1 Professionalism (6) TN state board of nursing protects the public from nurses, establishes licensure and state board exam, nurse practice acts determine what nurse can and can’t do in their state, regulates educational institutions ANA lobbies federally for American and Canadian nurses, develops code of ethics and standards of practice SNA affiliated with a state, lobby at local level Florence Nightingale Nickname: “lady of lamp” Viewpoint: Saw nursing as having charge on someone’s health based on having knowledge on how to put the body in such of state to be free of disease and recover from disease Wars: Crimean war Philosophy: notes for nurses on health maintenance & restoration Environment: importance of hygiene Accomplishments: Developed 1st organized program for training nurses First nurse epidemiologist Type of nurse: Sanitary nurse Scope of Practice/role of RN *ANA* Autonomy: performing independent nursing interventions (vital signs) Accountability: assume responsibility for all care provided Caregiver: help pt regain & maintain health (emotional, social, & spirituality) Advocate: protecting pt’s rights Educator: teach families & patients Communicator: need to communicate w/ different professions & people Manager: coordinate activities of pts’ to meet w/ different people Evidence based practice Practice of the nurse in the clinical setting with research-backed evidence guiding the kind of care (eg whoosh of air vs. ph strip for NG tube) APRN vs RN APRN has more clinical knowledge and clinical skills than RN and therefore different scope of practice; diagnoses and treats, examples are clinical nurse specialist, nurse practitioner, CNM, CNA 2 Maslow’s Heirarchy ethics (5) autonomy patients have the right to give consent, refuse medication, accurate information about their care, decide on course of tx Beneficence positive action to help others esp over self interest, eg: patient’s status changes, and now they need turning every two hours to prevent pressure ulcers. You as the nurse set up a turn schedule and make sure it gets done. Fidelity Faithfulness, keeping promises, eg: Nurse tells patient that they will be back in 1 hour to recheck pain and does Justice Fairness in resources, eg: Patient does not have insurance and is hospitalized. You provide health care services to them just like an insured patient Nonmaleficence Doing no harm, eg: It is time for you to leave your shift, but you notice one of the nurses on the other shift has not arrived. You agree to stay another hour to take care of your assigned patients until the nurse arrives or other help is found. Accountability Answering for own actions, eg: You give the wrong medication, call the physician, tell the family and care for the patient. You then tell you nurse supervisor and fill out an incident report. HIPAA Only person who can access PHI is someone with need to know; use de-identifiers, cannot tell anyone patient’s health info unless explicit permission, do not look at charts of patients who aren’t yours ANA code of ethics - Advocacy – standing up for a cause & what is the in the best interest for patient - Responsibility – professional obligations that must be followed, institutional specific policies & procedures, continuing education: stay competent w/in field - Confidentiality - HIPAA protects confidentiality of patient (have the right NOT to share information), Use de-identifiers, Will not divulge information, Do not look at other pts’ charts - accountability - answering for your own action, ensuring professional actions are explainable to patient & employer First step of applying ethics culture (2) Self analysis and values clarification to resolve ethical conflicts; ethical dilemmas occur in presence of conflicting values, so to resolve, must clarify values with facts and opinion differentiation 3 cultural encounter encourages healthcare professionals to engage in face to face intercultural encounters to prevent stereotyping cultural awareness process of examining one’s own bias and cultural background; awareness of oppression in medicine cultural assessment assessing the patient to see what their cultural belief are, including health beliefs, language and communication, family structure, support, dietary practices, health literacy, death practices discrimination acting on biases that person has stereotyping affiliating thoughts and beliefs to a group of people diversity including people from a range of SES, ethnic background, genders, etc prejudice holding a negative thought about people from a different group medical interpreter MUST GET BLUE PHONE OR INTERPRETER when patient speaks a different language—NEVER use patient’s family, direct questions to patient and not the interpreter safety (6) how to prevent fall fall risk assessment upon admission, paths uncluttered, items at bedside, call light, non slip socks, appropriate help to ambulate, chairs and wheelchairs locked, adequate lighting, side rails, lower bed, assistive devices at bedside, reduce psychoactive meds, address risk of postural hypotension, physical therapy side rails top two up at all times, others up only when order, is severely confused, or transporting restraints - Types: mittens, vests, siderails up, arm restraints, sedation drugs - Orders: renewed every 24 hours, must have physician order, physician must complete a face to face assessment, release pt q 2 hrs to for needs (ex. bathroom, food, fluids) - Assess extremity before putting on restraint for color, warmth, pulses, 2 fingerbreadths should fit in restraint, slipknot/ buckle, DO NOT TIE TO RAIL—part of bed frame that will move with patient - Documentation: time restraint was put on, location, type, behavior necessitating restraints, document q 15-30 minutes Exhaust all of these safety measures before resorting to restraints: move patient closer to nurse’s station, distractions,, frequent observations, bed alarms/chair alarms rights of medicine admin right drug, right dose, right route, right patient, right time, right documentation, right to refuse allergies ask upon admission and IMMEDIATELY document, always ask again when giving medications informatics (5) Subjective what the patient says objective anything that you observe or can be measured 4 guidelines FCOATS=factual (no opinions), complete, organized, accurate, timely, specific SOAP subjective, objective, assessment (w nursing diagnosis), plan (w importance of why intervention needed) fluid and electrolytes assess IV infiltration=edema, pitting, compare sides, cool to touch extraction=infiltration where medication causes harm, remove IV site, call physician, don’t apply heat or cold *prop arm after infiltration or extravasation* infection=redness, burning, edema or discharge, pain, remove IV and call physician, anticipate antibiotics phlebitis=inflammation of vein lumen—pain, redness, hardness (induration), remove IV and call, also anticipate antibiotics IV catheter breaks=emergency! tourniquet to stop it from acting as an embolus, take to x-ray signs of dehydration tachycardia, dry mouth, sunken eyes, flat neck veins, poor turgor, low BP, oliguria, hypotension, high BUN, high HCT signs of fluid overload high BP, tachy- or bradycardia, bounding pulse, rales or crackles, swelling and edema to lower extremities, sudden weight gain, infusion, SOB, jugular vein dissension, low HCT how much urine per hour at least 30mL per hour!! ~400 mL/shift caring (2) knowing the client complex process that occurs over time and over nurse-patient relationship, has two components: 1) continuity of care and 2) clinical expertise listening less talking, more hearing—necessary for meaningful interaction, take in and interpret instead of planning what you’re going to say next, enables you to respond back with what’s most important to them providing information providing up to date information is caring presence being present thought eye contact, tone of voice, listening, body language—answering call light, holding hand, being in their room, being there, being with—improved wellbeing for nurses and patients sensory (5) hearing impairment DO: make sure hearing aids are clean and turned on and installed! ask patients what accommodations they need, ask them to rate their hearing, put it on whiteboard, use communication board, stand nearby, let them see your lips, amplify alarms that are relevant to patient DON’T: assume elderly have hearing problems by raising voice without asking, speak into good ear (face patient!) vision impairment glasses nearby and on the patient! stand nearby, introduce yourself when you enter room, put on whiteboard, large print tactile impairment assess skin, turn water down to less than 120 degrees, assess for wounds and injuries, test water before you bathe patient, label hot and cold taps 5 expressive aphasia unable to speak or write language but can understand spoken or read language receptive aphasia does not understand spoken or read language but can communicate themselves sensory overload often in ICU—provide low stimulation environment, take off everything that isn’t necessary, reorient if needed, can involve anxiety sensory deprivation talk to patient, provide things to do, TV, fan nutrition (3) NG tube must confirm placement with x-ray or pH test (below 5–ATI says 4), prevent aspiration with bed 30-45, check residual before feeding, confirm placement every time dysphasia speech language pathologists does barium swallow to dx, watch patient eat, tuck chin, often holds food in cheeks, add thickeners to liquids, may regurgitate, encourage to swallow twice, suction nearby lab results if malnourished low albumin, low hemoglobin and hematocrit, low iron/ferrtitin, low glucose, low lipids, low vitamins D, low BUN hospital diet 1. NPO: Nothing by mouth, not even ice chips 2. Clear liquids: Anything you can see through (includes gelatin, fruit juice, or both) 3. Full liquid: clear liquids plus liquid dairy products, all juices, ice-cream & popsicles, can include pureed veggies 4. PureedL clear and full liquids plus pureed meats, fruits, and scrambled eggs 5. Mechanical soft: clear and full liquid + diced or ground foods + cream of soups 6. Soft/low residue: foods that are low in fiber and easy to digest (dairy products, eggs, bananas), no nuts or coconut 7. High-fiber: whole grains, raw and dried fruits 8. Low sodium: no added salt or 1-2 g sodium 9. Low cholesterol: no more than 300 mg/day of dietary cholesterol 10. Diabetic: balanced intake of protein, fats, and carbs about 1,800 cals 11. Dysphagia: pureed food and thickened liquids 12. Gluten free: no wheat, oats, rye, barley or their derivatives 13. Regular: no restrictions interprofessional registered dietician, nursing assistant often feeds patient, consult LPN who may be given tube feeds, provider elimination (6) incontinence overflow= over distended bladder, diminished voiding sensation, teach to double void stress=small volume loss, esp common in middle ages people who’ve given birth, teach Kegels bladder scanner independent intervention! can do if patient is retaining urine nocturia urinating a lot at night 6 dysuria painful urination clean catch clean vulva twice front to back with two different wipes, hold labia open, void into toilet, then into cup, then finish in toilet —NEVER GET SPECIMEN FROM CATHETER BAG 24 hour urine get large orange container, sign in patient’s room, if any urine doesn’t go in you start over, get rid of first void and start with next void bedpan use right bedpan (fracture bedpan is only for hip fractures), get patient sitting up on bed pan and then give them call light and privacy fecal occult blood test diet false positive—no red meat for three days, don’t take NSAIDs for 7 days false negative—avoid vitamin C/citrus for 3 days impaction common if they haven’t gone in a while but are leaking loose stool—check with digital exam enemas - Cleansing=infusion of fluid to stimulate peristalsis - Tap water=hypotonic, do not give to patients with electrolyte balance - Normal saline=isotonic, safest, only option for dehydrated people and children - hypertonic=hypertonic, pulls fluid into colon, good if can’t tolerate a lot of liquid, do not give to kids or dehydrated people - Oil retention=lubricate feces - Carminative=gas relief - Medicated enemas interprofessional partners urologist, gastroenteroligst, nursing assistant, dietician family dynamics (2) factors that influence a family (123-124) homelessness, DV, family caregiving, poverty what is a family? however the patient defines their family family as context focus on individual patient within a family—think family as context for patient family as patient focus on whole family as the patient—no individual focus family as system focus on each family member AND the family as a whole—combo of the two above mobility (6) complications pneumonia, decreased muscle mass, decreased ROM, urinary stasis, kidney stones, decreased peristalsis 7 osteoporosis when calcium is broken down from bones and into bloodstream, leading to weak bones, need weight bearing exercise how to get patient up dangle! prevent thermostatic hypotension ergonomics what you’re lifting needs to be close to center of gravity, have wide base, maintain good posture, bend from knees, avoid twisting, use equipment, raise bed to comfortable height, encourage patient to help, push and slide > pull and lift, ask for help, lift from legs and back positioning Sims—side lying Trendelenberg—head lower than body (reverse is just opposite) Fowlers—high is 60, mid is 45, low is 30 prone-stomach lithotomy—like obgyn supine-face up how to use crutches - - - support body weight with elbows at 20-30 degrees hold crutches in one hand while rising from chair tripod position is where crutches are 15 cm in front/side of feet upstairs=strong leg first downstairs=affected leg first at least 2 inches below axilla! weight on hands not axilla four point gait=most stable, weight on both legs 1. R crutch 2. L foot 3. R foot 4. L crutch three point gait=weight only on one leg 1. begin in tripod 2. move crutches and affect leg forward 3. move strong leg forward two point gait=partial weight bearing on both legs 1. R crutch and L leg at same time move forward 2. L crutch and R leg at same time swing through=same as three point but no weight at all on affected leg 8 how to use walker - For when patient has 1 weight bearing arm and leg, upper bar slightly below waist - Gait - - how to use cane 1. move walker ahead 6-8 inches 2. weight on arms and partial weight on affected leg Stand 1. walker in front of seat 2. push off CHAIR ARMS 3. move hands to walker one at time Sit 1. back up to chair 2. reach back one arm to arm of chair 3. reach back other arm 4. lower into chair - 2 points of support on ground at all times - cane on strong side - Gait 1. 2. 3. 4. interprofessional partners support body weight on both legs move cane forward 6-10 inch move weak leg to cane move strong leg past cane physical and occupational therapy, UAP delegation (6) rights of delegation Right task - safe, routine, have predictable outcome Right circumstances – context (i.e. potential for harm) Right person - within education & scope of practice to perform Right direction & communication – clear instructions (what, where, when, how) Right supervision & evaluation – surveillance & monitoring (met standards, policies/procedures); outcome evaluated RN responsibility *if someone doesn’t do what we delegated and it doesn’t get done, that’s ultimately our fault* DON’T delegate: nursing process, client education, assessment, judgment DO delegate to UAP: ADLs, bed making, specimen collection I/O, vital signs functional nursing LPN, UAP, RN, and secretary all working together at their own scope of practice sleep (2) sleep hygiene cool room, darkness, quiet, covers, fan, no electronics in bed, routine, no caffeine before bed narcolepsy sleep disorder of hypothalamus where patient needs stimulant medication (eg Provigil) to appropriately sleep 9 obstructive sleep apnea diagnosed with polysomniogram, when you don’t breathe intermittently at night, assess with >10 sec of not breathing, and Epworth sleep scale, more likely with obesity and men, bring CPAP to hospital Epworth sleep scale see if person has problems with daytime sleepiness symptoms of sleep deprivation eyelid drooping (ptosis), confusion, irritability, blurred vision, clumsiness, decreased reflexes, decreased alertness, decreased judgment, arrhythmias, increase sensitivity to pain, agitation, hyperactive, decreased motivation REM consolidation of memory, tissue reconstruction interprofessional partners pulmonologist, neurologist, polysomnographer, healthcare provider, secretary, UAP health care systems (3) nursing-sensitive outcomes outcomes we want from patient that nurse is involved in pain, such as changes in patients’ symptom experiences, functional status, safety, psychological distress, RN job satisfaction, total nursing hours per patient day, and costs things that influence healthcare disparities primary, secondary, tertiary care primary=dx and management of common illnesses, prenatal care, well baby care, family planning, patient centered medical care secondary=urgent care, hospital emergency care, acute medical-surgical care: ambulatory care, outpatient surgery, hospital, radiological procedures tertiary=specialty care (eg oncology, cardiology), ICU care, inpatient psych care self-management (3) risk of heart disease waist circumference (esp 2x height), smoking, diabetes, atherosclerosis 10 BMI BMI=kg/m2 OR lb*705/in2 <18.5=underweight 25-29.9=overweight 30-34.9=obesity class I 35-39.9=obesity class II >40=extreme obesity/class III causes of obesity genetic, lack of sleep, sedentary life style, food access (deserts), lack of exercise, medications, high carb/high fat diet self-efficacy self-management depends on belief that they can change; enhance this as nurse by assessing tools, adding tools spirituality (3) hope Several meanings that vary in the basis of how it’s being experienced Usually refers to an energizing source that has an orientation to future goals and outcomes People need hope in order to get better Absence of hope makes people feel that they can’t go on or motivation to get better FICA what is compassion literally to “suffer together”—connect us to patients, give us strength and tools to take care of patients, set goals and outcomes of getting better interprofessional partners chaplain, social worker collaboration (2) SBAR (this is straight from ATI) (Identification=hi I’m Hannah RN) Situation-client’s current problem Background-admission dx, medical history, outline of previous tx Assessment-analysis, including recent vital signs/data that backs up assessment Recommendation-suggested tx, interventions, medications 11 handoff handoff between two licensed people when patient is being transferred either from unit to unit, facility to facility, or shift to shift mentoring someone who comes alongside you to guide you in decision making what is inter professional collaboration maximizing strengths of each person on healthcare team, getting more done, everyone’s scope is respected and used advantageously, necessity of medical work infection (6) types of isolation contact—gown and gloves droplet—gown, surgical mask, gloves, maybe face shield; mask for visitors and for patient if being transported airborne—N95 and patient wears face mask, negative pressure room reverse/protective—gown, gloves, surgical mask, mask for client when leaving room, positive pressure room/HEPA filtration, protect patient C diff contact isolation! NEVER hand sanitizer, always wash hands for 20 min, patient’s items stay in room, clean anything leaving room with chlorine bleach TB airborne COVID droplet/airborne—N95, face shield, negative pressure, gown gloves varicella/chickenpox airborne and contact hepatitis B/HIV bloodborne—universal precautions localized vs system infection localized—red, hot, immobilized, painful, skin breakdown, swelling, draining from site esp purulent systemic—fatigue, malaise, confusion (esp older adults! older adults may not have fever!!!), fever, enlarged lymph nodes, high HR, low RR, low BP chain of infection 1. 2. 3. 4. 5. 6. healthcare associated infection 1. risk/cause=results from invasive procedures, antibiotic overuse, mutlidrug resistant organisms, sick/susceptible patients 2. prevention=HAND HYGIENE ALWAYS #1, chlorhexidine for bathing, pulmonary hygiene inter professional team members infection control nurse, infectious disease doctor, LPN, UAP, anyone in patient’s room Etiological agent--bacteria, viruses, fungi, protozoa, eg. HIV virus Reservoir—organism survives and may or may not multiply; eg. person with HIV Portal of exit--skin, blood, respiratory/urinary/GI/reproductive tract; eg. semen Mode of transmission--direct, indirect (vehicle or vector), airborne; eg. intercourse Portal of entry—skin, blood, mucus membranes; eg. vaginal or anal membrane Host factors—susceptibility; eg. immunocompromised person 12 pain (6) types of pain visceral pain=arising from internal organs, poorly localized, aching, gnawing, throbbing somatic pain=bone, muscle, tendon, connective tissue, well defined/localized, sharp or dull acute pain=transient (less than 3 mo), identifiable cause, guarding, facial expression, groaning, protective chronic pain=longer than 3-6 mo, cause may not be identifiable, great personal suffering, ADL interference, fairly normal vital signs neuropathic=pain that originates in NS nociceptive=pain that arises from non-NS tissue, eg somatic or visceral pain opioids increase fluid intake, fiber—treat constipation; monitor respirations and LOC; sedation; N/V; urinary retention; itching non pharmacological psin relaxation, guided imagery, distraction, massage, herbals addiction, tolerance, withdrawal, dependence Addiction – use of drug chronically despite harmful consequences Tolerance — lower response to drug due to repeated exposure (need more amt of drug to have effect) Withdrawal – stopping drugs & start to have side effects to compensate Dependence – adaptation to drug from long-term use (leads to tolerance) & body requires the drug cold/heat therapy may need order, only leave for 20-30 minutes because longer causes rebound, do not use on sensitive skin, patient can’t adjust settings, do not leave unattended if patient can’t move, remove cold if patient feels numbness, cold can be between 2-5x day pain is what the patient says it is how to assess pain OLDCARTS, reassess after meds, document on admission, shift assessment, before and 1 hr after meds, pain scales pain assessment for nonverbal pain FACES, signs of distress migraine headaches vessel spasms of cerebral arteries, triggers can be anger, fatigue, meds, food, stress, hormone changes; intense, throbbing, unilateral pain that worsens w moment, N/V, 4-72 hrs, photo/phonophobia, aura gout uric acid deposits cause inflammation esp in big toe, red/swollen/warm, assess kidney function and uric acid blood levels, manage with colchicine and NSAID, chronic with allopurinol skin integrity (6) stages of wounds and interventions 1. inflammation=3-6 days, homeostasis, macrophages remove debris 2. proliferative/granulation=3-24 days, epithelization, granulation, angiogenesis 3. maturation=after 21st ish day to months, collagen fiber remodeling, scar formation and contraction 13 stages of pressure ulcers - Stage 1: non-blanchable redness of a localized area usually over a bony prominence—discoloration of the skin, warmth, edema, hardness, or pain may also be present - Stage 2: partial thickness loss of dermis—shallow, open ulcer with a red-pink wound bed without slough, intact or open serum-filled or serosanguineous-filled blister - Stage 3: full-thickness tissue loss—subcutaneous fat may be visible, may include undermining and tunneling - Stage 4: full thickness tissue loss—exposed bone, tendon, or muscle, subcutaneous fat - Unstageable: the actual depth of an ulcer is completely obscured by slough or eschar; cannot be stages accurately until everything is removed; always a stage 3 or 4 underneath - Suspected Deep-tissue injury: a purple or maroon localized area of discolored intact skin caused by damage of underlying soft tissue from pressure and/or shear wound interventions - primary=topic skin care, manage incontinence, turn every 2 hours, support surface - secondary=pressure ulcer risk assessment/screening, Braden - tertiary=local care, adequate nutrition, redistribute pressure, monitor every 8 hours, appropriate dressing braden scale—score, what it means, categories, how to use Six Subscales: 1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. friction/shear Interpretation of Results=Value will range from 6-23 A lower total score (esp less than 18) indicates a higher risk for pressure ulcer development red, yellow, black colors red—moist dressing yellow—slough or infection, remove yellow tissue/discharge black—necrotic tissue, remove w debridement when to turn in bed/chair 2 hours beds, 1 hour chair intepressional wound care nurse, UAP, LPN interventions keep patient dry, avoid friction and shear, cover moist area with zinc, turn 2h, HOB below 30, use devices, ROM with PT, inspect skin q2h arterial ulcer “dying garden,” never prop!!, appearance is punched out venous ulcer blood pooling—do prop!! and use SCD, appearance is superficial and irregular shape gas exchange (5) difficulty breathing symptoms accessory muscles, dyspnea, retractions, spo2 below 95 or 90 (if resp disease) 14 complete oxygen order number of L OR spo2 to reach for + device—4L and above must be humidified early and late signs (RAT BED) Early=restlessness, anxiety, tachycardia/tachypnea Late=bradycardia, extreme restlessness, dyspnea is severe oxygen toxicity s/s nonrproductive cough, sternal pain, nasal pain, sore throat, hyoventilation nursing diagnoses ineffective breathing pattern, impaired gas exchange, ineffective airway clearance—priority is always ABCs (airway, breathing, circulation) first intervention with sob RAISE HOB atelectasis common after surgery, lower lung bases are diminished, collapse of alveoli, prevent with incentive spirometer incentive spirometer breathe in to raise ball to proper mark—“like sucking a thick milkshake”—Incentive is used with INspiration to INflate lungs; use 4x a day for 10x each time (so 40) pneumonia pooling of secretions in lungs as breeding ground for bacteria—can use postural draining to drain fluid so portion with most liquid is highest; incentive spirometer, cough up sputum interprofessional partners healthcare provider, RT (do SBAR so they know which patients are highest priority), pulmonologist patient education (2) best time patient isn’t in distress; edu about procedure while you’re doing a procedure teach back method ask patient to tell you what you just told them return demonstration ask patient to show you how to do something you just demonstrated assess knowledge ask what they already know, assess motivation, assess if they know what the intervention is for, assess educational level motivation critical! give them the benefits of whatever the intervention is domains of learning cognitive—understanding knowledge affective—emotional, motivational psychomotor—physical skill perfusion (6) assess for perfusion in extremeties compare legs, measure, assess pulses, assess temp, assess color, nail beds, capillary refill ECG normal values for PRI-0,12-0.2 normal values for QRS-0.08-0.12 bradycardia and tachycardia 15 how do you know normal sinus rhythm in place? every QRS has a P wave, PR and QRS are normal, one P wave for every QRS primary pacemaker SA node orthostatic hypotension 20 systolic or 10 diastolic drop when sitting or supine to standing inter professional team members telemetry, cardiologist development Erikson’s phases, esp young adult and up intimacy vs. isolation (20s) generatively vs. stagnation (30-50) integrity vs. despair (50+)
