Chapter 1 – Introduction to Nursing 8/29/2022 - Nurses with baccalaureate degree work with research. - Florence Nightingale changed the roles of nursing for the better good, by challenging prejudice, elevated the status of all nurses. - She established the first. Training school for nurses and wrote books about health care and nursing education. - She identified the personal needs of client and role of nurse in meeting them. - Established standards for hospital management - Recognized two components: health and illness - Believed nursing was separate and distinct from medicine - Recognized that nutrition is important to health - Instituted occupational and recreational therapy for sick - Stressed the need for continued education - Maintained accurate records, recognized as the beginnings of nursing research. - Definition of Nursing originated from the Latin word nutrix (to nourish) - Promotion of health, prevention of illness, collaborative care - Patient/client is central focus of all definitions - State Nurse Practice acts set laws and regulations for nursing practice. - Each State has their own Nurse Practice acts - Office of the professions is where our license to practice comes from - Four blended competencies: Cognitive, Technical, Interpersonal, Ethical/Legal (CTIEL) - Cognitive- thinking about the nature of thigs sufficiently to make decisions regarding care. - Technical- enable nurses to manipulate equipment to produce a desired outcome. - Interpersonal- Involve caring relationships. - Ethical/Legal- Enable nurses to conduct themselves morally and professionally. - Nursing Aims to promote health – state of optimal functioning or well-being. - Factors affecting health: Genetic inheritance, Cognitive abilities, educational level, Race and ethnicity and culture, age and gender, developmental level, lifestyle and environment, socioeconomic status. Guidelines for Nursing Practice - Standards of Nursing Practice - American Nursing Association (ANA) standards of practice protect and allow nurses to carry out our professional roles. - Nurse Practice Acts and Licensure-regulate the practice of nursing practice including education and licensure. - Nursing Process-guideline of nursing practice enabling nurses to implement their roles. - Each state has their own established set of laws. The Nursing Process One of the major guidelines for nursing practice Helps nurses implement their roles Integrates art and science of nursing Allows nurses to use critical thinking and clinical reasoning Defines the areas of care that are within the domain of nursing Chapter 6 – Values, Ethics, Advocacy - Values – belief about the worth of something. What matters, acts as a standard to guide one’s behavior. - Common modes of value transmission - Modeling – learn by modeling someone else, something that could be acceptable or unacceptable. - Moralizing – learn complete value system through others little opportunity to have different values. - Laissez-faire – little guidance can lead to confusion and conflict. - Rewarding and punishing- rewards or punished - Responsible choice – explore and make decisions. - Three main activities of valuing process - Choosing - freely from alternatives after careful consideration of the consequences of each alternative - Prizing (treasuring) -Involves pride, happiness, and public affirmation - Acting - Combining choice into one’s behavior with consistency and regularity on the value Professional values - Altruism: concern for welfare and well-being of others - Autonomy: right to self-determination - Human dignity: respect for inherent worth and uniqueness of individuals and populations - Integrity: acting according to code of ethics and standards of practice - Social justice: upholding moral, legal, and humanistic rights Types of Ethics: - Bioethics - Encompasses several fields of “life sciences” - Nursing ethics - Formal study of ethical issues that arise in the practice of nursing, Analysis used by nurses to make ethical judgments - Feminist ethics - Critiques existing patterns of oppression and domination in society especially affecting women and the poor Two Categories of Action-Guiding Theories: - Utilitarian: The rightness or wrongness of an action depends on the consequences of the action. - Deontologic: An action is right or wrong independent of its consequences. Principle-Based Approach to Bioethics: - Autonomy: Respect rights of clients to make health care decisions. - Nonmaleficence: Avoid causing harm. - Beneficence: Benefit the client. - Justice: Give each his or her due and act fairly. - Fidelity: Keep promises. - Veracity, accountability, privacy, confidentiality Characteristics of the Care-Based Approach to Bioethics: - Centrality of the caring relationship - Promotion of dignity and respect for clients as people - Attention to the particulars of individual clients - Cultivation of responsiveness to others - Redefinition of fundamental moral skills to include virtues - Remember- each time we care for a client there is an ethical decision that is made. - They are not the gallbladder in 302, they are someone. - Nursing is our profession it is nonnegotiable ethical standard. ICN Guidelines to Achieve Purposes of Code of Ethics: - Study the standards under each element of the code. - Reflect on what each standard means to you. - Discuss the code with coworkers and others. - Use a specific example from experience to identify ethical dilemmas and standards of conduct in the code. - Work in groups to clarify ethical decision making and reach consensus on standards or ethical conduct. - Collaborate with other professionals to apply standards in practice, education, management, and research. Ethical Experience and Decision Making/Ethical Problems - Ethical dilemma: Two (or more) clear moral principles apply but support mutually inconsistent courses of action. Ex. Doctor denies giving client morphine, but the nurse sees the client is in severe pain. - Ethical distress: Occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. Ex. Working a shift short handed when you know this is unsafe Advocacy in Nursing Practice - Primary commitment is to the Client. - Prioritization of good of individual client rather than society in general - Evaluation of competing claims of client’s autonomy and patient well-being Chapter 11 – The Health Care Delivery System IOM’s Six Outcomes for a New Health System for the 21st Century Safe Effective Efficient Patient-centered Timely Equitable Health Care: The Big-Pictures Issues Access to health care Quality and safety- medical errors!! Affordability Primary focus is health promotion. Hospitals today focus on acute care needs of the client. Read Table 11-2 Health Care network Characteristics of a Continuously Learning Health Care System Science and informatics: real-time access to knowledge; digital capture of the care experience Patient–clinician partnerships: engaged, empowered patients Incentives: aligned for value; full transparency Continuous learning culture: leadership-instilled culture of learning; supportive system competencies IOM’s 4-Tiered Strategy to Prevent Medical Errors Establishing a national focus to create leadership, research, tools, and protocols to enhance our knowledge about safety Identifying and learning from errors by developing a nationwide public mandatory reporting system Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care Implementing safety systems in health care organizations to ensure safe practices Health Care Settings Hospitals-focus on acute care needs. NOT CHRONIC Primary care centers- MD’s and APN’s provide primary health care services in offices and clinics. Ambulatory care centers and clinics Home health care-provides safe coordinated care at home. Hospital at home- safe and effective hospital level care in the home Extended care- provide medical and nonmedical care for people with chronic illnesses. Ranges from days to years. Specialized care centers and settings- provide care or a specific population or group. Located in easily accessible locations within a community. Health care services for the seriously ill and dying- Respite, Hospice, Palliative Health care agencies Health Care Services for the Seriously Ill and Dying Hospice provides physical, psychological, social, and spiritual care for dying persons. Respite care is provided for caregivers of homebound ill, disabled, or elderly clients. Parish nursing emphasizes holistic care, health promotion, and disease prevention activities. Voluntary agencies are community agencies that are often nonprofit and provide a setting for support groups Palliative Care- client and family centered care that optimizes the quality of life by anticipating, preventing, and treating the suffering. Chapter 24: Asepsis and Infection Control 8/30/22 Components of the Infection Cycle: Infectious agent: bacteria, viruses, fungi Reservoir: natural habitat of the organism Portal of exit: point of escape for the organism Means of transmission: direct contact, indirect contact, airborne route Portal of entry: point at which organisms enter a new host Susceptible host: must overcome resistance mounted by host’s defenses Infectious Agents: - Bacteria: Most significant and most prevalent in hospital settings - Virus: Smallest of all microorganisms - Fungi: Plant-like organisms present in air, soil, and water. - Parasites: malaria, intestinal worms Classification of Bacteria Spherical (cocci), rod shaped (bacilli), corkscrew shaped (spirochetes) Gram positive or gram negative based on reaction to Gram stain o Gram + have thick walls that stain violet- resist color removal o Gram – cell walls loss their color with alcohol –don’t stain Aerobic or anaerobic based on need for oxygen Factors Affecting an Organism’s Potential to Produce Disease Number of organisms Virulence Competence of person’s immune system Length and intimacy of contact between person and microorganism Possible Reservoirs for Microorganisms - Other people (cold viruses) - Animals (rabies) - Soil (Anthrax) - Food, water, milk (E. coli) - Inanimate objects (Influenza) Common Portals of Exit: Respiratory Gastrointestinal Genitourinary tracts Breaks in skin Blood and tissue Factors Affecting Host Susceptibility Intact skin and mucous membranes Normal pH levels Body’s white blood cells Age, sex, race, hereditary factors Immunization, natural or acquired Fatigue, climate, nutritional and general health status Stress Use of invasive or indwelling medical devices Stages of Infection: Incubation period: organisms growing and multiplying Prodromal stage: person is most infectious, vague and nonspecific signs of disease Full stage of illness: presence of specific signs and symptoms of disease Convalescent period: recovery from the infection Outcome Identification and Planning/Infection Control Demonstrate effective hand hygiene and good personal hygiene practices. Identify the signs of an infection. Maintain adequate nutritional intake. Demonstrate proper disposal of soiled articles. Use appropriate cleansing and disinfecting techniques. Demonstrate an awareness of the necessity of proper immunizations. Demonstrate stress-reduction techniques. Body’s Defense Against Infection - Body’s Normal Flora - Inflammatory Response - Immune Response Cardinal Signs of Acute Infection Redness (vascular, dilation of vessels) Heat (vascular, dilation of vessels) Swelling (increased blood flow and histamine) Pain Loss of function Laboratory Data Indicating Infection Elevated white blood cell count—normal is 5,000 to 10,000/mm3 Increase in specific types of white blood cells (Box 24-1 pg. 602) Elevated erythrocyte sedimentation rate Presence of pathogen in urine, blood, sputum, or draining cultures Elevated WBCs indicates an infection There are different types of WBCs and by looking at which ones are elevated we can tell what is going on in the body. • Neutrophils - Normal = 60–70%- Increased in acute infections that produce pus; increased risk for acute bacterial infection if decreased; may also be increased in response to stress (Usually the one that is elevated) • Lymphocytes- Normal = 20–40%-Increased in chronic bacterial and viral infections • Monocytes- Normal = 2–8%- Increased in severe infections: function as a scavenger or phagocyte • Eosinophil- Normal = 1–4%- May be increased in allergic reaction and parasitic infection • Basophil- Normal = 0.5–1% Usually unaffected by infections • Elevated erythrocyte sedimentation rate—red blood cells settle more rapidly to the bottom of a tube of whole blood when inflammation is present • Presence of pathogen in cultures of urine, blood, sputum, or other (wound) drainage Five Moments for Hand Hygiene (WHO) - Moment 1 – Before touching a patient - Moment 2 – Before a clean or aseptic procedure - Moment 3 – After a body fluid exposure risk - Moment 4 – After touching a patient - Moment 5 – After touching patient surroundings Endogenous – affects themselves than transferred to another area Exogenous – affected from the environment or someone else Iatrogenic – infected through medical treatment Bacterial Flora: Transient: attached loosely on skin, removed with relative ease Resident: found in creases in skin, requires friction with brush to remove Wash hands with soap and water if visible soiled (scrub for at least 20 seconds) Alcohol based cleanser (scrub for at least 15 seconds) o Before and after patient contact o After glove removal o Before donning gloves for a non-sterile procedure o After contact with objects in a patient’s room o When moving from a contaminated body site to a clean body site Four Categories Responsible for Majority of Hospital-Acquired Infections (HAIs) Catheter-associated urinary tract infection (CAUTI) Surgical site infection (SSI) Central-line associated bloodstream infection (CLABSI) Ventilator-associated pneumonia (VAP) MRSA Methicillin resistant staph aureus Overuse of (AB) antibiotics Over Rx of AB Treated with Vancomycin; Clindamycin Risk Factors for Vancomycin-Resistant Enterococci (VRE) Compromised immune systems Recent surgery (esp. abd or chest) Invasive devices (urinary or IV cath) Prolonged antibiotic use (especially vancomycin) Prolonged hospitalization CDC Recommendations to Prevent C. difficile Infection (CDI) Avoiding the use of electronic equipment that is difficult to clean (electronic thermometers) Disinfecting dedicated patient care items and equipment (stethoscopes) between patients Using full-barrier contact precautions (gown and gloves) Placing patients in private rooms; cohort patients with the same strain of CDI Performing meticulous hand hygiene Performing environmental contamination of rooms Educating health care providers (and patients/families as appropriate) on clinical presentation, transmission, and epidemiology of CDI Using antimicrobials at an appropriate dose and only when indicated Measures to Reduce Incidence of Nosocomial Infections - Constant surveillance by infection control committees and nurse epidemiologists - Written infection prevention practices for all agency personnel - Hand Hygiene recommendations - Infection Control Precaution techniques - Keeping patients in best possible physical condition Factors Determining Use of Sterilization and Disinfection Methods Nature of organisms present Number of organisms present (↑ number ↑ time) Type of equipment (some methods can damage equipment) Intended use of equipment (medical or asepsis) Available means for sterilization and disinfection Time (appropriate amount to disinfect) Personal Protective Equipment and Supplies - Gloves - Gowns - Masks - Protective Eyewear Standard Precautions Used in the care of all hospitalized patients regardless of their diagnosis or possible infection status Apply to blood, all body fluids, secretions, and excretions except sweat (whether blood is present or visible), nonintact skin, and mucous membranes New additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures Transmission-Based Precautions Used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. Don personal protective equipment (PPE) when entering the room of a patient on contact or droplet precautions. These categories recognize that a disease may have multiple routes of transmission: airborne, droplet, contact). Airborne Precautions- TB, Varicella, Measles (private room, negative pressure room, N95 mask, gown, gloves) Droplet Precautions- Rubella, Mumps, Influenza (mask, gown, gloves, private room) Contact Precautions- MRSA, C.dif (gown, gloves) Neutropenic Precautions- (private room, mask to protect patient) Aseptic Technique Includes all activities to prevent or break the chain of infection Two categories o Medical asepsis: clean technique Reduces number and transfer of organisms Non sterile (VS, bathing) o Surgical asepsis: sterile technique (box 24-6)pg. 617 Keep objects and areas free from microorganisms Sterile touches sterile Hands above waist, below neck Don’t walk away or turn your back 1 inch border of sterile field is considered contaminated When wet, the sterile field is no longer sterile Sterile fluids- 24 hours from opening Use of Surgical Asepsis Operating room, labor and delivery areas Certain diagnostic testing areas Patient bedside o For example, for procedures that involve insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine Patient Teaching for Medical Asepsis at Home Wash hands before preparing or eating food. Prepare foods at high enough temperatures. Use care with cutting boards and utensils. Keep food refrigerated. Wash raw fruits and vegetables. Use pasteurized milk and fruit juices. Wash hands after using bathroom. Use individual care items. Evaluating Patient Goals Use techniques of medical asepsis. Identify health habits and lifestyle patterns promoting health. State signs and symptoms of an infection. Identify unsafe situations in the home environment. Which of the following is the most significant and commonly found infection-causing agent in health care institutions? A. Bacteria B. Fungi C. Viruses D. Mold Which infection or disease may be spread by touching a contaminated inanimate article? A. Rabies B. Giardia C. E. coli D. Influenza During which stage of infection is the patient most contagious? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period Soaps and detergents (nonantimicrobial agents) are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms. A. True B. False Standard precautions should be used when caring for a noninfectious, postoperative patient who is vomiting blood. A. True B. False Chapter 7: Legal Dimensions of Nursing Practice Law Standard or rule of conduct established and enforced by government o Designed to protect the rights of the public Litigation: process of bringing and trying a lawsuit o Plaintiff: person bringing suit o Defendant: person being accused of a crime Types of Law Public law —government is directly involved Regulates relationships between individuals and government Private law — aka civil law Regulates relationships among people (nursing) Criminal law —concerns state and federal criminal statutes Defines criminal actions (e.g., murder, theft), falsification of Covid Cards Professional and Legal Regulations of Nursing Practice Nurse practice acts- law affecting nursing Standards- guidelines developed by peers (ANA) Credentialing- professional competence o Accreditation- process by which educational programs are evaluated; meet standards o Licensure- meeting criteria o Certification- validates specialty knowledge and clinical judgment Nurse Practice Acts: Reasons for Suspending or Revoking a License: Drug or alcohol abuse Fraud Deceptive practice Criminal acts: Falsification of Covid Cards Previous disciplinary actions Gross or ordinary negligence Physical or mental impairments, including age Due Causes for Revoking a License - Notice of investigation - Fair and impartial hearing - Proper decision based on substantial evidence Nurse’s Best Defense of License Investigation - Early Legal Counseling - Thorough preparation for all proceedings - Character and expert witness - Only discuss with your attorney Torts: Intentional and Unintentional Tort is a civil wrong that causes a claimant to suffer loss or harm, resulting in legal liability for the person who commits the tortious act. Torts: Intentional o Assault & battery (Assault is the threat and Battery is actually committing it) o Defamation of character o Invasion of privacy (HIPAA) HIPAA- Health Insurance Portability & Accountability) o False imprisonment o Fraud Torts: Unintentional o Malpractice Negligence Tort is a civil wrong that causes a claimant to suffer loss or harm, resulting in legal liability for the person who commits the tortious act. Liability Four elements that must be established o 1. Duty- obligation to use due care, what is standard of care o 2. Breach of duty: failure to meet the standard of care. o 3. Causation: the act of causing something. MOST DIFFICULT TO PROVE. o 4. Damages: actual harm or injury resulting to the patient. ATI: (2 & 3 are combined) Health Insurance Portability and Accountability Act – HIPPA To see and copy their health record; get a copy of their own chart To update their health record by informing the provider of changes To request correction of any mistakes To get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations To request a restriction on certain uses or disclosures To choose how to receive health information Privacy & Confidentiality of Health Care Records Box 7-2 Maintain individual logons & passwords. Codes change frequently Do not share logons and passwords Programs time out Make sure to log off Systems track which users view, delete or update information Discard printouts appropriately Sign agreements Categories of Malpractice Claims Failure to follow standards of care Failure to use equipment in responsible manner Failure to assess and monitor Failure to communicate Failure to document Failure to act as a client/patient advocate Outcomes of malpractice litigation: o All parties work toward fair settlement. o Case is presented to malpractice arbitration panel; brought to trial court. Areas of Potential Liability for Nurses Table 7-3 Nursing Process o Assessment o Diagnosis- (Not Medical) o Outcome Identification & Planning o Implementation o Evaluation Malpractice Litigation: Roles of Nurses in Legal Proceedings Nurse as defendant Nurse as fact witness Nurse as expert witness Nurse as defendant Do not discuss the case with those involved Do not alter patient records Cooperate fully with your attorney Be courteous on witness stand Do not volunteer any information Legal Safeguards for Nurses Best legal safeguard is competent practice Informed consent or refusal Contracts Collective bargaining Patient education Executing physician orders Delegating Nursing Care Documentation Appropriate use of social media Adequate staffing Whistle-blowing Professional liability insurance Risk management programs Just culture Incident, variance, or occurrence reports; Sentinel events and Never events Patients’rights Good Samaritan Laws Student liability Student Liability Legal responsibilities include: o Being prepared for clinical o DO NOT perform a clinical procedure without informing your instructor o DO NOT administer medication without your instructor physically present o You are responsible for knowing policies and procedures o Your Nursing Instructor shares responsibility for damages in the event of patient injury Safeguards to Competent Practice-Summary Developing interpersonal communication skills Respecting legal boundaries of practice Following institutional procedures and policies Owning personal strengths and weaknesses Evaluating proposed assignments Keeping current in nursing knowledge and skills Respecting patient rights and developing rapport with patients/ clients Keeping careful documentation Working within agency for management policies Types of Risk Management Programs Types o Safety program o Products safety program o Quality Assurance/ Quality Improvement/ Performance Management programs Informed Consent Is a Process: Elements of Informed Consent Disclosure Comprehension Competence Voluntariness Nursing responsibility (If the patient doesn’t know what the procedure is, it is not the nurses’ job to educate them on it, get the physician. Information Contained in Incident Reports (aka Safety Event Reports) All variables/information MUST be filled in: o Complete name of person and names of witnesses o Factual account of incident o Date, time, and place of incident o Pertinent characteristics of person involved o Any equipment or resources being used o Any other important variables o Documentation by physician of medical examination of person involved It is NOT part of the medical record. Follow procedure. Copy goes to Nurse Manager for QA/QI/PM. Five Legal Issues in Nursing - Signatures are Golden - Document, Document, Document - Report it or Tort it - Rights to Privacy - You’re Dosing WHAT?! - Verbal Orders The state nurse practice act is the most important law affecting nursing practice TRUE A nurse falsely imprisons a client by an unauthorized use of restraints Tort A nurse tells a client that she will put a diaper on him if he doesn’t use the urinal more carefully next time? What kind of tort Assault In a health care agency, informed and voluntary consent is needed for admission, for specialized diagnostic procedures, or medical surgical treatment and for any experimental treatments or procedures. True Nursing is caring for a client is about to undergo an elective surgical procedure. The nurse should take which of the following actions refarding informed consent? Make sure the surgeon obtained the client’s consent Witness the client’s signature on the consent form Explain the risks and benefits of the procedure Describe the consequences of choosing not to have the surgery Tell the client about alternatives to having the surgery Chapter 27: Safety, Security and Emergency Preparedness Factors Affecting Safety - Developmental Considerations - Lifestyle - Environment - Mobility - Sensory Perception - Knowledge - Ability to communicate - Physical Health State - Psychosocial Health State Nursing Assessments: Nursing History Physical Examination Access for history of falls or accidents Assess mobility status, ability to communicate, level of awareness or orientation, sensory and perception Note Assistive devices Identify potential safety hazards Be alert to history of drug or alcohol abuse Recognize manifestations of domestic violence or neglect Obtain knowledge of family support systems and home environments Risk Factor Assessments Perform a Home Safety Checklist Box 27-1 o Fire & burns o Electrical o Poisoning o Falls o Firearm injuries o Asphyxiation & choking Factors That Contribute to Falls Advanced age (>65) History of previous falls Poor vision Lower body weakness; Gait &/or balance issues, issues with posture, impaired mobility; chronic disease; problems with feet and/or shoes Medication regimen; including use of psychoactive Postural dizziness/hypotension Slowed reaction time; weakness, frailty Confusion or disorientation Unfamiliar environment Hazards in the home (and community) Patients Outcomes for Safety - Identify real and potential unsafe environment - Implement safety measures in the environment - Use available resources for safety information. - Incorporate accident prevention practices into ADLs (Activities of Daily Living) - Remain free of injury Safety Considerations for Fetus, Neonate & Infant - Avoid behaviors that might harm the fetus - Wash Hands - Never leave the Infant unattended - Use Crib Rails - Monitor setting for objects that are choking hazards - Handle infant securely while supporting the head - Place Infant on back to sleep - Use of toys - Use Car seats properly Safety Considerations for Toddler/Preschooler Supervise child closely to prevent injury. Select toys appropriate for developmental level. Childproof home environment; Prevent poisoning. Never leave child alone in bathtub. Be alert to manifestations of child abuse. Keep hot items on stove out of reach. Use car seats properly. Mandated in all 50 states. Teach about fire safety/practice emergency evacuation measures. Safety Consideration for School-Aged Child Help to avoid activities that are potentially dangerous. Provide interventions for safety at home, school, & neighborhood. Teach bicycle safety. Share the road. Teach about child abduction. Wear seatbelts. Continue immunizations as scheduled. Safety Consideration for Adolescents Teach safe driving skills and avoiding distracted driving. Teach avoidance of tobacco and alcohol. Teach risk of infection with body piercing and tattoos. Teach about guns and violence. Discuss & monitor dangers associated with the Internet. Teach about sexuality, STIs, and birth control. Get physical examination before participating in sports. Health Teaching in the Schools - Monitor the child’s use of the Internet - Get involved in school activities and ask pertinent questions - Volunteer for safety committees that include staff and parents - Ensure that the school’s emergency preparedness plan is current Safety Consideration for Adults - Remind them of effects of stress on lifestyle and health - Enroll in defensive driving course - Teach bicycle safety. Share the road - Counsel about unsafe health habits (reliance on drugs and alcohol) - Counsel about domestic violence Safety Consideration for Older Adults (over 65) Identify safety hazards in the environment to prevent accidents & make modifications as necessary. Smoke and carbon monoxide detectors Orient person to surroundings (avoid falls). Attend defensive driving courses or courses designed for older drivers. Encourage regular vision and hearing tests. Ensure hearing aids and eyeglasses are available and functioning. Use medication trays (avoid poisoning/ not taking). Objective document and report any signs of neglect and abuse. (Elder Abuse) Child Abuse/ Domestic Abuse / Intimate Partner Abuse (IPV) / Elder Abuse Safety while living with an abusive partner Safety planning with children Safety planning for pets Safety planning during pregnancy Leaving a relationship Monitor Elder Abuse Physiologic Hazards Associated with Restraints Box 26.5 Increased possibility of serious injury due to fall Skin breakdown Contractures Incontinence Depression Delirium Anxiety Aspiration and respiratory difficulties Death Types of Restraints Used for Adults and Children Check on Adults every 4 hours Check on children every 2 hours Fire & Safety / CPR & Defibrillation RACE Rescue Activate the ALARM Confine the fire Evacuate/Extinguish Pass Pull the Pin Aim at the base of the fire Squeeze the handle Sweep side to Side CPR & Defibrillation- see page 1520 Activate emergency response system; get AED, Begin CPR with CAB sequence: Chest compressions, Airway, Breathing, & Defibrillation/ AED Decreasing Equipment-Related Accidents Use only for intended use & be familiar with equipment. Handle equipment with care so as not to damage it. Use three-prong plugs. Do not twist or bend electric cords. Be alert to signs that equipment is faulty. Be alert to wet surfaces. Make certain defibrillator charging indicator light is on. Joint Commission Safety Goals (TJC) Improve patient identification. Improve communication among caregivers. Improve safety of high-alert medications. Eliminate wrong site, wrong patient, wrong procedure, & wrong surgery. Improve safety using infusion pumps. Improve effectiveness of clinical alarm systems. Reduce risk of healthcare acquired infections. Safety Events Reports (Incident Reports) Must be completed after any accident or incident in a health care facility that compromises safety Describes the circumstances of the accident or incident Details the patient’s response to the examination and treatment of the patient after the incident Completed by the nurse immediately after the incident All fields/variables/information are to be completed Provider sees patient, leave for Nurse Manager, to be sent to QI Is not part of the medical record and should not be mentioned in documentation Emergency Preparedness Disaster (natural or artificial) preparedness; plan, practice before it happens Bioterrorism- deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic (Table 27-2); ie, Anthrax, Botulism, Smallpox, Ebola Chemical terrorism- deliberate or unintentional release of a chemical that has the potential for harming people’s health Nuclear/radiation terrorism- intentional introduction of radioactive materials into the environment for purpose of causing injury or death Cyber terrorism- the use of high technology to disable or delete critical infrastructure data or information Emergency Preparedness: Chemical Terrorism Biotoxins: poisons from plants or animals Vesicants/blister agents: chemicals that severely blister the eyes, respiratory tract & skin on contact Blood agents: poisons absorbed into the blood Caustics (acids): chemicals that burn the skin, eyes & mucous membranes on contact Choking/lung/Pulmonary agents: chemicals that cause severe irritation or swelling of the respiratory tract Incapacitating agents: drugs that affect the ability to think clearly/ cause altered state of consciousness or unconsciousness Long-acting anticoagulants: poisons that cause bleeding Metals: agents consisting of metallic poisons Nerve agents: highly poisonous chemicals that prevent the nervous system from working properly: constricted pupils. red eyes, loss of consciousness, convulsions, respiratory arrest Organic solvents: agents that damage the tissues by dissolving fats & oils Riot control agents/tear gas: highly irritating agents Toxic alcohols: poisonous alcohols that can damage the heart, kidneys & nervous system Vomiting agents: chemicals that cause nausea & vomiting (n/v) Chapter 30 Perioperative Nursing Three Phases of Perioperative Period Perioperative Period (3 phases: Pre-op, Intraop & Post-op) Preoperative (preop): o begins with decision to have surgery, lasts until client is transferred to the holding room/operating room (OR)/procedural bed Intraoperative (intra-op): o begins when the client is transferred to the holding room/OR/procedural bed until transfer to the post-anesthesia care unit/recovery room (PACU) Postoperative (post-op): o lasts from admission to the PACU/other recovery area to complete recovery from surgery and last follow-up health care provider visit Desired Outcomes for the Surgical Patient Receive respectful and appropriate care Be free from injury & adverse effects Be free from infection & Deep vein thrombosis (DVT) (Blood clot forming deep in the vein) Maintain fluid & electrolyte balance (F&E), skin integrity, normal temperature Have pain managed Demonstrate understanding of physiologic & psychological responses to surgery Participate in rehabilitation process Classification of Surgical Procedures Table 30-1 Urgency (elective/optional, urgent, emergency), degree of Risk (minor or major) & purpose Types: o Diagnostic: screening, identify cause, help to confirm o Curative: removal of tissue o Preventative: controversial o Ablative: removal of disease part o Palliative: relieve or reduce intensity of an illness o Reconstructive: restore function to tissue o Transplantation: removing/moving an organ o Constructive: restore function w/congenital anomalies Laparoscopy procedure using a scope with minimal opening Laparotomy opening the patient Risk Factors and Strengths Assess by obtaining Health History Developmental level Medical and surgical history Medication history Medical (inc. allergies) and surgical history Medication/ Treatment history Nutritional status Use of alcohol, illicit drugs, or nicotine Activities of daily living and occupation Coping patterns and support systems Sociocultural needs Surgical Risk of Medications Anticoagulants: precipitate hemorrhage (aspirin and Heparin) Diuretics: electrolyte imbalances, respiratory depression from anesthesia (Lasix) Tranquilizers: increase hypotensive effects of anesthetic agents Adrenal steroids: abrupt withdrawal may cause cardiovascular collapse Antibiotics in mycin group: respiratory paralysis when combined with certain muscle relaxants Informed Consent Information Provider: o Description of procedure and alternative therapies o Underlying disease process and its natural course o Name and qualifications of person performing procedure- surgeon obtains consent o Explanation of risks and how often they occur o Explanation that the patient has the right to refuse treatment or withdraw consent o Explanation of expected outcome, recovery, rehabilitation plan, and course of treatment Nursing: Make sure the surgeon obtains the client’s consent & witness the client’s signature. Advance Directives - Living Wills - Durable Power of Attorney for health care Using Presurgical Screening Tests Chest x-ray Electrocardiography Complete blood count (CBC) o levels WBC (infection) 5-100,000 o HCT/HGB (bleeding, anemia) 150-300,000 Electrolyte levels Hyperkalemia ()/ Hypokalemia () (increased risk for cardiac problems) Urinalysis (potential kidney issues) Glucose screening Nurse’s Role in Presurgical Testing Ensure that tests are explained to the patient. Ensure that appropriate specimens are collected. Ensure that results are recorded in patient records before surgery. Ensure that abnormal results are reported. Preparing the Patient Through Teaching Surgical events and sensations Pain management Physical activities o Incentive spirometry (Guidelines 39-1)- several times per hour o Coughing (Guidelines 30-2)- every 2 hours o Deep breathing (Guidelines 30-1)- several times per hour o Leg exercises (Figure 30-2)- every 2 hours o Turning in bed- every 2 hours o Early ambulation- check order Pain is the fifth vital sign Nursing Interventions for Surgical Patients Hygiene and skin preparation Elimination Nutrition and fluids Rest and sleep Preparation and safety the day of surgery o Hand hygiene/Identification/Vital Signs/ Pre-op medications o Consent/ Lab results o Equipment & supplies o Remove makeup & personal clothing & prosthetics Typical Preoperative Medications Sedatives: Diazepam/ Valium, Midazolam/ Versed, Lorazepam/ Ativan o Antidote- Flumazenil/Romazicon Anticholinergics: Atropine/ Robinul o Antidote- Physostigmine/ Antilirium Narcotic analgesics: Morphine, Meperdine/Demerol, Butorphanol/ Stadol & Neuroleptanalgesic agents Fentanyl/ Sublimaze o Antidote- Naloxone/Narcan Histamine 2 receptor antihistamines: Cimetidine/Tagamet Ranitidine/Zantac, Sodium citrate/citric acid/Bicitra o No specific antidote TJC Protocol to Prevent Wrong Site, Wrong Procedure, and Wrong Person Surgery Preoperative patient identification verification process Marking the operative site Final verification just prior to beginning the procedure, referred to as the “Time Out” Outpatient/Same-Day Surgery Reduces length of hospital stay and cuts costs Reduces stress for the patient May require additional teaching and home care services for certain patients o Older patients, chronically ill patients, patients with no support system Outcomes for the Surgical Patient Receive respectful and culturally and age-appropriate care Be free from injury and adverse effects Be free from infection and DVT Maintain fluid and electrolyte balance; skin integrity, normal temperature Have pain managed Demonstrate understanding of physiologic and psychological responses to surgery Participate in rehabilitation process Nursing Interventions for Intraoperative Patients Identify patient Verify information by completing Pre-op Checklist Lab reports Consent Assess v/s and pain Start IV Administer pre-op meds Skin prep On-going assessment Time Out, OR counts, specimens Types of Anesthesia General anesthesia Moderate analgesia/conscious sedation Regional o Major Nerve blocks (peripheral) o Spinal anesthesia (subarachnoid block) o Caudal anesthesia (pudendal block) o Epidural anesthesia Topical and local anesthesia General Anesthesia General (systemic): administration of drugs by inhalation or intravenous route; asleep, CNS depression; rapid excretion & reversal effects. Used for any type and any age; and for emergencies. o 3 phases Induction: from administration of anesthesia to ready for incision Maintenance: from incision to near completion of procedure Emergence: starts when patient emerges from anesthesia and is ready to leave operating room Other Types of Anesthesia Moderate sedation/analgesia (conscious sedation/analgesia): used for short-term, minimally invasive procedures Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site (spinal, epidural); contraindicated if back injury; awake, loss sensation; good for older adults o Major Nerve blocks (peripheral) o Spinal anesthesia (subarachnoid block) o Caudal anesthesia (pudendal block) o Epidural anesthesia Topical and local anesthesia: numbs: used on mucous membranes, open skin, wounds, burns General Anesthesia Stages - Loss of consciousness - Amnesia - Analgesia - Relaxed skeletal muscles - Depressed reflexes Return of Consciousness Unconscious Response to touch and sounds Drowsiness Awake but not oriented Awake and oriented Postoperative Assessments and Interventions (Initial Every 15 Minutes for 1 hr) Purpose: to monitor for complications Vital signs & oxygen saturation, includes pain Respiratory status (airway, pulse oximetry) Cardiovascular status (blood pressure) Temperature (color & temperature of skin) Central nervous system status (level of consciousness/alertness, movement, shivering) Fluid status (Intravenous fluids) I & O Surgical site/wound status/ tubes Gastrointestinal status/ GI (nausea and vomiting) Comfort, Position & safety Cardiovascular Complications- monitor Hemorrhage: restlessness, anxiety, frank bleeding & hypotension, cold, clammy skin, weak, thready pulse; cool, deep rapid resp, urine output, thirst, apprehensiveness Shock: cold, clammy skin, pale skin, tachycardia (rapid pulse), tachypnea, rapid breathing, n/v, enlarged pupils, weakness or fatigue, dizziness or fainting Thrombophlebitis: pain/cramping in calf or thigh, red & swelling in affected extremity, elevated temp, increase diameter Pulmonary embolus: dyspnea, chest pain, cough, cyanosis, tachypnea, tachycardia, anxiety, apprehensiveness, panic Interventions to Prevent Respiratory Complications Monitoring vital signs Implementing deep breathing & coughing, Incentive spirometry Turning in bed every 2 hours Ambulating Maintaining hydration Avoiding positioning that decreases ventilation o Low fowlers (15-30 degrees) o Semi fowlers (30-45 degrees) NG tube,cardiac,neuro o Fowlers (45-60 degrees) lung expansion o High/Full Fowlers (60-90 degrees) dyspnea Monitoring responses to narcotic analgesics Surgical Asepsis (Ch 24) – see box 24-6 Used in OR, L&D, for certain testing, and at bedside Catheters, IVs, sterile fields, sterile dressings, injectable meds PPE- donning (on) and doffing (taking off) Sterile gloves to prevent contamination Sterile field; opening packages; sterile forceps; the 1-inch border around the sterile field is considered contaminated When wet, the sterile field is no longer sterile Open closest to time of use- prolonged exposure is contaminated Keep objects in sight so we don’t contaminate them Avoid coughing and sneezing In sterile attire move back to back, OR, front to front; objects below waist, above neck and behind are contaminated When opening fluids – considered sterile for 24 hrs Chapter 2: Theory, Research, and Evidence- Based Practice What is Nursing? Knowledge + Application of Skill Knowledge = Nursing School, Continuing Education Skill = Practice, Experience Chapter 5: Cultural Diversity Nursing Culture - Scrubs - Own nursing language - Nursing shift report - Collaborative - Helpers Rude hand gestures in other countries Mexico – Putting hands on his signal hostility Spain and Greece – The America OK sign is one of the rude hand gestures France – A rude gesture is to snap fingers of both hands Middle East Culture – thumbs up signs is an offensive finger gesture Chapter 46: Spirituality
