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tAble of contents
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The professional nurse
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Infection prevention
25
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Nursing theory
Evidence-based practice
Nursing process
Nursing ethics
Health care delivery
Health promotion
Population health
Cultural competencey
Caring and communication
Patient safety
Vital signs
Head-to-toe assessment
Medication administration
Medication dosage calculation
Pain management
Activity, mobility, and exercise
Oxygenation and airway maintenance
Nutrition
Electrolyte imbalances
Skin and wound care
Hygiene
Urinary elimination
Bowel elimination
Crisis and disaster
Legal considerations
Documentation
1
FIFE
The professional EE
nurse
Levels of Nursing Proficiency
1 Novice:
*Student nurse or RN in a new setting with
no previous experience.
2
Advanced
Beginner:
o
* RN with some experience in a clinical
setting.
O
3 Competent:
*RN with 2-3 years experience in the same
clinical setting.
n
4 Proficient:
* RN with over 2-3 years experience in the
same clinical setting.
5 Expert:
O
*Lengthy experience in a clinical setting.
-
-
.
-
Nursing Process Steps
-
A
D
O
P
I
E
Assessment
* Advanced Practice Registered Nurse
* Clinical Nurse Specialist
*Nurse Practitioner
* Certified Registered Nurse
Anesthetist
*Nurse Educator
*Nurse Administrator
*Nurse Researcher
Diagnosis
Influences on Nursing
Outcomes Identification
*Rising cost of healthcare
*Affordable Care Act
*Medically underserved populations
*Demographic changes
Planning
Implementation
Trends in Nursing
Evaluation
Responsibilities of a Nurse
*
*
*
*
Career Development
-
Accountability
Autonomy
Advocate
Caregiver
* Communicator
* Educator
* Manager
→
I
Nursing Code of Ethics
* Ideas of right and wrong that define the
principles nurses use to provide care on a daily
basis.
⑦
1 Evidence-Based Practice:
* Improves patient safety by basing
nursing practice on the current
available evidence.
2 Quality and Safety Education for
Nurses:
* Core Competencies:
* Patient-centered care
* Teamwork and collaboration
* Evidence-based practice
* Quality improvement
* Safety
* Informatics
-
FEET
AFFAIRE
NURSING
THEORY
is
I
2
Nightingales Environmental Theory
Peplaus Interpersonal Theory
-
* Nurses should be able to manipulate the
environment in a way that will best promote the
patient’s overall health and quality of recovery.
* The nurse-patient relationship is broken
into several stages:
Environmental factors that can be controlled:
-
*
*
*
*
*
Light
Hygiene
Nutrition
Noise
Ventilation
O
1 Pre-Orientation:
-
*Nurse gathers data related to the
patient before patient interaction.
* Ex- receiving report at the start of
a shift.
2 Orientation:
o
-
* Nurse and patient meet for the
first time, issues/problems the patient
is experiencing is determined, and
goals are formed.
Orems Self-Care Deficit Theory
1 Patient participation in self-care
activities improves patient outcomes.
2 The nurse should assist the patient
when necessary to meet the patient’s
physical, psychological, developmental,
and sociological needs.
3 Working Phase:
* The nurse carries out nursing
interventions and therapeutic
activities.
4 Resolution:
* Termination of the nurse-patient
relationship.
o
3 When assisting a patient with their
I
self-care needs, the nurse should
encourage the patient to assist to the
best of their ability.
/
Practice
Research
l
←
.
Theory
Leiningers Culture Care Theory
p
* Nurses need to incorporate the patient’s
culture, values, and beliefs into the
patient’s plan of care in order to provide
effective, culturally congruent care.
.
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3
Evidence-Based practice
PICOT Questions:
-
What is Evidence-Based Practice?
* Evidence-based practice is a step-by-step
process that promotes the best
healthcare practices to achieve the best
patient outcomes.
P: Patient population of interest
*Age, gender, disease, etc.
I: Intervention of interest
* Evidence-based practice integrates:
*Treatment, test, etc.
C: Comparison of Interest
1 Relevant, critically appraised evidence.
*Typical standard of care
compared to your plan of care.
2 The nurses own clinical experience
and expertise.
3 The patients own preferences
and values.
O: Outcome
*Desired result of the nursing
intervention.
7 Steps of Evidence-Based Practice:
T: Time
*Amount of time required
1 Cultivate a spirit of inquiry.
* Question current clinical practices and
methods.
2 Ask a clinical question in “PICOT” format.
Hierarchy of Evidence
-
3 Collect the best evidence.
o
* Review hospital policy, existing guidelines,
quality improvement data, and journal
articles.
o
4 Critically appraise the evidence.
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f
Reviews of
RCTs
* Evaluate and determine the
credibility, value, and usefulness of
the data.
:
6 Evaluate the outcome of your practice
decision.
*Determine if the intervention worked
and if it was effective.
7 Share the outcomes with others.
Rel
iab
le
-
Controlled trail, no
randomization
-
st
Case studies
Mo
O
5 Integrate the evidence with your
own clinical expertise and your patient’s
preferences.
*Apply the research and data to
your plan of care.
Controlled trial with
randomization (RCT)
Reviews of qualitative studies
Qualitative studies
Opinion of experts
#
.
4
Effi EEF
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Nursing
Process
4. Planning
o
What is the Nursing Process?
-
* Nurse must establish priorities when creating
the plan of care.
* Maslows Hierarchy of Needs
* There are 3 types of planning:
1. On admission after assessment
2. Ongoing planning during care
3. Discharge planning
* The nursing process is a 6-step
process for nurses to follow to achieve
the best possible patient outcomes.
* The process provides a framework
to create a care plan for the patient.
Steps of the Nursing Process:
-
Maslows Hierarchy of Needs:
2. Diagnosis
* Analyze assessment and determine what
nursing diagnoses are relevant to the patient
and situation.
* Nursing diagnoses are clinical
judgements about the patients current/
potential health problems or needs.
3. Outcomes Identification
* Identify and set measurable and
achievable goals and outcomes for the
patient.
* Goals should be both short and long-term.
* Goals promote individualized care and
patient participation.
po
Im
Self-esteem
st
Mo
µ
* Collect data related to patient health and
situation.
* Information is gathered from patient
medical history, observation, patient
interviews, physical examinations and
diagnostic reports.
* Collect subjective and objective data.
*Subjective: symptoms, feelings, and
descriptions from patient.
*Objective: Observation and physical
assessment.
* Interpret and document data.
rta
nt
1. Assessment
o
Love and belonging
Safety and security
.
ii.
Physiological
5. Implementation
* Implement the identified nursing
interventions.
* Promote, maintain, and restore patient
health.
* Perform nursing actions and document
care.
6. Evaluation
÷
:
* Evaluate the patients responses to the
implemented nursing interventions.
* Determine if the patient has met the
goals and expected outcomes.
* Determine the effectiveness of the
care plan.
Nursing ethics
Ethical Principles:
* Standards of right and wrong in relation
to social values and norms.
Values:
* Personal beliefs that influence behavior.
Morals:
* Personal beliefs about what is and is
not acceptable for yourself to do.
Basic Principles of Ethics:
1 Advocacy:
*Support of the patient's rights.
2 Accountability:
*Taking responsibility for your own
actions.
3 Responsibility:
*Respecting and carrying out
professional responsibilities.
4 Confidentiality:
*Protection of patient Privacy.
Ethical Dilemma:
* Occurs when there is a conflict between
2 moral principles, not enough scientific
data, and the decision will heavily impact
the patient.
Ethical Principles for Patient Care
1 Autonomy:
* An individuals right to make their own
decisions.
2 Justice:
* Fair and equal healthcare and
distribution of resources.
3 Beneficence:
* Acting in the best interest of others.
4 Non-maleficence:
* The commitment to do no harm.
5 Fidelity:
* Remaining faithful to promises
6 Veracity:
* Commitment to tell the
truth.
4
Solving an Ethical Dilemma:
1 Question if it is an ethical dilemma.
2 Gather all important information
related to the dilemma.
3 Reflect on your own values.
4 State the dilemma and related issues.
5 Analyze all possible options.
6 Select a plan that most closely aligns
with the ethical principle in question.
7 Apply the plan and evaluate the
outcome.
5
IT RARE
REA
Health
Care PFEIFER
Delivery
6
.
Participants
T
EE
O
.
* Consumers
* Providers
* Unlicensed providers
Healthcare Settings
*
*
*
*
*
*
Hospitals
Provider's offices
Urgent care
Homes
Schools
Hospices
*
*
*
*
*
Levels of Healthcare
0
1 Preventive:
o
-
* Education and prevention.
2 Primary Care:
n
.
* Health Promotion.
* Provider offices, clinics, schools.
Community health dept.
Occupational health
Surgical centers
Assisted-living
Adult day care
3 Secondary Care:
o
-
* Diagnosis and treatment
* Inpatient, emergency care centers.
O
4 Tertiary Care:
* Specialized care.
* ICU, specialty units and centers.
-
Healthcare Plans
1 Medicare:
*Federally funded program for adults 65
or people with permanent disabilities.
2 Medicaid:
*Federally and state funded program for
patients with low income.
5 Restorative Care:
* Helps patients reach functional
potential.
* Home care, rehabilitation, extended
care.
6 Continuing Care:
* Prolonged care.
* Hospice, assisted living, pallitive care.
3 Private Insurance:
*Traditional Fee-for-service plan.
ta
4 State children's Health Insurance program:
*For uninsured children up to age 19.
5 Affordable Care Act:
*Also known as Obamacare, increases
access to healthcare and decreases
healthcare costs.
.
Issues Facing Healthcare Delivery
-
}
1 Nursing shortage
2 Provider competency
3 Quality and safety
*Patient Satisfaction
*Outcomes directly related to nursing
care.
4 Nursing Informatics and technological
advancements
5 Globalization of healthcare
.
7
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HEALTH
PROMOTION
.
.
Internal Variables Affecting Health:
*
*
*
*
*
*
*
Educational level
Developmental stage
Age
Perception of functioning
Spirituality
Emotional Factors
Genetics
Levels of Prevention:
-
⇐tE
Tertiary
Prevention
Secondary Prevention
External Variables Affecting Health:
*
*
*
*
*
*
Culture
Family practices
Socioeconomic status
Psychosocial factors
Environment
Lifestyle
Risk Factors:
:
1 Genetics:
* Determines predispositions to hereditary
disorders.
* Heart disease, cancer, etc.
2 Gender:
*Some diseases are more common in a
certain gender.
3 Physiological:
*There are certain states in which people
are more at risk.
*Ex- pregnancy.
4 Environment:
*Frequent exposure to toxic chemicals or
pollutants at home or work.
o
5 Lifestyle:
-
*Stress, substance abuse, sun exposure,
poor diet, lack of exercise.
O
6 Age:
-
*Certain health conditions become more
common with aging.
Primary Prevention
1 Primary Prevention:
* Focused on health promotion, disease
prevention, and wellness education.
* Immunizations, yearly wellness visits,
fitness activities, health education.
2 Secondary Prevention:
* Focused on diagnosis and intervention
to delay disease progression.
* Disease screenings, early treatments,
exercise programs.
3 Tertiary Prevention:
* Focused on rehabilitation, prevention of
long-term consequences, and promoting
independence.
* Rehabilitation centers, support groups.
Nursing InterventionS:
-
J
* Assess patient risk factors
* Encourage patient behavior-change if
necessary.
* Promote healthy behaviors.
ed
Prime
referee
Population
Health
Social Determinants of Health
* Social determinants of health are factors
that contribute to an individual's current
state of health.
O
1 Biology and Genetics:
*Sex and age
8
Vulnerable Populations:
1 People living in poverty:
* Hazardous environments, high-risk
jobs, less nutritious diets.
O
2 Older adults:
-
-
O
2 Personal Behavior:
* Alcohol, drug use, sex practices, smoking.
-
* Chronic diseases and a greater need
for health services.
O
3 Homeless individuals:
-
* No proper shelter, poor nutritional
status, lack of access to healthcare.
4 Immigrants:
* Language barriers, lack on benefits,
lack of resources.
3 Social Environment:
* Discrimination, income, gender.
5 People with mental illness:
* Higher risk for homelessness and abuse.
4 Physical Environment:
* Living conditions.
* Urban or rural area.
6 People in abusive relationships:
* Possible fear of seeking healthcare.
Roles of a Community Nurse:
o
.
5 Health Services:
* Access to healthcare.
* Access to health insurance.
Health Disparities:
* A higher burden of disease, disability, or
mortality experienced by disadvantaged
populations that is preventable.
* Related to unequal distribution of
resources.
* Can be related to sex, race, ethnicity,
education. income, sexual orientation,
or geography.
*
*
*
*
Caregiver
Educator
Counselor
Collaborator
*
*
*
*
Epidemiologist
Patient Advocate
Change Agent
Case Manager
Community Health Assessment:
* Identifies key heath needs of a population
or community through data collection.
O
1 Structure:
-
* Geography, services, housing,
transportation.
o
2 Population:
* Age, sex, growth, density, ethnicity,
religion of members of the community.
O
3 Social System:
* Government, education system, and
health system.
-
-
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Cultural
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Culture and Perception of Illness
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and Disease:
What is Culture?
* Customs, norms, and values passed
through generations of a particular
nation, people, or group.
* Illness: How patients and their families react to
a diagnosis or disease.
Transcultural Nursing:
-
*Disease: The actual physiological and biological
disease process in the body.
* Nursing with a primary focus of
understanding similarities and
differences of cultures in order to
provide culturally competent care.
-
-
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get
grog
⑧
Culturally Congruent Care:
* Nursing care that aligns with the patient's
cultural beliefs, values, and worldview.
.
-
.
Cultural Competency:
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* The ability of a healthcare provider to
provide care that meets the cultural beliefs
and practices of their patients.
Cultural Assessment:
5 Components of Culturally
Congruent Care:
1 Cultural Awareness:
*Examine your own biases, beliefs,
background, and assumptions.
2 Cultural knowledge:
*Knowledge of the beliefs, values, and
practices of many cultures.
* Completed with the goal of gathering
3 Cultural Skills:
information that is relevant to the patients
*Ability to collect relevant cultural data that
culture to form a culturally congruent plan
will influence the care of your patient.
of care.
4 Cultural Encounters:
Ask about:
*Engagements with culturally diverse patients
that provide opportunities to learn about
* Cultural affiliation
other cultures.
* Cultural restrictions
* Health beliefs and practices
5 Cultural Desire:
* Religious affiliation
*Motivation to learn about other cultures
* Nutrition
and become more culturally aware.
* Primary language
* Values
-
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Caring
and communication
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Aspects of Caring in Nursing:
Therapeutic Communication:
-
1 Be Present:
* Creates a sense of openness and
understanding.
*Forms a connection between nurse and
patient.
* Includes eye contact, body language, tone
of voice.
* Encourages patient to express thoughts
and feelings.
* Creates trust and respect between nurse
and patient.
o
2 Listening:
*Interpret and understand what the patient
is saying in an accepting and non-judgmental
way.
-
O
3 Touch:
*Conveys a sense of comfort and security
to the patient.
*Be aware patient's cultural practices
related to touch.
-
4 Relief of symptoms:
*Improves the patients level of comfort
and conveys respect and dignity.
5 Family Care:
*Know the family as well as you know the
patient.
J
Therapeutic Communication
Techniques:
o
1 Active Listening:
* Paying complete attention to the patient.
o
2 Body Language:
* Sit facing patient
* Maintain comfortable eye contact and
open position.
3 Touch:
* Be comforting and nonthreatening
* Ask permission before initiating touch.
4 Silence:
* Allows patient to sort out their thoughts.
5 Validation:
* Acknowledge patient's feelings / thoughts.
6 Paraphrase:
*Restate what patient said to show active
listening.
-
-
Hi
5 Levels of Communication:
* Intrapersonal:
* “Self-talk", your own thinking.
* Interpersonal:
*Face-to-face, between nurse and another
person.
* Small-Group:
*Between a small number of people.
* Public:
* Speaking to an audience.
* Electronic:
* Communication using technology.
=
Non-therapeutic Communication
* Discourages the patient from expressing
their feelings.
* Damages the nurse-patient relationship.
=
J
-8
*
*
*
*
*
*
Non-therapeutic
Communication Techniques:
Personal questions opinions
Asking for explanations
Approval or dissaproval
Arguing
False reassurance
Changing the subject
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Patient
safety
FAT
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Basic Physiological Safety:
* Oxygen
* Nutrition
* Temperature
* Must be met before any
other needs!
Falls:
O
* Older adults, people with vision or
balance problems, and people on certain
medications are at higher risk.
* Fall prevention = major nursing priority.
Safety Risks By Age:
-
Fall Prevention:
-
o
1 Infant- Preschool:
*
*
*
*
*
*
-
* Injuries, accidental poisoning, choking.
2 School-Age
*Head injuries, bicycle accidents, car
accidents.
3 Adolescent:
*Alcohol and drug use, sexually transmitted
infections, car accidents.
4 Adult:
*Alcohol use, smoking, stress, car
accidents.
5 Older Adult:
*Falls
11
Complete a fall-risk assessment
Place call bell in reach of patient
Provide adequate lighting for patient
Orient patients to their setting
Keep bed in low position with locked brakes
Keep floor clear of obstructions
Seizure Precautions:
*
*
*
*
Maintain airway patency
Remove items that could cause injury
Do not restrain patient
Lower patient to floor or bed
Seclusion and Restraint:
O
Personal Risk Factors:
-
*
*
*
*
*
Patient age
Impaired Mobility
Sensory or communication deficits
Lifestyle
Lack of safety awareness
Risks in Healthcare Facilities:
-
* Falls
* Accidents that result from an action of the
patient.
* Procedure- related accidents
* Equipment-related accidents
* Use only when less restrictive measures are
not effective.
* Must obtain order from provider ASAP.
* Assess skin integrity frequently and
provide range-of-motion exercises.
* Regularly determine need for restraints.
Fire Safety:
o
R:
A:
C:
E:
O
Rescue patients
Activate alarm
Contain fire
Extinguish fire
D
Pull pin
Aim at base
Squeeze handle
Sweep area
P:
A:
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FEE
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Infection
12
i ÷÷÷:
Types of Pathogens:
* Bacteria
* Viruses
* Prions
* Fungi
* Parasites
Types of Immunity:
-
Virulence:
o
* A pathogens
ability to invade
and damage a
host.
O
1 Innate: immunity we are born with.
Standard Precautions:
-
* Precautions that apply to all patients.
*Hand hygiene
*Gloves when in contact with bodily
fluids
*Masks and eye protection when there is
potential spraying of bodily fluids.
-
* Skin and mucous membranes.
c2 Adaptive: acquired when people are exposed
to diseases or vaccinations.
O
3 Passive: immunity that is produced by an
external source and is only temporary.
*Ex- through breastfeeding
-
Chain of Infection:
1 Causative agent: the pathogen.
2 Reservoir: areas and objects
where the pathogen can grow
and multiply.
3 Portal of exit: the means by which the
pathogen can leave the reservior.
4 Mode of transmission: how the pathogen can
spread from one place to another.
5 Portal of entry: where the pathogen is able
to invade the host.
6 Susceptible host: people with compromised
defense mechanisms.
Stages of Infection:
J
E.
1 Incubation: time between pathogen invading the
host and the first symptom.
2 Prodromal Stage: time between onset of first
symptoms to more distinct symptoms.
3 Illness stage: acute, illness-specific symptoms.
4 Convalescence: Acute symptoms dissapear,
recovery begins.
=
Transmission Precautions:
-
O
1 Airborne Precautions: protects against
-
droplet infections smaller than 5 mcg.
*Ex- measles, varicella, tuberculosis.
*Private room
*Masks (N95 or HEPA respirator for
tuberculosis)
*Negative pressure room.
*Full face protection if chance of
splashing or spraying.
2 Droplet Precautions: protects against
droplets larger than 5 mcg.
* Ex- strep, pneumonia, rubella, pertussis,
mumps.
* Private room or placed with another
patient with the same condition.
* Masks
o
3 Contact Precautions: protects caregivers
-
when within 3 feet of the patient.
* Ex- shigella, wound infections, herpes,
scabies.
*private room or placed with another
patient with the same condition.
* Gloves and gown.
* Infectious dressing material put into
non-porous bag.
Personal Protective Equipment:
=
4 Protective Precautions: protects patients
Donning PPE:
1. Hand hygiene
2. Gown
3. Mask
4. Goggles
5. Gloves
-
Removing PPE:
1. Gloves
2. Goggles
3. Gown
4. Mask
5. Hand hygiene
-
who are immunocompromised.
* Private room with positive airflow and
HEPA filtration.
* Mask for patient when out of their
room.
13
Vital Signs
÷÷i÷÷
Temperature:
Oral: (mouth)
*Normal= 96.80-100.4°F or 36-38°C.
*Place thermometer under the tongue.
*Only use with patients age 4 and older.
Tympanic: (ear)
*Normal = 0.5-1.0°F or 0.3-0.6°C higher
than oral.
*Pull ear back and place probe in outer ear
canal.
* For patients older than 3 months.
Rectal:
* Normal = 0.9°F or 0.5°C higher than oral.
* Patient in SIMS position, place probe 1-1.5
inches in.
*Do not use on patients with diarrhea or if
they are on bleeding precautions.
*Use on patients older than 3 Months.
Axillary: (armpit)
* Normal = 0.9°F or 0.5°C lower than oral.
* Place in center of armpit and hold arm
down.
* Can be used with all ages.
Temporal: (forehead)
*Normal = 1.0°F or 0.5°C higher than oral.
*Slide probe across forehead to temporal
artery.
*Can be used with all ages.
'
Respirations:
* Rate = full inspirations and expirations in one
minute.
*Normal = 12-20 breaths / minute (adults),
30-40/min (newborns), 20-30/min (children).
* Depth = how much the chest wall expands
with each breath.
* Rhythm = time intervals between breaths.
Pulse Oximetry:
* Measures oxygen saturation
* Clips onto finger or earlobe
* Normal = 95-100%
Pulse:
*Rate = beats / min
* Normal = 60-100 beats (min (adult)
* Pulse rate is usually higher in children.
* Rhythm: intervals between pulses.
* Strength: strength of each contraction/
beat.
0 = absent
1+ = diminished
2+ = brisk, as expected
3+ = increased, strong
4+ = bounding
* Tachycardia: Pulse over 100 beats / min.
* Bradycardia: Pulse under 60 beats / min.
* Radial pulse most common for
measurement.
* Measure 30 seconds and multiply by 2.
* Most common pulse points:
* Carotid * Popliteal
* Brachial * Dorsalis pedis
* Ulnar
* Posterior tibial pedis
* Femoral
Blood Pressure:
* Width of cuff should be 40% of arm.
* Cuff should be placed 1 inch above the
elbow crook in line with brachial artery.
* Inflate cuff 30mm Hg above estimated
palpated systolic pressure.
* Release pressure slowly until first clear
sound (systolic) and release after
sounds disappear (diastolic).
Systolic
Diastolic
* Classifications:
Systolic
*Recorded as:
< 120
Diastolic
< 80
Prehypertension
120-139
80-89
Stage 1 hypertension
140-159
90-99
Stage 2 hypertension
> 160
> 100
Normal
14
Head-To-Toe Assessment
Ets
Mouth:
O
General Survey:
*
*
*
*
* Lips should be pink, moist and
smooth.
* Gums and mucous membranes
should be pink with no lesions
* Teeth should be clean, white,
and smooth.
Physical appearance * Behavior
Body structure
* Mood and speech
Nutritional status * Hygiene and dress
Mobility
Vital Signs:
y
* Temperature * Blood pressure
* Pulse
* Oxygen Saturation
* Respirations
* Uvula should be pink,
midline, and should move.
* Tonsils should be the same
color as the surrounding
area.
Lungs and Heart:
0
Head and Face:
y
* Head:
* Should be symmetrical and proportionate
to body.
* Assess for depressions, masses, and
deformities.
* Face:
*Features should be symmetrical and
proportionate.
* Assess for touch sensation and motor
function by asking patient to run through a
series of expressions.
* Chest should be round, convex, and
symmetrical.
* Palpate chest surface for lumps and
lesions.
* Percuss thorax and compare each side.
* Auscultate lung sounds on both the anterior and
posterior sides in ladder formation.
* Auscultate heart sounds:
* Aortic: 2nd right intercostal space.
* Pulmonic: 2nd left intercostal space.
*Erbs Point: 3rd left intercostal space.
*Tricuspid: 4th left intercostal space.
*Mitral: 5th intercostal space at
midclavicular line.
Neck:
* Lymph Nodes:
* Palpate from lower head and down the
neck for enlarged nodes.
* Thyroid:
* Palpate while instructing patient to swallow.
* Assess for any enlargement or masses.
* Trachea:
*Should be midline with no masses.
J
Eyes:
i.IS
* Assess coordination by asking patient to
move their eyes in the six cardinal
directions.
* PERRLA: pupils clear, equal, round, reactive to
light, and accommodating.
* Note any abnormal discharge or tenderness.
Ears:
O
Nose:
O
* Check for lesions,
deformities, and discharge.
* Tympanic membrane
should be intact and
landmarks visible.
* Should be midline and
symmetrical.
* Mucous membranes
should be intact and
pink.
-
Throat:
O
Abdomen:
*
*
*
*
Inspect shape and symmetry.
Auscultate bowel sounds in all 4 quadrants.
Percuss all 4 quadrants.
Palpate all 4 quadrants and assess for rebound
tenderness.
Skin:
O
* Inspect skin's color, moisture, turgor, texture, and
presence of lesions.
* Assess color, firmness, curvature, and capillary
refill or nails.
* Assess cleanliness and distribution of hair.
f
Peripheral Arteries:
* Assess strength and equality of pulses.
* Assess the presence of edema.
* Edema assessment:
1+ : 2mm depression, immediate rebound
2+ : 3-4mm depression, rebound < 15 seconds
3+ : 5-6mm depression, rebound 10-30 seconds
4+ : 8mm depression, rebound in > 20 seconds
15
I
Medication Administration
administration
Pharmacokinetics
A
4. Inhalation Route:
o
* Administered through nasal or oral
passages.
€0
5. intraocular Route:
*Administered to the eye area for
a localized effect.
-
Absorption: medication reaches the
bloodstream from the site of administration.
Distribution: medication is distributed to
tissues and organs.
Metabolism: medication reaches the
intended site and begins to break down.
Excretion: metabolized medication leaves
the body through the kidneys, bowels, lungs
and glands.
.
.
-
-
Types of Medication Orders:
-
.
-
1. Routine Orders:
O
-
.
*Given on a regular schedule until the
provider cancels or replaces the order.
2. PRN Orders:
o
*Given at the request of a patient
or when the RN observes the need.
3. One-Time Orders:
÷
*To be given once at a specific time.
4. STAT Orders:
*To be given once and immediately.
5. Now Orders:
*To be given once up to 90 minutes
after the order is given.
.
Medication Actions
J
-
Therapeutic effects: expected response
Adverse effects: unintended responses
*Side effects
*Toxic effects: excess amounts in blood
*Idiosyncratic reactions: unexpected
response
*Allergic reactions
Medication Interactions
-
f
Routes of Administration
1. Oral, Buccal, and Sublingual:
*Most convenient and easiest.
*Avoid if patient has difficulty
swallowing, GI issues, or vomiting.
2. Parenteral Routes:
*Intradermal: injection into the dermis
*26-27 gauge, 10-15 degree angle
*Subcutaneous: injection below the dermis
*25-27 gauge, 45-90 degree angle
*Intramuscular: injection into a muscle
* 18-27 gauge, 90 degree angle
*Intravenous: injection into a vein
*16-24 gauge, 15-30 degree angle
3. Topical Administration:
O
*Applied to the skin or mucous membranes
for a localized effect
*Apply evenly with gloves and applicators
=
.
-
-
l
l
6 Rights of Medication Administration
1. Right medication
2. Right dose
3. Right patient
4. Right route
5. Right time
6. Right documentation
Components of Medication Orders
*
*
*
*
* Route
Patient’s full name
Date + time of order * Time/frequency
* Provider’s signature
Medication name
Dosage
Preventing Medication
Errors
J
i
* Read labels 3 times and compare with
MAR.
* Use at least 2 patient identifiers.
* Double check all calculations.
* Follow the 6 rights of medication.
administration.
*Document all medications as soon as they
are given.
i
IT Calculation
THENIET I
dosage
IT
Conversions:
s
16
Liquid Dosages:
s
* Order: 30mg Prozac PO daily
* Available: Prozac 20mg per 5mL
* Solve: How many ML should be administered?
30 mg
5 mL
7.5 mL
20 mg
X
a
②* -x
*
*
*
*
1
1
1
1
Kg = 2.2 lbs
mg = 1,000 mcg
g = 1,000 mg
oz = 30 mL
*
*
*
*
1
1
1
1
L = 1,000 mL
tsp = 5 mL
tbsp = 15 mL
tbsp = 3 tsp
Rounding:
Injectable Dosages:
*
*
*
1
Order: Benadryl 80mg IM four times/day.
Available: Benadryl 50mg per mL.
Solve: how many ML will be administered?
mL
80 mg
1.6 mL
50 mg
X
* Less than 1.0 = round to nearest
hundredth
* Greater than 1.0 = round to nearest
tenth.
-x-=£
Dimensional Analysis:
y
Weight-Based Dosages:
* Order: 600mg acetaminophen q 6 hrs PRN
* Available: 300mg tablets
÷
1 Determine the unit that you are calculating.
* Tablets
2 Determine the quality available.
* 1 tablet
3 Determine the dose available.
* 300 mg
4 Determine the desired dose.
* 600 mg
5 Do you need to convert units?
* No
6 Set up the problem and solve.
Desired dose
Quanity
×
Available dose
1 Tablet
600 mg
x
-
X
-
300 mg
=
2 tablets
O
X
Solid Dosages:
* Order: Motrin 800mg PO 3 times a day
* Available: 400mg tablets
* Solve: how many tablets per dose?
1 Tablet
400 mg
-
x
800 mg
2 Tablets
=D
X
-
ng
* Order: Amoxicillin 40mg per 1 kg divided into
2 doses
* Available: Amoxicillin suspension 400mg 15mL.
* Solve: how many ML given per dose for a
22lb child?
1 Convert lb to kg: 22 lb / 2.2 = 10 kg
2 Calculate dose in mg: 40 mg 1o kg 400 mg
1 kg
X
3 Divide dose by frequency:
400mg / 2 = 200 mg per dose
4 Convert mg to mL:
200mg
5 mL
X
400 mg
2.5 mL per dose
IV Flow Rate with Electronic Pump:
J
* Order: 1000 mL of D5W in 8 hours
Volume = X ml/hr
Time
1000 mL = 125 mL/hr
o
8 hours
Manual IV Infusions:
* Order: 1200mL to
* Solve: how many
is 15 gtts 1mL?
1200
Volume
Drop
X
Time (min) factor 360
be infused over 6 hours.
gtt/min if the drop factor
mL
-
-
min
x
15 gtts
-
1 mL
50 gtts/min
=L
lit
IT
Pfi
FEET IF
PAIN
MANAGEMENT
17
.
Physiology of Pain:
* Transduction:
* Conversion of painful stimuli to electrical
impulse.
* Transmission:
* Electric impulse travels along nerve fiber.
* Perception:
* Awareness of pain in the brain.
* Modulation:
* Muscle reflexes that move the body away
from painful stimuli.
-
-
-
-
* Pain threshold: point at which someone feels
pain.
* Pain tolerance: amount of pain someone can
stand.
=
Types of Pain:
1 Chronic:
* Ongoing, lasting over 6 months.
2 Acute:
* Temporary, has a direct cause, often
alters vital signs.
3 Nociceptive:
* Caused by tissue damage, localized.
4 Neuropathic:
* Caused by damaged pain nerves.
Pain Assessment:
* Heart rate, respiratory rate, blood pressure,
and muscle tension may be increased.
* Expected behaviors include restlessness,
guarding, crying, grimacing, decreased
attention span.
*Ask:
* Location and feeling of pain?
* Rate pain on scale of l-10?
* When did it start?
* Is it constant or intermittent?
* What makes it better?
* What makes it worse?
Factors That Influence Pain:
1 Age
O
* Infants can't verbalize pain.
2 Cognitive function
O
* Patients with cognitive impairment may
have difficulty verbalizing pain.
3 Fatigue
y
4 Genetic sensitivity
5 Anxiety or fear
o
6 Culture:
* Influences people's meaning of pain.
s
J
Patients at Risk for Pain
Under-Treatment:
*
*
*
*
Older adults
Patients with substance abuse disorders.
Children
Infants
Non-pharmacological Pain
Management:
*
*
*
*
*
*
Relaxation
Guided imagery
Distraction
Music
Cutaneous stimulation: heat. ice, etc.
Acupuncture, acupressure.
Pharmacological Pain Management:
T
e
1 Non-opioid analgesics:
* Ex- acetaminophen
* Monitor liver function
* Take with food
O
2 Opioids:
* Ex- morphine
* Used to manage acute, severe pain
* Consistent timing of administration is
important
* Monitor:
* Respiratory depression
* Sedation
* Urinary retention
* Orthostatic hypotension
* Vomiting
* Constipation
-
⇐±i÷⇐÷
E. iii. Mobility
RELIENT and
EREMITE
Activity
Exercise and Activity:
-
* Important for maintaining health.
* Treatment for chronic illnesses.
* Enhances functioning of all body systems.
18
J
Pathological Influences on
Activity:
1 Disorders involving bones, joints, and
muscles:
* Osteoporosis: reduction of bone mass.
* Osteomalacia: inadequate bone
calcification.
* Arthritis: inflammation in joints.
* Joint degeneration
2 Damage to the central nervous system:
* Paralysis
3 Musculoskeletal trauma:
* Broken bones
-
Assessment of Activity:
-
* Assess body alignment and posture.
* Ask if patient has any muscle or joint pain.
* Ask if patient has shortness of breath or
chest pain during activity.
* Ask how often the patient exercises.
Effects of Exercise:
* Increased cardiac output and stronger
contractions
* Improved venous return
* Improved alveolar ventilation
* Improved basic metabolic rate
* Improved muscle tone
* Improved tolerance to physical activity
* Reduced bone loss
* Improved stress tolerance
Transfer and Positioning:
-
* Use mechanical lifts or teams when patient
is unable to assist.
* RN should widen stance for more stability.
* RN should lower their center of gravity.
* RN should Face the direction of movement.
Activity and Chronic Illness:
T
Maintaining Mobility:
:
* Stretching exercises
* Active Range of motion exercises
* Low-intensity walking.
Assistive Devices for Walking:
1 Walker:
* Provides stability
* Patient steps. Moves Walker forward,
then steps again.
2 Cane:
.
* Cane goes on the stronger side of the
body.
* Patient moves cane forward, steps
forward with weaker leg, then stronger leg.
o
3 Crutches:
o
1 Hypertension:
* Usually for temporary use.
A
* Exercise reduces blood pressure.
* Position the grips so bodyweight isn't on
o
2 Coronary Heart Disease:
armpits
* Reduced mortality and morbidity
* Crutches can be used with a 2-point or
* Improved ventricular function
swing-through gait.
* Increased functional ability
* When ascending stairs: step up with
o
3 COPD:
unaffected leg, then crutches and
* Helps to lessen progressive deconditioning
affected leg follows.
that causes dyspnea.
* When descending stairs: crutches are
O
4 Diabetes
placed on the stair below, affected leg
* Improved glucose control and lower blood
follows, then unaffected leg.
sugar levels.
-
-
-
GE
Qb
-
:
-
EB.EgqtoE.mhghamaaa.at
Oxygenation
19
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J
Physiological Impacts on
Oxygenation:
1 Decreased oxygen carrying capacity:
* Ex: anemia, carbon monoxide poisoning.
o
2 Hypovolemia:
* Reduced blood volume (dehydration, shock).
O
3 Decreased inspired oxygen:
* Ex: airway obstruction.
O
4 Increased metabolic rate:
* Ex: pregnancy, wound healing, exercise.
-
-
-
E
Oxygen Therapy:
F¥iE
1 Low-Flow Oxygen Delivery:
* Nasal cannula:
* Delivers 1-6 L / Min, 24-44 %
* Assess Patency of nose
* Assess for skin breakdown
* Simple Face Mask:
* Delivers 5-8 L / Min, 40-60%
* Assess for proper seal and fit
* Assess For skin breakdown
* Partial Rebreather Mask:
* Delivers 6-10 L / Min, 40-70%
* Reservoir bag should not completely
deflate.
* Non-rebreather mask:
* Delivers 10-15 L / Min, 60-100%
* Frequently assess valve function
-
-
Changes in Respiratory Function:
=
1 Hyperventilation:
* Rapid respirations causing exhalation of
excessive amounts of carbon dioxide.
2 Hyperventilation:
* Inadequate oxygen intake.
3 Hypoxia:
* Inadequate tissue oxygenation
* Life-threatening
Pneumothorax: Air in the pleural space.
Hemothorax: Blood and fluid in the pleural
space.
o
Lifestyle Factors:
* Nutrition
* Exercise
* Smoking
* Substance abuse
* Stress
Pulse Oximetry:
o
* Measures oxygen saturation in blood.
* Measure when patient is experiencing:
* Wheezing
* Coughing
* Cyanosis
* Changes in respiratory rate
* Normal finding = 95-100 %
* Values may be lower in older adults and
patients with COPD.
IT
-
2 High-Flow Oxygen Delivery:
* Venturi mask :
* Delivers 4- 12 L / Min, 24-50%
* Assess flow rate and ensure tubing
is free of kinks.
* Aerosol Mask:
* Face tent, tracheostomy collar
* Delivers at at least 10 L / min
* High humidification
Incentive Spirometry:
-
* Promotes deep breathing
* Prevents postoperative respiratory
complications.
Pursed-Lip Breathing:
-
* Deep inspiration and extended exhalation
* Prevents alveolar collapse
Diaphragmatic Breathing:
T
* Improves breathing efficiency
* Focuses on breathing more with the
diaphragm and less with the accessory
muscles.
NUTRITION
NUTRITION
iBaFBFEAm
imma
www.pogzt.BE
.
Units of Nutrition:
-
Nutrition Assessment:
-
1 Carbohydrates:
-
* Dietary History:
* What patient eats in a day
* Fluid intake
* Allergies
* Appetite
* Religious and cultural restrictions
* Activity levels
* body's main source of energy.
* Ex: whole grain bread, potatoes, brown rice,
etc.
O
2 Proteins:
* Growth, maintenance, and repair of tissue.
* Ex: beef, whole milk, poultry, etc.
←
3 Fats:
* Most calorie dense
* Provides vitamins and energy.
4 Water:
* Critical for cell function.
5 Vitamins:
* Necessary for metabolism.
6 Minerals:
*Essential for biochemical reactions in body.
-
-
* Clinical Measurements:
* Height and weight
* Skin fold measurements
* Lab values (cholesterol, electrolytes, etc.)
* BMI:
-
Underweight
Normal
Overweight
Factors Affecting Nutrition:
* Financial Status:
* Low income patients may not have access
to nutrient-dense foods.
* Appetite:
* Can increase or decrease with illness,
medication, and pain.
* Age:
* Affects nutritional requirements.
* Religion and culture:
* Some cultural practices influence food
choices.
#
-
-
Eating Disorders:
TL
1 Anorexia:
O
-
* Consistent restriction of caloric intake.
* Intense fear of gaining weight.
O
2 Bulimia:
* Recurrent cycle of binge eating and
purging.
O
3 Binge-Eating Disorder:
* Repeated episodes of binge eating.
* Lack of control.
Obese
Extremely Obese
< 18.5
18.5 - .9
-29.9
30-34.9
> 35
Therapeutic Diets:
* Clear liquid: clear fruit juice, gelatin, broth.
* Full liquid: clear liquid plus liquid dairy.
* Puree: liquids plus pureed meats, fruit, and
eggs.
* Mechanical: liquid and diced /ground foods.
* High fiber: whole grains, fruits.
* Low sodium: no added salt, under 2g
sodium.
* Low cholesterol: less than 300 Mg / day.
*=
Diabetic: Balanced intake of carbs,
proteins, and fats.
* Dysphagia: thickened liquid, pureed food.
#
#
T
z
-
Recording Input and Output:
J
-
-
20
* Important for patients with fluid and
electrolyte imbalances.
* Weigh patients:
* Same time of day
* After voiding
* Wearing the same type of clothing.
21
FIFI
THEImbalances
FEIFFER
Electrolyte
Hyponatremia:
Causes:
Headache
Confusion
Dizziness
Lethargy
Hypokalemia:
*
*
*
*
Symptoms: *
*
*
*
*
*
*
*
K
< 3.5
Causes:
*
*
*
*
Symptoms: *
*
*
*
Causes:
*
*
*
*
Na
> 145
Diabetes insipidus * Fluid losses
Heat stroke
Dehydration
Sodium retention
Hyperthermia
Tachycardia
Thirst
Restlessness
Hyperkalemia:
Ca
< 9.0
K
> 5.0
Sepsis
* uncontrolled
Trauma
diabetes
Kidney failure * Dehydration
Metabolic acidosis
Hypercalcemia:
* Hypothyroidism
Diarrhea
Pancreatitis * Alcoholism
Malabsorption
Vitamin D Deficiency
Causes:
Numbness
* Prolonged QT
Tingling
interval
Muscle spasms
weak Pulse
Symptoms: *
*
*
*
Hypomagnesemia:
Causes:
Hypothermia
Tachycardia
Nausea
Edema
Hypernatremia:
Hyperthermia * Weakness
Symptoms: * Irregular pulse * Abdominal
Weak pulse * Muscle cramps
* Irritability
cramps
Hypotension * Flattening T-Waves
* Parenthesis
* V-fib
Respiratory distress
* Decreased reflexes
Hypocalcemia:
*
*
*
*
*
*
*
*
Vomiting
* Bulimia
Diarrhea
* Corticosteroids
Gastric suctioning
Osmotic diuretics
Symptoms: *
*
*
*
Causes:
< 135
* Heart failure
Fluid loss
Hyperglycemia * Diuretics
Inadequate sodium intake
Increased ECF volume
*
*
*
*
Symptoms: *
*
*
*
Causes:
Na
Mg
< 1.3
Diarrhea
* Alcoholism
Gastric suction
Thiazide diuretics
Malnutrition
Symptoms: *
*
*
*
* Dysrhythmias
Tatany
* Tachycardia
Seizures
Hypoactive bowel
Hypertension
*
*
*
*
Bone cancer
Hypothyroidism
Prolonged Immobilization
Glucocorticoid use
Bone pain
* Heart dysthymia
Constipation
* Anorexia
Weakness
Deceased reflexes
Hypermagnesemia:
Causes:
Ca > 10.5
Mg
> 2.1
* Kidney failure
* Low adrenal function
* Laxatives containing Mg
Symptoms:
* Muscle paralysis * Coma
* Cardiac arrest
* Hypotension
* Decreased respiratory rate
EE EFF
EA and
Skin
Wound Care
22
¥i¥÷¥¥¥¥
Stages of Wound Healing:
-
Pressure Wound Staging:
-
1 Inflammatory Phase:
o
* Stage 1:
* Skin intact, but non-blanchable
* Appears reddened
* Stage 2:
* Involves epidermis and
dermis
* Wound is visible and appears
similar to blister/shallow crater
* Stage 3:
* Involves subcutaneous tissue
and may extend down to fascia.
* No tunneling, or exposed
muscle, tendon, or bone.
* Stage 4:
* Extends into muscle, tendon, or
bone.
* May have tissue necrosis and
tunneling.
* Unstageable:
* Stage can't be determined due
to eschar obscuring the view.
-
* Lasts 3-6 days after injury
* Vasoconstriction and WBCs in the area.
* Localized redness, warmth, swelling.
o
2 Proliferative Phase:
* 3-21 days after the inflammatory phase.
* Replacement of lost tissue.
3 Maturation phase:
o
* After day 21, can last up to 1 year.
* Strengthening of collagen, regaining a more
normal appearance.
-
-
Healing Processes:
1
Primary Intention:
* Little to no tissue loss.
* Clean edges (ex-surgical incision).
* Heals quickly, minimal scarring.
2 Secondary Intention:
* Loss of tissue with separated edges.
* Pressure wounds, burns.
* Longer healing time, more scarring.
3 Tertiary Intention:
* Very separated and deep.
* High infection risk.
* Significant drainage.
Assessment of Wounds:
-
* Assess color:
* Red: healthy regeneration=cover wound
* Yellow: healthy drainage=clean wound
* Black: eschar=debride wound
* Assess size of wound:
* Length, width, depth
* Presence of tunnels
* Presence of redness / swelling
#
-
Possible Complications:
T
-
-
FIE
-
* Dehiscence: separation of a sutured wound.
*=
Evisceration: dehiscence that involves the
protrusion of internal organs.
FIE
Types of Drainage:
-
* Serous: clear, watery plasma
* Sanguineous: bright red, active bleeding
* =
Serosanguineous: serum and blood, watery
and blood-streaked.
* Purulent: Infected, thick yellow, green, or
brown drainage.
* Purosanguineous: pus and blood.
-
#
o÷÷÷p
#
FIE
Wound Drains:
1 Jackson-Pratt drain:
* tube connected to bulb that creates
negative pressure.
O
2 Hemovac Drain:
*Similar to Jackson-Pratt but can hold
more mL of drainage.
O
3 Penrose Drain:
*Open tube, empties onto absorptive pad.
-
-
KEEFE EE
Hygiene
Oral Hygiene:
o
Factors Influencing Hygiene:
*
*
*
*
*
*
*
Social and cultural practices
Personal hygiene preferences
Socioeconomic status
Motivation
Body image
Age
Functional ability
FEE
"
AI
Safety Considerations:
* Know proper technique for using hygiene
tools such as razors, toothbrush, etc.
* Be aware of any special considerations
the patient has.
* Ex: Fall risk, aspiration risk
* Work at a comfortable height
* Older adults have more fragile skin
and mucous membranes.
* Dentures need to fit properly
Bathing:
Types of baths:
* Full bed bath
* For completely dependent patients.
* Partial bed bath
* Cleans only certain areas of the body.
* Face, armpits, perineal area.
* Tub Bath
* Shower
Considerations:
* Allow patient to test the temperature of the
water before beginning the bath.
* Make sure the patient is as covered as
possible during the bath with a blanket or
towel.
* Use fresh water when cleaning the
perineal area.
Perineal Care:
O
* Clean from front to back
* Remove all fecal matter
* Dry completely when finished
23
* Before performing oral hygiene, assess
for responsiveness, risk of aspiration,
and ability to swallow.
* Brush all surfaces of the teeth and at
gum line.
* If the patient has dentures, remove
and brush gently with dentures
cleaner, rinse with room temperature
water, and store in a denture cup.
Nail Care:
o
* Assess size, shape, and condition of
nails.
* Look for clubbing, and brittleness.
* Do not cut the nails of patients with
diabetes and peripheral vascular
disease.
* Instead, file nails using a nail file.
Hair Care:
* Brush or comb the patients hair daily
* Ask patients about their preferences
for hair care practices.
* Shampoo troughs and shampoo caps
can be used to shampoo the hair of
bedridden patients.
Shaving:
O
* Use an electric razor with patients
who are prone to bleeding or are on
anticoagulants.
* Hold skin taut and slide razor in the
direction of hair growth.
* Use shorter strokes around the chin/lips.
Foot Care:
O
* Don’t moisturize between the toes.
* Ensure proper fit of socks and shoes.
* Contact provider if infections are
present.
FIERI
EMI
Urinary FINE
Elimination
o
Factors Affecting Urinary
Elimination:
Types of Incontinence:
-
* Age:
* Children typically have control of their
bladder by age 5.
* Women who have had children can have
a weaker pelvic floor from childbirth.
* Older adults have a loss of muscle tone
in their bladder.
* Pregnancy:
* The fetus compresses the bladder,
causing a higher urination frequency.
* Diet:
* Sodium = decreased urination
* Immobility
*=
Pain
Decreased urge to urinate
* Surgery
* Medications
-
y
F
J=
Collecting A Specimen:
U
1 Routine urinalysis:
* Non-sterile procedure, use clean specimen
cup
* Collect during voiding or from catheter
2 Clean-catch specimen:
* Sterile specimen cup
* Collect from midstream
3 Sterile specimen for culture and sensitivity:
* Collected from straight or indwelling catheter
* If it is an indwelling catheter, clamp the
tubing below the port and let fresh urine
collect in the tube.
4 Timed urine specimen:
o
* Collected at intervals over a specified time
period (Ex: 24 hours)
* Begins after the first void
* Specimens are refrigerated
* Stress:
* Caused by increased abdominal
pressure.
* Ex: sneezing, laughing, lifting.
* Overflow:
* Caused by an over-distention of the
bladder.
* Urge:
* Caused by being unable to reach
a bathroom fast enough because
the urge comes on too quickly.
* Reflex:
* Caused by the bladder contracting
without warning.
* Usually caused by nerve damage
* Functional:
* Caused by being unable to respond
to the need to urinate.
* Ex: impaired mobility
* Total:
* Complete, involuntary loss of urine.
F
#
-
L
-
Catheterization:
* Types of catheters:
1 Indwelling catheters:
* Foley catheter
2 External catheters:
* Condom catheter
3 Short-term catheters
* Straight catheter
-
Urinary Diversions:
* Ureterostomy: one or both ureters are
connected to the abdominal wall.
* Nephrostomy: a tube from the renal pelvis is
connected to the abdominal wall by a stoma.
Catheter care:
* Catheter insertion is a sterile
procedure.
* Ensure urine is flowing before
inserting the balloon.
* Remove catheter as soon as possible
to reduce the chance of infection.
* Clean the site daily with mild soap or
perineal cleanser.
* Assess skin integrity regularly.
-
24
In FEI
IT
LI IT Y
Bowel
Elimination
'
Factors Affecting Bowel
Elimination:
'
25
Diarrhea:
SL
* Frequent loose or liquid stool.
* Causes:
* Viral and bacterial infections of the GI
tract.
* Antibiotic therapy
* Inflammatory bowel disease
* Irritable bowel syndrome
* Complications:
* Dehydration
* Skin breakdown of perineal are
* Fluid and electrolyte imbalances
* Interventions:
* Determine cause
* Apply moisture barrier after perineal care
-
* Age:
* Children do not have bowel control until
the age of 2 or 3.
* Older adults have decreased peristalsis
and gastric emptying.
* Diet
* Fluid intake
* Psychological factors
* Physical activity
* Immobilization suppresses peristalsis.
* Positioning:
* Immobile patients cannot maintain
normal “squat” position.
* Pain
* Surgery
* Medications
E¥
Constipation:
* Difficult or infrequent elimination of
hard, dry stool.
* Causes:
* Improper diet
* Reduced fluid intake
* Immobilization
* Medications
* Advanced age
* Complications:
* Fecal impaction
* Hemorrhoids, rectal fissures
* Bradycardia, hypotension, syncope
*Interventions:
*Increase fiber and water consumption.
* Give stool softeners or suppositories.
-
Impaction:
o
* Hardened stool becomes stuck in the rectum
and can not be expelled.
* Main indication is the patient being unable to
pass stool for several days.
* Can be removed with cleansing enemas,
suppositories, or digital removal.
-
-
Characteristics of Stool:
* Normal:
* Yellow, brown
* Soft and formed
* Abnormal:
* White/clay, black, red, bloody
* Foreign bodies, oily, hard, or liquid
Ostomies:
1 Colostomy:
* Ends in the colon
* More formed stool
2 Ileostomy:
* Ends in the ileum
* Frequent liquid stool
Ostomy Care:
* Empty pouch when 1/2 to 1/3 full
* Assess for skin breakdown every time
the pouch is changed.
Specimen Collection:
o
1 Fecal occult blood testing:
-
* Measures amounts of blood in the stool.
* Small amounts of stool are placed onto
a test card with an applicator.
2 Stool culture for parasites/ova:
r
* Sample is placed into a clean specimen
container.
-
EERIE
ERIE
? FREE
Crisis RE
and
disaster
26
,
Disaster:
O
Fire:
O
* A mass casualty or event that
interrupts or overwhelms the normal
functioning of a hospital.
* “RACE”
R: rescue all patients in the area.
A: sound the fire alarm to notify
others and EMS.
C: contain the fire by closing the door
to the room the fire is in.
E: extinguish fire if it is small enough
to put out with a fire extinguisher.
g-
Internal Emergency:
* Emergencies that occur inside of
the medical facility.
* Ex: loss of power, loss of water,
fire.
External Emergency:
* Emergencies that occur outside of the
medical facility.
* May bring an influx of patients
* Ex: Hurricane, disease epidemic, building
collapse.
Triage:
O
* Disaster triage is different from the
triage system that is used during normal
circumstances.
* Categories:
1 Class 1 (Emergent):
* Injuries are life-threatening, but there
is a high chance of survival.
2 Class 2 (Urgent):
* Major injuries that are not lifethreatening.
* Can wait 45-60 minutes
3 Class 3 (Non-Urgent):
* Minor injuries tryst do not need
immediate attention.
4 Class 4 (Expectant):
* Patients who are not expected to live.
* Comfort measures can be
provided.
E
_Qo#-
g
Severe Storms:
o
*
*
*
*
Close windows and shades
Move beds away from windows
Relocate mobile patients into the hallways
Don’t use elevators if possible
Biological Pathogens:
* When identified, decontaminate the area
* Isolate affected patients
* Only transport patients for necessary
treatments.
Chemical Incidents:
* Avoid contact with the chemical.
* Administer care to affected patients
as needed.
* Determine the name and concentration
of chemical.
* Clean all areas that chemical has come
into contact with, including patients
clothing and bedding.
Hazardous Material:
*
*
*
*
Avoid contact with the material
Contain the hazardous material
Notify the hazardous material team
Decontaminate affected patients using
water and soap and place contaminated
material in sealed bags.
KE
PEER RRR
Legal ERMEY
Considerations
tf
Legal Regulation of Nursing:
* Nurse Practice Acts:
* Defines the legal scope of nursing practice
* Standards:
* Healthcare Agency Policy and Procedure
* Credentialing:
* Accreditation
00
,
* Licensure: NCLEX
* Certification
-
-
P
Crime:
O
00
⑤
* A wrong against a person, property, or the
public.
*Misdemeanor: punishable by fines of
less than 1 year of imprisonment.
* Felony: Punishment of over 1 year of
imprisonment.
Torts:
* A wrong committed against a person or
property that is tried in civil court.
*Unintentional Tort:
* Negligence
* Malpractice
* Quasi-intentional Tort:
* Defamation of character
* Breach of confidentiality
* Intentional Tort:
* Assault
* Battery
* False imprisonment
-
¥
-
Professional Negligence:
* When a professional fails to act in a
way that someone else with the same
training and experience would.
* Failure to:
* Follow the standards of care of
the medical facility.
* Use equipment safely
* Document care properly
* Notify the provider of a change
in patient status
-
27
s
Safeguards for Competent
Nursing Practice:
* Understand boundaries of nursing
practice.
* Respect and advocate for patient rights.
* Document carefully and completely.
* Follow agency policies and procedures
HIPPA:
O
* Ensures the confidentiality of patient health
information.
* Patient files and papers should not be left
in public areas
* Passwords to electronic medical records
should not be shared.
Informed Consent:
* When a patient signs written consent for a
treatment or procedure.
* The patient should know:
* Why they need the treatment
* The potential risks
* Other potential options
* The role of the nurse is to serve as a
witness for informed consent.
Advance Directives:
J
* Living will:
* A legal document that specifies the
patients wishes for medical treatment if
they become incapacitated.
* Power of Attorney:
* A legal document that appoints a health
care proxy to make medical decisions for
the patient if they are unable.
-
.
-
Mandatory Reporting:
* Nurses must report:
* Suspicion of elder or child abuse
* Diagnosis of communicable disease
28
Documentation
Purpose of Medical Records:
*
*
*
*
*
*
*
Communication
Care planning
Legal documentation
Diagnostic orders
Quality improvement
Research / Education
Reimbursement
Guidelines for Documentation:
+
* Information should be:
T
* Factual:
* Objective information about what a
nurse sees, hears, feels, etc.
* Nurse should not write any opinions
* Avoid using generalized statements.
* Accurate:
* Only use acceptable abbreviations and
use correct spelling.
* Complete
*Information should be thorough and
contain all essential information.
* Current
* Documentation should not be delayed.
* Label all entries with date, signature,
and credentials.
* Organized:
* Information should be presented in a
logical order.
-
Confidentiality:
* All patient health information should be
kept confidential and is protected under
HIPPA.
* Do not share information with other
patients or health team members who
are not treating the patient.
* Patients have the right to access their
own information.
* Don’t leave patient information in areas
where it may be accessed by
unauthorized people.
e.
Documentation Formats:
1 Narrative:
* Written in “story” format in chronological
order.
* Addresses patient status, care, events,
treatments, interventions, and patient
responses.
2 SOAP Note:
* S: subjective (Patient stated “I feel
worried because...)
* O: objective (Patients BP reading high)
* A: assessment (Anxiety related to...)
* P: plan (Encourage patient to...)
3 PIE Note:
O
* P: problem (Anxiety related to...)
* I: intervention (Encouraged patient to...)
* E: evaluation (Patient responded by...)
4 Focus Charting:
* D: data (Patient stated they were
worried because...)
* A: action (Encouraged patient to...)
* R: response (Patient responded by...)
,
µ;
-
Methods of Documentation:
* Narrative documentation
* Problem-Oriented Medical Record:
* Main focus is patient problems
* Organized by problem or diagnosis
* Charting by exception:
* Progress notes are written when
assessment findings are not normal
findings.
* Case management
* Inter-professional approach
* Utilizes critical pathways
Incident Reports:
* Incident reports need to be filed when there
is an event that is not congruent with the
standard procedures of the facility.
*Ex: patient falls, medication errors
* Report is confidential and filed with the risk
management agency
* Incident reports DO NOT go in the medical
record of the patient.