Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Fall2016
PersonalLectureNotes
!READFIRST!
Disclaimer!
These notes were taken for personal use and are subject to error, incomplete information, spelling
errors,misunderstoodconcepts,andnonstandardabbreviations.Alwaysconsultyourtextbooksand
instructorsforclarificationofunclearmaterialandspecificlabvalues.Theauthorofthispublication
takesnoresponsibilityforpossibleerrorscontainedwithinthisdocument.Byviewingbeyondthispage,
youhaveagreed toverifythrough otherpublished sources and withcurrent faculty, allinformation
containedwithin.MayGodhavemercyonyoursoul.
NUR111
Week1
September6,2016
*Clinicalweek19104ONLYat07:30(forthe1st2weeksofclass)
Alwayscheckblackboarddaily
SkillslabinCLL(1stfloor)
SecondweekclinicalBRINGfulloutlineforfurtherorganization
Dopreconfbeforeclass
Informalwritingassignisduethisweek
Academicadvisorisyourclinicalinstructor
ChaonofCO:
clinfacult
Tina
Skilllablabhoursarepostedondoors
MakefriendswithSNAlookinstudentlounge
Mathtestadninweeks9,12,14
Nursingprocess5steps(onblackboardalso)
assessment1collectdatafrom1or2source
diagnosispatientproblem(nurdiagnosishandbookAckley)
Planningpriorities,
implementationbasedonnursesclinjudgement
Evaluationandrepeat
7partsofwellnessmodel:
Withyouinthecenter
emotional
physical
social/cultural
environmental
occu
spiritual
Intellectual
FamlilyandculturalbelifesandpracticesisHUGEinfluenc
*Leveelsofprevention:
Priprevent
secon
tert
LookatHealthyPeople2020forextra
Florencenightingalenurse(Lister,JSnow)
*Reviewmicroterminology
Asepsis
Medical:
cleantechnique
reducingthenumberofpathogens
Surgical:
*rememberthepatientisthemostimportantpart,whatsbestforthepatient?
theyneedtounderstand,knowtherational
HealthPromotion:
NYSmandatoryInfectionTraining($30)every4yearsiscoveredinclassS6505b
TONIGHT:
studygroup
testeachother
*NYSmandatorypacket(whenlinkisavailable,answerthe6questions),Duebyweek3
NUR111
Week2
September13,2016
*onexamsofttherewillbeapracticetestwith100possibleattempts.Thisisusedtotestresident
softwareafteranycomputerupdates.
SNAmeeting9104wed.16:0017:00
Mathinthisnursingprogramisdimensionalanalysisnotratios
*asepsisquizonblackboard(problemsgettingittoblackboardbutprobablyavailabletoday)
elements..
Safety,activity,mobilitylecture
Thinkabout:falls,movement,medicationmistakes,pressureulcers,
safetyfreedomfrompsych,andphysicalinjury
ThinkfromMazlowsperspective
(inclass)Josiekingstory.JosiekingpatientsafetyfoundationJohnsHopkinshosp
*knowaboutthemajorgoverningbodiesthatworkwithnursingandhealthcare(ANA,IOM,JCAHO,nat.
patientsafetygoals)
Childrenunder5injuriesaretheleadingcausesofdeath
Schoolagehome,environmental,contactsports,attemptscomplexmotoractivities
Adolescentdriving,needtobeaccepted,relationshipissues,substanceabuse,mentalhealth
Adultslifestylehabits,smoking,drinking,obesity
Olderadultsphysiologicchanges,osteoporosis,decreasedmuscle.85%ofeldershavenotprepared
theirhomeforaging!
Conductsafetyassessmentofpatientshome(homecare)
Poisoncontrol(www.aapcc.org)911,18002221222
*knowelectricalsafety,plugsafety,electricandwater,routingwires,overheating
Hospitalcentered
Falls,pathogens,malfunctioningequipment,medengenderingoverwatch,medicationerrors,MSDS
Otherthings
Fire,nosmoking,(mostfirescausedfromelectricoranesthesia),knowRACE,extinguishers,staycalm
Fallassessmentforms/tools,assessandreassess.Assessconfusion,medications,drugs/ETOH,clutter
NursingprocessADPIE
Planninghaveameasurableplanforthepatient
Implementtheplanstoreachthegoalandreassesstheneedforanymodificationoftheplan
Lackofsafetyinthehospitalisabigproblem
Huddlesaboutsafety
JACOinitiatedaspeakupcampaignforpatientreporting
neverevents
Thecultureofsafety
Rootcauseofsafetyissues(rootcauseanalysis)
CUSPcomprehensiveunitbasedprogram
Incidentreporting(Quantrose)anassessmentofhowtheincidenthappenedandhowtocorrectitin
thefuture,meantnottobepunitive
Restraintsusingrestraintsaremoredangerousthanfallsasthenewtrend.
Alwaysassesseachpatient,assessmedicationrestraintsvsotheroptions
*readtextforoptionsotherthanphysicalrestraints
Restrainedpatientscanleadtopooroutcomes
Maintainpatientrightsanddignitywhenemployingrestraintsandreassessforsafety
**testeachotherabouttheunitterms**REVIEWINSTUDYGROUP
AgoalofmovementistopreformADLs
WhenassessingADLsworkwiththepatienttodeveloprealisticandattainablegoalsforselfcareand
living
Baseofsupport(centerofgravity)importantinbalanceandavoidingselfinjury
**lookatmathPPTsonblackboard
STRESSandCOPING
Stressorscausesstressandcausesacertainresponse
Stressorscanbeinternal,external,situational,maturational,sociocultural
Internalstresscanbeanxiety,..
Maturationalthroughoutalifespanandchangedependingonage;
Childbullying,peers,school
Teenagersappearance,hormonalchanges,sex,grades,career,bodyimagechanges
Adultsfamily,money,career,
Sociocultural
War
Poverty
Physicalhandicaps
Homelessness
Religionandrace
Stressstimulatesasympathetic/adrenergicresponse(pupilsdilate,parastalsisdecreasesm,bloodsugar
goesup
P.775potterandPerrystress
Mildanxietymayenhanceawarenessandlearning
Moderate
Severegreatlyreducedfunctioning,onlyfocusesonafewdetails,unabletofocus,notincontrol
Panicmorephysicalsymptomsrequiringimmediate,sometimesphysicalremovalfromthestimulation
GASgeneraladaptationsyndrome
A3stageresponse
1alarm
2resistance
3exhaustion,canleadtodeath
P.780782generalguidelinestominimizeanxietyandstresshealthpromotion
Steps:
identifystress
Verbalize
Identiftstrengths
Recognizepositive..
Nursing111Lecture
Week3
09202016
Nursepracticeactgovernshownursespractice(maybedifferentin
eachstate).Ensuresweallpracticeataminimumstandard.
Controlledpracticeactmedswithahighabusepotentialare
regulatedtopreventabuseandtheft.Outlineshowordersare
placed,research,lawenforcement.
diversionofnarcoticstheftbyahealthcareworker.
Nursingimplications
Tells,assessment,NursingDx,teaching,nursingoutcomes
i.e.:assessforskinrash,assessforGIbleeding,
6RightsofMedicationAdministration:
RightMedication
RightDose
RightPatient
RightRoute
RightTime
RightDocumentation
Pharmacokineticshowamedisabsorbed,distributed,andeliminated
*pillisquickerthantransdermal?
HTNdecreasesbloodflowandthereforedecreasesdrugdistribution
Fatsol.S.watersol.Medicationsfatsol.Isretainedbetter/storedintheSQtissue
BBBfatsolubleonlycanpassthroughtheBBB
Albumenisthemainbindingproteinformanymedications,albumenlevelscandictateamountofbound
medication
Metabolism:
liverisprimarymet.Site
diseasesmaydecreasethemetabolismwhichcouldleadtoaccumulationandtoxicity
Excretion:
age
ProviderDxandRxwritesorders
Pharmacymixes,evaluatesanddistributesmedications.Willalsomonitorpatient
Nursegivesandmonitorspatient,evaluateseverythingusereferencestoassistinevaluation
Patientcompliance,abilitytotakemedications,reportbackresponse/adverseRxn
Patientteaching:
names
dose
whentotake
adverseRxn
foodinteractions
adverseeffects
whotocall
storage
dosage,routeandfrequencyismostoftenmissedpartsofthemed.Order
**Inbackofclinicalsectionwhatmustbedocumentedforapatientrefusalofdocumentation**
removeandhaveonhandforclassesP.167
MedicationCalculationLecture
**week#9medicationexam
A. providerorder
Writtenby:(MD,PA,NP)
Properlywritten
Accuracy(dose,route,freq,spec.considerations
Availdose
Wherecanthemedsbefound?
Readlabelcarefully!
c.
Medicationcalcformula.Pickonewayofcalculationanduseitalways
studyin2006dimensionalanaly.Higheraccuracythanothersystems
**Doallmathonpaper/calculator(notinyourhead)
**dontleavelabelsoffofcalculations
Lecture09272016
Week4
Startedexam07:34ended08:13
Used7%powerfor1stnursingexam
Thingstododifferentfornextexam:
Opentop(questionwindow)wider
RememberIhaveanonlinecalculator
Getcomfortableearplugs
Sitinbackofroom
Clickoncontinuewithoutdisablingantiviruswhenaskedinthebeginningoftheexam
(Idid)butrememberAdderallbeforeexam(1/2hr45minbefore)(09:00feltfulleffect)
Q:dowegetourscrappaperbackduringreview?
Q:willthereeverbeselectallthatapply
Willsettingtheonscreentimerhelpstayontrack?
Remembertokeepscreenbrightnessawayfromfullbrightness
RememberstudentloginisMnumber
DoesExamSoftgiveyouyourscoreattheend?
Signinforclassonsheetbeforeexam
ReviewrationalesforanswerstounderstandhowtobestanswerNCLAXtypequestions/
wording
Fornextweek:
**filloutbasicnutritionneeds(pink)packet
MCC5k
satOct.8
signupinJennysofficetovolunteer
Nextweeknutritioninconferencepickuphandout(pink)infrontoronblackboardfordiscussion/
watchvideosupersize
Professionalcommunication
Protectspatientsafety,rights,legally(ifyoudidntdocument..
arelevantaccountofcare
MARpronouncedmar..
Components:
admissionsnote
orders
Hx/exam
progressnotes
criticalpathways
variance
problemlist(assumingitsupdatedcorrectly,alotofcutpastedone)
patientcaresummery
dischargesummaryforms
Kardex
Fluiddocument
updatedasordersareentered
usuallyelectronic
usedduringhandoff
Flowsheets
Visualizetrending
documentingtrendsandgoalprogress
ifthereisabnormaldata,documentandwritenote,assessment,planandresponse/interventions
Confidentiality
HIPPA
protectatallcosts
patientpermissiontoresearchanduseascontinuingED
HIM(healthinformationmanagement)departmenttoobtainfullchart
allelectronicaccessistraceable
EMRelectronicmedicalrecord
Standardsofcare
JACOwatchdogaccreditingbody
institutionshavetheirownstandardsandpolicies
Timelydocumentation,possiblyforgetting,poorcare
documentwithinthecontextofthenursingprocess(ADPIE)
Documentation
vitalsigns
comprehensive
providescontinuityofcare,alwayswatchingthepatientgoodhandoff,helpsunderstandingofwhere
patienthasbeenandtheirgoals.
supportsutilizationreimbursementandbilling
mustbefactualandobjective
directpatientobservations
Accuracy:
crossoutcorrectly(singlelinethrough,ERROR,date,initial)
avoidunnecessarywords,beconcise,onlyapprovedabbreviations(sheetsomewherein
packet?)
completewithadditionalobjectivedata
remembertobetimelysoyoudontforgetorcausepotentialpatientharm
Organization:ADPIE,logicalorder,clear,tothepointwithoutextrainformation
Thinkinalinearmanor
Examplesofnote:
assessmentwhatitappears
Dxitsrelatedtoswollencalf
Plan:notifyprovider,elevate,sch.Ultrasound
Impression:whatdidwedoactually
Evaluation:effectofpainmedshowispatientfeeling,vitals
DocumentintheformatOkdwithyourfacility
EMRelectronicmedicalrecord
HERElectronichealthrecord
leadstothedevelopmentofnursinginformaticsnursinginformaticscanspeakbothRNandIT
language(forresearchanddatapulls)
SOAPIEverycommonlyseen,separateinsignificantdatafromrelevantdata
Avoidrepetition
Focuscharting
data,assessment,response
Chartingbyexception:
onlydocumentabnormalities
reducesamountofdocumentation
promotesconsistencyindocumentation
Handoff
providescontinuityandsafety
mustdevelopaflow/style
SBAR
Teleorverbalorders:
Writeorder,sayback
Usuallyemergentorafterhours
Incidentreport:
WriteASAP
Writtenbythepersoninvolved
Witnesses/involved
Equipmentinvolved
**DONOTmentionincidentreportinmedicalrecord
Communicatewithpatient/family:
introduceandidentifyyourself
askpatienthowtheywanttobeaddressed
useunderstandableterminology,explain
useopenendedquestions
provideprivacy
askforpermissiontotalk(tofamily/friends)
avoidpolitics
Nursing111Lecture
Week5
10042016
**seejennyaboutvolunteeringat5K,
**bringAckleystolecturefromnowon
NursingDx:
Nausea
Anunpleasantfeeling,mayresultinvomiting
Foodaversion
Gagging
Inc.salivation
Sourtasteinmouth
Avoidmovement
Distractions
Odorfreesetting
LimitPOintake
Smallmeals
Inc.fluids
Blandfoods
Lowstress
Crackersonhand
Antiemetics
Tx:
Nutritionimbalance,lessthanabodyrequires:
Caloricintakedoesntincludesubstancesthatsupportbodygrowthandsupport
Elderly,adolescents,poorlydesigned/faddiets
Definingcharacteristics:
Cramping
Aversiontofood
Abdominalpain
Bodyweight20%underideal
Hairloss
Capillaryfragility
Misconceptions
Poormuscletone
Overweight:
excessiveweightforageandgender
Under2yoa>95percentile
Children218BMI>85%butunder95%orkg/m2
AdultBMI>25kg/m2
Riskforoverweight:
Excessivefatintakeforageandgender
Riskfactors:
AdultBMIapproaching25kg/m2
ChildrenBMiapproaching85%,consumptionofexcessivesweets/sweetenedbeverages
Eatingdisorders
MyPlate
USDA.org
Balancedcalorieswithphysicalactivitytomanageweight
Consumemoreofcertainfoods(healthyfoods),limitlowqualitybeef,limitfillers
Limitsodium<99mg/day,lowsugar
Wholegrains,fatfree/dairyfreeproducts
Balanceyourcalories(www.mayoclinic.org/healthylifestyle/nutritionandhealthy
eating/indepth/calorie...)
CalculateBMR
Howdowesucceed?
Eatslower
Payattentiontoyourfood(noTV/computer/nodrivingandeating)
Listentobodyclues
Payattentiontoyourenvironment,eatingisasocialactivity
Useasmallerplate
Aglassofcoldwaterbeforeameal
Apportionsmalleramounts
Share
Plantotakehomeaportionofthefood
Eatmoreof:
Vegetables
Fryits
Wholegrains,brownrice,(fiber)
Fatfreemilkor1%(childrenandwomenneedmilk/calcium)
Thingstoeatlessof:
Sugars,salts,solidfats(atroomtemperature/Crisco/lard)
Lookforsodium>2300
Readthelabel
Increasewaterintake
Unsweeteneddrinks
Lookathealthypeople2020forfurther
Table451P&P
Promotethrough:
Education
Healthpromotion
Rolemodels
Readingfoodlabels:
Howtomakehealthychoices
Howtopromotehealthinyourpatents
RequiredbytheFDA
Empowersconsumers
Providesguidelines
Whereisthelable?
Whatdoesitcontain(servingsize,nutritionalvalue)?
(caloriesfromfatsisgoingaway2016)
(avg.fibercontentis3grams)
Basedona2000caldiet
Beawareof:
Servingsize
Sodium,sugar,
Limitfatto5678GMsaday
Checkcaloriesperserving
Getenoughfiber,vitamins,minerals,othernutrients
Checkforallergies
Informationisbasedona2000cal./daydiet
CHANGEStolabels:
Newaddedsugarsmustbeidentified
Naisadjustedtoa2,300dailyvalue
KandDwillberequired(AandCwillbeoptional)
Terms:
Caloriefree(<5calperserving)
Sugarfree(<0.5GMS)
Reduced(<25%oforiginal)
*whentheseitemsareremovedsugarorsaltisaddedtomakeupforlackoftaste
Highfiber(>5GRMfiber)
Goodfiberis2.5to4.9GMS
NUR11110112016
Week6
NANDAI(Ackleys)
Nursingprocess:
Systematic
5steps(ADPIE)
Criticalthinkingandthenursingprocessissimilar(nursingprocesscentersaroundcritical
thinking)
Thisisanationalpracticestandardandthefoundationofcriticalthinking
Weneverstopassessing,itsacontinuousprocessthatbuildsonitsself
awrongassessmentwillbogdownthecontinuingcircle
gaininfoaboutthepatientscurrentandpastHx
usuallynursingpaperworkwillguideyouthroughtheassessment
Subjectiveexactlywhattheysaid
Primarysourcepatient
secondaryfamily/caregivers,otherhealthcareprofessionals
Professionalliterature
Datacollectionmethods:
interviewstructurednursecontrolled,setthetone
openendedquestions(usually)
Statesofinterview:
Openingbuildrapport
Bodycomm.Datacollection
Closing
EXAM:
Inspect,Palp,percuss,ausc
Organizedata(electronic,paper)(basedonMaslows)
Validatedata:
Doublecheck
Dontassume
Dontmakeamedicaldiagnose
AmedicalDiagnosis:
Etiologytheprobablecauseoftheproblem
Comparedatawithexpectedfindings
isdataabnormal?
whatistheabnormalitycausedby?
Dataclustering:
afterassessment
organizedata
lookforpatterns
makeinference..helpfultoanursingdiagnosis
Includethepatientintheplan
DoesClusterdatasupportyourDx?
Isitanursing,medical,orcollaborativeproblem(section3Ackleyswillhelpwiththis
**etiologymustbewithinthedomainofnursing*NOTAMEDICALDIAGNOSIS*
AnursingDxisabasisforselectinganursinginterventiontoachieveanoutcomewhichtheRN
isaccountabilityfor
CollaborativeDxstartwithpotentialcomplications(foundinsection2ofAckleys)
Etiology(theR/Tphrase)theprobablecause,inthedomainofnursingpractice
NUR11110182016
WEEK7
Functionofwaterinthebody:
Regulatestemp
Lubricatesjoints
Lessburdenonthekidneyandliverthrough
flushingofwasteproducts
CarriesOxygenandwaste
Dissolvesmineralsandnutrientstobecarried
tothebody
Preventsconstipation
Protectsbodyorgans
Moistensmucusmembranes
ImportantValues:
Normaloutput4080ml/hr
(min.30ml/hr)
+
K 3.55mEq
Na+135145mEq
Cl95105mEq
HCT3550%
pH7.357.45
specificgravityofurine1.0101.025
Fluidcompartments:
IntracellularInsidethecell(mediumforcellularmetabolism)
ExtracellularOutsidethecell(transportsystemfornutrientsandwaste
Interstitialfluidsbetweenthecellsofthebodyandthebloodvessels
Transcellularfluidsfluidsthatsurroundorgans(CSF,pluralfluid,synovialfluid)
Electrolytes:
Particlesinasolution
Inwater(solvent)
Breaksupintoseparatelychargedions
MeasuredinmEq/L(thecapacityofthecationstocombinewithanionstoformamolecule
Definition:
CationpositivelychargedelectrolyteNa+,K+,H+
AnionNegativelychargedelectrolyteCl,O
Functionofelectrolytes:
Regulateswaterdistribution
Transmitnerveimpulses
Acid/basebalance
Majorelectrolytesincompartments:
intracellularion:
**K+:functionskeletal,cardiac,smoothmuscleactivity,sourcebananas,figs,oranges,IV
fluids/medications
Deficitsseeninuseofdiuretics
Cancausemusclecramping,
Mainextracellularelectrolyte:
SodiumNa+
Functionregulateswaterlevels
Source:processedfoodtablesalt,IV
Fluid/electrolytemovement
Betweencompartments,acrosssemipermeablemembrane
Constantmotion
Equilibrium,homeostasis
Movement:
1stwayosmosis(osmosis=water)watermovestomaintaintherelativebalanceinthecompartments
2ndwaydiffusion(diffusion=electrolytes)electrolytesmovefromhightolow
Watchthesciguys:scienceathome,SF1SE14:thenakedeggosmosis(playingwitheggs,vinegar,and
cornsyrup)
Reninangiotensinaldosteronesystem(anadaptivemechanism)
Factorsaffectingfluid/electrolytes:
age
gender
environmenttemperature
lifestyle
illness
medications(laxatives,diuretics)
Nursingfluidmanagement:
Identifyrisks:
MedHxacute/chronic
Medications
Developmentalage
Socioeconomic/environmental
Functionallevelsurinaryhabits,anychanges?
Usualfood/fluidintake(elderlydrinklesstoavoidincontinence..espwomen)
Balance=IO
Monitorintake,output,
Intake:
Useinml
Measureateyelevel
Flatsurface
Atthebottomofthemeniscus(beaccurate)
*recordonlyoftheinitialvolumeoficechips
CounttubefeedsPLUSflushes
Includeliquidsgivenwithmeds
Output:
Trendhourly,Qshift,Qday
Norm4080ml/hr,(min30ml/hr)
Outputincludes:tubes,drains,wounddrainage,liq.feces,urine
Weights:
Trendsinlongtermfluidstatus
Balancescale
Sametimeoftheday
Sameclothes
Samescale
(morningisthebesttimetoweighapatient)
Labvalues:
K+
Na+
Cl
HCT
3.55.0mEq
135145mEq
95105mEq
3550%(volumeofRBCsinplasma0
Lessfluidvol=higherHCT,morefluid=lowerHCT
ABG:
pH
7.357.45
acidosisvs.alkalosis
specificgravitymeasureofsolutesinurine
1.0101.025sg
(highersg=dehydration)
Nursingprocessfluidandelectrolytes
NursingDx:
Excessfluidvolume:
Def.increasedisotonicfluidretention
Definingcharacteristicsassessmentdata
Adventitious(abnormal)lungsounds(crackles),interstitialedema
Edema
JVD
AlterationinB/P
Alteredmentalstatus
Alteredresp.pattern
Alteredspecificgravity
Anxiety
Definingcharacteristics:
Dyspnea
DecreaseinHCT
Electrolyteimbalance
IexceedO
Weightgain(significantweightgainis(>510lbsinaweek)
(remembertohavemorethan1definingcharacteristicforyournursingdiagnosis)
Assesslungsoundstolistenforpulm.Edema
Lookforperipheraledemanote1+to4+pitting
Assessat:dorsalpedal,behindankle,shin
holdfor5seconds
Estimatedepthoffingerprint
Measuredindepthofanickel
1+=1nickel
2+=2nickels
3+=
4+=
JVD:
(positionofpatientwhenassessing???)
Planning:
Setpatientgoalsoroutcomes.Whatisyourplanforpatientwithexcessfluid?
Dec.edema
Clearlungs
Labswnl
DecreasedJVD
Weightloss
NormalI&O
**Patientteaching
Interventions:
Monitoranxiety(2*toSOB)
MonitorRR
Monitorchangeinresp.rate
Monitorchangeinlungsounds
Monitorweights
Mon.I&O
MonchangesinJVD,edema
Monitorlabs
Somepatients:
Onfluidrestriction,explaintopatient
Deficientfluidvolume:
Defi.Dec.intravascular,interstitial,orintracellular
Def.characteristics:
Alteredms
Decurine
Dryskin/mucusmembranes
Incheartrate
IncHCT
Suddenweightloss
Urinedark
Thirst
Week
(loosing1%ofweightduetofluidlosscanbesymptomatic)
Planning:
Setpatientgoals:
Normalurine
Vswnl
Elasticskinturgor
Orientedx3
**patientteaching
Interventions:
EncouragePOintake(givereasoning),teachwhatfluidstodrink
IVfluids
Monitorvs
Orthostatic
MonitorI&O,mweights,labs,
FoleyPRN
Trendsover24hrs
Skinturgor:
**handsareNOTthebestarea(chest,shins)
Assessment/riskfactors:
Activefluidloss
Barriertoaccessfluids
Comp.regulationsystem
Excessivefluidlossvianormalroutes
Ageextremes
Factorsaffectingfluidneeds
Fluidlossthrough(abnormalrouts)
Insuff.Knowledgeaboutfluidneeds
Ptsmostlikelyfordeficits:
Confused
Coma
Bedridden
Infants/elderly
Prevention:
Teachwarningsigns(weakness,thirst,dryskin,drymucosa,inc.weight
Interventions:
(sameandaboveDx)
Fluidshifts:
3rdspacing:
Abdomen(ascites)
Intotissues
Lookswollenbutactuallyfluiddeficient
Document:
Assessmentdata:
Dxtest
I&O
Weights
Lungs
Edema
*patientresponse(aftereachintervention/medicationgiven)
*patientteaching
Nursing111Lecture
10252016
WEEK8
URINEELMINATION:
Maintainsfluid/electrolytebalance
Isaclosed,sterilesystem
Anatomy:
Kidneys,ureters,bladder
**Bladderholds400600ml
**micturition(voiding,urination)
Bladderhasstretchreceptorswhichsendsmessagetospinestimulating
(importantinpatientswithspinalcorddisruptionandmaycauseretentionduetonospinalcord
stimulation.Therefore,catheterizationcanbeimportant)
Privacycanbeveryimportanttosomepeople(shybladder),beawareandrespectful
Theveryyoungandelderlymayhaveadditionalproblemsaffectingappropriateurination
Factorsaffectingurination:
gender,religious,privacy,fluidintake,meds,ingestion
Physiologic:
DM,arthritis,spinalcordinjury,prostateenlargement,diagnostics(endoscopyofbladder,
catheterizationespeciallylongterm>1Mo.Youloosethenaturalurge/sensationtosensethe
needtourinate),hypnoticsandsedatives,anesthesia(loosethesensationatapointofthe
spinalcord
Nursingassessment:
Subjective:
patterns
dysuria
urgency
frequency
nocturia2xormorepernight(sleepdisruption)
enuresis(bedwettinginanabnormaldevelopmentalpoint)
incontinence(isitnew?acuteincont.maybeduetoaninfection)orbecauseofchildbirth.Kegels
canbeencouragedtohelpstrengthenthemuscledinvolved
ASSESSMENT:
shouldbealightstrawcolor
faintaroma
clear(notturbid)
15002500mlina24hrperiod
urineismadeoupof94%waterand4%solids(na,Cl,)
DXTEST:
microscopicanalys.
acetones(ketones)=0
Albumin/protein=0
RBC/redcolor=0(maybenormalinmenstruation)
Glucose=0
WBC=05%
Casts==0
SG=1.0101.025
pH=4.58(alk.IscommonwithUTIs,acidicurine=metabolicdisease)
**KNOWNORMALSFORABOVE
Diuresislargeamtofurine
Oliguria<500ml/24hrsor<30ml/hr
Anuria<100ml/24,
hematuriabloodintheurine
Physicalexam:
femalesbettheclitvagina
males
Assessfor:swelling,discharge,discomfort
distensionlookjustabovethepubicsymp.,palpation/percussion
Trackml/hrofurine
assessretentionandretentionwithoverflow(dribblingincontinenceorurinaryfrequency)treatby
usingleaseinvasiveinterventionsfirst.
useofBladderScan
Catheterization:
Riskofinfectionishigh
Requiressteriletechnique
Normalresiduals=0afewmls(afterthepatienturinatesandiscatheterized)ifthereisahigh
residual,noteandcontactprovider
NURSINGDIAGNOSIS:
Functionallyurinaryincontinence:
r/talteredcognitive,alteredenviron,impairedvision,neuromuscular,
definingchar:
completelyempties..
earlymorningincontinence
Planning:
patientwillusebathroom
eliminateincontinence
suggestpsycheval.
accesstoatoilet(onthesameflooraspatient)
**GOALS=SMART**
Interventions:
reassessment
assessmental/physical
bladderdiary
medreview
providetoilet
OTreferral
appropriateclothing
bladdertraining
Skincare
undergarments(optionsexpense,embarrassing,smell)
cath.
patientteaching
Evaluate:
DOCUMENT!
NURSINGDIAGNOSIS:
URINARYRETENTION:
r/tblockage,highureteraltol.
Assessment:
absentoutput
dribblingvoid
distension
overflowincontinence
Planning:(goals)
demon.Consistentabilitytovoid
residual<200250ml
befreeofUTIs
Nursinginterventions:
PMH
painassessment
physicalassessment
recog.RetentionasAMEDICALEMERGENCYCALLMD
reviewmeds
attemptnoninvasivetechniques
insertcath.UsingCDCCAUTIrecommendations
Goalofmanylongtermcarefacl.Istoreduce/eliminateurinarycatheters
UMBRELLADx:
impairedurinaryelimination:
adysfunctioninurineelimination
CDCrecommendations:
useonlyforappropriateindications
leaveinonlyaslongasneeded
ensureonlytrainedpersonnelinsertsandmaintainscath.
changemonthly
useaseptictechnique
useclosedsystem
maintainurineflow(gravity,bagbelowthebladder)
practicehandhygieneandstandardprecautions(followCDCguidelines)
UTIinfections:
EDUCATION:
Drinkfluids(upto2500ml/appropriateoutput~2400ml)
Voidwhenurgeisfelt
Propercareavoidharshsoaps,powders,syntheticunderwire(yogapants,tightjeans)
KnowS/s:
Frequency
Urgency
Dysuria
IfDxwithaUTIfinishALLABX
Careforindwellingcath:
Dailyperinealcare
Maintenanceofclosedsystem
Aseptictechnique
B0WELELIMINATION
Defecationisnormal
Largeintestine
absorptionofwaterandnutrients,secretion,elimination
Factorsaffecting:
age
diet
regulardietaryintake
foodintolerance
Fluidintake
2500ml/day
Nursing111
11012016
WEEK9
OXYGEN
4phasesofrespiration:(mustallbeintacttomaintainlife)
pulmonaryvent.
Alveolar./capillarygasexchange
transportofgasses
peripheralcapillarygasexchange
Inspirationanactiveprocess
Expirationpassiveprocess
Requirements:
unobstructedairway
IntactCNS
Intactbrainstem
Abilitychestcavitytoexpandandcontract
Abilityoflungstoexpandandcontract
Diffusion(def)amovementofgasesfromhighcons.Tolowcons.
Movementofgaseslungstoheart,hearttotissue
Requiresintactcardiovascularsystem
OxygenistransportedonthehemoglobinintheRBCs,CO2transportedonRBCsANDINTHEPLASMA
Peripheralcapillarygasexchange:
diffusionmovementofgasfromhightolowconcentration
Regulatorysystems:
NURALCONTROL:
brainstempons/medullaoblong.
cerebralcortex(C3,C5)
CHEMICALCONTROL:
chemoreceptors9medula,aorta,carotidarteries
Factorsaffectingrespirations:
stressfight/flight
Environmentaltitude,occ.Hazards
Lifestyleexercise,smoking
Healthstatus/diseaselungs,nervoussystem(COPD)
Medications(opiates,
Age
infants
children
elderly
Affectinggastransport:
effectivepump
adequateperipheralvasc.
adequateplasma
normalRBCs(size,shape,number,)
oxygencarryingcapacity
diet(Fe)
Infants:
infants3060RRM
Child>1yr22RRM
matureimmunesystem
increasedriskforresp.illness
Elderly:
dec.lungelasticity
shallowresps
agingcardiovascular.System,inefficientpump
environmentalhazardsthatdegradesystems
dec.immuneresponseriskforresp.illness
Generalassessment
Reportrestlessnessorconfusion
reportabnormalbreathingpatterns
report:cough,sputum,chestpain
cardiacsymptoms:fatigue,weakness,lightheadedness
medHx:Resp.,Neuro,Card
Environment
Medications
Lifestyle:activevs.sedentary
Diet:Feintake
Diet:
DietandFe
Significance:formationofHgb
SourcesofFe:organmeats./redmeat(highestlevels),seafood,oats,prunes,rasins,kidneybeans,
chickpeas
Absorptionof:Vit.C(increasesFe),Calcium(decreasesFe)
PopulationthatrequireincreasedFe;
lessthan10MO
pregnancy
lactation
menstruation
Deficiency:
vegetarians
Breathingpatterns:(objectivedata)
eupneanormal
tachypnearapid
bradypneaslow
orthopneaposition,situp
Cheynestokesdeeptoshallowrespswithperiodsofapnea
dyspneadifficulty
Useofaccessorymuscles
Pulseoximetry
Breathsounds:
normalclear
abnormaladventitious
Lungsecretions:
normal
absentorsmallamount
clear
Oxygensat.
anestimationofHgbOxygensaturation
normal92100%
Skincolor:
indicatesoxygenationstatus
normal=pink
Generalassessment:
Dxtests:
RBC
normal3.55.0million/cu.mm
Hgb
Norm1212g/100ml
Hct
3550%
Chestassessment:
symmetrical
prominentclavical
A/P1/3tooftransversediameter
presenceofpect.Perinetum/excovicum,barrel,
Abnormal:
**Hypoxia
**mentalstatus(earlysign)
**restlessness(earlysign)
tachypnea
dyspnea
lightheadedness
tachycardia
cyanosis(latesign)
Areastoassesscyanosis:
nailbeds
circumoral
sublingual
conjunctiva
earlobes
*buccalmucosa
*lips
*palms/souls
(*moreeasyindarkskinnedindivid.)
Cough:acompensatorymech.Tocleartheairway
subjectivedataoccurrence,triggers,productive/non
Objective:
Sputum:
color
amount
odor
consistency
blood?
Nursingdiagnosis:(*knowthesediagnosis)(seeblueBasicOxygenationneedshandout
*Ineffectiveairwayclearance:
inabilitytoclearsecretionsorobstructionsfromtherespiratory
R/T:
definingcharacteristics:absentcough,adventitiouslungsounds,cyanosis,difficultyverbalizing,
Interventions:auscultate,monitorresps,monitorABG,elevateHOB,incentivespirometer,meds
*Ineffectivebreathingpattern:
inspiration/expirationsthatdonotprovideadequate.
Generalassessment:
monitor
RR
breathpattern
breathsounds
cough
Optimizebreathing
position
fowlers
leanforward
pursedlipbreathing
pushfluids
humidifiedOxygen
Meds:(knowbold!!)
**guifeisen
**Dextromethorphan
forcoughwithoutproduction/coughsuppressiononly
Cardiovascularsystem:
promotefluidintake
inc.fluid,dec.bloodviscosity
O2asordered
**avoidpetroleumjellywithOxygen
**avoidsmoking.
Monitorskincolorforcyanosis
monitorRBC,Hgb,HCT
2typesofFe:
Fegluconate
Fesulfate(morelikelytocauseconstipationandGIupset)
Avoidcalcium
Takewithvit.C
InsurepatientiscomfortabletodecreaseO2demands
(withoutanMDorder)
treats/sthatinc.O2demands
assistinADLs
moderateactivity
restperiods
RESTANDSLEEPLECTURE:
Restisimportanttorecovery,repair,recoveryfromillness
GOALS:
reducenoisefromstaff,otherpatients,machinesandalarms
strangesounds
patientdoesnotfeelwellifyoudontfeelwellyoudontsleepwell
stress
unfamiliarsurroundings
Nursing111
11082016
WEEK10
**FORTHISWEEK:
MedcartonWednesday(time)
ISBARforclinical
nursingprocesspaper(part1)forclinical(P.Puffer),onlyfirstpart,nottheoutcomesyet
Implementation:
4thstep
Continuousprocess(cyclical,doesntstop)
actual/potentialhealthproblems=NursingDx
Evidencebasedpractice:(Def)basedonresearchandevidence(clinicaldecisionmakingbasedon..)
EBmedicinerequirespatientbuyin
ExofEBmed.:handhygiene,CAUTIprotocol,fallprecautions,siderailsdown(becauseEBresearch
showsmoreinjuriesreportedwithrailsup)
**asevidencechangessomustthepractice
Stepsinimplementation:
assess
reassess
needforassistance?
Implementationnursingstrategies(woundcaredry/barrierpro.)
Fornursingprocesspaper:
(P.Puffer),onlyfirstpart,nottheoutcomesyet
partiallymetmeans,thepatientisworkingonit,maynotneedtochangependingreassessmentlater
reviewAckleys:
Nursing111Lecture
Week11
11152016
Woundcare
Ingeneral,sterileglovedwoundcareisnotdoneasmuchasinclass(catheterplacementisALWAYS
donesterile).
VACwounddressingintermittentvacuumtopromotehealing
RNsroleinwoundcareis:assessment(!always),changedressings(withorders),stagingwound**is
withinscopeofpractice**
localvs.systemicinfections
iatrogenicinfectionstopbybreakingthechainofinfection,washhands,PPE,
EBPevidencebasedpracticepracticebasedonwellformedscientificstudiesandproof.
stage34ulcersmaynotbereimbursedbyinsurancebecausetheyarepreventable
defenseagainstinfection
(normal)humanflorahelpsmaintainthebodythrougha*symbioticrelationship
nonspecific
3systemsofdefense
Innateimmunity:
1skin,mucus,secretions
2macrophages,NKcells,inflammatoryresponse
Adaptiveimmunity
3lymphocytesBandTcells,antigenspecific,memory
Inflammationprocess
rapidvasodilationoccurserythemaincreasedbloodflownearthesite
tissuedamagereleaseofchemicals
edemaaccumulationoffluid
painfrompressurebuildup
WBCsarrive(leukocytosis)
(phagocytosis)
inflammatoryexudate:
**serousvs.sanguineousorpurulentvs.serosanguineous
tissuerepair:
granulationtissuefragile,healingtissuegranulationtissuehealsfromthebottomupandoutsidein.
astissuehealstissueisformeddifferentlyfromnativetissue(keyloids)
Specificdefense:
immuneresponseslow,calledwhennonspecificmethodsarenotenough
***askJackeyaboutconceptmaps
extremesinagesaremoresusceptible
healthyadultstendtogetmorevirusesvs.bacteriapossiblybecausebetterhygiene,immunity,
Riskfactors:
age,heredity,stress,medications(chemo),nutrition,disease(AIDS,Cancer),therapies(chemo)
Increasedcortisone(stress)inthesystem=decreasedimmuneresponse
Nursingprocess:
Assessment:
askquestionspainscale,time,onset,change,duration,patientsobservations,ADLs?
Objective:
observationsphysicalassessment,**LABDATA,
**WBC500090005to9(MCCvalues)
remembertodoanassessmentbeforecallingaprovider
CBCwithDiff:
(focusedonthedifferential)
nutro
basal
eos
mono
lymp
C&S:(urine)
e.coliiscommon
Woundculture:
Bloodculture:
bacteriaintheblood
NursingDx:
SMART,TEA
Woundhealing:
**primaryintentioncleanwoundmargins,approximation,littletissueloss,littlescaring,littleinfection
**secondaryintensionjaggedmargins,infection,*leftopen,healsfromthebottomupwith
granulationformulation,scarringismoreextensive
reviewfactorsthatinfluencewoundhealing:
circulationisneededforwoundstoheal
KNOW:
abrasions
lacerations
puncture
Contusionecchymosis,
Incision
Review:
woundcultureSTEPS
SkinIntegrity:
epidermallayer
dermallayerinner,tensilestrength,collagen,
frictionvs.shearinjuries
macerationmoisttissueinjury(avoidmoisturizerbetweentoesindiabetics)
reactivehyperemiauseofaTKtofirstblanchandthenflushwhentheTKisremoved
Riskfactors:
impairedsensoryperception,DM,spinalinjury,ALOC(sedation,coma,anesthesia)
Classificationofpressureulcers:
Lookingatsize,depth,appearance.Oncestageditremainsthatstagethroughoutrecovery
Stage1nonblanchable,warm,red,
State2fullthickness,open,sloughing,blistering,
Stage3SQlayersarevisible,undermining/tunneling,
State4bone/tendon/muscleisvisible
unstageableunabletoseefullstrataofwound
Treatmentdependson:
depth,whatcausedit,color,appearance,
slough=bacteria
red=granulation/healing
black=necrosis
NursingDx:
impairedskin..vs.tissue
preventioniskey
reducerisknursesjob
moisture=breakdown
Managementofwound:
usuallyneedanorder(MD/surg.Maywanttopreform1stchange)
moisturepromotesepithelialmigrationandhealing
debridementremovalofnonviabletissue
autolyticdigestescars
wettodrydressing
surgicaldeb.
irrigation
chemicaldeb.(Dankins,maggots)
**Knowwhatdressingyouwoulduseonwhichwounds
Nursing111
Week12
11222016
BASICNEEDS:SEXUALITY
TowardthebottomofMaslows
physiological,psych,culturalfactorsinfluencing
difficulttodefine,individualexpression
nouniversalnormal
consentingadultsiskeyinthedefinitionofsexuality
*crucialtoapersonsidentity
sexandreligionarethe2subjectsthatnurseshaveaproblemtalkingabout
involvesawiderangeofneedsanddesires,mustbewithinyourrealmofknowledge
sex.Healthypeopleincludes
knowledge
abletoexpressfullsexualpleasure
tomakeautonomousdecisions
*experiencesexualpleasure
capableofsexualexpressionthroughcomm.Love,emotion
abletoaccesshealthcareforpreventionofSTD
abletomakefreereproductivechoices
Componentsofsexhealth:
howonevaluesselfasasexualbeing
abilitytocontributeinarelationship
bodyimage
*centralpartofselfconcept
continuouschange
bodyperception
canbealtered:changeswithlifeevents(trauma,disease,age)
Componentsofsexhealth
genderidentity
onesimageofmale/female
morethanbiologic:inc.soc.Andcultural
maynotconformtoonesbio.Sex/anatomy
Componentsofsexualbehavior
GNDERROLEBEHAV.
perceivesgender
appropriatebehavior
outwardexpressionofmalenessorfemaleness..
Sexualpromotion
ED
responsiblesexbehavior
STDs
contraception
Importanttotellyoungchildrenaboutappropriatesexualparts
tofacilitatefutureconversations
protectagainstabuse
followsontoSTDprevention,andcontraception
Sexdevelopmentthroughthelifecycle:
childprefersoneparentoveranother
sexualityinfluencedbyculture
religioninfluencesvalues
ethics
guidelines
sexualexpression
meds,illness,diseasecaninfluencesexuality(sideeffectsofmeds,unabletoperformduetoillness)
BeforeobtainingaptssexualHxclarifyyourowncanhelptheRNunderstand
everyoneshouldhavesometypeofsexualhistory
screenforSTD
reviewillnessesandmedsthatmayeffectsex
evaluatesexproblems
Shouldinclude:
sexualactive?
areyouunhappywithsexualfunction?
experiencingandsexdifficulties?
hassexactivityadverselyimpactedyourpartner?
peopleindom.ViolenceWANTyoutoask
anySTDconcerns
birthcontrol
selfexams
Mustbenonjudgmental:
askquestions
reviewSx
startgeneral
somepeoplecomplainabout
askhasanyoneeverspokentoyouabout..
PLISSITallRNsshouldbeabletofunctionatthe1st3levels
Ppermission
Lilimitedinformation
SSspecificsuggestions(mostbecomfortable)
ITintensivetherapy(byaspecialist/practitioner)
Inappropriatebehavior:
exposing
sexjokes
offeringsex
askingforpericare
Dontbeafraidtoconfront,saystoporthatthatbehaviorifnotacceptable
SELFCONCEPT:
Defourownviewofourselves,
ifyoudontcareaboutyourselfhowcanyoucareaboutothers
youmusttreatothers
*Alwayssubjective
itsalwaysevolvingchangeswithlifestages,events,socialmedia,TV,radio,religion,relationships
Selfconcept:
basedinindividuality,age,race/culture,gender,sexuality
strongpersonalitymakesiteasiertohelpotherswiththeirs
Bodyimage:
doIlooklikeeveryoneelse?
isthereadeficitorpartsmissing
appearance
culture./society
canverybasedonlocation,socialstrata,economics,school,family,background,
Physically:
ifapersonhasapos.bodyimageislikelytotakecareofthemselves
Roleperformance:
howyoucarryoutyourrole
whatsocietyexpects
abilitytoperformthatrole,newjob,school,illness,coworker(clearexpectationsareneededto
progressthroughtheprocess)
Selfesteem:
individualjudgement,emotionalappraisal,selfworth
isgreatlyinfluencedbypos./neg.views
wehavetoknowhowwearedaytoday(howourptsaredaytoday)
offersupporttoanyonewhoneedsit
positivereinforcement,eventoself,canimproveselfesteem
behonestwithself,knowandfollowbeliefs
takeresponsibilityforactions
thiscreatesstability
identifyneedforgrowthandworktowardagoal
Apos.Selfesteem:
betterabletomaintainrelationships
resistspsychillness/physical
adaptandacceptchangesandadapt
Factorsthatalterselfconcept:
anyrealorperceivedchange
individualperception
changethatoccursphysically,spiritually,emotionally,sex,culture,health
crisis
Identitystressors:(biginadolescence)
roleperformance:roleambiguity,roleoverload,roleconflict,rolestrain
bodyimagestressor:Affect,appearance,health,functionorstructure,internalchanges
Selfesteemstressors:
failuretoadaptcanleadtocrisisandlowselfconcept
HowcantheRNchangethepatientsselfconcept
ther.Communication
selfawareness
personalselfconcept
withpatients:usepos.andmatteroffact,buildtrust,beawareoffacial/bodylanguage
AsRN:prevent,identifyearly,implementTxforstressors
Basicneeds:
Perceptualalterations
6senses:
Whatinfluences:
ageextremesin
meaningfulstimuluswhattypeofinteractions
Amounttoomuchortoolittleisnotgood
socialinteractionhowfrequently
Environsound,light,occupation
cultural
Meaningfulstimuli:
providesinfoaboutenvironment
necessaryfordevelopment
reducessensorydeprivation
ex:TV,music,pets,clocks,calendar,pics,people(someareimportantfororientation)
(alackofstimuliaffectsthepersonsabilitytoreactappropriately)
Nursesrole:
identifysens.Alterations
alterenvironmenttopromotesafety
assistpt.tointeractwithenvironment(getglasses,getdentures,getcallbell,TVwithremote,orientto
room)
Assessmenttodeterminewhoisatrisk:
elderly,sick,thoseinanonstimulatingenvironment,hearing/visionloss,
Hx:
family,Pt,friend
identifydeficits,leveloffunction,meds?,
SensoryalterationHx:
(495)
assessforptawareness
Mentalstatus:
LOC
memory
appearance
emotions
cognitiveabilities
Physicalexam:
testallsenses
yourobservations,followcommands
anyassistivedevices?
(patientwilltrytohidethingsfromyou)
Abletoselfcare
ADLs
abilitytocompletetasksbills,meds,driving
Healthpromotion:
dailyroutine
healthscreenings
gotodoctor
Environmentalhazards:
wheredotheylive
housesetup
safetyrisks
meaningfulstimuli
Work
Communicationmethods:
writtenlanguage
hearingdeficit
reading
alternatemethods?
Socialsupport:
family
mealsonwheels
friends
dotheyfeelsupported?
**review
careofhearingaid
Sensorydeficitvision
Contactlenscare(P.844)4014
Nursing111
Week13
11292016
ENTERp.7
IV,def.
fluidandormedicationsdelivereddirectlytotheintervascularspace
fast(dangerous)
IVcatheter:
selecttheappropriateequipment
Centralvsperipheralcannulation:
centralgoesdirectlytotheheart
peripheraltakesmoretimetoreachtheheart
needleisremovedandthecatheteristakenout(remindpatientaboutthis)
selectappropriateIVbagsize,fluid,admin.Set,catheter
selectifyoucanusegravity(leastamountofmechanics,butalsohasdrawbacks)vs.IVpump
IVflowsfromhigherpressuretolowerpressure(venouspressure)
considerviscosityesp.inadministeringblood
18GAislargerthana22GA
thehigherthebagisabovetheheartthehighertheinfusionpressure(thehighertheflowrate)
thelargerthevein/catheterthefastertheflow
lowerviscosityflowsfaster
ProposeofIV:
forfluidreplacement/electrolytes/blood
restorationtherapy(TPN)(ashorttermtherapy,usuallyusedwithpatientswhoneedtogivegutarest)
IVdrugadministration(muchfaster,rapidaccesstocirculatorysystem)(mustreassessoften)
Intracellular
incells
Extracellular
inthebloodvessels
Interstitialfluid
outsidethebloodvessels
(CSF/synovial/)
WhenadministeringIVfluids(esp.rapidly)watchforfluidoverload/edema)
Osmosisdef.
movementofwater
Diffusiondef.
movementofelectrolytes
movementof
Osmolalitydef.
concentrationofsolutesinasolution
Tonicitydef.
howtheconcentrationofanIVeffectshowosmosisanddiffusion
Isotonicsolutions:
balancedsolution,staysinthevascularspace(bed)
usedtoreplacefluiddeficits
watchforfluidoverload,edema,SOB,
useforDx:lowB/P
Hypertonicsolutions:(D5,LR)
pulledfluid/electrolytesINTOtheintervascularspace)
higherosmolalitythanblood
usedtodec.edemaandexpandvascularvolume
Hypotonicsolutions:(1/2NS,0.45%NaCl)
(ifyouseeanunusualorderforIVormedsaskprovidertoconfirm)dutyofnurse
**musthaveordertoD/CandIV
IVsusedforshorttermfluidreplacement(oralreplacementisbetterinlongterm)
Isotonic
fluidandelectrolytes
Hypotonic
Hypertonic(notusedasmuch)
lesssolutethanplasma
plasmafl.Levelisgreaterthanthecells
fluidmovesintothecells
usedtoTxcellulardehydration
Commonabbreviations:(p.8)
NS=normalsaline0.9%
D5W=5%Dextroseinwater
LR=closesttoplasma,Na,Ca,Cl,lactate
D5
1/2NS
D5LR
ComplicationsofIvtherapy:
infiltrationinadvertentadmin.Ofanonvesicant(nonblistering)sol.Intothesurroundingtissue
swelling/blanchingatsite
dec.IVflow
pain
(90%ofadmittedpatientsreceiveanIV)
Phlebitis:
inflammationofavein
increasedriskforbloodstreaminfection
Asses
pain/warmth
linearpatternofredness
**(ifanIVinfiltratesyoumayreplacetheIVbecausetheIVorderstillstands)
Circulatoryoverload:
fluidaccumulatesfasterthanthecirc.Systemcantransport,filterandexcrete
Assess:
peripheralEdema
dyspnea
JVD
rales
increasedheartrate
elevatedB/P
Infection:
Assess
drainagefromIVsite
warm/rednessatsite
fever(concomitantwithIVsitechange)
Bestpractices:
correctIVsol.
Correctflowrate
dateandtimehung(max.24hours)
patencyofthetubing(kinkedtubing)
AssessIVsite:
infection
infiltration
phlebitis
bleeding
monitorlabs(esp.ifadministeringmeds)
*changeIVevery3days(agencydependent)**96hourscontinuous,24hoursifIVisbrokenatany
time)newresearchcoming.
Bestpractices:
maintainaclosedsystem
keepairout(**<270mlmax)
aseptictech.
scrubthehub
Patientteaching:
purposeofIV
careofsite/equipment
abnormalitiestowatchfor
tellfamilydonttouchthepump(silencingalarm/restartingpump)
Infiltration:Phlebitis:
changeIVsite
applywarmcompresses
(canbedonewithexistingMDorder)
Infection:
changeIV
culturesite(MDorder)
Antibiotics(MDorder)
Circulatoryoverload:
dec.IVratetoKVO
interventionstoimproveO2
anticipateMDorderingdiuretics
CommonIVmeds:
Insulin
Heparin
Opioids
IVK+
neuromusc.Blockade
chemomeds.
Oxytocicmeds(maternitymedicationstoinducelabor)
(usuallyawarninglabelonpackage)highalertmedications(*alwaysuseapumpforthese)
Monitorlabvalues:
heparin
insulin
monitorforintendedandunintendedsideeffects
Potassium:
Alwaysdilute
neverIVP
ISavesicant
monitorserumK+levels(norm3.55)
**neveraddtoanexistingIVinfusionbag(ratiowillbeoff)
Documentation:
assessment
site
Pt.response
adverseRXN
typeoffluid
flowrate
volumeinf.
Typeofivdevice(gravityvspump)
dressingchanges?(marktime/dateondressing)
(followfacilityspec.protocols)
Elderly/peds:
physiol.Assessment
IVequipmentneeded
ageappropriatepsych,.Support
(inelderlycirculatoryproblems/renalfunct.)
Nursing111
Week14
Lecture12062016
CultureandHeritage
Culturecarehealthcarethatisculturallysensitive,appropriate,competent
Takesintoaccountthesettinginwhichthepatientlivesandhishealthcareproblems
Musthaveabasicknowledgeofthecultureyoureworkingwith
Mustbeculturallyappropriate
Ifapatientrequestsaspecifictypeofcaregiverstaffmanagershouldassess
Thereasonbehindtherequest.Thepatientcanmaketherequestbutitmaynot
Begrantedjustbecauseofpreference.
Cultureisshared
cult.Iscommunicatedbygroupsofpeople
dynamic,adaptive,everchanging
changesslowlyinresponsetogroupneeds
adaptivenatureallowsthegroup/culturetosurvive
Beliefsandpractices
magicoreligious:
health/illnesscontrolledbysupernaturalforces
biomedical
lifeabdprocessescontrolledbyabiochemicalprocessandcanbemanipulatedbyman
Holistic
balanceandharmony(3Dpatient)maintainedinforcesofnature
(apatientwhocantconsentfortreatment./refusalmustbetreatedbyacceptedmedicalpracticesfthe
patientcouldbeharmed)
Whoistheauthorityfigure?
children(seen/notheard?)
elders(keepersofwisdom?)
genderroles(canthespousebeinvolved?)
values(whosvaluesareinvolved?)
addressingthepatientcorrectly(Mr.,Mrs,patientpreference)
Communication:
Verbal
speed
silence
voice
useofinterpreters
Nonverbal:
touch
eyecontact
facialexpression
posture
space:intimate=11/2feet,personal=11/24feet,social412,public12+
EdwardTHallproxemics(studyofdistance)
Culturalassessment:
staplefood
foodprep
remedies
Sexualviews
Beproactive
Assessyourself
7stepstoculturalcompetency:
Culturalsensitiveinteractions:
Heritageassessmenttool:
ManagingCare
CRITICALTHINKING
criticalthinkingispartofthenursesday,allday
itsactive,purposefulorganized,cognitive,
CriticalThinkingisanactive,purposeful,organizedcognitiveprocessusedtocarefullyexamine
onesthinkingandthethinkingofotherindividuals.
CriticalThinking
ISNOT
Automaticresponses
Unclearcomments
Uninformedresponses
Irrationalstatements
Assumptions
Learnedovernight
Beingacritic
Takingresponsesatfacevalue
IS
Lookingatthewholepicture
Beingaware
Evaluation
Drawingconclusions
ThecoreofeverygoodRN
Continuousprocess
Beingopenminded
Looksateachpatientasbeingunique
Isaboutwhatis
TalkwithyourclassmatesandcomeupwithanexampleofISandISNOTcriticalthinkingthis
semester:
ClinicalDecisionMakinginvolvescriticalthinking..butISNOTthesamething.Whataresome
differencesandsimilarities?
CDMvs.Crit.Thinking:
CDM=problemsolvingbasedonexperienceandknowingthept.well,
confident
independentthought
fairtoeverypatient
accountableaskifyoudontknow,beresponsible
dontlabelpatients(uncooperative,drugseeking)
Crit.Thinking,Differences:
Differences
Similarities
CharacteristicsorAttitudesofACriticalThinker
1. Confident:
2. Independentthinker
3. Fair:
4. Accountable:
Otherattitudesincluderisktaking,disciplined,persevere,creative,curious,possessintegrity,
truthseeking,openminded,analytical,systematic,inquisitive,matureandhumble.
GeneralCriticalThinkingandDecisionMakingProcess
ScientificMethod
ProblemSolving
DecisionMaking
Basedonevidence,research,methodical*alwaysusethis
CompareandContrasttheNursingProcessandCriticalThinkingSeeVennDiagram(Iwillgive
youinclassbutisalsoonBb)andcompletethisonyourowntime
LetsWorkOnThoseCriticalThinkingSkills..SeehandoutforScenarios(giveninclass)
DescribetheVariousFunctionsoftheRN
Autonomy/Accountability
Communicator
Caregiver
Advocate
Educator
Communicator
Manager
Candoalotwithoutorders,(oralcare,barrier
cream,*Oxygenbecauseitsneeded
immediately*,
Helpmanagediseases,comforts,spiritualhelp,
Speakforthepatientiftheycant,takechargeand
offer/getresources
Teachpatient/familynecessaryteachings(meds,
breathing,when/howtowalk)
Othernurses,NA,LPN
ManagingPatientCare
**VitalInformationforNCLEX
NotJustBeingANurseManager
whatcanIdelegate?
whataremypriorities?
ManagingPatientEncompassesTheFollowing:
1.
2.
3.
4.
5.
6.
Useoforganizationalresources
UsingresourcestoprovidepatientcarePT,nutrition
Usingtimeproductivelygetasmuchdone
Settingpriorities
Collaboratingwithhealthcareteam
Usingyourleadershipskillstomanageothersontheteam
CompareandContrastLeaderandManager
Whocanbenurseleader?Whocanbeanursemanager?Canyoubebothatsametime?
Whoisinchargeoftheclinicalunit?
CharacteristicsofanEffectiveLeaderP.280(212)
Characteristic
Howisthisaccomplishedbythemanager?
EffectiveCommunicator
Consistentinmanaging
conflicts
Knowledgeableand
Competent
RoleModel
ParticipatoryApproach
Showsappreciation
Delegatesappropriately
GuidesStaff
Displaysempathy,
understanding
Motivatesandempowers
Proactiveandflexible
Focusesonteam
development
ListfromPotterandPerrycombinesmanagerandleaderattributesDOYOUAGREE??
FourFunctionsofaManagergiveanexampleofeachfunction
Planning:staffing
Organizingptcare
Directingstaff
Coordinating
HowdoesthestaffRNfunctionasaManager?Examples?
Planning
Organizing
Directing
Coordinating
LetstalkaboutDelegationandAssigning
**ANA(AmericanNursesAssociation)andNCSBN(NationalCouncilofStateBoardsofNursing)
bothdefineddelegationastheprocessforanursetodirectanotherpersontoperformnursing
tasksandactivities.NCSBNdescribesthisasthenursetransferringauthoritywhileANAcallsthis
atransferofresponsibility.Both**meanthataregisterednurse(RN)candirectanother
individualtodosomethingthatthatpersonwouldnotnormallybeallowedtodo.**Bothstress
thatthenurseretainsaccountabilityforthedelegation.Effectivedelegationshouldresultin:
1.
2.
3.
4.
5.
Achievementofquality,safepatientcare
Improvedefficiency
Increasedproductivity
Empoweredstaff
Skilldevelopmentofothers
**LOOKATNYSSCOPEOFPRACTICEOVERBREAK**
whatisassessment?
datacollection?
whatcanbedelegated?(youassumetheskillsaredonerightbywhoever)
whocandowhat(LPN,tech,)
**delegatevs.assign:
Assign:
Delegate:
FiveRightsofDelegation
RightsofDelegation
Examples
RightTask
RightCircumstances
Istheoutcomepredictable?
RightPerson
RightDirection
RightSupervision
SomeimportantnotesaboutthesetermsandNYStrytolookitup.Where???
DELGATIONVSASSIGNMENT
EffectiveDelegation
1. Assessknowledge
2. Assessskills
3. Matchtasks
4. Communicateclearly
Listenattentively
Providefeedback
ThisiscrucialcontenttoknowforNCLEXdolotsofpracticequestions!!
ADMISSION,DISCHARGE,TRANSFERINGAPATIENT:
wehavepatienttrust,morecontactthananyoneelse
dischargeplanningstartsonadmission
requirescollaboration
involvesfamily/patient/HIPAA(becarefulonwhoyougivewhatinfoto,whoelseisaround)
inemergencyroomHIPAAcangobeyondnormallimitationsbecauseofalackofinfo
andimmediateneedforinfotoTx.Youcanreceiveinformationfromanyonewithout
consentbutcannotgiveinfowithoutconsent.Cangetverbalconsentofwitnessed(ifno
signedconsentifavailable)
usetherapeuticcommunicationintalkingwithpatient:
activelistening
payattention
smile
showempathy*notsympathy
professionalism
ViewRSAshorts(youtubevideos
lookforduringadmission:
biodata
CC
HPI
PMH
All.
Imm.
Meds
FamHx
supportsystem
disabilities
dischargeneeds
Modificationofproc.
agesupportsystem,precautions(young/old)
levelofwellnessperceivedvs.actualwellness(whattheywillseekhelpfor?)
understandwhattheybelieveandeducatethem
cultureimpactonillness,beliefsandpractices
Contagioncheck:
haveyoubeenoutofthecountry?
immunizations?
cough,fever,
Transfer:
becauseofchangeinptconditionneedinghigher/lowerlevelofcare
RNresponsibilities:
collaborative
advocateforthepatient
identifyresources
helptoreduceptandfamilystress
Transfertips:
transport
report
dressed
meds/items(*makesureallitemsgowiththepatient)
sendchart(*originalMOLSTform)
phonereport
Receivetransfer:
obtainchart
Professionaltelephone:
clearly
statename,title,facility,unit
nosidebarconversations
quiet
repeatback
facts(professional)
Receivingtelephonereport:
doc.Dateandtime
nameandcredentials
accurate
signnotewithnameandcredentials
Dischargeplanning:
onadmission
smoothtransition
insurecontinuityofcare
coordinationofservices
Dischargeplanning:
whywasD/cs
ongoingassessment
dischargeneeds
supportperson
teaching
d/cinstructions
D/Cinstructions
meds
medsreconciliation(whatmedswereputonandtakenoffduringadmission)
Txandproc.
activityandrestrictions
dietandactivity
healthpromo
whentocallMD
AMAdischarge:
askwhytheyarerefusing
notifyRNsupervisor/MD
patientsignsappropriateforms
assistptwithdischarge
12132016
Week15
Nursing111
SpiritualityandReligion:
Faith
tobelieveinsomething/someone
providesstrength
givesmeaningtolife
(mayincludevalues,language,rituals)
Religion:
community
organizedsystemofbeliefsandpractices
guidance
Spirituality:
partofbeinghumanthatseeksmeaningthroughinterintraandtranspersonalconnection
reflectionofinnerexperience
asenseofbalanceandpurpose
Characteristics:
Meaninghavingpurpose,canmakesenseoflife
valueshavingcherishedbeliefsandstandards
transcendenceappreciatingadimensionthatisbeyondyourself
connectionrelatingtoothers,nature,ultimateother
Becomingreflection,allowinglifetounfoldandknowingwhoyouare
Factorsaffectingspirit.
pastexperience
culture
perceivedimportance/value
lifestyle
family
availablesupport
environment
society
Spiritualneeds:
meaningandpurpose
trust
respect/value
meaningoflife
creativity
belongingtoacommunity
hope
forgiveness
dignity
values
connectionwithGod
vision
Preparationandacceptancefordeath
Notforgivingcauseslongtermproblems,movetowardforgivenessifatallpossible
NursingHxcommonopenendedquestions:
arethereanyreligiouspracticesimportanttoyou?
howwillbeingsickinterferewithyourreligiouspractices?
howisyourfaithhelpfultoyou?T.Turner(thesis)
howmightIsupportyou?
visitfromspiritualcouncilor
whatareyoursourcesofstrength?
Dontpushyourbeliefsonthepatientorpersuadethemtochangetheirbeliefs
Cuestospiritualpreferences:
presenceofreligiousobjects
Commonpractices:
holidays
sacredwritings
symbols
praying/meditation
diet
healing
dress
birth/death
Assessspiritualwellbeing:
senseofinnerpeace
compassion
reverenceforlife
generosity
capacityforunconditionallove
gratitude
humor
wisdome
abilitytotranscendself
appreciatebothunityanddiversity
Spiritualdistress:*(nursingDx)
expresslackofhope
refuseinteraction
suddenchangeinspiritualpractice
expressabandonment
callforordenyspiritualleaders
Spiritualdistress/(riskfor):
Interventions:
presence,justbeingthere,beingavailable,allowthepatienttoexpressthemselves
offersupport
assistincreatingaquietenvironmentandprivacy
adjustnursingcarearoundspiritualneeds
referraltospiritualcouncilor(staywithinyourrealm)
Cluestospiritualdistress:
depressed
crying
Nursing112precourseupdate:
Lavenderpacketbooksfornextsemester
Yellowpacketcommonmedsfor112(importantformedpass)**MUSTBEFILLEDINFORCLASS**
Whitepacketreadingassignmentsforweek12(muchfromPotter&Perry
Singlewhitesheetfirst2weeksofclinical(oncampus),includeswhatsdue,when,howtoprepare
**Nursing112welcome01182017Room8100**
Checkemailatleastdaily
Lossandgrieving:
4types:
1situationalsudden,
2Actualmayberecognizedbyothers,apersonmaynolongerexperience
3perceiveddefinedbypersonexperiancing
4anticipatory,potential
Sourcesofloss:
lossofaspectofself(limb)
lossofexternalobjects(car,clothing)
separationoffamiliarenvironment(moving,changeinschool,job)
lossoflovedones(childrenmoveout,lossoffriendship,death)
Chronicillness:
frequentlyseeninelderly
incidencetriples>45
people>65haveatleast1chronicillness
whathaveyouseenthissemester?
Factorseffectingloss:
age/developmentallevel
meaningofloss/significance
culturalyourcustomsandbeliefs
spiritualcanbesupportiveandguiding
copingstrategies
socioeconomicstatusmiddleandupperclassesgenerallyhavemoreresourcestodealwithissues(a
joballowingtimeoff,moneyforburial,
supportsystemhowwedealwithloss
natureoflossordeath
Grief=emotionalresponse:
aunique,personalresponse
(quoteVickiHarrison)
Behavioralresponseknownasmourning,theactionsanindividualgoesthrough,highlyvariable
Bereavement=subjective
4thingstolookat:
stateofawareness
closedawareness,Pt.,isunawareofimpendingdeath
familymaylackunderstanding
providermaynothavetoldtheprognosis
Mutualpretenseeveryoneknows,noonewantstotalkaboutit
pt.maynottalktoprotectfamily
maysensediscomfortfromhealthcareworkers
Openawarenesseveryoneknowsandistalkingaboutit
noteveryonecancopewiththis(familyandnursingstaff)
providesopportunitytofinalizeaffairs
Video:AwalktorememberJamiessick(YouTube)
NursingHistory:
relationships
supportsystem
natureofloss
lifegoals(met?Change?)
griefpatternshowdoYOUdealwithit?
selfcareselfcareofthefamilymember,areyoueating/sleeping?..takeabreakandgetcoffee,is
familytalkingaboutit?,ispatienttakingmeds?
hopegivescomfort,planningforthefuture,
cultural/spiritualbeliefsspecificafterdeathcare?,spec.prayersbefore/afterdeath?
Copingstrategies:
Physicalassessment:
(stressresponse)adrenergicresponse
Emotionalresponse:
crying
changeinappetite
sleep
concentration
verbalizeloss
ElizabethKublerRoss:stagesofgrieving
Grief
Denial
Anger
Depression
Bargaining
Acceptance
ThelastsongJonah2010(YouTube)
Normalgrieving:
common,universalreaction
guilt
disbelief
hopeless
noenergy
crying
inabilitytoconcentrate
Complicatedgrief:abnormalafter1year,effectsthepersonslife
leavingbedroomsetup
avoidsmemorial
guiltm,dec.selfesteem
conciderssuicide
minoreventstriggersgrief
Maybedueto:
complicatedrelationship
multipledeaths
failuretogrieve
lackofsupportsystem
pastmentalhealthissues
NursingDx:Grieving:
anormalcomplexprocess
Complicatedgrieving:
adisorderresultinginfunctionalimpairmentaffectingjob,family,relationships.
mayhavethoughtsofsuicide
lackofmaintenanceofbasiclifeneeds
decreaseddailylifefunctions
Nursinginterventions:
bepresent
usetherapeuticcomm.
evaluate
supportgriefprocess
educatefamilyonhowtocare(emptyfoley..)
offercondolences(hug,holdhand,)
offertimetohavefamilyreflect
allowtimetoofferselftofamily/patient
identifycomm.Resources
Careforyourself
whendoYOUneedcounseling
tellingthefamilyandPt.thatitsOKtodie(**thisisOKtodo)
offercounseling/spiritualcounc.asappropriate
PalliativeCare:
Allencompassing:
acutecare
Hospice
..
CarewithgoaltoreliefofSx,pain,stress,regardlessofDx(givenatthesametimeascurativecare)
(notacurebutsupportandcomfort)
customizabletotheindividualpatient
Hospice:
addressqualityoflifewithregardstocomfortandsupport
itdoesntmeangivinguphope
notjustforpatientsbutforthefamily
meetphysical/psychologicalneedtomaintain
providehighqualitycare
providedeathwithdignity
respectPt.asaperson
gttoknowthePt.
includethePt.inalldecisions
whatsimportanttothepatient?
music,pet,arttherapy?
Pettherapyisimportantforallinvolved(family,Pt.staff)
Meetthephysiologicneedsofthepatient:
managepain
personalhygene
resp.distress
nutritionaskwhattheywant,favoritefood/beer?,suckonfoodiftheycantchew
positioningcomfort
elimination
(deathrattlesecretioninthroatduetodecreasedgag/swallowresponse)treatthisforfamily
applymakeup/jewelryifrequested
WhatstheRNsrole?:
support
holdhand
makeprocesseasier
aguideforthepatientandfamily
dontbeinarushwithPtorfamily
whatcanyoudoforthefamilytomakethencomfortable?
facilitatemourning
educateandletthemknow..
facilitatecopingstrategies
listentoPt.,family
Howdowefeel:
identifypersonalfeelings
dontimpostourbeliefsonothers
providecompassion
care/closure
identifyhope
S/Sofimpendingdeath:
decreaseinfood/drink
restlessness
inc.sleepiness
changeinrespirations
Imdying
progressivelylongerapneas
alterationsinresp.pattern
Osign(mouthopen)
incontinence
bloodinurine,changeinappearance
changeinvitalsigns
swelling
mottlinginextremities
cyanosis
dec.temperature
inc.rigidity
lackofpupillaryresponse(afterdeath)
ClinicalS/S:
Heartrate(apicalpulse)
Respirations
noresponsetostimuli
nopupilresponse
Changes:
Algormortis
bodytemp
Lvormortis
poolingofblood
Rigormortis
stiffening
Postmortemcare:
honorrituals
removetubesanddrains
bathe
changelinens
ensureproperID
documentallcare(timeyoufoundthem,providernamenotified,whowasinattendance,care
provided)
familywillgiveclueswhenitsoktoremovedeceased
Organdonation:
callandreferdonornetwork
ruleoutsmayincludeadvancedage/infections
Advanceddirectives:
legaldocuments
patientspreferences(speakintermspatientwillunderstand)
provideeducationonwhatisavailabletoPt.
Thispageleftintentionallyblankfornogoodreasonatall