D⇐€⇐⇐⇐⇐€ tAble of contents 1 2 3 4 5 6 7 8 9 10 11 The professional nurse 12 13 14 15 16 17 18 19 20 21 22 23 24 Infection prevention 25 26 27 28 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. . ' v :¥⇐⇐ii ÷÷ 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. € 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 EE FEE 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 err EEE River EEE 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. - - ' rises ima ;D 's 's :# HEY : aw ti 's & :m Competency Cultural r ' 9 ' . Culture and Perception of Illness J 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. - - D get grog ⑧ Culturally Congruent Care: * Nursing care that aligns with the patient's cultural beliefs, values, and worldview. . - . Cultural Competency: J * 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 - Doo - 10 MEEE TEA EEE Caring and communication EEE EEE se 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 T.EE?TTTF Patient safety FAT ÷i± 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: S: S: M} IT fi prevention TIRE FEE TREEET 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 ftp.EHMMMII.ae Baotou Litman THEY Eta ¥= 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.