Final Flashcards
(175 cards)
1
Q
The level of promoting health but also preventing illness
Health promotion Health education Immunizations Early detection and treatment Environmental protection
A
Primary level of health care
2
Q
The level of diagnosing and treating a patient
Emergency care
Acute and critical care
Elaborate diagnosis and treatment
A
Secondary level of health care
3
Q
The level of rehabilitation, health restoration, or palliative care
Rehab
Long term care
Care of the dying
A
Tertiary level of health care
4
Q
Nurse is responsible for overseeing the total care of a number of hospitalized patients on a specific unit.
- 24 hours a day, 7 days a week, even if they do not deliver the care personally
- Encompasses teaching, advocacy, decision making, and continuity of care
- Provides comprehensive, individualized, consistent care
- Should work consistently on the nursing unit, challenges include the variable number of part-time nurses
A
Primary nursing care
5
Q
Oldest Method –> Private Duty Nursing
Total Patient Care –> Nurse is responsible for total care of the patient during the nurse’s working shift
-Assesses needs, makes nursing plans, formulates nursing diagnosis, implements care, and evaluates the effectiveness of care
-Do not necessarily care for the same patient every time
-Nurse is responsible for several patients
A
Case method nursing care
6
Q
Consists of a leader
- An RN leads a team that is composed of other RN’s, LPN’s, and CNA’s.
- Staffing team reports to them
- Has accountability for all of the care
Consists of members
-assigned specific functions or procedures to perform for all clients. (medications, treatments, bedside nurse)
Consists of conferences
-utilized to communicate and develop a plan of care
A
Team nursing care
7
Q
Nursing Case Managers responsible for a case load of patients in the hospital
- Assessing patients and their homes/communities
- Coordinating and planning care
- Collaborating with other health professionals
- Monitoring patients progress through follow-ups
- Evaluating patient outcomes
Work with insurance companies to help patient receive the best possible care in the most cost-effective way
A
Case management nursing care
8
Q
What are the 5 nursing care methods
A
Function nursing care Case management nursing care Primary nursing care Case method nursing care Team nursing care
9
Q
- Leader makes decisions for the group
- Assumption is that the group is externally motivated and incapable of independent decision making
- Very effective in emergency situations & when a project must be completed quickly and efficiently.
- Likened to a dictator: gives orders and directions to the group
- Productivity is usually high, but autonomy and self-motivation low.
- Degree of openness and trust between group & leader is low.
A
Autocratic (authoritarian) leadership style
10
Q
- Leader encourages group discussion and decision making
- Assumes individuals are internally motivated and capable of making decisions
- Leader acts as a facilitator towards goals
- Allows more self-motivation and creativity among members (must have cooperation and coordination among members)
- Often very effective in the health care setting
A
Democratic (participative) leadership style
11
Q
- Leader assumes group in internally motivated and needs autonomy
- Leader assumes a “hands off” approach and tends to minimize the amount of direction and face time needed
- There may be a lack of cooperation & coordination
- Works well if you have highly trained and motivated group
A
Laissez-faire (non-directive/permissive) leadership style
12
Q
- Leader assumes group is externally motivated, but does not trust them to make decisions
- Leader relies on organizational rules and policies – takes an inflexible approach
- Leader motivates through systematic rewards and punishments
- Empowered by the office they hold
A
Bureaucratic (transactional) leadership style
13
Q
- The leader adapts the leadership style to the situation
- There is concern for interpersonal relationships and a focus on activities that meet group members’ needs
- Could end up using any of the previously mentioned styles, determined by the group’s needs
A
Situational leadership style
14
Q
- No one person is considered to have more knowledge or ability than another in the group
- In essence, all are leaders
A
Shared leadership style
15
Q
The transferring of responsibility for the performance of an activity or task to another member of the health care team while retaining accountability for the outcome
A
Delegation
16
Q
What are the 5 rights of delegation
A
The right task The right circumstances The right person The right communication/understanding The right supervision/evaluation
17
Q
A dynamic, flexible environment that is concerned with the specific needs of an individual patient and/or groups of patients to promote a positive living experience and positive health changes.
A
A therapeutic environment
18
Q
Characteristics of a therapeutic environment
A
- Adequate Comfort (temperature, ventilation, lighting, nonskid surfaces….)
- Safe environment
- Individualization of patient care
- An atmosphere that encourages communication
- A feeling of “security” for the patient
- A feeling of self worth for the patient
- Diversional activities
19
Q
What is the RACE acronym for a fire
A
R- RESCUE anyone in immediate danger if it does not endanger your own life
A- sound the ALARM
C- CONFINE the fire by closing all doors and windows
E- EXTINGUISH the fire or if the fire is too large, EVACUATE the area
20
Q
What is the PASS acronym for a fire extinguisher
A
P- Pull the pin
A- Aim the nozzle at the base of the fire
S- Squeeze the handle
S- Sweep from side to side
21
Q
What are you going to look for when assessing mobility
A
- Alignment of the spine while standing and sitting
- scoliosis: C or S curve of the spine
- kyphosis: hunchback - Balance by asking the patient to sit or stand with their eyes closed
- swaying to one side indicates inability to maintain balance - Gait by watching the patient walk
- should be rhythmic and even, symmetric, head is erect, body weight is easily supported - Joints by range of motion
- note limitations
- look for symmetry and discomfort - Muscle strength in the hands (clients squeezes your wrist) in the feet (client pushes foot against your hand)
- grade response of a 0 to 5 scale
22
Q
What should you consider when ordering restraints
A
First assess and develop alternative ideas because restraints are only temporary
Next find the least restrictive but one that will still provide safety
Evaluate face to face with patient within one hour or restraints being used
Order must be renewed every 24 hours
23
Q
Using the restraints correctly
A
Follow directions
Correct size
Secure restraints to bed frame not bed rails
Continually monitor for circulation, movement, and sensation
Remove them at least every 2 hour for ADLs
Stop when you can
24
Q
Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.
A
Pressure ulcer
25
Contributions to pressure ulcers
Pressure intensity
Pressure duration
Tissue tolerance
26
An observable skin change
Appears as a defined area of persistent redness in lightly pigmented skin or a red, blue or purple hue in darker skin.
Nonblanchable erythema
There are no open skin areas.
May be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Stage 1 pressure ulcer
27
There is partial-thickness skin loss involving epidermis and/or dermis
Superficial
Presents as an abrasion, blister or shallow crater with a red/pink wound bed
No slough
Stage 2 pressure ulcer
28
Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Presents as a deep crater with or without undermining of adjacent tissue
Bone/tendon/muscle is not visible – slough may be present
Depth varies by anatomical location
- Bridge of nose, ear, malleolus do not have subcutaneous tissue and can be shallow
- Areas of significant adiposity can develop deep ulcers
Stage 3 pressure ulcer
29
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (such as tendons)
Undermining and sinus tracts may also be present.
Depth also varies by anatomical location
Slough or eschar may be present
Stage 4 pressure ulcer
30
A pressure related injury to subcutaneous tissue under intact skin
Initially, these lesions have the appearance of a deep bruise
May herald the subsequent development of a Stage III-IV pressure ulcer
Mottling may be present.
Document as “unstageable” – DO NOT stage as a Stage I pressure ulcer!
Suspected deep tissue injury
31
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Unstageable
32
Wound drainage that is clear and watery
Serous
33
Wound drainage that is bright red
Sanguineous
34
Wound drainage that is pale, red, and watery
Serosanguineous
35
Wound drainage that is thick, yellow, green, tan, or brown
Purulent
36
Type of healing:
- Tissue surfaces have been closed
- Minimal or no tissue loss
- Example: closed surgical incision
Primary intention
37
Type of healing:
- When extensive tissue loss occurs
- Edges cannot or should not be closed
- Burns, pressure ulcers, big lacerations
- The wound becomes filled by scar tissue
- Takes longer for wound to heal – chance of infection is greater
- Could be permanent loss of tissue function if scarring is severe
Secondary intention
38
Type of healing:
| Starts healing by secondary intention and then wound is later closed to heal by primary intention.
Tertiary intention
39
When does wound healing begin?
Immediately upon wounding with vasocontriction
40
The first phase of wound healing that occurs immediately with the onset of vasoconstriction, platelet aggregation, and clot formation
Hemostasis
41
This phase of wound healing lasts 3-6 days
| It is marked by vasodilation and phagocytosis as the body works to clean the wound to begin the repair process
Inflammatory
42
The phase of wound healing when capillaries grow across the wound and increase blood supply
Proliferative
43
The phase of wound healing when the wound is remodeled or contracted
Usually 1 or 2 years after injury
Maturation
44
What is the RYB color code
Red- protect the wound
Yellow- cleanse the wound
Black- debride the wound
Treat black, then yellow, then red
45
Important things to remember when applying heat and cold
Heat causes vasodilation and should be kept on no longer than 30 minutes (after this a rebound effect will cause vasoconstriction) and allow 30-60 min before applying it again
Cold causes vasoconstriction and should be kept on no longer than 30 minutes (after this a rebound effect will cause vasodilation) and allow 30-60 minutes before applying cold again
46
Nurses should consider these things when giving hot and cold therapy
Assessment of the skin.
Assessment of client’s ability to detect temperature changes.
Medical conditions, such as diabetes or circulatory disorders
The very young and very old are more sensitive to temperature changes
Ensuring proper operation of equipment
47
What is the purpose of the Braden scale and Norton scale
To give a numerical score to rate the patients level of risk for pressure ulcers
48
The order of Maslows hierarchy of needs
1. at the bottom also most important in the pyramid: physiological needs; air, nutrition, water, elimination, rest, sleep, thermoregulation
2. safety needs
3. love needs
4. esteem needs
5. self actualization needs
49
Guidelines for prioritizing needs of the patient
- Immediate effect on survival
- Effect on other needs
- Timeframe and available resources
- Client’s perception of need
- Family’s perception of need
50
Steps to providing culturally diverse care
1. Communication
- Avoid slang words and medical terms
- Speak slowly and respectfully
- Keep making sure they understand
- Use focused, open-ended, nonjudgmental questions
- Recognize whether or not to establish eye contact
2. Space
- How close to the patient should you be
- Recognize if touching is appropriate
3. Social organization
- What is important to them; family, religion, organizations
4. Time
- Do their schedules conflict with med administration, appointments
5. Environmental control
- Their beliefs about health and illness
- Their culture could affect the way they respond to health activities
6. Biological variations
- Can affect types of illnesses, their response to treatments
51
Sacred or holy matters that belong to or relate to a god or church
Spirituality
52
How to clinically assess for spirituality
1. the environment
- prayer books
- bibles
- music
2. their behavior
- do they pray before meals
3. their verbalization
- do they mention God
53
Phases of the nursing process
1. Assesment: gathering info about the patients condition
2. Nursing diagnosis: identify the patient's problems
3. Planning: set goals of care and desired outcomes and identify appropriate nursing actions
4. Implementation: perform the nursing actions identified in planning
5. Evaluation: determine if the goals and outcomes were achieved
54
Describe an independent nursing intervention
Requires no supervision or direction from others
| Does not require a physician's orders or an order from any other professional
55
Describe a dependent nursing intervention
The nurse carries out the physician's orders
Not within the scope of the nurses practice to order the intervention, but it is okay for them to carry out the intervention
56
Describe a collaborative nursing intervention
Carried out in collaboration with another health care professional
57
A statement that describes the client’s actual, potential or wellness human response to a health problem that the nurse is competent and licensed to treat.
The 2nd phase of the nursing process
Nursing diagnosis
58
What are the 4 types of diagnoses
```
Actual (3 part)
-impaired skin intergrity
Risk for (2 part)
-risk for injury
Wellness (1 part)
-readiness for enhanced family coping
Possible
-possible social isolation with unknown etiology
```
59
The triggering event or stressor initiates the cascade of events (stimulus)
Stimulus based models
60
Based on Reactive Scope Model:
- Each physiologic system is used to describe the process of the sequence of events and predict outcomes
- Interpretations of stress are as individual as the responses to stress but the physiologic pathway triggered is predominately the same.
Response based models
61
Assumes the client & environment are inseparable (each affects the other)
Considers individual differences to explain variations among individuals under comparable conditions
Transaction based models
62
People experience anxiety and increased stress when unprepared to cope with stressful situations.
Adaption model
63
Stressors due to hospitalization
```
New roles
Different roles than used to
Threat to self concept
Loss of privacy
Financial concerns
```
64
Nursing interventions for stress and self concept
Assess the client's and the family's coping abilities
Interventions:
-communicate effectively
-encourage appropriate expression of feelings
-encourage self affirmations
-introduce change gradually
-effective teachings
-terminate relationship in a timely manner
65
Interventions for anxiety and stress
```
Get exercise, rest, and proper nutrition
Relaxation techniques
Spirituality
Support systems
Medications
```
66
Nursing interventions with sexual needs
```
Provide accurate, honest, information in an open environment
Empathetic listening
Nonjudgemental communication
Encourage safe sex practices
Referrals such as OB/GYN or therapists
```
67
Stage 1 of sleep
- Transition between drowsiness and sleep
- Only lasts a few minutes
- Feels as though daydreaming if awakened during this state
- Heart rate decreases
68
Stage 2 of sleep
- 40-50% of sleep time
- Can be easily awakened
- Muscles relax
- Body functions slow
69
Stage 3 of sleep
- Deep sleep
- Body functions continue to slow
- Sleep walking and bed-wetting can occur
- Dreams occur- often realistic
70
REM (Rapid Eye Movement) stage of sleep
- Both eyes move rapidly
- Low or absent muscle tone
- BP and HR fluctuate
- Oxygen consumption increased
- Dream can occur- vivid, wild, unrealistic
71
Common sleep disorders
Insomnia
-inability to obtain enough sleep necessary for functioning
Sleep apnea
-interruption of breathing during sleep (obstructive or central)
Narcolepsy
-neurologic disorder causing daytime sleepiness, sudden sleep attacks lasting 10-15 minutes
Sleep deprivation
-REM or NREM deprivation
Restless leg syndrome
-neurologic disorder, unpleasant sensation of legs that causes the person to want to move them
72
Symptoms and causes of insomnia
Symptoms
- difficulty falling asleep
- difficulty staying asleep
Causes
-stress, age, exercise, pain, fear, disturbed circadian rhythm
73
Symptoms and causes of sleep apnea
Symptoms
- daytime sleepiness
- fatigue
- decreased sex drive
- morning headaches
Obstructive causes
-obesity, deviated septum, nasal polyps, enlarges tonsils
Central causes
- brain stem injury
- encephalitis
- muscular dystrophy
74
Treatments for narcolepsy
Stimulants
Meds to suppress REM sleep
Brief naps
Exercise
75
Symptoms and causes of sleep deprivation
Symptoms
-blurred vision, clumsiness, decreased reflexes, decreased response time, cardiac dysrhythmias, hyperactivity, irritable, disoriented, sleepiness, headache, nausea
Causes
-illness, stress, aging, medications, environment
76
Symptoms and causes of restless leg syndrome
Symptoms
-creepy, crawling, burning, twitching, aching of legs
Causes
- pregnancy
- European ancestry
- increases with age
- genetic
77
What should be included in a sleep assessment
Normal sleep patterns
Recent situational changes
Caffeine, nicotine, and alcohol intake
Physical cues of tiredness
78
Interventions to assist with sleep
```
Modify the environment
Perform sleep rituals
Sleep patterns
Relaxation techniques
Keep a consistent routine
```
79
Sleep patterns in adults
typically 8 hours of sleep
takes 7-10 minutes to fall asleep
body naturally changes sleeping positions through night
1-2 awakenings per night and this only increases with age
15-30 minute naps are energizing
80
Questions to ask when assessing good nutrition
Normal eating patterns
- food preferences
- how is their appetite
- special diets
- cultural/religious influences on diet
Identify risks
- determine their knowledge of nutrition
- recent weight loss/gain
- identify presence of anorexia, dysphagia, chewing issues
- on any medications
- socioeconomic issues
81
What to look for when doing a physical assessment of nutrition
General
- Energetic, alert, attentive
- Erect posture
- Healthy skin, nails, hair, teeth, and gums
- Well developed muscles
Measurements
- height and weight
- waist
- skin folds
- arm circumference
Calorie count
Mouth inspection
- condition of dentures
- moist saliva production
- cuts, lesions
82
Measures the bloods oxygen carrying capacity
Hemoglobin
83
The percent of RBC in 100ml of blood
Hematocrit
84
Protein markers that help assess nutritional status
Serum albumin
85
Interventions to promote healthy nutrition
Educate them on the importance of a healthy diet
Rooms should be clean and free of strong odors
Rooms should be a relaxing atmosphere
Oral care
Time meds to control nausea and pain
Serve foods in appetizing manner at correct temperature
Small servings if appropriate
Proper positioning to help with chewing and swallowing
Encourage client to be active as possible; but partial assistance with their meals is okay
Make sure consistency of food is appropriate
86
Nursing responsibilities for tube feedings
Fowlers position with 30 degree head elevation
Keep accurate I&O measurements
Follow agency policy for flushing and placement of tubes
This skill is not delegated to assistive personnel (AP)
87
Different liquid consistencies
Liquid is to be ordered by a physician
Thin liquids
- all liquids
- consistency is non restrictive
- nothing added
Nectar
- apricot or tomato juice consistency
- some liquids will require slight thickening agent
Honey
- some liquids can still be poured but slowly
- requires thickening agent
Pudding
-Spoonable, but when spoon is placed upright it will not stay upright
88
Identify the 3 types of grief
Normal grief
-experienced feelings, behaviors, reactions that are expected
Anticipatory grief
-Grieving before the loss has occurred
Disenfranchised grief
-Society doesn't define the loss as a loss and the person does not gain support from others
89
Developed a framework for understanding the process of dying, which is also applicable for the process of grieving.
-The model should be used as a guide and not rigidly adhered to.
Kubler-Ross Stages of Dying
90
What are the 5 stages of the Kubler-Ross stages of dying
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
91
Interventions to assist dying patients and their families
```
Explore their perception of loss
-What stage?
-Is there hope?
What support is available
Is there more we can provide
Readiness to discuss and deal with loss
Advanced directives
```
92
Preparation of the body after death
```
Viewing by the family for transport/storage
Close eyelids
Remove all tubes
Wash body, clean/brush hair
Dress in clean gown
Fresh top sheet
Lying flat with hands on chest
Dentures in
```
93
Stiffening of the body that occurs about 2-4 hours after death
Results from lack of ATP, which causes muscles to contract and joints to immobilize
Usually leaves the body after about 96 hours
Rigor mortis
94
the gradual decrease of the body’s temperature
Algor mortis
95
RBC’s break down, releasing hemoglobin, which discolors tissues (usually in lowermost areas of body)
Livor mortis
96
Symptoms that can accompany grief
Anxiety, depression, weight loss, vomiting, fatigue, headaches, dizziness, fainting, blurred vision, sweating, rashes, palpitations, chest pain, dyspnea
97
Durable power of attorney for health care
| DNR: do not resuscitate
Living will
98
a notarized statement appointing someone else to manage health care treatment decisions when the client is unable to do so.
Health care proxy
99
Rules and regulations by which society is governed
Laws
100
Legally defines and describes the scope of nursing practice
Regulates who will practice nursing
Establishes the state board of nursing
-Indiana State Board of Nursing
Nurse Practice Act
101
Created by elected legislated bodies
| Either Criminal or Civil
Statutory Law (Nurse Practice Act)
102
Created by administrative bodies (State Board of Nursing)
| Enforce statutory law
Administrative Law
103
Created by judicial decisions made in court
| Interprets statutory law
Common Law
104
Willful acts that violate another’s rights
| Assault, Battery, Defamation
Intentional
105
Acts such as negligence of malpractice
Unintentional
106
Conduct that falls below the standard of care
1. An act that resulted in harm to another person
2. The omission of an act that would have prevented harm
Negligence
107
That part of the law of negligence applied to the Professional Person.
It is the failure of a professional person to act within acceptable standards of his/her profession.
Malpractice
108
4 elements of malpractice
Duty
Breach
Injury
Cause
109
Legal responsibility of a student nurse
Liability is shared by the student, instructor, facility, and university
Do not perform anything you are unprepared for
Expected to perform as professional nurses
110
Patient’s agreement to allow something to happen after being provided complete information
Risks, benefits, alternatives, consequences of refusal
Informed consent
111
Nursing requirements for informed consent
Brief but complete explanation of the procedure or treatment
Name and qualifications of those doing procedure
Description of the serious harm
Explanation of alternative therapies
Pt must be told they have a right to refuse procedure
Pt must be capable of understanding information
112
A nurses signature on an informed consent form means..
Pt voluntarily gave consent
Signature is authentic
Pt is competent to give consent
Verifies pt was informed about procedure
113
when a patient allows a procedure to be done (such as an injection) without signing a form
Implied consent
114
a damaging written statement that defames a person’s character
libel
115
a damaging oral statement that defames a persons character
slander
116
Attempt or threat to harm another, coupled with the ability to harm
Patient believes harm will come as a result of the threat
No actual contact is necessary
Example: the nurse threatens to restrain a patient if he doesn’t do as he/she asks
assault
117
Any intentional touching of another’s body, or touching/holding without consent
Injury is not a requirement
If the nurse actually restrained the patient in the previous example, it would be considered this
-Always includes an assault.
battery
118
suggest there are specific pain receptors in the body
Specificity theory
119
Body’s natural supply of opiate like substances
Activated by stress and pain
Possible occupy receptors in the brain where pain is perceived
Endorphins
120
proposes that a gate control system modulates sensory input following stimulation of the skin before pain perception and response is evoked
Gate control theory
121
Describe the body's reaction to pain
Moderate pain- increased responses (BP, HR, dilation)
| Severe pain- decreased BP, HR and constriction/tension
122
```
Brief duration
The end is expected
Onset usually immediate
may subside with or without treatment
Self limiting
complete relief is expected to come soon
Often frightening for the client
Once pain is relieved, full attention can be give towards recovery
```
Acute pain
123
```
Lasts a prolonged period of time
May never gain relief
Remissions and exacerbations
Client can become frustrated and depressed
Pain becomes part of client’s life
```
Chronic pain
124
Can be acute, chronic or both associated with progressive processes.
May be described as intractable.
Often described as all-consuming and interfering with quality of life.
Examples:
-Arthritis
-Cancer
Malignant pain
125
The assessment process of pain
```
Physical signs and symptoms
-vital signs, diaphoresis, dilation, tension, N/V
Subjective report
-location, intensity, quality, pattern
Methods used for pain control
Attitudes
Coping responses
Family/Pt expectations
Current medications
What causes/increases pain
```
126
Pain relief measures or interventions
```
Remove painful stimuli from the environment
-wrinkles, bandages, dressings, position
Apply gate theory
-back massage, warm bath, heat or cold
Sensory input
-music, tv, talking to others
```
*treatment for chronic pain involves cognitive and behavioral strategies such as relaxation or hypnosis
127
Pharmacological treatment of mild to moderate pain
Nonnarcotics
- Acetaminophen (Tylenol)
- NSAIDS (Nonsteroidal anti-inflammatory drugs)
- -Ibuprofen
- -Aspirin
128
Pharmacological treatment of severe pain
Opioids (narcotics)
- Bind to opiate receptors
- Results in alteration in perception of and response to pain
129
Myths/misconceptions of pain
- lack of evidence of the pain makes nurses feel like they are only going to cause a drug dependence
- fear of being fooled by a client who isnt actually in pain
- biases toward certain diagnoses
- -obese, elderly, alcoholics, surgery patients
130
Who mandates what needs to be documented
```
Professional standards of practice
Nurse practice acts
Accreditation agencies
Regulatory agencies
Reimbursement agencies
Institutional nursing policies
```
131
What are the different charting formats
```
POMR (problem oriented medical record)
--SOAP
--PIE
Traditional or narrative nurses’ notes
Focus charting
CBE (charting by exception) charting
Flowsheets and databases
```
132
What is POMR charting
* Focuses on one diagnosis.
* It is client-centered.
* Follows the nursing process.
SOAPIER
- subjective
- objective
- assessment
- plan of care
- interventions
- evaluation
- revision
133
A chronological written account of the client’s status, nursing interventions provided and the effectiveness of the interventions
Narrative nurses notes
134
Notes are focused around:
An acute change or behavior
Specific medical conditions
Follow-up to a more complete assessment
Encourages nurses to include any client concern, not just problem areas.
Focus may be written as a nursing diagnosis
Organization of note:
D - data (objective & subjective)
A - actions (nursing interventions)
R - response (evaluation of effectiveness of actions)
Focused charting
135
Standards of practice are integrated into documentation forms
Nurse only documents significant findings or exceptions to the pre-defined norms
CBE (charting by exception)
136
record simple data such as vital signs, neuro checks, etc (routine care)
used to document nursing interventions and evaluation if the facility only uses SOAP notes without the IER.
flow sheets
137
Important points when documenting electronically
* Do Not Share your password with anyone! (It is your legal electronic signature)
* Log off when leaving a terminal – even if only for a few minutes
* Never display information on a monitor where someone else can see it
* Never print information and leave it unattended
* Follow agency policy for correcting documentation errors
* With computer entries: if the computer does not allow you to capture all the information you feel is necessary, then write what you want to include on a piece of paper and add it to the chart.
138
Guidelines for charting
- Record all entries legibly and in ink.
- Some places use different colors for different reasons or shifts
- Begin each entry with the date and time
- Example: 2/12/14 1200
- Chart chronologically
- Leave no blank spaces, end with a line over, your first initial, last name, and title
139
Describe the chain of infection
1. The infectious agent or pathogen
2. The reservoir or source for pathogen growth
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Susceptible host
140
Describe the infectious agent or pathogen
The agent capable of causing the infection process
```
Depends on:
the # and virulence of the organism
ability to enter the body
susceptibility of host
ability to live in the host
```
Infections
141
Describe the reservoir
The source of the microorganism
Humans, plants, animals, environment, food, drinks, feces
142
Describe the portal of exit
```
Respiratory tract
GI tract
Urinary tract
Blood
Skin
Reproductive tract
```
143
Describe the method of trasmission
Direct
- touching
- biting
- kissing
- intercourse
- droplets if within 3ft of each other
- --sneezing, coughing, talking
Indirect
- vehicle such as pens, food, toys (fomites)
- vector such as an insect
- airborne such as dust
144
Describe the portal of entry
Same routes used to exit
| Intact skin is the first line of defense
145
Describe the susceptible host
The person at risk for infection
| Depends on individuals degree of resistance
146
The CDC's 2 tiers of precaution
Tier 1. Standard precaution
| Tier 2. Transmission based precaution
147
Describe standard precautions for infections
1. Used in the care of all hospitalized clients, regardless of diagnosis or infection status.
2. Applies to blood, body fluids, broken skin, mucous membranes.
3. Wash hands after contact with above whether or not gloves were worn.
4. Wear gloves when touching above or contaminated items.
5. Wear mask, eye protection, or face shield if splashes or sprays can be expected.
6. Wear gown to protect clothing if splashes or sprays could occur.
7. Handle equipment contaminated with above carefully to prevent transfer of microorganisms
8. Special handling of contaminated linen .
9. Prevent injuries from used scalpels, needles & place in puncture-resistant containers.
148
Describe transmission based precautions
1. airborne precautions
-for clients with known or suspected
infections caused by airborne droplet
nuclei smaller than 5 microns.
-examples: measles and T.B.
-provide: private room with negative air
pressure, wear respiratory device when
entering room, limit time pt is out of
room (mask on pt).
2. droplet precautions
-for pts with infections caused by particle
droplets larger than 5 microns.
-examples: mumps, diptheria, pneumonia
-provide:
private room
wear mask if within 3 feet of patient
limit time pt is out of room (mask on pt)
3. contact precautions
-for clients with infections transmitted by
direct contact with client or items in
environment.
-examples: GI, Respiratory, Skin, or
Wound infections, etc.
-provide:
*private room
*wear gloves
*wear a gown if possible contact with
infected surfaces or items
*limit movement outside of room
*limit use of equipment to client or clients
with same infecting microorganism
149
Proper donning of PPE
1. Wash Hands
2. Gown
3. Face Mask (all types)
4. Goggles
5. Gloves
150
Removing PPE
1. Gloves (wash hands)
2. Goggles
3. Gown (turn wrong side out)
4. Mask (untie bottom strings first if applicable)
151
How to promote regular bowel elimination/defacation
1. Privacy
2. Timing - go when urge recognized
3. Adequate fluid intake (8-10 glasses/day)
4. Adequate food intake (increase fiber)
5. Regular exercise
6. Positioning - squatting & leaning forward if possible
152
How to promote regular voiding/urination
1. Adequate intake (6-8 glasses recommended)
2. Up to toilet if possible
3. Privacy
4. Warm water over perineum
5. Fingers in warm water
6. As normal a routine as possible (up every 2-3 hours)
7. Adequate time
8. Strengthening pelvic floor muscles
9. Promote Comfort
10. Bladder Retraining
153
Steps for routine catheter care
1. Fluid intake up to 3000cc/day
- -Decreases the likelihood of urinary stasis and infection
2. Encourage foods that acidify urine
- -may reduce UTI and calculus formation
3. Perform routine perineal care
4. Only change catheter if necessary
5. Client teaching
6. Empty bag at least every 8 hours
154
How to get a proper clean catch/midstream urine sample
1. clean perineum or penis with soap & water, then with an antiseptic wipe
2. have client start voiding
3. place container into stream of urine
4. don’t touch perineum or penis
5. collect 30-60 ml
6. cap specimen cup - clean outside with disinfectant if necessary
7. label & take to lab
8. document
155
Physical examination of the urinary system
Inspection
Skin and Mucosal Membranes
Place patient in supine position
Look for bulging at the symphysis pubis
Urinary meatus during perineal hygiene
Palpation
Palpate for tenderness and bladder distension
Bladder Ultrasound (Scanner)
Estimates the total volume of urine in the bladder
Ultrasound gel to lower abdomen & place probe so outline of bladder fills screen
156
Assessment of urine
Intake and Output
--Normal Kidneys ~ 60ml/hr (1500ml/day)
Color
- -Normal ~ pale, straw or amber colored
- -Abnormal ~ dark amber, dark orange, red, tea, brown
- -Hydration affects color:
- -Concentrated urine ~ darker in color
- -Diluted urine ~ almost clear or very pale yellow
- -Some foods and meds can affect urine color
Clarity
- -Normal ~ Transparent, no sediment
- -Abnormal ~ Cloudy (pathology present)
Blood or mucus
Odor
- -Ammonia in nature
- -Concentrated urine much stronger
Amount
--Each Void/ 24 hour period
157
Physical examination of bowel elimination system
1. Listen to bowel sounds
- -Normal is high-pitched gurgling, irregular, 5-30 times per minute
- -Hyperactive ~ Loud, high-pitched, rushing
- -Hypoactive ~ Soft, pause between sounds
- -Absent ~ must wait five full minutes
- -Gurgling ~ rumbling
2. Palpate abdomen
3. Examine rectum and anus
158
Different contours of the abdomen
Flat
Scaphoid (sucking in)
Rounded
Protuberant (looks pregnant)
159
How to collect a stool specimen
1. Have pt defecate into clean bedpan or
commode
2. Try to avoid contact with urine & tissue
3. Use tongue blade to transfer specimen to container
4. Usually need 1 inch or 15-30 ml of liquid stool
5. May need all of stool for a timed test
160
Enema administration
Sterile technique is unnecessary.
Wear gloves.
Explain the procedure, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.
161
Diagnostic tests for urinary elimination
BUN (Blood Urea Nitrogen) and Creatinine Clearance
--Evaluate renal function
Urinalysis (UA)
- -Color
- -Clarity
- -pH (Normal: 4.6-8)
- -Specific gravity (Normal: 1.015-1.025)
- -Proteins (None)
- -Glucose (None)
- -RBC’s (None)
- -Ketones (None)
Urine Culture and Sensitivity
162
Discuss suctioning
Excessive secretions in the upper airway will decrease oxygenation.
Suctioning is necessary when patient cannot expectorate mucus effectively
163
Assessment of circulatory system
1. General behavior and appearance
2. Skin color
- may be pale, cyanotic or dusky red due to venous or arterial insufficiency
3. Skin temperature
- cool if arterial blood supply to extremity is impaired
4. Skin integrity
5. Hair and nail growth
6. Capillary filling
7. Varicose veins
- dilated veins when standing can indicate inadequate venous function
8. Peripheral pulses
9. Edema
164
Assessment of respiratory system
```
Vital signs
Skin color
Chest wall movements
Posture when breathing
Palpate for:
--tenderness
--lumps
--bilateral chest expansion
```
165
Phases of a fever
```
Onset (cold or chill phase)
--patient is cold
--try to decrease heat loss
Course or plateau phase
--patient is warm
--try to increase heat loss
Afebrile or flush phase
--skin warm, flush, diaphoretic (sweating)
--client has more energy
```
166
Before starting an assessment
Adequate lighting
Quiet, comfortable environment
Look and observe before touching
Explain assessment techniques you will use
Have all equipment ready to go
Keep in mind standard precautions when in contact with blood or body fluids
Privacy – draping, visualize one system at
a time
167
The first step in the assessment process
Usually carried out during the interview and the physical exam
To detect normal characteristics or significant physical changes
inspection
168
```
Use of touch
Use of fingertips and palms of hands
To detect size, shape, tenderness, temperature, texture, vibration, masses….
Light
Deep
```
palpation
169
One or both hands are used to strike the body surface to produce a sound
Helps assess denseness or hallowness of underlying body structures, location and level of organs, tenderness, masses or tumors…
percussion
170
Listening to body sounds with the use of a stethoscope
Amplifies sound
Bowel sounds, heart sounds, lung sounds…
auscultation
171
order to perform an assessment
* order to perform: inspection, palpation, percussion, auscultation
* exception is for bowel sounds: inspect, auscultate, percuss and palpate (to avoid altering bowel sounds)
172
Older adult focus on assessment
Obviously, by this time, most adults have had exposure to physical exams and assessments
May still feel apprehensive and modest
Important to prepare for all procedures before beginning
Provide for privacy, draping….
Changes with aging may require adaptation of the physical assessment. Ideas?
173
Organizes data collection in terms of Gordon’s 11 functional health patterns
Health perception, nutrition, activity, elimination, cognitive, self-perception, roles/relationships, sexuality, coping, values, sleep
Subjective data collected this way, and then physical assessment is done via head-to-toe
Functional assessment organization
174
Collect data starting at the head and then working downward to the toes in a systematic way
Head to toe assessment
175
Focuses on the pathophysiology within specific body systems (such as cardiovascular, respiratory…)
Body systems assessment
