foundations final
Evaluation (nursing process)
- Progress toward outcomes - Conduct systematic, ongoing, criterion-based evaluation - Include patient and significant others - Use ongoing assessment to revise diagnoses, outcomes, plan - Disseminate results to patient and family
Feeding a patient
-Assess patient for special needs-fatigue or immobile -Comfortable: Offer bedpan/urinal beforehand -Assist-cutting up food, feeding -Dignity -Unhurried -Converse -Blindness-clock -Preferences:feed one thing at a time or all together;how they like -Puree-no teeth or bad dentures -Special equipment: Suction cup on bottom, 2 handled cups, unbreakable dishes.
Realistic (SMART Goals)
-To be realistic a goal must represent an objective toward which one is both willing and able to work -a goal can be both high and realistic -a gaol is prob realistic if the person believes it can be accomplished
Benner's stages of nursing proficiency
1. Novice-learning 2. Advanced Beginner- new graduate 3. Competent- gaining experience 4. Proficient-quickly take in all aspects of a situation 5. Expert-sees what needs to be achieved and how to do it; consulted for advice
Nursing Outcomes Classification (NOC)
A classification system that defines and describes patient outcomes to nursing interventions.
Timely in SMART goals
A goal should be grounded within a time frame. With no time frame tied to it there's no sense of urgency
therapeutic relationship
A professional, interpersonal alliance in which the nurse and client join together for a defined period to achieve health-related treatment goals
informed consent
A written agreement to participate in a study made by an adult who has been informed of all the risks that participation may entail.
Role of the Nurse Aide
ADL's Care of living space Nouishment Documentation Attend Required In-services Use policy and procedure manuals No Assessing
choking hazards
Accurate diet for patient Cut or chopped food in small pieces Head of bed up Alternate solids and liquids Feed pt. Slowly Allow time to chew and swallow
Effective Communication Techniques
Active listening open ended questions seeking clarification offering self using silence using touch
Nursing Interventions
Activities that the nurse plans and implements to help the patient achieve identified outcomes
ergonomics(nursing)
Adapting the environment using techniques and equipment to prevent injury and provide efficient care Reduce frequency of injuries and associated cost Shared responsibility between employee and employer Use as many large muscles as possible Keep load between knees and shoulder Stand erect with good posture Place feet apart and knees bent Push pull or role Use arms to support the object Avoid twisting Get help Use lift or 2 people Count (to 3)
factors that impact safety
Age/Development Lifestyle Mobility and Health Sensory Perceptual Alterations Cognitive Awareness Emotional State Ability to Communicate Safety Awareness Environmental Factors
ANA
American Nurse Association Tracks healthcare legislation Promotes interests of the nursing profession
apie
Assessment Plan Implementation Evaluation
burn hazards
Assist with hot liquids Check tub/bath temperature Monitor patients while in tub - Never leave unattended Supervise patients while they smoke Monitor equipment when heat is in use Watch sun exposure Check cords Keep pot handles on stove out of reach
perineal care
Bathing or cleaning the area of the body which includes the genitals (external sex organs), groin and rectal areas. Usually called peri-care.
Role of the Nurse
Caregiver Communicator, Teacher/Educator Counselor Leader Researcher Advocate
Assessment includes
Collecting data Using a systematic and ongoing process Categorizing data Recording data
nursing scope of practice
Defined by Nurse Practice Acts Supervise and Delegate Follow Policies Only perform duties for which trained Refuse assignment if not in scope of practice Keep safe environment Protect patient rights
Professionalism
Dependability Accuracy and Precision Sensitivity/Respect Integrity/Honesty Cooperation Communication Representation of Christ
Age Related Safety Factors
Diminished strength Not sleeping Lack of balance Distracted driving
Blood borne pathogens
Disease-causing organisms transferred through contact with blood or other body fluids
Medical Records
Files that contain the documentation of patients' medical history, record of care, progress notes, correspondence, and related billing/financial information.
getting a sbar report
Hi. My name is __________________ and I'm a student nurse from MVNU. Today I will be caring for ___________ I know that she/he ________________ I plan to ________________________ Is there anything else I need to know
Hospital National Patient Safety Goals
Identify Patient Correctly Improve Staff Communication Use medicine correctly
signs and symptoms of infection
Inflammation, redness, swelling, pain, loss of function Drainage: green, yellow, white, pus Cellulitis: enflamed, red, hot, swollen Weakness, headache, malaise (fatigue) Fever, increased pulse, change in BP
ICN
International Council of Nursing Ensures quality care for all
Stair Hazards
Keep doors to stairwells closed at all times 2 person chair life to care pt. Down stairs
5 step observation process
Look at patient for signs of distress Look for environmental hazards Look for equipment operation Look for interaction with others Detailed look at patient
Seizure management
Loosen clothing Keep safe: remove pillows or hard objects, remove glasses Place in lateral (recovery) position Keep airway clear: use suction as needed Stay with patient Note time, sequence, limb movement, skin, pulse, and respirations Put patient on side
physical restraints
Medical-surgical management Behavioral management
Falls risk factors
Mental confusion Impaired mobility Diminished senses Wet floors Tripping hazards Throw rugs Equipment
Droplet precautions
Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by large particle droplets expelled during coughing, sneezing, talking, or laughing.
NLN
National League for Nursing; sets standards for excellence and innovation in nursing education
Airborne precautions
Negative air flow, Small droplet (HEPA filter), measles, chicken pox, varicella zoster, TB. n 95 mask
Poisoning Hazards
Never leave meds unattended (put away and out of reach) Remove Styrofoam and plastic Monitor plants: some can be poisonous If ingested, identify substance Call poison control
Oxygen safety
No candles, cigarretes in the area, *AVOID USE OF ELECTRIC RAZORS* , hairdryers, electric blankets, electric heaters that may cause a spark -AVOID use of flammable or oil based products
Diagnosis (nursing process)
Not the same as disease diagnosis Ask yourself: What's the problem? What's it related to or caused by? What assessment findings led me to the problem?
Delegate When?
Patient is stable Task is within worker's job description You're able to teach and supervise You've planned how to monitor
weighing a patient
Perform quality control on a scale by balancing the scale first before weighing a patient
Result of falls
Physical injury Fear of falls Reduce activities Unnecessary dependence Loss of function Decreased socialization and quality of life
Seizure precautions
Pillow under head Bed in lowest position Suction and oxygen available Padding around siderail
PASS (Fire Safety)
Point/pin - Pull the pin. Aim- Aim at the base of the fire, not at the flames. Squeeze - Squeeze the lever. Sweep - Sweep the nozzle from side to side.
PICCS
Professionalism/privacy Infeciton control Communication Comfort Safety
narrative notes
Progress notes written in a source oriented record that address routine care, normal findings, and patient problems identified in the plan of care.
promoting comfort care
Provide basic care and comfort Non-pharmacological comfort measures Encourage verbalization of fear and discomfort
Fall interventions
Raised toilet seats Transfer belts Lock brakes Limit use of powder identify medications that increase risk call light near by teaching and orientation
RACE (fire safety)
Rescue—Rescue anyone in immediate danger. Alarm —Activate the fire code and notify appropriate person. Contain—Confine the fire by closing doors and windows. Evacuate—Evacuate patients and other people to safe area.
giving sbar report
S - Today I cared for _______________ B - I (provided this care) ____________ A - I found that _________________ R - She/He is currently __________ and will need _______________.
ways to promote privacy
Shut the door Knock Pull the curtain Keep them as covered as possible Confidentiality Passwords No cameras at facility No identifying information
STTI
Sigma Theta Tau International honor society
SBAR
Situation Background Assessment Recommendation
disaster readiness
Stay calm Reassure patients Follow policies Check status of patients Implement Emergency Response Plan Practice Drills!
Barriers to communication
Stereotyping Excessive questioning Deflecting Giving advice Excessive talking Pat Answers False Reasurance Patronizing language
firearms
Store in locked cabinets Bullets in different location Teach children Keep unloaded Avoid alcohol Careful cleaning
Denture Care
Supplies: Tooth brush, tooth paste, gloves, paper towel, small wash cloth, basin, dentures & cup 1. put on gloves\ 2. line sink w/ wash cloth 3. run luke warm water 4. put tooth paste on tooth brush 5. Brush dentures 6. Rinse cup & fill with water 7. Place dentures in cup 8. Clean up
hygiene
The habits and practices of cleanliness and care you perform regularly to take care of yourself and your body
Communication Process
The messenger Coding Message Channel: speaking, writing, graphics, video Decoding The recipient Feedback
clinical judgement
The observed outcome of critical thinking and decision-making. It is an interactive process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions in order to deliver safe client care.
drowning
The process of experiencing respiratory impairment from submersion or immersion in liquid.
Electrical Hazards
Too many plugs in one outlet Grounded: three prongs Charring around outlet
Introduction
Use your first name, student nurse, MVNU State you are working with other staff Ask how to address the patient/client Introduce your clinical instructor Ask.. what can I do for you today?
restraints
Very rarely used in long term care More for mental institution Last resort Strict regulations apply
Hand washing
Wash your hands thoroughly when finished with the activity. Use antibacterial soap and warm water. Rinse well.
Gloving
Wear gloves when contact with blood or other potentially infectious materials is possible Remove gloves after caring for a patient Do not wear the same pair of gloves for the care of more than one patient Do not wash gloves
Attainable (SMART Goals)
When a functional goal is realistic in relationship to the client's current condition.
patient bill of rights
a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate,respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan in a way that he or she understands; a continuity of care; confidentiality privacy;participation in planning care and treatment; refusal of care; use of grievance mechanisms; treatment without discrimination;an itemized bill and explanation of all charges; and review of the medical record and/or copy at reasonable fee.
code of ethics
a guideline to help marketing managers and other employees make better decisions
abdominal thrusts
a method of attempting to remove an object from the airway of someone who is choking
ambulation
ability to walk
delegation steps
assess and plan communicate ensure surveillance and supervision evaluate and give feedback
complete bed bath
bath administered to totally dependent patient in bed
partial bed bath
bath in which only certain body parts are bathed or in which the health care provider bathes those parts of the body that the patient is unable to bathe
oral care
care of the mouth, teeth, and gums.
General Documentation Guidelines
date and time use military time and full date make sure it is legible and permanence use black pen accepted terminology accuracy right sequence appropriateness conciseness completeness
Nursing Process
five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating
SMART goals
goals that are specific, measurable, attainable, realistic, and timely
Maintaining a safe environment
good lighting; work alone when prepping meds; dont leave meds unattended; lock meds; lock cart; prepper must also administrator
Measurable (SMART)
how will you demonstrate and evaluate the extent to which the goal has been met
chain of infection
infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host
factors affecting communication
language (interpreter should be a professional) Developmental Stage Roles/Relationships Attitudes (Respect & Acceptance) Culture Gender Values/perceptions Personal Space
Enlopement
leaving without permission Always know where your patient is Report missing patient immediately Follow policies and procedures
noise hazards
loud noise that can damage hearing
contact precautions
measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface
evaluation written
outcome met, partially met, not met why it was or wasn't met
planning(nursing process)
outcomes and interventions
PPE
personal protective equipment. gloves, gowns, lab coats, masks, face shields
medical asepsis
practices designed to reduce the number and transfer of pathogens; synonym for clean technique
pie
problem intervention evaluation
Nursing Diagnosis
problem + the etiology
patient centered care
providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
chemical restraint
something that will sedate the patient
what do you assess during a assessment
start with initial assessment food and fluid elimination activity/rest pain safety psychosocial and spiritual
surgical asepsis
techniques used to destroy all pathogenic organisms, also called sterile technique
nursing interventions written
the nurse will
outcome written
the patient will
transfer
to move a patient from one place to another
Specific (SMART Goals)
who, what, when, where, why, how