• Absorption - movement of drug into the bloodstream
• Distribution - drug transport to sites of action
• Metabolism - chemical conversion of drug into metabolites that can be excreted
• Excretion - elimination of drug from the body

Absorption

• Movement of drug into the bloodstream
• Affected by:

• Route of Administration (local vs. systemic)
• Form (liquid, capsule, etc.)
• Drug Solubility (water or fat soluble)
• Blood Flow
• Body Surface (stomach has a lot of surface area)
• Food (food in stomach can slow absorption as long as 2 hours)
• pH

Distribution

• Drug transport to sites of action
• Factors affecting:

• Cardiovascular Health
• Local blood flow (at target area)
• Membrane permeability
  -Blood-Brain Barrier (water soluble medications can't get into brain)
• Protein-binding capacity (medication binds to protein albumin, only portion that is unbound is therapeutic)

• Biotransformation: chemical conversion of drug into metabolites that can be excreted (enzymes break down medication into metabolites, usually in liver)
• The slower the metabolism, the greater the risk of toxicity
• Factors affecting metabolism: liver function, other medications, health status
• First Pass Effect - medications that are deactivated in the liver before reaching systemic circulation; must be delivered parenterally to avoid GI tract

• Elimination of the drug
• Primarily through kidneys (BUN & creatinine clearance indicators of kidney function, hydration helps body eliminate drugs)
• Also through liver, lungs, bowel, sweat, mammary glands (constipation can increase medication effects)

• Route (oral vs. IV)
• Age, Weight, Gender (important in children, fat distribution)
• Environment (heat or cold)
• Nutritional/Hydration (fiber, constipation, diarrhea, when you ate)
• Pathological States (disease)
• Genetic Factors (racial groups - diuretics work better in African-Americans, opiods work differently in Asians)
• Psychological Factors (placebo effect, mind can heal the body)

• MAO Inhibitors and Tyramine (found in aged foods)
• Coumadin and Green Leafy Vegetables (Vitamin K - antidote to Coumadin)
• Milk (don't take w/tetracyline)
• Grapefruit (don't take w/calcium channel blockers)
• Potassium (w/Lasix encourage potassium rich foods; don't take w/ACE inhibitors)
• Full or Empty Stomach

• Physiologic Changes
• Mechanical/Cognitive
• Polypharmacy

■  Delayed but more complete
■  Gastric pH is less acidic because of decreased acid production in the stomach.
■  Decreased gastric pH delays absorption of medications absorbed in acid environments.
■  Because of decreased intestinal motility, drugs remain in the system longer, allowing for more absorption.

■  Low albumin level could create a problem with plasma protein binding.
■  Increased risk of toxicity due to multiorgan slowdown.
■  Altered because of less lean mass
■  Less body water, greater body fat
■  Dehydration, poor nutrition, and electrolyte imbalances decrease absorption.

■  Presence of diseases may decrease metabolism of the drug.
■  Changes due to age, higher blood concentration, and less excretion cause greater chances of toxicity.
■  Some drugs interfere with the liver’s ability to metabolize another drug.

■  Decreased glomerular filtration rate inhibits excretion from the kidneys.
■  Diminished renal function inhibits excretion, thereby increasing the risk of toxicity.

• Receptor Activity
  -Agonist (mimics receptor)
  -Antagonist (blocks receptor)
  -Partial Agonist
• Examples/Classifications: beta blockers, antihistamines, anticoagulant, corticosteroids, beta-adrenergic agonist, ACE inhibitors

• Oral
• Sublingual
• Buccal
• Topical
• Enteral (in stomach but not in mouth)
• Parenteral (outside of the digestive system)

• liquids, elixirs, syrups
• suspension solutions
• powders
• capsules
• tablets
• coated tablets
• enteric coated tablets
• sustained or extended release

• Intradermal
• Subdermal
• Intramuscular
• Intravenous

• Medication Reconciliation
• Take vitals, check labs (don't delegate)
• Know and use your resources (drug book, pharmacist)
• Contact the physician for clarification, concerns, questions
• Know what can be crushed, opened, stored
• Watch for drugs with similar names
• Watch for multiple units of same medications (eg. shouldn't need to give more than 4 pills)
• Teach patient about meds
• Don't administer meds you did not prepare
• Dont give unlabeled meds

• Watch for high alert medications
• Identify patient using two identifiers (name, DOB, check wristband, medical record number)
• Seven Rights
• Three Checks
• Check for allergies
• Check for swallowing issues
• Honor patient's concerns
• Document!
• Don't use abbreviations

TRAMPED

• Right Time
• Right Route
• Right Amount (dose)
• Right Medication
• Right Patient
• Right Effect
• Right Documentation

Do TRAMP and compare against MAR

1 - when you retrieve and prepare medications

2 - after you prepare medications as you are putting bottles/packages back in drawer

3 - at the bedside before you administer medications

• Check the patient
• Consult a drug reference source for side effects to the medication
• Identify type of error
• Notify nurse manager or supervisor
• Notify physician and obtain orders
• Incident Report
• Full disclosure to patient

Unintended, often predictable, physiological effects that are usually well tolerated by patients. They occur at the usual prescribed dose and may be immediate (e.g., dizziness) or delayed (e.g., constipation).

Life-threatening allergic reaction that occurs immediately after administration. The allergic response produces sudden constriction of bronchioles, edema of the larynx and pharynx, severe shortness of breath, wheezing, and severe hypotension.

An unexpected, abnormal, or peculiar response to a medication. May take the form of extreme sensitivity to a medication, lack of response, or a paradoxical (opposite of expected) response, such as agitation in response to a sedative.

The increased response to repeated doses of a drug that occurs when the rate of administration is greater than the rate of metabolism and excretion.

• meaning and purpose, gratitude
• feelings of faith, hope, peacefulness
• ability to love, forgive, pray 
• creative expression (song, music, art, writing)
• appreciating a dimension beyond oneself
• intraction with othrs to share thought, feelings, and beliefs
• feel respected and valued
• prepare for and accept death

• Spiritual/Religious belief system
• Personal spirituality
• Integration within a spiritual community
• Ritualized practices and restrictions
• Implications for medical care
• Terminal events planning

• Withdrawal
• Disorientation
• Blood pressure & puls
• Body temperature
• Diaphoresis
• Skin color
• Changes in breathing
• (hearing is one of last senses to go)

• any information told to you by the client (family or caregiver)
• often documented as direct quotes
• includes thoughts, feelings, beliefs, and sensations
• may be used to clarify objective data

• Gathred through a physical assessment, laboratory data or diagnostic tests
• Can be measured or observed by healthcare provider
• May be used to validate subjective data

• Subject: usually the patient
• Action Verb: describes actions that you can see, hear, smell, feel, or measure
• Performance Criteria: standards for evaluating the client's performance
• Target Time: includes date and time
• Special Conditions: amount of assistance or resources

• Right Task
• Right Circumstance
• Right Person
• Right Communication
• Right Supervision
• (cannot delegate tasks tat involve the nursing process, education)

• Used for energy
• Carbohydrates
• Proteins
• Fats (Lipids)

• Vitamins
  -Fat Soluble
  -Water Soluble
• Minerals
  -Major Minerals
  -Trace Minerals
• Water 

• DRI for is 40% - 65%
• Carbohydrate contains 4 kcal/gram
• Functions include:
  -provide energy for metabolism
  -fuels energy for muscle and organ function
  -sole energy source for brain
  -helps regulate protein and fat metabolism 

• Monosaccharides
  -Glucose (blood sugar)
  -Fructose
• Disaccharides
  -Sucrose (table sugar)
  -Lactose (milk sugar) 

• Polysaccharides
• Starch
• Glycogen (stored in liver, muscles)
• Fiber (undigestible, body can't break down)
  -Soluble (lowers blood sugar, lowers cholesterol)
  -Insoluble (aids in digestion)
  (whole grains take longer to break down, 1/2 of starches should be whole grains) 

• Tissue building - Protein is the structural material of every cell in the body.
• Metabolism (Enzymes)
• Immune system (Lymphocytes, antibodies)
• Fluid Balance - Because they attract water, proteins in cells and the bloodstream help regulate fluid balance.
• Acid-Base Balance - Blood proteins function as buffers, helping to regulate acid- base balance.
• Secondary Energy Source - proteins can be broken down to provide energy when stores of the other energy nutrients are inadequate

• Amino acids are building blocks of proteins
• 20 amino acids
• Essential Amino Acids - must come from diet, body cannot manufacture
• Nonessential Amino Acids - easily synthesized in body
• Complete Proteins - contain all the essential amino acids, from animal products
• Incomplete Proteins - from nuts, grains, legumes - do not contain all the essential amino acids in one food, but can combine foods to provide all the essential amino acids (beans & rice, peanut butter on whole wheat bread)

• Nitrogen balance occurs when intake and output of nitrogen are equal.
• Positive nitrogen balance exists when nitrogen intake exceeds output, making a pool of amino acids available for growth, pregnancy, and tissue maintenance and repair.
• Negative nitrogen balance exists when nitrogen intake is lower than nitrogen loss. This occurs in illness, injury ( e. g., burns), and malnutrition.

• 4 kcal/gram
• DRI for adults is 10% - 35% of calories

• concentrated form of energy 9 kcal/gram
• supplies tissue needs (hormones, cell membrane, protection, insulation, covers nerve fibers, absorption of fat soluble vitamins)
• enhance flavor, texture, and satiety
• diet high in fat is linked to cardiovascular disease, hypertension, and diabetes mellitus
• no more than 20% - 35% of calories should come from fat (10% or less from saturated fat)

Polyunsaturated fatty acids contain two or more unfilled spots for hydrogen. At the spot( s) where the molecule does not have a hydrogen attached, it becomes kinked and does not pack together. This is why these fats are liquid at room temperature.

(found in plant oils)

• A waxlike substance needed for the formation of cell membranes, vitamin D, estrogen, and testosterone. Cholesterol is synthesized in the liver, and it is also found in animal foods.
• Very Low Density Lipoprotein (VLDL) - carries triglycerides to tissue
• Low Density Lipoprotein (LDL) - "bad" cholesterol
• High Density Lipoprotein (HDL) - "good" cholesterol, removes cholesterol and returns to liver

-the body cannot manufacture it

-its absence creates a deficiency disease

-linoleic acid (omega- 6)

-alpha- linolenic acid (omega- 3)

-help protect against heart disease

-Omega-6 fatty acid is found mainly in polyunsaturated vegetable oils, nuts, and seeds.

-Omega-3 fatty acid can be obtained in adequate amounts by eating fatty fish (e.g., tuna, shellfish) twice a week

• do not provide energy
• important for metabolism, enzyme reaction, break down nutrients
• some are water soluble, some are fat soluble

• 13 essential vitamins, build and maintain tissues
• Water Soluble
  -excreted in urine, must have every day
  -Vitamin C and B Complex
• Fat Soluble
  -stored in fat, don't need every day
  -since stored, levels can become toxic
  -Vitamins A, D, E, K 

• Pellagra: A disease caused by a deficiency of niacin and protein in the diet and characterized by skin eruptions, digestive and nervous system distrubances, and eventual mental deterioration
• Beriberi: A disease caused by a deficiency a thiamine, endemic in eastern and southern Asia and characterized by neurological symptoms, cardiovascular abnormalities, and edema
• Scruvy: A disease that occurs when you have a severe lack of vitamin C (ascorbic acid) in your diet. Causes general weakness, anemia, gum disease, and skin hemorrhages
• Rickets: A softening of bones in chidren due to deficiency or impiared metabolism of vitamn D, phosphorus or calcium, potentially leading to fractures and deformity. Rickets is among the most frequent childhood diseases in many developing countries
• B12 and Pernicious Anemia
• Folic Acid and Megaloblastic Anemia

Function: Night and color vision, Cellular growth and maturity, Maintaining healthy skin and mucous membranes, Growth of skeletal and soft tissues, Reproduction

Sources: Fish liver oil, liver, butter, cream, egg yolk, yellow fruit, green leafy vegetables, fortified milk

Effects of Deficiency: Night blindness, xerosis, xerophthalmia, keratomalacia, skin lesions

Function: Collagen synthesis, “ Cementing” substance for capillary walls, Antioxidant, Iron absorption, Immune function

Sources: Citrus fruits, tomatoes, potatoes, green vegetables, cauliflower

Effects of Deficiency: Anemia, tissue bleeding, easy bone fracture, gingivitis, petechiae, poor wound healing, joint pain, scurvy

Function: Regulates blood calcium levels. Regulates rate of deposit and resorption of calcium in bone.

Sources: Fish liver oil, fish, fortified milk, sunlight exposure

Effects of Deficiency: Bone and muscle pain, weakness, softening of bone, fractures, rickets

• Function: Synthesis of clotting factors, Bone development
• Sources: Green leafy vegetables, liver (Intestinal bacteria synthesize a form of vitamin K, so deficiency is unlikely.)
• Effects of Deficiency: Increased bleeding

• Function: Cellular metabolism (producing energy from glucose and storing energy as fat), Nervous system function, Gastrointestinal system function, Cardiovascular system function
• Sources: Whole grain, enriched cereal, beef, pork,liver, peas, beans, nuts
• Effects of Deficiency: Peripheral neuritis, loss of muscle strength, depression, memory loss, anorexia, constipation, dyspnea, decreased alertness and reflexes, fatigue, irritability, beriberi

• Function: Cellular metabolism to produce energy
• Sources: Enriched breads and cereals, chicken, tuna, liver, peanuts, dairy products
• Effects of Deficiency: Weakness, poor appetite, indigestion, dermatitis, diarrhea, headache, dizziness, insomnia. Chronic: CNS damage (confusion, neuritis, dementia), pellagra

• Function: Metabolic reactions, Maintain myelin sheath, Hemoglobin synthesis
• Sources: Dairy products, meat, poultry, fish, liver, milk, cheese, eggs
• Effects of Deficiency: Pernicious anemia, irreversible nerve damage, memory loss, dementia

• Function: Cellular metabolism, Neurotransmitter synthesis, Cell division, DNA synthesis, Hemoglobin formation
• Sources: Green leafy vegetables, asparagus, liver, yeast, eggs, beans, fruits, enriched cereals
• Effects of Deficiency: Megaloblastic anemia, neural tube defects

• Function: Synthesis of hemoglobin, general metabolism (e.g.,of glucose), antibody production, drug detoxification in the liver
• Sources: Meats, eggs, spinach, seafood, broccoli, peas, bran, enriched breads, fortified cereals
• Effects of Deficiency: Small, pale RBCs, anemia

• Function: Increases resistance to dental caries
• Sources: Fluorinated water, toothpaste, dental treatment, seaweed, fish, tea
• Effects of Deficiency: Increased dental caries

• Function: Cofactor for many enzymes involved in growth, insulin storage immunity, alcohol metabolism, sexual development and reproduction
• Sources: Primarily meats and seafood; also legumes, peas, and whole grains
• Effects of Deficiency: Skin rash, diarrhea, decreased appetite, hair loss, poor growth and development, poor wound healing

• Trace minerals are essential, but in a lower concentration.
• copper, fluoride, iodine, iron, zinc

• Major minerals (macrominerals) are minerals that the body needs in amounts of 100 mg/ day or greater.
• calcium, magnesium, phosphorus, potassium, sodium

• Metabolism
  -Basal Metabolic Rate (BMR) or Resting Energy Expenditure (REE) - what is used at rest, 66% of total energy requirements are used for BMR- lean body tissue burns more at rest that fat - proteins and carbs take more energy to burn 
  -Thermic Effect of Food - The heat produced by the body after a meal
  -Physical Activity - few people burn more due to physical activity than from BMR
• A person's total energy requirement is the number of kcalories necessary to replace those used for basic metabolism plus those used for physical activity 

• Energy expenditure decreases during food restriction or starvation and calories are burned more efficiently (when you cut calories, metabolism slows down, also slows down if you are sedentary)
• BMR or REE affected by body composition, growth periods, body temperature, environmental temperature, disease processes and prolonged exercise (when someone has a fever, must supply more nutrients - "feed a fever")

• a person can be malnourished with regards to certain nutrients without being underweight
• protein-calorie malnutrition leads to muscle and fat wasting, lethargy, weight loss, weakened immunity, risk for infection, changes in mental status, edema, pressure ulcers and delayed wound healing
• The prevalence of malnutrition in hospitalized patients reported as between 37% - 62% depending on criteria used

• sensory deficit
• gastrointestinal
• psychological or social isolation
• financial barriers
• chronic illnesses
• increased fat deposits/decreased muscle mass

• Anthropometric Assessment (measurement of the body)
• Biochemical Data
• Clinical
• Dietary Data

• Height and Weight
• Calculate BMI (Body Mass Index)
• <18.5 = underweight
• 18.5-24.9 = normal
• ≥30 = obesity
• IBW (Ideal Body Weight)
• Percentage Weight Change Calculation
• weigh at same time w/same clothing on same scale
• Daily fluctuations of ±2 lbs reflect water weight
• Midarm circumference and triceps or scapular skinfold, abdominal girth, waist to hip ratio

• RBC count
• Male: 4.7 to 6.1 million cells/mcL
• Female: 4.2 to 5.4 million cells/mcL
• WBC count
• 4,500 to 10,000 cells/mcL
• Hematocrit
• Male: 40.7 to 50.3%
• Female: 36.1 to 44.3%
• Hemoglobin
• Male: 13.8 to 17.2 gm/dL
• Female: 12.1 to 15.1 gm/dL
• Platelets
• 150,000 - 450,000
• MCV, MCH, MCHC, RDW

• Glucose: 64 to 128 mg/dL
• BUN (blood urea nitrogen): 7 to 20 mg/dL
• ↑BUN may = dehydration (encourage fluids)
• ↑BUN + ↑Creatinine may = kidney dysfunction
• Creatinine: 0.8 to 1.4 mg/dL
• Calcium - serum: 8.5 to 10.9 mg/dL
• Chloride: 101 to 111 mmol/L
• Sodium: 135 to 145 mEq/L
• Potassium: 3.5 to 5.0 mEq/L
• Phosphorus - serum: 2.4 to 4.1 mg/dL
• Albumin: 3.9 to 5.0 g/dL
• protein in the blood

• Total cholesterol: 100 to 240 mg/dL
• CO2 (carbon dioxide): 20 to 29 mmol/L
• Alkaline phosphatase
• ALT (alanine transaminase)
• AST (aspartate aminotransferase): 10 to 34 IU/L
• Direct bilirubin: 0.0 to 0.3 mg/dL
• Total bilirubin: 0.2 to 1.9 mg/dL
• (these are indicators of liver function)
• Uric acid: 4.1 to 8.8 mg/dL
• if uric acid is high, may indicate gout

• LDL: 60 to 130 mg/dL
• HDL: greater than 40 mg/dL
• Total cholesterol: less than 200 mg/dL
• Triglycerides: 10 to 150 mg/dL
• VLDL: 2 to 38 mg/dL
• (lipid panels are often done while fasting)

• Vitamin D (important for calcium absorption)
• Vitamin B12
• Vitamin A: 50 to 200 mg/dl
• Prealbumin: 12-42 mg/dl (fluctuates on a daily basis, most accurate indicator of malnutrition)
• Thyroid Function (metabolism)
• Finger Stick Blood Sugar (FSBS): 70-110 mg/dl

• Regular
• Advance as Tolerated
• NPO (nothing by mouth)
• Ice Chips
• Clear Liquids
• Full Liquids
• Dysphagia Diets: Mechanical Soft, Pureed, Nectar or Honey Thickened fluids
• Low Na++, Low Fat, ADA
• Lactose Intolerant, Food Allergies

• Homeostasis, in terms of energy balance, occurs when the number of kilocalories eaten equals the number used to produce energy
• To lose 1 pound of body fat/week, an adult must have an energy deficit of 3800 calories (500 calories/day)
• The combination of balanced diet and regular physical activity have a stronger effect on balance than either strategy alone

• Etiology or Intervention
• Vegan (plant products only), Lacto- (dairy products), Lacto-Ovo (dairy and eggs)
• Monitor protein, B12, D, Calcium, Iron, and Zinc (B12 is only found in animal products, may need supplementation)
• Omega 3 fatty acids found in fatty fish
• Teach complementary proteins: grains, nuts, seeds and legumes and beans can be combined

• Build lean muscle mass by consuming protein and exercising
• Supplemental Vitamin D, B12, and Calcium
• Water!
• Manage Constipation (increase fiber)
• Salt restriction: use substitutes (be careful, most salt substitutes use potassium chloride) or herbs and spices
• Provide nutrient dense foods (Older adults need fewer calories but the same amount of nutrition)
• (Omega 3 may prevent dementia)

• Offer frequent small meals
• Limit fluids with meals
• Keep environment neat and clean and free from unpleasant sights/odors
• Colorful, varying textures and flavors may help with gustatory deficit
• Encourage socializing at mealtime
• Make sure patient is comfortable/pain free
• Encourage family to bring in foods that the patient likes

• Toileting and Oral Hygeine before meals
• Encourage socialization/out of bed
• Open food containers and orient them to their tray
• If they need help with feeding, give them time to chew and swallow
• Record amout of food and fluid
• Know interventions for patients with impaired swallowing

The nurse is completing a nutritional assessment of her client. He notes that the client's diet intake is 40% Carbohydrate, 20% Protein and 40% Fat. The nurse would recommend that the client:

a-increase carbohydrate intake and lower fat intake

b-decrease protein intake and fat intake

c-increase fat and protein intake

d-increase carbohydrate and protein intake

An elderly patient has a decubitis ulcer with drainage, mobility impairment and a large amount of interstitial fluid. She has dysphagia and consumes few than 500 calories per day. She is in:

a-positive nitrogen balance

b-anabolism

c-negative nitrogen balance

d-antrhopometric crisis

Women's bodies normally contain more _______ and less _________ than men's bodies.

a-carbohydrate, protein

b-fat, protein

c-protein, ash

d-water, fat

Which of the following techniques is used to estimate the body's protein stores?

a-estimating body frame size

b-measuring midarm circumference

c-calculating the body mass index

d-determining triceps skinfolds

1. balance calories
2. enjoy your food but eat less
3. avoid oversized portions
4. eat more vegetables, fruits, whole grains, fat-free or 1% fat dairy products
5. make half your plate fruits and vegetables
6. switch to fat-free or low-fat milk
7. make half your grains whole grains
8. cut back on food high in solid fats, sugars, salt
9. compare sodium in foods
10. drink water instead of sugary drinks

which patient is most likely experienceing a positive nitrogen balance? a patient admitted:

a-with third-degree burns of his legs

b-in preterm labor

c-from a nursing home who has been refusing to eat

d-with acute pancreatitis

A patient has anemia. An appropriate goal would be that the patient will increase his intake of which nutrient?

a-calcium

b-magnesium

c-potassium

d-iron

Which laboratory result most accurately refects a patient's nutritional status?

a-albumin

b-prealbumin

c-transferring

d-hemoglobin

Patients may be deficient in which vitamin during the winter months?

a-vitamin A

b-vitamin E

c-vitamin D

d-vitamin K

A nurse is planning dietary teaching for a client who is a vegetarian. Which of the following nutrients is likely deficient in the client's diet? Select all that apply.

a-protein

b-carbohydrates

c-vitamin B12

d-magnesium

e-potassium

a-protein

c-vitamin B12

to lose 2 pounds of body fat per week, an individual must eat ___ fewer kilocalories each day for 7 days without a change in energy expenditure

a-1000

b-1500

c-2000

d-2500

What percentage range of an adult's kilocalories is recommended as the maximum to be obtained from fat?

a-20 to 30

b-20 to 35

c-30

d-more than 50

Fill in the appropriate calories per gram for the following macronutrients.

Protein:

Carbohydrates:

Fats (Lipids):

Protein: 4 

Carbohydrates: 4

Fats (Lipids): 9

• xerosis (red, itching, fissures)
• loss of subcutaneous fat
• loss of elasticity
• regeneration time
• chronic disease
• increased risk for breakdown
• increased healing time

• mobility
• nutrition
• hydration/fluid balance
• sensation
• circulation
• medications
• moisture (maceration, excoriation, incontinence)
• illness/fever/infection
• temperature
• lifestyle (smoking, diet, exercise, piercings-tattoos-tanning, hygeine)

of the following factors, which would put a client at greatest risk for impaired skin integrity?

a-the medication digoxin
b-moisture
c-decreased sensation
d-dehydration

• palpable, non-palpable, fluid filled
• above the skin, below the skin
• by size and shape
• macule: less than 1 cm, solely a change in color
• papule: solid elevated, circumscribed, less than 1 cm (eg. wart)
• nodule: larger than 1 cm
• pustule: filled with pus
• by configuration
• annular: circular - begins in center and spreads to periphery (eg. ringworm)
• confluent: lesions run together (eg. hives)
• linear: a scratch, streak or stripe

• Intentional vs. unintentional
• Based on skin integrity
• closed (intact) - contusion, hematoma, abscess
• open - abrasions, incisions, lacerations
• Level of Contamination
• clean - surgical incision
• clean contaminated - surgal incision that may become infected - respiratory, digestive
• contaminated - break in asepsis
• colonized  - chronic wounds have bacteria, but not doing any harm
• infected - bacteria overwhelm and do harm - releasing toxins, invading neighboring tissues, can go systemic

• Acute - short duration, expected to heal without complications
• Chronic
• Pressure ulcers - caused by pressure, often over bony prominences
• Arterial ulcers - inadequate circulation of oxygenation blood to tissue causing tissue ischemia and damage
• Venous stasis ulcer - incompetent venous valves (blood can't get back to heart and lungs) resulting in venous pooling and edema
• Diabetic ulcers

• superficial - only the epidermal layer of the skin
• partial thickness - extend through the epidermis but not through the dermis
• full thickness - extend into the subcutaneous tissue and beyond
• penetrating - full thickness wound that involves internal organs

• Inflammatory/Defensive Phase
• Hemostasis
• Inflammation and phagocytosis
• Reconstructive/Proliferative Phase
• Fibroblasts and collagen
• Granulation tissue
• Maturation Phase/Epithialization
• Remodeling
• Scarring

• Hemorrhage
• Internal (hematoma)
• External
• Infection
• Dehiscence
• Evisceration
• Fistulas

• Caused by unrelieved pressure that compromises blood flow to the area resulting in ischemia
• Most commonly occur over bony prominences
• Also caused by friction and shearing and moisture
• 15% of hospital patients, 10% of home-care patients and 20% of long-term care patients have pressure ulcers
• Risk assessment and prevention are key interventions

• color
• integrity (WNL: skin is warm, dry, and intact)
• texture
• lesions
• turgor/moisture
• hair distribution
• edema
• dressing

• temperature
• tenderness
• crepitus
• edema

laboratory and diagnostic tests:

• Complete Blood Count (CBCs)
• Erthrocyte Sedimentation Rate (ESR)
• C-Reactive Protein (CRP)
• Comprehensive Metabolic Panel (albumin, total protein, kidney function, glucose)
• Wound and Blood Cultures, Biopsy
• Coagulation Studies (PTT, PT/INR)

Braden scale:

• sensory perception
• moisture (too much or too little)
• activity
• mobility
• nutrition
• friction and shear

• arterial ulcers
• venous stasis ulcers
• diabetic ulcers
• pressure ulcers
• hyperemia
• redness that does not blanch is the first sign of skin breakdown
• with dark skin may present as discoloration or firmness

• acute wounds
• local infection: purulent or foul smelling drainage, erythema, edema, warmth, increasing pain
• systemic: fever, chills, general malaise, ^WBCs, ^HR and RR
• Chronic Wounds: foul odor, change in the color of the wound bed, new tunneling, absence of granulation tissue, or it becomes friable (bleeds easily)

■ Monitor any reddened areas closely.
■ Turn every 1– 2 hours, as appropriate.
■ Turn with care (e.g., avoid shearing) to prevent injury to fragile skin.
■ Post a turning schedule at the bedside, as appropriate.
■ Avoid massaging over bony prominences.
■ Utilize specialty beds and mattresses, as appropriate.
■ Avoid use of “donut” type devices in the sacral area.

Other Interventions
■ Nutrition Management 
■ Positioning
■ Pressure Management
■ Skin Surveillance

■ Monitor characteristics of the wound, including drainage, color, size, and odor.
■ Cleanse with normal saline or a nontoxic cleanser, as appropriate.
■ Apply an appropriate ointment to the skin/lesion, as appropriate.

Other Interventions
■ Pruritus
■ Management
■ Skin Surveillance
■ Wound Irrigation

■ Débride the ulcer, as needed.
■ Cleanse the ulcer with the appropriate nontoxic solution, working in a circular motion from the center.
■ Cleanse the skin around the ulcer with mild soap and water.
■ Monitor for infection in the wound.
■ Position every 1– 2 hours to avoid prolonged pressure.

Other Interventions
■ Wound Care
■ Pressure Management
■ Infection Protection
■ Medication
■ Administration

• Assessment
• Bony prominences
• Skin folds
• Braden Scale
• Meticulous Skin Care
• Do not massage over bony prominences
• Manage Moisture
• Keep linens dry and wrinkle free

• Frequent position changes
• #1 way to prevent pressure ulcers
• Avoid friction and shearing
• Use Draw Sheet
• Use of therapeutic mattresses, cushions, and pillows
• Adquate Nutrition
• Vitamin C, Zinc, Protein, and Fluids
• Patient and Family Teaching

• Relieve Pressure!!!
• Promote Granulation
• Remove debris and necrosis
• Absorb excess exudate
• Keep moist
• Debride if necessary
• Keep surrounding skin dry
• Prevent or Treat Infection
• Manage Edema
• Promote Circulation

• Sharp: use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue
• Mechanical: may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage
• Enzymatic: the application of a topical enzymatic agent to the wound
• Autolysis: use of an occlusive moisture-retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue

• Protect from contamination and heat loss
• Aid hemostasis
• Absorb drainage
• Debride the wound
• Splint the wound site
• Prevent drying of the wound bed
• Keep the surrounding tissue dry and intact
• Provide comfort to the patient

• Removes exudate, slough, foreign material and microorganisms
• Promotes tissue healing
• Be careful not to damage granulating tissue
• Normal Saline is best (irrigation or cleansing)
• Keep periwound area clean
• Use principles of clean technique or sterility

• Determine whether there are any contraindications to treatment (impaired circulation, bleeding, wound complications, impaired sensation, inability to tolerate treatment)
• Moist Heat - irrigations, compress, hot soaks, sitz bath - reapply and change water frequently to maintain constant temperature
• Dry Heat - electric heating pads, disposable hot packs, hot water bags
• Never place heat source directly on skin
• Apply heat intermittently, leave on for no more than 15-20 minutes at a time (helps prevent tissue injury, helps prevents rebound)

• Determine whether there are any contraindications to treatment (impaired circulation, bleeding, wound complications, impaired sensation, inability to tolerate treatment)
• cooling baths, cold compress, ice collars, ice bags, commercially prepared ice packs, aquapads
• avoid direct contact with skin
• apply cold intermittently, no more than 15-20 minutes at a time to help prevent tissue injury and prevent rebound

• Stage I - Non-blanchable erythema of intact skin, in individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators
• Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater
• Stage III - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining
• Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with Stage IV ulcers
• Non-stageable - a pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible: this means that wounds covered with eschar and/or slough cannout be staged, and should be documented as non-observable or non-stageable
• Deep tissue injury - pressure-related deep tissue injury under intact skin or deep tissue injury under intact skin

• document using the "clock system" with head=12:00 (example: 2 cm undermining at 3 o'clock)
• tunneling - course or pathway that can extend in any direction from the wound, results in dead space
• undermining - tissue destruction underlying intact skin along wound margins
• sinus tract - a drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface

• type:
• sanguineous - thin, bright red
• serosanguineous - thin, watery, pale red to pink
• serous - thin, watery, clear
• purulent - thick or thin, opaque tan to yellow
• foul purulent - thick opaque yellow to green with offensive odor
• amount
• none - wound tissues dry
• scant - wound tissues moist, no measurable drainage
• small - wound tissues very moist, drainage <25% dressing
• moderate - wound tissues wet, drainage involves 25 - 75% dressing
• large - wound tissues filled with fluid - involves >75% dressing
• odor
• describe presence or absence of odor - strong, foul, pungent, fecal, musty, sweet

• adherence of the tissue
• nonadherent - easily separated froum wound base
• loosely adherent - pulls away from wound, but attached to wound base
• firmly adherent - does not pull away from wound
• amount - describe in % (example: 50% wound bed covered with soft yellow slough, 50% beefy red granulation tissue), may also use "clock system" in describing location of necrotic tissue in wound bed
• tissue types
• slough - usually lighter in color, thinner and stringy in consistency, color - can be yellow, gray, white, green, brown
• eschar - usually darker in color, thicker and hard consistency black or brown in color
• granulation tissue - it is usually beefy-red, granular, bubbly in appearance; should be differentiated from a smooth red wound bed; color of tissue - red, pink, pale pink or full dusky red
• epithelialization - can appear as deep pink, then progress to peraly pink/light purple from edges in full thickness wound or may form islands in the wound base with superficial wounds
• foreign bodies

• definition - defined or undefined edges
• attachment - attached or unattached edges
• rolled under (epibole) - macerated - fibrotic - callused
• border shape

• occiput
• acromion process
• scapula
• olecranon
• sacrum
• ischial tuberosity
• lateral knee
• metatarsals
• calcaneus
• lateral malleolus
• medial malleolus 
• trochanter
• coccyx
• lumbar vertebrae
• thoracic vertebrae

• Is the freedom and independence in purposeful movement
• Refers to adapting to and having self-awareness of the environment
• Depends on the successful interaction between the Musculoskeletal System and the Nervous System

• Promote safety when mobility is impaired
• Encourage increased mobility
• Recognize and treat risk factors associated with immobility
• Promote independence in performing activities of daily living

• Lean muscle mass is replaced by fat deposits
• Impaired Balance (wider stance, cognition)
• Altered Calcium Metabolism (fragility of bones, changes in height and posture)
• Degenerative Alterations in Joints (limited range of motion - pain)

• Atrophy
• Joint Stiffness/Contractures
• Calcium Loss/Renal Calculi/Fracture
• Pooling of Secretions/Infection
• Increase Workload on the Heart/Venous Stasis and Edema
• Risk for Clotting/DVT
• Orthostatic Hypotension

• Integument (skin breakdown)
• Gastrointestinal (constipation, malnutrition)
• Genitourinary (urinary tract infection)
• Psychological (isolation, dependence, loss of dignity)

• Decreased risk of cardiovascular disease
• Increased muscle tone and flexibility
• In some cases Resting Energy Expenditure (REE) increases up for to 48 hours after exercise
• Decreased risk of diseases associated with obesity
• Possible decrease in appetite
• Beta-endorphin released for improved mood

• Isotonic (moving joint during muscle contraction-weight training with free weights)
• Isometric (muscle contraction without movement-low risk for injury, can be used when on bedrest)
• Isokinetic (machines that control resistance and move joints through full ROM)
• Aerobic (acquires energy from metabolic pathways that use oxygen-jogging, biking, brisk walking, swimming)
• Anaerobic (when amount of oxygen taken in does not meet the needs required by the body)

• Reposition patient every 2 hours (Log Rolling if necessary)
• Position for optimal lung expansion
• Teach Deep Breathing and Coughing
• Skin Assessment and Care
• Use of pillows, air mattress, trochanter rolls
• Use of pull sheets
• Use of mechanical lifts and transfer boards

• Use a gait belt when ambulating
• Use assistive devices when transferring
• Ask for help from staff
• Refer to physical therapy as ordered
• Know proper body mechanics

• Stand with body in alignment and erect posture
• Use wide base of support
• Keep items close to your body
• Avoid bending and twisting
• Use the muscles of your legs as the power for lifting
• Face the direction of movement
• Raise or lower height of bed to maintain good posture

• Respiratory Rate & Depth
• Lung Compliance
• Lung Elasticity (elastic recoil)
• Airway Resistance

• Calcification of costal cartilage leads to diminshed expansion and recoil
• Diminished cough reflex leading to difficulty expelling mucus or foreign material
• Diminished ability to increase ventilation when oxygen demand increases
• Fewer Cilia
• Declining immune response
• GERD (reflux)

• Heart muscle loses contractile strength
• Heart valves become thicker and more rigid
• Increased vascular resistance
• Dysrhythmias

• Respiratory Infections
  -upper tract (cold, flu)
  -lower tract (bronchitis, pneumonia, TB)
• Pulmonary System Abnormalities
  -structural
  -airway inflammation and obstruction
  -alveolar-capillary membrane disorders
  -atelectasis (collapsed alveoli) 

• Pulmonary Circulation Abnormalities
  -Thrombus (blood clot)/Embolus (moving blood clot - serious)
  -Edema
• Clotting Disorders 
• Central Nervous System Abnormalities
• Neuromuscular Abnormalities

• Hypertension
• Congestive Heart Failure
• Atherosclerosis
• Peripheral Vascular Disease
• Anemia
• Dysrhythmias
  -Artieral Fibrilation (A-fib)
  -Heart Block 

• Chronic Obstructive Pulmonary Disease (COPD)
  -Bronchitis
  -Emphysema
• Asthma
• Pneumonia 

• Hypoventilation
• Dyspnea or Shortness of Breath
• Increased Risk for Infection (stasis of secretions)
• Sleep Apnea - upper airway constriction when lying down
• Increased risk for Artherosclerosis and Hypertension

• Oxygen Saturation (SaO₂)
• Measures light absorption by hemoglobin in the circulaitng red blood cells and calculates percentage of oxygenated hemoglobin.
• Should be >94%
• Monitoring can be intermittent or continuous
• Usually placed on finger, but can also use toe, ear lobe
• Movement, light, poor circulation and fingernail polish can affect

• TPR, B/P (vitals)
• Apical Pulse (rate-regular or irregular, rhythm, murmurs)
• Pulse Deficit (difference between apical and radial pulses)
• Pallor/Cyanosis

• Skin Integrity
• Color
• Temperature
• Hair Distribution (no hair on limbs may mean poor circulation - not enough oxygen getting to cells so hair can grow)
• Peripheral Pulses
• Edema (if with no pulse in extremity, may mean clot)
• Capillary Refill (if more than 3 seconds, problem w/circulation)

• Shortness of Breath
• Anxiety
• Tachypnea
• Tachycardia
• Pallor to cyanosis
• Adventitious breath sounds
• Confusion

• RBC count (varies with altitude)
  -Male: 4.7 to 6.1 million cells/mcL
  -Female: 4.2 to 5.4 million cells/mcL
• WBC count
  -4,500 to 10,000 cells/mcL
  (higher may mean infection, lower may mean immunocompromised)
• Platelets: 150,000 - 400,000/ mm3 

• Hemoglobin (part of RBC that carries oxygen - low may indicate anemia)
  (varies with altitude)
  -Male: 13.8 - 17.2 gm/dL
  -Female: 12.1 - 15.1 gm/dL 

• Pulmonary Function Test
• Spirometry (measures inhalation)
• Peak Flow Monitoring (measures exhalation)
• Radiologic Studies (chest x-ray, CAT scan)
• Doppler studies
• EKG (electrical activity of heart)
• Echocardiogram (ultrasound of the heart)

• A disorder usually associated with long-term smoking
• Abnormal inflammatory response of the lungs to noxious particles or gases
• Airflow limitation that is not fully reversible
• Bronchitis (chronic): chronic productive cough
• Empysema: permanent enlargement of the air spaces and destruction of lung walls. Increase residual volume/decreased chest compliance and elastic recoil

• Decreased Cardiac Output r/t pump failure a.e.b. HR 110 O₂ Sat 88% on room air, cyanotic nail beds
• Risk for Activity Intolerance r/t cardiac insufficiency and pulmonary congestion as evidenced by rales ausculated in bilateral lower lungs

• Pneumonia is an acute inflammation of the lung tissue caused by a microbial organism
• Ineffective airway clearance r/t retained secretions and excessive mucus as evidenced by ineffective cough, adventitious breath sounds, dyspnea

• An abnormally low level of red blood cells, hemoglobin, or both
• Causes of anemia include blood loss, abnormal destruction of red blood cells, and deficiencies of red blood cell production (iron deficiency, vitamin B12 deficiency, folic acid deficiency, aplastic anemia, and anemias of chronic disease and chemotherapy)

• Angina (chest pain)
• Fatigue/Weakness/General Malaise
• Restlessness/Anxiety
• Dyspnea
• Nail beds, skin, mucous membranes and conjunctiva become pale
• Tachycardia
• Cold intolerance

• Continuous Positive Airway Pressure
• Pressure keeps airways open during inspiration when muscles collapse
• Used most often with sleep apnea (also with premature infants)
• BiPAP uses two levels of pressure, one for inspiration and another for expiration

• Measures inhalations
• Useful to teach patients to deep breath and cough
• Used for patients who are at high risk for atelectasis or pneumonia