Protect against droplet infections smaller than 5mcg and that remain airborne (larger droplets fall).
"My Chicken Hez TB" & VRSA
- Chicken Pox
- Herpes zoster
- Standard precautions
- Negative pressure room (private)
- Mask (n-95 for TB)
- VRSA includes contact precautions
C - Cane
O - Opposite
A - Affected
L - Leg
Contact precautions protect visitors and caregivers (when they are within 3ft of the client) against direct client and environmental contact infections
- MRSA (VRSA requires airborne precautions)
- Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, staph)
- Wound infections
- Enteric infections (C-Diff)
- Eye infections (conjunctivitis)
- Gown, gloves, goggles, private room
When going up stairs, the good leg goes first, followed by crutches, then affected leg. (The opposite when going down stairs.)
RNs do not delegate what they can EAT
E - Evaluate
A - Assess
T - Teach
- Predictability of outcome
- Potential for harm
- Complexity of care
- Need for problem-solving and innovation
- Level of interaction with client (need for psychosocial support or education)
Droplet precautions protect against droplets larger than 5mcg and travel 3 to 6 ft from the client.
- Scarlet Fever
- Private room, mask
Clients that are allergic to the following may be at risk for a latex allergy:
Bananas, Apricots, Cherries, Grapes, Kiwis, Passion Fruit, Avocados, Chestnuts, Tomatoes, and/or Peaches
- Pt is supine with HOB at 45o
- Frequently used during procedures such as NG tube insertion and suctioning
- Allows for better chest expansion and ventilation
- Pt lies on side with most of the weight on the dependent hip and shoulder.
Good sleeping position, but the client must be turned regularly to prevent development of pressure ulcers on the dependent areas.
A 30o lateral position is recommended for clients at risk for pressure ulcers.
Modified Trendelenburg Position
- Client remains flat with legs elevated above the level of the heart.
- This position is used to prevent and treat hypovolemia and facilitates venous return.
Order of Assessment
I - Inspect
P - Palpate
P - Percuss
A - Auscultate
EXCEPT with the abdomen:
I - Inspect
A - Auscultate
P - Percuss
P - Palpate
High Fowler's Position
- Pt is supine with HOB at 90o
- Promotes lung expansion by lowering diaphragm; used for clients experiencing dyspnea
- Pt sits in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client’s lap. The client rests his arms on the over-bed table.
- Position allows for chest expansion and is especially beneficial to clients who have COPD.
- Pt lies flat on abdomen with head to one side
- Position promotes drainage from the mouth but inhibits chest expansion
- The entire bed is tilted with the foot of the bed lower than the head of the bed.
- This position promotes gastric emptying and prevents esophageal reflux.
- Pt is supine with HOB at 30o
- Often used to prevent regurgitation and/or aspiration
- Pt on side halfway between lateral and prone positions. (Weight is on the anterior ileum, humerus, and clavicle.)
The lower arm is behind the client while the upper arm is in front. Both legs are flexed, but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee.
- Comfortable sleeping position for many clients
- Promotes oral drainage.
- Pt is on back with head and shoulders elevated slightly on a pillow
- The entire bed is tilted with the head of the bed lower than the foot of the bed.
- This position is used during postural drainage, and it facilitates venous return.
The Joint Commission
Regulatory agency that sets quality standards for the accreditation of health care facilities
Preventative Health Care
Focuses on educating and equipping clients to reduce and control risk factors of disease.
Examples include: programs that promote immunizations, stress management, and seat belt use.
Primary Health Care
Emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. Requires a sustained partnership btwn the client and provider.
Examples include: office or clinic visits and scheduled school or work-centered screenings (visions, hearing, etc.)
Secondary Health Care
Includes the diagnosis and treatment of emergency, acute illness, or injury.
Examples include: care that is given in hospital settings, diagnostic centers, or emergent care centers.
Tertiary Health Care
Involves the provision of specialized, highly technical care.
Examples include: oncology centers and burn centers.
Restorative Health Care
Involves intermediate follow-up care for restoring health.
Examples include: home health care, rehabilitation centers, and skilled nursing facilities.
Continuing Health Care
Designed to address long-term or chronic health care needs.
Examples include: hospice, adult day care, and in-home respite care.
Death: Formal Definitions
Death is determined by one of two criteria:
1. An irreversible cessation of circulatory and respiratory functions
2. Irreversible cessation of all functions of the entire brain, including the brain stem
Based on the Uniform Determination of Death Act (UDDA)
Informed Consent: The Nurse's Role
- Witnesses the informed consent
- Ensure that the provider gave necessary info
- Ensure that client understood info given
- Have client sign informed consent form
- Notify provider if client has questions, doubts, or seems unclear -- it is the provider's responsibility to give clarification
- Documents questions, reinforcement of teaching, the use of an interpretor
- Suspicion of abuse: child, elder, domestic violence
- Communicable diseases (via health dept. protocols) -- there are 60+ reportable commincable diseases as defined by the CDC
S - Subjective Data
O - Objective Data
A - Assessment (& nursing diagnosis)
P - Plan
I - Intervention
E - Evaluation
Addresses the needs of healthy clients to promote health and prevent disease with specific protections.
- immunization programs,
- child car seat education,
- nutrition and fitness activities,
- health education in schools.
Focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent a worsening health status
- Communicable disease screening and case finding
- Early detection and tx of diabetes
- Exercise programs for older adult clients who are frail
Aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning.
- Prevention of pressure ulcers as a complication of spinal cord injury
- Promoting independence for the client who has traumatic brain injury
Middle adults (35-65) typically experience decreases in ...