Docsity
Log inSign up
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources
Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study
Go to the blog

Functional Health Assessment & Tissue Integrity: A Guide for Healthcare Professionals, Study notes of Nursing

Ridgewater CollegeNursing

A comprehensive overview of functional health assessment and tissue integrity, covering key concepts, assessment techniques, and evidence-based care practices. It explores the factors influencing functional health, describes components of a functional assessment, and explains physiological and hygiene practices across the lifespan. The document also delves into the assessment and management of pressure ulcers, including stages, prevention, and treatment strategies. Additionally, it covers oxygenation and perfusion assessment, cardiovascular assessment, and abdominal assessment techniques, highlighting lifespan considerations. This resource is valuable for healthcare professionals seeking to enhance their understanding of functional health and tissue integrity.

Typology: Study notes

2023/2024

Uploaded on 10/30/2024

laura-alsleben
laura-alsleben 🇺🇸

10 documents

1 / 13

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
NURS 2710 Concept Outcomes & Test Blueprint – Exam #3
Concepts: Mobility, Hygiene, Tissue Integrity, Oxygenation, Cardiovascular, & Abdominal (Weeks 9 – 11)
Concept: Mobility – Hygiene = 11 questions
1. Identify factors related to mobility across the lifespan.
Developmental Stage: Mobility capabilities evolve throughout life, starting from infancy where motor skills
develop gradually, through childhood and adolescence where physical abilities improve, to adulthood where
mobility may peak, and finally to older adulthood where declines in mobility may occur due to aging.
Physical Health and Fitness: Good physical health and fitness are essential for maintaining mobility.
Muscle Strength and Flexibility: Strong and flexible muscles are crucial for mobility.
Joint Health: Healthy joints are necessary for smooth movement.
Balance and Coordination: Balance and coordination are vital for mobility and fall prevention, especially in older
adults.
Cognitive Function: Cognitive abilities, including attention, memory, and executive function, play a role in
mobility.
Environmental Factors: The physical environment can either facilitate or hinder mobility.
Social Support: Social connections and support systems can impact mobility.
Healthcare Access: Access to healthcare services, including preventive care, rehabilitation, and assistive devices,
can affect mobility outcomes.
Psychological Factors: Psychological factors such as motivation, self-efficacy, and resilience can influence
mobility.
2. Explain nursing measures to prevent complications of immobility.
Repositioning
Walking
ROM
Skin care
Nutrition and hydration
Respiratory care
Assistive devices and mobility aids
Fall preventions
Bowel and bladder management
Pain management
Psychosocial support
Patient education
3. Perform evidence-based practices.
pf3
pf4
pf5
pf8
pf9
pfa
pfd

Partial preview of the text

Download Functional Health Assessment & Tissue Integrity: A Guide for Healthcare Professionals and more Study notes Nursing in PDF only on Docsity!

NURS 2710 Concept Outcomes & Test Blueprint – Exam # Concepts: Mobility, Hygiene, Tissue Integrity, Oxygenation, Cardiovascular, & Abdominal (Weeks 9 – 11)

Concept: Mobility – Hygiene = 11 questions

  1. Identify factors related to mobility across the lifespan.  Developmental Stage : Mobility capabilities evolve throughout life, starting from infancy where motor skills develop gradually, through childhood and adolescence where physical abilities improve, to adulthood where mobility may peak, and finally to older adulthood where declines in mobility may occur due to aging.  Physical Health and Fitness : Good physical health and fitness are essential for maintaining mobility.  Muscle Strength and Flexibility: Strong and flexible muscles are crucial for mobility.  Joint Health : Healthy joints are necessary for smooth movement.  Balance and Coordination : Balance and coordination are vital for mobility and fall prevention, especially in older adults.  Cognitive Function : Cognitive abilities, including attention, memory, and executive function, play a role in mobility.  Environmental Factors : The physical environment can either facilitate or hinder mobility.  Social Support : Social connections and support systems can impact mobility.  Healthcare Access : Access to healthcare services, including preventive care, rehabilitation, and assistive devices, can affect mobility outcomes.  Psychological Factors : Psychological factors such as motivation, self-efficacy, and resilience can influence mobility.
  2. Explain nursing measures to prevent complications of immobility.  Repositioning  Walking  ROM  Skin care  Nutrition and hydration  Respiratory care  Assistive devices and mobility aids  Fall preventions  Bowel and bladder management  Pain management  Psychosocial support  Patient education
  3. Perform evidence-based practices.

 Identify at-risk patients  Repositioning  Support surfaces  Skin assessment  Moisture management  Nutritional support  Patient and caregiver education  Documentation and quality improvement

  1. Identify risks to functional health.  Developmental abnormalities  Physical or psychological trauma  Disease  Social and cultural factors  Physical environment  Age  Cognitive factors  Level of depression  Comorbidity
  2. Describe components of a functional assessment.  Comprehensive assessment - Should be done when the person has demonstrated a loss of function - Has experienced a change in mental status - Has multiple health conditions - Considered a frail elderly person living in the community  Screening - Should be done for children in regards to meeting milestones  Two types of functional assessment - Self-reporting  Subjective perceptions of their own functional abilities - Performance-based  Observing and evaluating someone as they perform functional tasks or activities in real-life settings
  3. Explain physiological and hygiene practices across the lifespan.  Higher risk for falls  Poor health  Poor oral health  Metabolic health  Wash face first

Concept: Tissue Integrity = 24 questions

  1. Identify persons at risk for altered tissue integrity.

 Stage 2

  • Partial thickness of the skin
  • Skin loss involving epidermis, dermis, or both  Stage 3
  • Open wound (skin loss)
  • Full thickness tissue loss
  • Visible fat  Stage 4
  • Full thickness tissue loss
  • Exposed bone, muscle, tendon
  1. Describe the process of wound healing.  Stage 1
  • Relieve pressure
  • Encourage frequent turning and repositioning
  • Use pressure relieving devices
  • Implement pressure reduction surface
  • Keep client dry, clean, and well-nourished and hydrated  Stage 2
  • Maintain a moist healing environment
  • Promote natural healing
  • Provide nutritional supplements
  • Administer analgesics  Stage 3
  • Clean and/or debride with the following  Prescribed dressing  Surgical intervention
  • Provide nutritional supplements
  • Administer analgesics
  • Administer antimicrobials  Stage 4
  • Clean and/or debride with the following  Prescribed dressing  Surgical intervention
  • Perform nonadherent dressing changes every 12 hr.
  • Treatment can include skin grafts
  • Nutritional supplement
  • Administer analgesics
  • Administer antimicrobials
  1. Major cause of developing pressure ulcers
  • Lack of mobility
  • Incontinence
  1. Identify the types of wound drainage.  Drainage (Exudate)
    • Results of healing process
    • Serous drainage
    • Sanguineous drainage
    • Serosanguineous drainage
    • Purulent drainage
    • Purosanguineous
  2. Describe the evidence-based tool used to predict pressure ulcer risk.  Braden scale
    • Mobility
    • Nutrition
    • Friction 15. Identify factors that influence wound healing.  Protein  Vitamin C
  3. Describe ABCDE of moles  Asymmetry
    • Symmetrical  Border
    • Clear on where it starts and ends  Color
    • Should be the same all over  Diameter
    • Should be less than 6mm  Evolving
    • Should be staying the same shape/size
  4. Identify populations at risk for thermoregulation alterations.  Low birth weight baby  Elderly  Chronic illness (diabetes)  Homeless  People living in very hot or cold climates
  5. Describe primary prevention strategies to prevent hyper/hypothermia.  Primary prevention
    • Avoid exposure to temperature extremes
  • A picture of the heart’s electrical activity
  • Shows the precise sequences of electrical events occurring in the cardiac cells
  • Allows monitoring of myocardial contraction
  • Identifies rhythm, conduction disturbances, and overall cardiac function
  • Abnormal findings include  ST-segment elevation or depression  T-wave  P wave  QT interval  QRS complex  PR interval  Arrhythmias  Heart rate - Tachycardia = more than 100bpm - Bradycardia = less than 60bpm  ABG (Arterial Blood Gas) Analysis
  • Oxygenation
  • Measures the levels of oxygen in arterial blood
  • Carbon dioxide
  • pH levels
  • Bicarbonate
  • Oxygen saturation
  • Abnormal findings include  Low oxygen (below 60 mmHg) indicates hypoxemia  High carbon dioxide (above 45 mmHg) indicates hypercapnia  Low pH (below 7.35) indicates acidosis  High pH (above 7.45) indicates alkalosis  Low bicarbonate (below 22 mEq/L) indicates metabolic acidosis  High bicarbonate (above 26 mEq/L) indicates metabolic alkalosis
  1. Perform a cardiovascular assessment  Inspection
  • Expected findings  Skin color uniform and appropriate for race bilaterally  Equal hair distribution on upper and lower extremities

 Absence of jugular vein distention (JVD)  Absence of edema  Sensation and movement of fingers and toes intact

  • Unexpected findings  Cyanosis or pallor, indicating decreased perfusion  Decreased or unequal hair distribution  Presence of jugular vein distention (JVD) in an upright position or when head of bed is 30- degrees  New or worsening edema  Rapid and unexplained weight gain  Impaired movement or sensation of fingers and toes
  • Palpation  Excepted findings  Skin warm and dry  Pulses present and equal bilaterally  Absence of edema  Capillary refill less than 2 seconds
  • Unexpected findings  Skin cool, excessively warm, or diaphoretic, Absent, weak/thready, or bounding pulses, New irregular pulse  New or worsening edema  Capillary refill greater than 2 seconds  Unilateral warmth, redness, tenderness, or edema, indicating possible deep vein thrombosis (DVT)  Auscultation
  • Expected findings  Carotid pulse
  • Unexpected findings  Carotid bruit  Critical conditions to report immediately
  1. Basic rhythm identification

Tachycardia (100-160bpm) Atrial Fibrillation (any bpm) Atrial Flutter (flutter waves, reg, or not reg) Ventricular Tachycardia [V-Tach] (100+ bpm) Ventricular Fibrillation [V-Fib] (no pulse, all over the place)

  1. Identify evidence-based care based on oxygenation assessment data  Oxyhemoglobin (oxygen bound to hemoglobin molecules in the RBC) hemoglobin saturated with oxygen in arterial blood
    • Normal SaO2 is > 95%, anything under 90% requires further assessment and treatment.  PaO2 (partial pressure of oxygen dissolved in arterial blood) – travels as oxygen molecules dissolved in blood and is measured as PaO2. (In simplest terms it is the amount of oxygen that is not bound to HB, but is in the plasma)
    • 80 to 100 mm Hg Mild hypoxia: 60-79 mmHg, Moderate hypoxia: 40-59 mmHg, and Severe hypoxia: less than 40 mmHg  If the patient is hypoxemic, the low oxygen content in his blood will be reflected in low PaO2 and SaO values.
  2. Describe objective and subjective manifestations of impaired oxygenation

 Objective assessment

  • Clubbing in the enlargement of the fingertips that occurs with chronic hypoxia, such as in COPD, or congenital deficits in pediatric patients
  • A barrel chest results from air trapped in the alveoli, signs of chronic hypoxia  Subjective assessment
  • How to assess the level of SOB with a patient  The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath or difficulty breathing. Patients can be asked to rate their dyspnea on a scale of 0 to 10, similar to using a pain rating scale. The feeling of dyspnea can be very disabling for patients. There are many interventions that a nurse can implement to help improve the feeling of dyspnea and, thus, improve a patient’s overall quality of life.  It is also important to ask patients if they are experiencing a cough. If a cough is present, determine if sputum is present, and if so, the color and amount of sputum.  Sputum is made up of mucus and other secretions that are coughed up from the mouth. The body always produces mucus to keep the delicate tissues of the respiratory tract moist so that small particles of foreign matter can be trapped and forced out, but when there is an infection in the lungs, an excess of mucus is produced. The body attempts to get rid of this excess by coughing it up as sputum. The color of a patient’s sputum can provide clues about underlying medical conditions.
  1. Recognize abdominal assessment techniques to reflect variations across the lifespan

 Expected findings

  • Absence of pain or tenderness
  • Absence of masses  Unexpected findings
  • Pain on palpation, Guarding, Rigidity
  • Rebound tenderness
  • Masses noted that are not previously documented
  • Genitourinary  Expected findings
  • Clear, pale, yellow urine
  • Absence of pain, urgency, frequency, or retention  Unexpected findings
  • Dark or bloody urine, foul odor, or sediment present
  • Dysuria
  • Urinary frequency
  • Urinary urgency
  • Urinary retention
  • Critical conditions to report immediately  Unexpected findings
  • New or worsening melena, Bloody stools
  • Hematemesis
  • Signs of dehydration associated with diarrhea and vomiting, such as <30mL urine/hour