how to assess pain across the lifespan. What are the right tools for the right
ages?
Oucher and faces for children
o The wong baker FACES scale consists of six cartoon faces with word
descriptors, ranging from a smiling face on the left for no pain (or hurt)
to a frowning, tearful face on the right for worst pain (or hurt).
o Numeric Rating Scale (NRS): The NRS is most often presented as a
horizontal 0 to 10 point scale, with word anchors of no pain at one end
of the scale, moderate pain in the middle of the scale, and worst
possible pain at the end of the scale. Giddens 271- 272
Pain symptoms can be different in older adults from children
22. What are patient education methods for chronic pain?
Giddens 272
It is particularly important to ask questions
Keep living a normal life, have goals
23. 4 scenarios on which patient to medicate first related to tissue integrity
Always IV first, always highest first, acute pain gets treated first
24. Role of herbal remedies related to health maintenance?
Cranberry juice for uti, aloe accelerates wound healing, chamomile antiinflammatory,
Herbal remedies are prominent in healthcare
Most frequent used is cranberry, soy, garlic,
25. What things should a nurse take into consideration related to pre-op assessment?
History of medication, allergies, vital signs, medical history,
Mark the operative site with an ink
In most hospitals the patient enters a holding area, also known as the
preanesthesia care unit or presurgical care unit (PSCU), outside the OR. In the
PSCU the nurse explains the steps for preparing the patient for surgery, reviews
the preoperative checklist, assesses the patient's readiness both physically and
emotionally, and reinforces teaching. Nurses in the PSCU are members of the OR
staff and wear surgical scrub suits, hats, and footwear in accordance with
infection control policies. In some ambulatory surgical settings a perioperative
primary nurse admits the patient, circulates for the operative procedure, and
manages the patient's recovery and discharge.
(Potter 1271)
26. Role of herbal remedies(therapies) and antibiotics in tissue integrity
Aloe good for wound healing, accelerates wound healing
Pg 652 potter
Antibioticas are used for infection, and antiinflammatory
27. How does an RN assess for chronic pain?
For patients with chronic pain, a thorough pain assessment includes affective,
cognitive, behavioral, spiritual, and social dimensions. In the home care setting
family members assess pain. Using the ABCs of pain management is an effective
way to manage pain (Potter 970)
Inadequate pain assessment is the single greatest barrier to effective pain
management. Data such as vital signs and patient behaviors are not reliable
indicators of pain, especially long-standing, chronic pain. It is important to
distinguish between persistent and episodic, positional, or breakthrough pain.
Therefore it is essential that a comprehensive pain assessment include a detailed
history to elicit the following characteristics of pain: quality, location, intensity,
duration, and precipitating and alleviating factors. Differentiating between types
of pain (e.g., visceral, bone, neuropathic) is important in developing an effective
pain management plan. (Lewis 279)
Find a way to find the pain tolerable
If you're taking a narcotic for arthritis pain, keep in mind that alcohol and drugs
containing acetaminophen or Tylenol don't mix. The combination can greatly
increase your risk of severe liver damage.
When you take narcotic drugs, you also run the risk of developing a tolerance to
the drugs. That means that you need more and more of the drugs in order to get
the same effect. You also run the risk of becoming dependent or even addicted.
Also, narcotic drugs can cause side effects constipation, drowsiness, dry mouth,
and difficulty urinating.
Tertiary intention: wound left open for several days, then wound edges are
approximated, ex: wounds that are contaminated and require observation for signs
and inflammation
Primary Prevention : conservation of quality/ ex: safety program, health
education, healthy diet
Secondary Prevention: treat & resolve, maintain highest level of quality of life/
Ex: HIV screening/ early detection, prevention of diability
Tertiary Prevention: maximize recovery, get most functioning back/promote self
care as much as possible, find community resources
Potter 1181
33. What lab data is indicative in pressure ulcers?
1186 potter protein, calories, nutrients, vitamin C, Zinc, Vitamin E & A
Calories: fuel for cell energy
Protein: fibroplasia, angiogenesis, collagen formation, and wound remodeling
Vitamin A: epithelialization, wound closure ,inflammatory response
34. What assessment data is needed for wound healing?
You need to assess pressure ulcers at regular intervals using systematic parameters
to evaluate wound healing, plan appropriate interventions, and evaluate progress.
Assessment includes depth of tissue involvement (staging), type and approximate
percentage of tissue in wound bed, wound dimensions, exudate description, and
condition of surrounding skin.
(Potter 1179)
You need to assess the type of tissue in the wound base; this information is used
to plan appropriate interventions. The assessment of tissue type includes the
amount (percentage) and appearance (color) of viable and nonviable tissue.
Granulation tissue is red, moist tissue composed of new blood vessels, the
presence of which indicates progression toward healing. Soft yellow or white
tissue is characteristic of slough (stringy substance attached to wound bed), and it
must be removed by a skilled clinician before the wound is able to heal. Black or
brown necrotic tissue is eschar, which also needs to be removed before healing
can proceed. (Potter 1180)
One method for assessment of a pressure ulcer is the use of a staging system.
Staging systems for pressure ulcers are based on describing the depth of tissue
destroyed. Accurate staging requires knowledge of the skin layers. A major
drawback of a staging system is that you cannot stage an ulcer covered with
necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The
necrotic tissue must be debrided or removed to expose the wound base to allow
for assessment. (Potter 1179)
35. Know the roles of drains in post-op patients
The health care provider inserts a drain into or near a surgical wound if there is a
large amount of drainage. Some drains are sutured in place. Exercise caution
when changing the dressing around drains that are not sutured in place to prevent
accidental removal. A Penrose drain lies under a dressing; at the time of
placement a pin or clip is placed through the drain to prevent it from slipping
farther into a wound (Fig. 48-10). It is usually the health care provider's
responsibility to pull or advance the drain as drainage decreases to permit healing
deep within the drain site
Promote healing, prevent infection
36. What things do you look for in skin integrity assessment?
The assessment of skin involves taking a history, conducting an examination of
the skin, and performing diagnostic testing.
o Inspection: Examination of the skin starts with inspection, which includes
color and presence of lesions. Normal adult skin is a consistent color,
ranging for individuals from light pink, to olive tones, to deep brown, with
relatively darker shades in areas of sun exposure.
o Palpitation: The skin should be smooth and intact with an even surface,
and minimal perspiration or oiliness except after exercise or heat
exposure. There should not be dryness, peeling, or cracking, although
there may be calluses over the hands, feet, elbows, and knees. Skin folds
should not be excessively moist or macerated. Turgor