Foundations of Professional Nursing Exam 2

Objective: Deliver Medications Safely 6 rights of medication administration

1. Right Medication: Nurse needs to compare HCP/s written order with MAR when it is ordered initially. Nurses verify medication information whenever new MAR's are created/ distributed or when patients transfer from one nursing unit or health care setting to another. -When preparing medications from bottles or containers, compare the medication label with the MAR 3 times: before removing the container from drawer/shelf, as the amount of medication is removed from the container, and at patients bedside before administering the medication. -Keep medications separate from other medications -You cannot delegate preparation of medication to another person and then administer the medication to the patient - If a patient questions the medication, withhold it and recheck it against the HCP's order. -If a patient refuses medication, discard it rather than returning it to the original container. Unit-dose medications can be saved if they are not opened -If a patient refuses narcotics, follow agency procedure by having someone else witness the "wasted medication". 2. Right Dose. The unit dose system is designed to minimize effects. If you have to calculate medications/do conversions, have another qualified nurse check the calculated dose. -Medication errors often occur when pills need to be split. The pharmacist can split pills, label, and package them and then send to nurse for administration. Use a tablet splitter if not. HCP's need to avoid ordering medications that require splitting. -Tablets are sometimes crushed or mixed in food. Completely clean a crushing device before crushing a tablet so the patient does not receive part of a medication that was not prescribed. -Do not use a patient's favorite food/liquid because meds can alter their taste and decrease patients desire for them. -Some medications have a special coating (extended-release capsules) to prevent them from being absorbed too quickly. These medications should not be crushed. 3. Right Patient: Before administering a medication, use 2 identifiers (patients name, their medical record number, telephone number) -DO NOT use patients room number as an identifier -To correctly identify the patient, you usually compare the patient's identifiers on the MAR with the patient's identification bracelet while at the patient's bedside. 4. Right route: Always consult the HCP if an order does not include the route of administration. Alert HCp immediately if specified route is not the recommended route. Make sure to label syringe after preparing medication and be sure to remove caps from the tip of the oral syringe before administering meds because it can result in patient aspirating it, thus blocking the trachea. 5. Right Time: To administer medications safely, you need to know why a medication is ordered for certain times of the day and whether you are able to alter the time schedule. -A preoperative medication to be given "on call" means that you give the medication when the operating room staff members notify you that they are coming to get a patient for surgery. -Give a medication ordered PC (after meals) within half an hour after a meal, when a patient has a full stomach. -Give a STAT medication immediately -Give priority to time-critical medications that must act and therefore be given at certain times. Administer them 30 mins before or after the scheduled time -Give all routinely ordered non-time critical meds within 1-2 hours before or after the scheduled time. -Administer a prn sleeping medication when a patient is prepared for bed 6. Right Documentation: Always document medications accurately at the time of administration and verify any inaccurate documentation before giving medications. -Before administering a medication, ensure that the MAR clearly reflects a patient's full name, the full name of the ordered medication, the time the medication is to be administered, the dosage, route, and frequency.

types of reports

Hand Off Report: -Happens any time one health care provider transfers care of a client to another -Provides continuity of care -Includes up-to date information, required care, treatments, medications, services, any recent or anticipated changes -Can be given face-to-face, over the phone, or in writing -Efficient and timely - ensures client's safety! Hand off reports: what to include -Essential background information -Identify client's diagnoses or problems -Describe observations and responses -Share significant information about family members -Continuously review discharge plans -Relay significant changes -Describes instructions given in teaching plan and client's response -Evaluate results of nursing or medical care measures -Be clear about priorities for next shift or point of care Provider report orders: -Physician/nurse practitioner is responsible for direct medical tx -Nurses follow orders UNLESS believe they are in error or harmful -Your responsibility: check all orders and if you feel in error or harmful you MUST clarify with physician and if still in doubt contact nursing supervisor - chain of command -If you carry out an inaccurate or inappropriate order you are legally responsible for harm! Provider reports informing providers: -Be prepared for the call - use ISBARR, have your client's health record opened, & note pad to write notes -Situation - the reason for the contact -Complete full and accurate assessment -Identify appropriate signs/symptoms associated with diagnosis or treatment -Request for action/orders -Read back verify all orders received by phone or verbally (read back the orders you received) -Transcribe all orders correctly -DOCUMENT the provider contact and their response, any follow up contact, and client's response Provider reports: Telephone reports and orders: -Contact: physicians, lab, radiology, PT, OT, unit to unit, ancillary departments -Be clear, accurate and concise - use ISBARR -Document every call you make to & receive from a healthcare provider -Document time of call, who made the call, who was called, to whom information was given, information & orders received, verification of the information & orders with the provider -TO = telephone order - over the phone -VO = verbal order - this is being discouraged -ALL telephone & verbal orders must be repeated and verified (TO/RBVO, VO/RBVO) -Later provider will verify and sign off -within 24 hours/facility policy Make sure and verify/read back/have person giving orders read back/verify Provider reports: Telephone reports & orders: ISBARR -ISBARR is a preparation form to prepare to contact busy healthcare professionals. The contact needs to be focused, short, and to the point. ISBARR is not part of the client's health record. -Identify - yourself and client -Situation - purpose for your communication -Background - brief Pt's history and condition -Assessment - your assessment findings -Recommendation - request for action or orders -Read Back - repeat back verify if an order was received Transfer reports: -From unit to unit, ER to unit, unit to ICU, transfer to another facility -Can be done by phone or in person or both -Include: --Name, age, Provider, medical diagnosis --Summary of progression --Current Health Status --Allergies --Emergency Code Status (DNR) --Family support --Nursing diagnosis, problems --Critical assessment findings/interventions needed --Need for special equipment (isolation, traction, mattress, sx) -DOCUMENT !!! Incidence/ occurence report: -An incident is any event that is not consistent with the routine operations of a health care unit or "routine care" of a client (example: falls, needle stick, medication errors, omissions of orders) -Always contact the client's provider -The incident report is a facility report about the incident and is not part of the client's health record. -Document in the client's health record what happened, what was observed, contact, orders. -Do not mention the incident report -Utilize agency policy for documenting -Utilized in quality improvement programs—focus on outcomes—maintaining and improving quality Rapid Respose Team Report: -Rapid response team - activated in the event a client exhibits signs and symptoms of physiological instability -Anyone may activate the rapid response team -Designed to intervene during this critical period -Team members assist in the assessment and stabilization of the client -Such teams have become a widely used client safety intervention -The outcomes of a rapid response are: --client is stabilized and remains on the unit --client is transferred to appropriate critical care unit --client is transferred for medical intervention (e.g. surgery, cardiac cath lab) Rapid Respose Team Team members: different in different institutions -ICU team leader -House supervisor -Respiratory care -Primary nurse -Rounding hospitalist or client's primary care physician Criteria for activating the team: -Something just doesn't seem right -Respiratory distress Hypotension/syncope/diaphoresis/pallor/decreased LOC -New, repeated, or prolonged seizures -Chest pain (cardiac) unresponsive to nitroglycerin -Acute change in mental status/suspected stroke -Dysrythmias Rapid response team advantages: -Increased time to spend with clients -Better access to information -Enhanced quality of documentation -Reduced errors of omission -Reduced hospital costs -Increased nurse job satisfaction -Compliance with accrediting agencies -Development of a common clinical database Rapid response mechanism: -Firewalls -Antivirus and spyware-detection -Automatic sign-off -Placement of computers in restricted areas -Use of access codes -Use of passwords

Factors influencing health (TEST)

Internal= age, behavior, beleifs, gender, heredity, self-esteem, sexual identity. External=Culture, Education, Environment, Lifestyle Relationships, Socioeconomic status From birth to death health and wellness fluctuates and changes.

Develop a plan of care to treat pressure ulcers PU prevention

Prediction and prevention of pressure ulcers: -Risk assessment =Braden scale (23=normal/not at risk for PU) -Sensory perception, moisture, activity, mobility, nutrition, and friction and shear -Prevention=Economic consequences -When a patient develops a pressure ulcer, the length of stay is extended and the overall cost of care increases. -Prevention includes special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.

Utilize therapeutic communication to promote effective nurse-client relationsip communication techniques

Therapeutic communication=encourage expression of feelings, ideas convey acceptance & respect -"Tell me how does this new diagnosis make you feel?" -"How do you think your life might change now?" Therapeutic communication techniques; 1. active listening (both verbal & nonverbal) 2:1 ratio listening:talking. -Use SOLER: S=sit facing the client (are there to listen) O=open posture (open to what person has to say) L=lean toward the client (you are interested in the interaction) E=eye contact (to convey involvement and willingness to listen) R=relax (or else convey not interested or discomfort with patient) 2. clarify= to help you to understand the client -"Help me understand what you mean when you said..." -"Could you please clarify for me..." -"I am not sure I understand how you perform..." -to check you understand the message correctly, restate unclear message to clarify senders meaning or else you can make invalid assumptions. 3. relevant questions= to seek info needed for decision making -"How often do you take your pain medication at home?" -"How did you cope with increased stress in the past?" -open-ended questions allow the patient to take the lead and introduce pertinent info about a topic -close ended=yes or no answer 4. focus=to help the client to target one issue -"All this is important, but let's focus on..." -"Let's discuss your recovery process right now..." -"Please tell me what makes you most anxious about providing care for your wife at home..." -focus on key concept of message -use it to guide the direction of the conversation to important areas. 5. paraphrase= to help you to understand the client, but CAUTION=avoid projecting your own understanding & emotions -Through paraphrasing, you send feedback that lets a patient know that he or she is actively involved in the search for understanding. 6. summarize= this is to help both you and the client to understand -can add info, clarifies expectations, and helps patient recall topics and they know you analyzed their communication. 7. confront= WITH CAUTION to help the client to face actual issue 8. observations= to help client focus on non-verbal & verbal cues and helps them become aware of inconsistencies of attitudes, beliefs, and behaviors. 9. self-disclosure=tell patient about you to show patient you understand his experience. 10. humor=coping strategy that can reduce anxiety and promote positive feelings. it provides emotional support and humanizes the illness experience. It enhances teamwork, relieves tension, and helps nurses develop a bond. The goal is to bring hope and enhance well-being and the therapeutic relationship. 11. feelings (pleasant or unpleasant) -help patient express emotions by making observations, acknowledging feelings, encouraging communication, giving permission to express "negative" feelings, and modeling healthy emotional self-expression. If patients don't express feelings, stress and illness may worsen. -"You make me feel uncomfortable..." -"I understand that your anger is not directed toward me..." 12. hope=essential for healing 13. touch=express concern and caring to establish a feeling of connection and promote healing. Convey's affection, emotional support, encouragement, tenderness, and personal attention. 14. silence=helps nurse and patient observe one another. Sort out feelings, think about how to say things, and consider what has been communicated. silence can prompt people to talk. it allows the patient to think and gain insight. 15. providing information -"Let me help you understand how your atrial fibrillation increases your risk for stroke" -"You are taking this antibiotic, because..." 16. empathy=key to unlocking concern and communicating support for others. -"It must be very frustrating..." -"If must be very difficult for you to ..." -"I can see you are upset..." NOT sympathy="I am sorry."

Common record keeping forms

-Admission nursing history forms -Flow Sheets/Graphic Records - VS, hygiene -Client summary - updated frequently --Provides current orders, treatment, diagnostics, activity, diet --Overview of client - demographics, MD, diagnosis -Acuity Records -generated for hours of care Also known as acuity level -Standardized Care Plans -preprinted, chosen & implemented -Discharge Summary Forms -DC planning should start at admission and be revised throughout the stay!!

Discuss the effects of geriatric considerations on oxygenation

-Mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability -Changes in the older adult's cough mechanism lead to retention of pulmonary secretions, airway plugging, and atelectasis -Increased risk of respiratory infections -Changes in the thorax lead to problems with chest expansion and oxygenation

Discuss means to secure client safety indications for restraints

-Physical restraints: any manual method that immobilizes or reduces the ability of a patient to move freely -Chemical restraints: medications used to manage a patient's behavior that is not standard treatment for patient's condition --Both used when a patient's behavior interferes with their care or to maintain patient safety --Used as a last resort

Develop a plan of care to treat pressure ulcers factors that promote wound healing

Wound Debridement: 1. Mechanical 2. Autolytic 3. Chemical 4. Sharp/surgical 1. Clean in a direction from the least contaminated area (from wound/incision to the surrounding skin or from isolated drain site to the surrounding skin) 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating (19 g needle/35 ml syringe), allow the solution to flow from the least to the most contaminated area. Purposes of Dressings: -Protect a wound from microorganism contamination -Aid in hemostasis -Promote healing by absorbing drainage and debriding a wound -Support or splint the wound site -Protect patients from seeing the wound (if perceived as unpleasant) -Promote thermal insulation of the wound surface -Surgical wounds healing by primary intention=common to remove dressings as soon as drainage stops. -Healing by secondary intention wound dressings= the dressing material provides wound moisture or assists in debridement. -The dressing technique varies, depending on the goal of the treatment plan for the wound. -If the goal is to maintain a moist environment for clean granulating wounds, it is important to not let the saline-moistened gauze dressing dry and stick to it. -In contrast, if the goal of care is to mechanically debride the wound using a saline wet-to-dry dressing. When wounds such as a necrotic wound require debriding, use a wet-to-dry dressing technique. Place the moist dressing (contact dressing) into the wound, and allow it to dry. The contact dressing debrides necrotic tissue and debris. In this case, the contact dressing is allowed to dry so it sticks to underlying tissue, and debridement occurs during removal. During a Dressing Change: -Assess the skin beneath the tape. -Perform thorough hand hygiene before and after wound care. -Wear sterile gloves before directly touching an open or fresh wound. -Remove or change dressings over closed wounds when they become wet or if the patient has signs or symptoms of infection, and as ordered. Dressings: -Packing a wound=Assess size, depth, and shape -Securing=Tape, ties, or binders -Comfort measures=Carefully remove tape, Gently clean the wound, and Administer analgesics before dressing change. -Wound size, depth, and shape are important in determining the size and type of dressing used to pack a wound. -Dressing= flexible and in contact with entire wound surface and appropriate material used to pack the wound. - Many new dressing materials such as alginates are also used for packing. -Gauze= saturate it with ordered solution, wring out, unfold, and lightly pack into the wound. The entire wound surface needs to be in contact with moist gauze dressing. -DONT pack the wound too tightly. -Treatment modality for wounds=negative-pressure wound therapy (NPWT) or vacuum-assisted closure (V.A.C.). - NPWT= the application of subatmospheric/negative pressure to a wound through suction to facilitate healing and collect wound fluid. -Use tape, ties, or a secondary dressing and cloth binders to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient's level of activity. -To remove tape safely, loosen the ends and gently pull the outer end parallel with the skin surface toward the wound. Apply light traction to the skin away from the wound as the tape is loosened and removed. Adhesive remover also loosens the tape from the skin. If tape covers an area of hair growth, pull in the direction of the hair growth for less p/t. discomfort. -Another method to protect the surrounding skin on wounds that need frequent dressing changes is to place strips of hydrocolloid dressings on either side of the wound edges, cover the wound with a dressing, and apply the tape to the dressing. To provide even support to a wound and immobilize a body part, apply elastic gauze or cloth bandages and binders over a dressing. -Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimizes stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound. Administering analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug) also reduces discomfort.

Health promotion (TEST)

health promotion= activities to reach more stable levels of health (exercise/nutrition) wellness education= help people to achieve greater understanding and control of their lives. (physical awareness, stress management, self-responsibility) illlness prevention=avoid decline in health or functional levels. immunization programs protect patient from actual or potential threats to health

What is the difference between disease & illness?

illness= state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with that person's previous condition. Not synonymous with disease. Acute illness vs. chronic illness. Illness behavior= how people react and respond to their disease processes. Illness affects patient and the family. disease= a disorder of body, system, or organ.

Utilize therapeutic communication to promote effective nurse-client relationsip elements of communication

autonomy & responsibility assertiveness behavior courtesy & manners demeanor personal appearance trustworthiness use of names

Prioritize interventions based on client risk and logical progression and progress -establishing priorities

-The very first step in any circumstance is assessment. Even in emergent life threatening situations assessment is done prior to interventions. In emergent situations immediate interventions are taken if the assessment reveals life threatening results. This is something you learned during BLS class. Once the appropriate intervention is initiated for a life threatening result the assessment is continued for need for additional life-saving interventions and the cause of the life threatening condition. This is something that is taught in Advanced Cardiac Life Support (ACLS). The steps taken with a pulseless client are: -Make sure the scene is safe. -Assess for responsiveness. -Call for help. -Assess for pulse. -If no pulse, start chest compressions and rescue breathing. -While CPR is continued, assessments are continued looking for the cause of the cardiac arrest and need for advanced cardiac life support interventions. -For urgent and routine circumstances complete the assessment prior to any intervention.

Delegation and Collaboration QUIZ 1. Care plan includes a client to get up and go to bathroom evry 2 hours while awake. The RN delegates task to whom? 2. A client has asthma. The RN contacts who to delever a medication by a device known as a nebulizer? 3. The plan is for a 76 year old who was admitted for a stroke to go to a nursing home. which person will help the family place the client in a nursing home? 4. patient has had a stroke and struggles to do ADL's like getting out of bed and dressing. Who does the Rn delegate? 5. a client develops confusion and is moved to a room closer to the nursing station for safety concerns, which of the following would RN ask to correct the room number in admission document?

1. Certified Nurse Aide 2. Repsiratory therapy 3. Social worker 4. occupational therapy 5. unit secretary

5 characteristics of quality documentation and reporting

1. Factual avoid opinions, "appears" or "seems" use client's exact words in quotations. 2. Accurate "adequate amount" vs. "360 ml" correct spelling no unapproved abbreviations 3. Complete pertinent data but don't write a novel 4. Current timely, chart as soon as intervention is complete 5. Organized logical order, concise, clear, to the point example - head-to-toe assessment Subjective data - client's description of episode Use quotes, if narrative charting Information: onset, location, severity, duration, frequency, precipitating, aggravating, and relieving factors—describe in their words use client's own words Client behavior - confusion, anxiety Question to gain information on: onset, behaviors exhibited, precipitating factors, client's verbal behavior Objective data - what you find: rash, tenderness, breath sounds Onset, location, description -Treatments - what you did (bath, enema, dressing change) --Time completed, equipment used, client's response (can include both objective and subjective data collection) -Medication administration- concurrently with medication administration or immediately after administration; also document: time medication given, preliminary assessment findings -Client Teaching - information presented, method of instruction, client response -Discharge Planning - measurable client goals or expected outcomes, progress towards goals, need for referrals -Contacts - contacts with other health care professionals for the benefit of the client order requests, consults

Documentation quiz: 1. which of the following is the best example of application of the 5 characteristics of quality documentation? 2. Which of the following is subjective data? 3. which of the following is an example of charting by exception? 4. when does discharge planning start? 5. when are handoff reports provided? 6. What is true about provider orders? 7. A RN receives an order for 1000000 units of heparin IV push for a post-operative patient. the nurse knows the patient will bleed to death is that dose of heparin is administered. What action will the nurse take next? 8. Which of the following is true about an incident report? 9. what are the elements of ISBARR 10. which of the following are reasons to call for the rapid response team. mark all

1. The client reports sharp pain rated 8 out of 10 at the site of the abdominal incision with onset at 0910. Oxycodone 5mg PO administered at 0915 2. the client states "i am so tired, but i cannot sleep" 3. WDXL bright red raised rash on forearm 4. admission 5. anytime the client is transferred from one nurse to another 6. a nurse is legally obligated to follow provider orders as written 7. contact the provider, question the order, and request a different order 8. do not document into the client record that an incident report has been filed 9. Identify situation background assessment recommendation read back 10. BP 86/55 pulse=32 beats per min skin is pale, cool, diaphoretic new onset of acute confusion (stroke)

Chain of infection

Infectious process= four stages: 1. incubation period 2. prodromal stage 3. illness stage 4. convalescece Defenses against infection= 1. normal flora (Microorganisms) -Maintain a sensitive balance with other microorganisms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquiring a disease. 2. Body system defenses (Organs) 3. Inflammation -Signs of local inflammation and infection are identical. -Vascular and cellular responses -Exudates (serous, sanguineous, or purulent) -Tissue repair Types of HAI (Health Care-Associated) infection: 1. Iatrogenic—from a procedure 2. Exogenous—from microorganisms outside the individual 3. Endogenous—when the patient's flora becomes altered and an overgrowth results

informatics

ANA Definition of Nursing Informatics (2008): "A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice." Nursing informatics facilitates the integration of data, information and knowledge to support clients, nurses, and other providers in their decision-making in all roles and settings

Discuss O2 therapy -indications for O2 therapy -target O2 ranges -O2 toxicity

Any condition affecting cardiopulmonary functioning affects the ability of the body to meet oxygen demands 1. Pulmonary system problems -ineffective airway clearance (airway obstruction) -ineffective breathing pattern -impaired gas exchange 2. CV system problems -anemia -hypotension -changes in HR 3. Changes in metabolic O2 demand -infections -pregnancy -large injuries & surgeries 4. Decreased oxygen-carrying capacity Ex. anemia; carbon monoxide poisoning 5. Hypovolemia Ex. shock; severe dehydration 6. Decreased inspired oxygen concentration Ex. airway obstruction; hypoventilation; decrease oxygen in environment at high altitudes 7. Increased metabolic rate increases oxygen demands Ex. Exercise; pregnancy; infection 8. Decreased in ventilation Ex. musculoskeletal abnormalities; pregnancy; obesity; trauma

Differentiate Health and Wellness

Health= a condition/state of complete physical, mental, and social well-being, not just the absence of disease or infirmity and all people free of disease are not equally healthy. It is not a static condition. Constant change and adaptation to stress result in homeostasis. To evaluate health, consider the whole person. Health= a state of well-being. Wellness= a dynamic state of health in which an individual progresses toward a higher level of functioning, achieving an optimum balance between internal and external environments. Wellness is considered a conscious, self-directed and evolving process of achieving full potential. Wellness is considered a conscious, self-directed and evolving process of achieving full potential. Wellness is positive and affirming. Wellness is an active engagement to seek a higher level of functioning within the state of health. Health and illness are individual concepts: -"Being healthy means...."I want to live until I am 90 years old", "I can do anything I want", "I no longer have cancer" -"Healing does not take place alone; it takes place in context of family." -Being healthy="to be happy alone and with others" or "to be without excessive worry, fear, and stress"

Objective: Discuss Pharmacokinetics basics: Pharmacokinetics...continued Absorption=when medication molecules pass into the blood from the site of medication administration.

Factors that influence absorption: 1. Route of Administration: Each route has a different rate of absorption. -Skin=absorption is slow because of the skins physical makeup. -Oral medications pass through GI tract so the rate of absorption is slow -Mucous membrane/respiratory airways=absorbed quickly because these tissues contain many blood vessels -IV injection=most rapid absorption because meds are available immediately when they enter the systemic circulation. 2. The ability of a Medication to Dissolve: -depends on its form of preparation. Liquid state medications are absorbed more readily than tablets/capsules. -Acidic meds pass through gastric mucosa rapidly -Basic Meds are not absorbed before reaching the small intestine. 3. Blood flow to the site of Administration: -determines how quickly meds will absorb. -The richer blood supply to site of administration, the faster the meds are absorbed. 4. Body Surface Area: -Larger surface are= absorbed at a faster rate, which explains why more meds are absorbed in the small intestine than the stomach. 5. Lipid Solubility: -Because cell membrane is made of a lipid layer, highly lipid-soluble medications cross cell membranes easily and are absorbed quickly. -medication can be given with or without food. -Some meds absorb more easily between meals because food changes medication structure and sometimes impairs absorption. -some Medications taken together can interfere with one another, impairing absorption of both.

develop a care plan for a client with a fever Fever

Fever=elevated body temp develops. Initiate interventions to treat fever. The objective is to increase heat loss and reduce heat production and prevent complications. The HCP attempts to determine the cause of elevated temp. by isolating the causative pyrogen. -Antipyretics are meds that reduce fever. Acetaminophen and nonsteroidal inflammatory drugs like ibuprofen can reduce fever by increasing heat loss. Nonpharmacological therapy for fever= evaporation, conduction, convection, and radiation.

Objective: Discuss Pharmacokinetics basics: Pharmacokinetics

For the medication to be useful therapeutically, it must be taken into a patients body; be absorbed and distributed to cells, tissues or a specific organ, and alter physiologic functions Pharmacokinetics=the study of how medications enter the body, reach their site of action, metabolize, and exit the body. You use knowledge of pharmacokinetics when timing medication administration, selecting the route of administration, and evaluating patients response

Utilize therapeutic communication to promote effective nurse-client relationsip forms of communication

verbal nonverbal=all 5 senses 7% verbal 38% vocal cues 55% body cues nonverbal communication: 1. personal appearance=includes physical characteristics, facial expression, and manner of dress and grooming. the factors communicate physical well-being, personality, social state, occupation, religion, culture, and self-concept. 2. posture & gait (manner or walking pattern) are forms of expression. the way people sit, stand, and move reflect attitudes, emotions, self-concept, and health status 3. facial expression convey emotions 4. eye contact signals readiness to communicate. Maintaining eye contact shows respect and willingness to listen. Lack of eye contact can indicate anxiety, defensiveness, discomfort, or lack of confidence in communicating. always interpret persons culture when interpreting eye contact meaning. eye movements communicate feelings and emotions. being at same eye level helps establish autonomy. 5. gestures=emphasize spoken word. they carry specific meaning or create messages with other communication cues. 6. sounds=sighs, moans, groans, or sobs also communicate feelings and thoughts combined with other nonverbal communication, sounds can help send clear messages. they have several interpretations: moaning conveys pleasure and suffering. 7. territoriality & personal space=need to gain, maintain and defend ones right to space. territory provides people with a sense of privacy, identity, and security/control Verbal communication Aspects: 1. vocabulary= communication is unsuccessful if senders and receivers cannot translate one anothers words and phrases. Ex. patient with other languages = use translator. 2. denotive and connotative meaning=some words have several meanings. individuals who use a common language share the denotative meaning. Connotative meaning=interpretation of the meaning of the words influenced by thoughts, feelings, or ideas that ppl have about the word -you need to select words carefully, avoiding easily misinterpreted words, especially when explaining a patients medical condition or therapy. 3. pacing=speak slowly and enunciate clearly. Think before speaking and develop awareness of the rhythm of your speech to improve pacing 4. intonation=tone of voice affects the meaning of a message. can express enthusiasm, anger, concern, or indifference 5. clarity and brevity= speak slowly, enunciate clearly, and use examples to make explanations easier to understand. should be simple, brief, and direct. 6. timing and relevance=even though a message is clear, poor timing prevents it from being effective. Excellent opportunity to communicate with the patient is while performing assessments, administering meds, and performing procedures.

Develop a plan of care to treat pressure ulcers Pressure ulcer information

-Dermal-epidermal junction= Separates dermis and epidermis -Epidermis=Top layer of skin -Dermis= Inner layer of skin and Collagen -Pressure ulcers present a significant healthcare threat to patients with restricted mobility, chronic diseases, and the elderly. -Facility associated pressure ulcers add to the patient's LOS, delay the patient's recuperation, and increase the patient's risk for complications. --Currently CMS is working towards changing -Medicare guidelines to no longer reimburse the costs associated with nosocomial pressure ulcers, therefore admission assessments and prevention are vital. --Many states have already initiated mandatory pressure ulcer reporting for acute and long term care facilities. Multiple terms to describe pressure ulcers: -Bedsore -Decubitus ulcer -Pressure sore A pressure ulcer= a localized area of tissue necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. Causative Factors: -Pressure is the major causative factor in the development of a pressure ulcer; however, several factors play a role in determining whether pressure is sufficient to create an ulcer: --Intensity of the pressure --Duration of the pressure --Tissue tolerance Capillary Closing Pressure: -The term capillary closing pressure describes the minimal amount of pressure required to collapse a capillary. -Tissue anoxia develops when an external pressure causes the vessels to collapse. -Capillary closing pressure is between 15-32 mm/Hg. Duration of Pressure: -Duration of pressure must be considered in tandem with the intensity of pressure. -Low intensity pressures over a long period of time can result in tissue damage just as high intensity pressure over a short period of time can result in tissue damage. Tissue Tolerance: -Tissue tolerance describes the condition of the skin and the supporting structures to redistribute the applied pressure. -Extrinsic factors that affect tissue tolerance: --Shear --Friction --Moisture Shear: -This force is caused by the inner play of gravity and friction. -For example: When the head of the bed is elevated more than 30 degrees the sliding of the body transmits pressure to the sacrum. Friction: sometimes referred to as sheet burn -This is the mechanical force exerted when skin is dragged across a coarse surface such as bed linens. -This is also frequently observed with restless patients. --This is why a lift sheet and 2 people are advised to lift the patient as opposed to dragging the patient up in bed. Moisture: -Moisture, specifically incontinence, alters the resiliency of the epidermis to the external force. -Both shear and friction are increased in the presence of both mild and moderate moisture. --This is why good skin protection and containment is critical.

Objective: Discuss Pharmacokinetics basics: Pharmacokinetics...continued Excretion: After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands. The chemical makeup of a medication determines the organ of excretion.

-Gaseous and volatile compounds (nitrous oxide/alcohol) exit through the lungs -Deep breathing and coughing help eliminate analgesic gases more rapidly after surgery -Exocrine glands excrete lipid-soluble medicaitons -meds that enter the hepatic circulation are broken down by the liver and excreted into the bile -Factors that increase peristalsis (laxative, enemas) accelerate medication excretion through the feces -kidneys=main organ for medication excretion. Some meds escape extensive metabolism and exit unchanged in urine. Others undergo biotransformation before kidneys excrete them -adequate fluid intake (50 ml/kg/hr) promotes proper medication elimination.

Discuss means to secure client safety fall risk factors

-History of falls -Age -Mobility -Strength -Medications -Sedatives; antihypertensives; laxatives; diuretics -Elimination habits -Frequency; incontinence -Cognition -Confusion or overestimating abilities -Equipment -Vision Fall Risk Assessment Tools: -Morse Fall Risk Assessment (if score >50 then considered high fall risk) -Hendrich Fall Risk Assessment -John Hopkins Fall Risk Assessment -STRATIFY Risk Assessment Tool --Need to assess patients on admission, every shift and when there is a change in condition MORSE FALL RISK TOOL 1.History of falling Yes-25 No-0 2.Secondary diagnosis More than one active diagnosis-15 Only one active diagnosis-0 3.Ambulatory aid Furniture-30 Crutches/cane/ walker-15 None/bedrest/nurse assist-0 4. IV therapy/heparin (saline) lock IV or attached to equipment-20 No IV or equiment-0 5.Gait Impaired-20 Weak-10 Normal-0 6.Mental status Overestimates abilities/forgets-20 Normal-0 1)Add up score 2)> 50 points is considered a high fall risk

Discuss means to secure client safety consequences of falls

-Injury --fractures, internal bleeding; head injuries; soft tissue injuries -Disability -Death --6th leading cause of death in patients over the age of 65 -Diminished quality of life -Increased length of stay in acute care settings -Increased complications in acute care settings -Increased risk for requiring long term care

develop a plan of care to prevent complications of immobility effects of immobility

-Mobility=able to move freely independently -Immobility=inability to move independently -Nurses must be able to assess their patient's level of mobility and plan care based on that assessment by providing interventions to prevent complications that could occur for the immobile or partially immobile patient. - Immobility causes: Metabolic, Respiratory, Cardiovascular, Musculoskeletal, Integumentary, Psychosocial, and urinary elimination changes Metabolic Effects of Immobility: -Decreases metabolic rate -Alters the metabolism of carbohydrates, fats, and proteins -May cause fluid, electrolyte, and calcium imbalances -May cause GI (gastrointestinal) disturbances such as decreased appetite and constipation Respiratory Effects of Immobility: -Reduced lung expansion -Respiratory muscle weakness -Increased risk for atelectasis (collapse of alveoli) -Increased risk for hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions) Cardiovascular Effects of Immobility: -Orthostatic hypotension= Drop in SBP by 15 mmHg or drop in DBP by 10 mmHg and an increase in HR by 15% when moving from supine to standing -Increased workload of the heart resulting in a decreased cardiac output= Heart is working harder and less efficient -Increased risk for thrombus formation (DVT - deep vein thrombosis or PE - pulmonary emboli)= Caused by an alteration in blood flow in calf veins Musculoskeletal Effects of Immobility: -Loss of endurance -Decreased muscle mass and strength= The normal loss of muscle mass and bone mass can be rapidly accelerated when muscles and bones are not used for weight-bearing activities like standing and walking -Decreased stability and balance -Impaired calcium metabolism= Can result in osteoporosis -Joint abnormalities= Can lead to joint contractures (fixation of joint) or foot drop (foot permanently fixed in plantar flexion) AND Contractures can form after only 8 hours of immobility in an older patient Urinary Elimination Effects of Immobility: -May result in urinary stasis= Urine leaving the renal pelvis is unaided by gravity -Increases the risk of urinary tract infection -Immobility limits access to the bathroom, which in turn, increases the likelihood of urinary incontinence -Increases the risk of renal calculi=Stones that lodge in the renal pelvis secondary to lack of gravity and hypercalcemia -Because peristaltic contractions of ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters. this is called urinary stasis and increases the risk of UTI's/renal calculi. Integumentary Effects of Immobility: -Increased risk of pressure ulcers= A result of prolonged ischemia (decreased blood supply) to tissue AND Damage occurs when the pressure on the skin exceeds the pressure inside the capillaries supplying blood to the skin (15-32 mmHG is the minimal closure capillary pressure) -Trauma to fragile skin, including ecchymosis and skin tears, occur when patients need more assistance getting up and down Psychosocial Effects of Immobility: -Emotional and behavioral responses - loss of independence can cause the patient to have a sense of isolation -Sensory alterations = Alterations in sleep patterns and increases hostility/anxiety -Changes in coping=Depression and withdrawal

Develop a plan of care to treat pressure ulcers interventions to promote PU healing

-NSG DX:Impaired Skin integrity r/t shear and friction secondary to Stage II Pressure Ulcer AEB superficial open area on coccyx -EO (long term): The client will show signs of a healing Stage II pressure ulcer prior to discharge. -EO (short term): The client will maintain intact skin over other high risk pressure areas during the shift. Interventions: -Eliminate or reduce cause -Nutrition/dietary consult -Increase mobility= PT/OT consult -Reposition at least every 2 hours=This may or may not be enough -Turn patients who are on pressure-redistribution support surfaces just as you would for those who are not -Avoid 90 degree sidelying position --This creates intense pressure to the trochanter --Instead 30 degree sidelying position alternating with supine position -HOB should be elevated no longer than 1 hour after meals or tube feeding --HOB should be 30-45 degrees or lower as patients condition allows -If the client is an aspiration risk consider speech pathology consult for video swallow -Monitor sacral area and all bony prominences -Heels-heels-heels --Must use pillows or commercial pressure redistribution products even on support surfaces --Sheepskin heel protectors do not prevent pressure -Utilize pillows or positioning wedges -Clients in wheelchairs should be repositioned every 15 min. --Clients can be taught to reposition themselves by doing w/c push-ups --Consider a seating clinic (Involve PT/OT to evaluate w/c cushions) -Manage incontinence and moisture -Utilize support surface --Bariatric clients require bariatric beds -Educate clients and staff on prevention -Evaluate effectiveness of prevention Evaluation EO # 1 partial met: The client has s/sx of a healing Stage II pressure ulcer on the coccyx area aeb granulation, smaller measurements, and minimal sersosangionous exudate noted on 10/10/12. Evaulation EO #2 fully met: The client has no other s/sx of skin break down noted 10/8/12.

Methods of documentation

-Paper and electronic health records -Narrative documentation -Problem-Oriented medical record -Source record -Charting by exception - know what "normals" are -Case management plan and critical pathways Electronic health record electronic medical record: -Digital version of the client's medical record -Longitudinal electronic record of client health information generated by one or more encounters in any care delivery system -Provides continuity of care from one episode of illness to another -Mandated by federal regulation -Facilitates institutional evaluation of nursing care services Electronic Health Record Paper Medical Record: -record of rapidly changing emergencies such as a code blue (resuscitation) or rapid response -Backup record when the computer systems are down or under maintenance -Paper forms are scanned into client's record after the fact SOAP/SOAPIE Notes: -SOAP S=Subjective-client's verbalization O=Objective-what is measured and observed A=Assessment-diagnosis based on the data P=Plan-what you are going to do -SOAPIE I=Intervention-how you are going to do it E=Evaluation-did it work/modifications made PIE notes: -PIE notes are also problem oriented with a nursing origin P=Problem I=Intervention E=Evaluation -Labeled or numbered according to the client's problems -Resolved problems are dropped -Continued problems - addressed daily Focus Charting: -Narrative Form -Use of DAR notes D=data (both subjective and objective) A=Action or nursing intervention R=Response of client (successful or not?) -A different approach not designed for just problems—includes client's concerns not just problem areas, follows the nursing process

Discuss means to secure client safety complications of restraints

-Pressure ulcers -Pneumonia -Constipation/Incontinence -Embarrassment -Increased agitation Policy to restraints: -Strict regulations have to be followed when patient is in restraints -Must be familiar with agency specific policy -General rules: --Provider order required (must be obtained within 1 hour of application if placed in an emergency) --Order has to be evaluated and renewed every 24 hours --Assess and document the continued need for restraints and the patient response every 2 hours

Discuss means to secure client safety alternatives to restraints

-Re-orientation and diversion -Relocate patients -Evaluate medications and laboratory data -Camouflage lines and tubing (ex. IV sleeves) -Self releasing security belts (ex. Omni belt, roll belt) -1:1 observation

Prioritize interventions based on client risk and logical progression and progress levels of priorities

-The order of priority is based on client need. -The first level of priority is concerned with emergent life threatening, limb-threatening, sight-threatening conditions. 1. Safety risks for client and potential rescuer - secure safety 2. No pulse - start CPR 3. Obstructed airway - take steps to open the airway 4. No breathing (with pulse) - start rescue breathing 5. Poor circulation (low blood pressure, signs of shock) - position, collaborate with provider, & treat 6. Very high blood pressure -collaborate with provider, & treat 7. Severe hypoglycemia - provide carbohydrates & protein 8. Signs of a myocardial infarction (heart attack) - call 911 or rapid response 9. Signs of a stroke - call 911 or rapid response 10. No circulation to a limb - call 911 or rapid response -The second level of priority is concerned with urgent conditions that have a potential to lead to complications or become life-threatening. 1. Mental status change -consult with provider & treat 2. Severe pain -pain control measures 3. Acute urinary elimination retention - collaborate with provider & catheterize 4. Untreated severe medical conditions -collaborate with provider 5. Moderate hypoglycemia - provide carbohydrates & protein 6. Moderate to severe hyperglycemia - collaborate with provider 7. Critical lab values* - collaborate with provider 8. Infection risks - infection control measures -*Critical lab value is a potentially dangerous level of some lab test and requires immediate client assessment & consultation with the provider for orders. For example a very low potassium renders the client at high risk for lethal cardiac rhythms. Orders for potassium replacement are needed. -The third level of priority is concerned with routine tasks. 1. Time sensitive interventions - scheduled tests, assessments, medications, & interventions 2. Logical order of interventions requiring nursing judgment a. Client comfort b. Sterile to clean to dirty c. Economic use of time d. Order of procedures e. Order of use of instruments, materials, & supplies f. Economic use of materials & supplies g. Reduction of walking steps for nurse & other staff

Identify human health needs: health Models=

1. Health Belief Model - perceived threat of disease is influenced by individual perceptions and modifying factors ultimately resulting in likelihood of action Components 1. involves an individuals susceptibility to illness 2. an individuals perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of illness, and cues to action (advice from family and friends) 3. The likelihood that a person will take preventative action depending on a persons perception of benefits/barriers to taking action 2. Health Promotion Model=health is a dynamic state, not just the absence of disease-promoting behaviors result from individual characteristics, experiences, and specific knowledge and affect This model focuses on the following 3 areas 1. individual characteristics and experiences 2. behavior specific knowledge and effect 3. behavioral outcomes in which patient commits to or changes a behavior 3. Holistic Health Model = health is the integration of emotional, spiritual, sexual, and physical well-being. There is an emphasis on the body's natural ability to heal and a possible integration of alternative therapies into the health care plan. (meds, music therapy, guided imagery) because these are effective, economical, noninvasive, nonpharmacological components to traditional care. Nurses use holistic therapies either alone or in conjunction with conventional medicine. The nurse considers the patient to be ultimate exerts concerning their health and respect patients subjective experience as it is relevant to maintaining health or assisting in healing. The patients are involved in their healing process 4. Maslow's Hierarchy of Needs -some human needs are more basic than others -individuals must meet the needs at lower levels before progressing to the higher levels -this is basic to nursing care for patients of all ages in all settings; however the focus is on the patient's individual needs, not on strict adherence to hierarchy. -the extent to which people meet their basic needs is a major factor in determining their level of health -Needs from low to high: 1. physiological needs= breathing, food, water, shelter, clothing, sleep, sex 2. safety= health, employment, property, family social security 3. love and belonging=freindship, family, intimacy, sense of connection 4. self-esteem=confidence, achievement, respect of others, the need to be a unique individual 5. self-actualization= morality, creativity, spontaneity, acceptance, experience purpose, meaning, inner potential

Utilize therapeutic communication to promote effective nurse-client relationsip 5 levels of communication

1. Intrapersonal (within an individual). also called self-talk. peoples thoughts and inner communications strongly influence perception, feelings, behavior, self-esteem. be aware of the nature and content of your own thinking. The positive self-talk provides a mental rehearsal for difficult tasks or situations so individuals deal with them more efficiently and with increased confidence. nurses use this to develop self-awareness and positive self-esteem that enhances appropriate self-expression. 2. Interpersonal (between 2 individuals) (Heart of Nursing (Peplau)) -The nurses ability to relate to others in important for interpersonal communication. This includes the ability to take initiative in establishing/maintaining communication, to be authentic, and respond appropriately to other people. Also requires a sense of mutuality (the nurse-patient relationship is a partnership that are both equal participants). One on one communication between nurse and another person that often occurs face to face. It includes all symbols and cues used to give and receive meaning. Important to validate the meaning of different opinions, values, beliefs, experiences as a nurse. Meaningful interpersonal communication results in exchange of ideas, problem-solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. 3. Transpersonal (spiritual domain) 4. Small Group=interaction that occurs when a small number of people. Usually goal-directed and requires an understanding of group dynamics. Communication should be organized, concise, and complete. 5. Public=interaction with an audience. Effective public communication increase audience knowledge about health-related topics, health issues, and other issues important to nursing practice.

Chain of infection QUIZ!!!! 1. what Is a portal of exit 2. is touching your face after washing your hands, a break of asepsis 3. why is the host susceptible 4. what are the modes of transmission from the scenario? 5. what is the best intervention to prevent spreading an infectious agent 6. sneezing= incison= chemotherapy= alien marcrobes= wife= vectors= 8. which of the following are vectors? 9. what are the portals of entry?

1. sneezing 2. true 3. right arm incision, poor nutritional status, and chemotherapy 4. vectors-insects, dropped used tissues, a spray of mucus 5. hand washing 6. portal of exit portal of entry/susceptible host susceptible host infectious agent reservoir transmission 7. portal of exit, portal of entry, susceptible host, infectious agent, reservoir, transmission 8. dust particles, trash, insects 9. mouth, nose, right arm incision

Mobility Quiz 1. A nurse knows which of the following is the best intervention for a client at risk for pressure ulcer 2. a client with complications following a hip replacement is on enforced bed rest and at risk for pneumonia and atelectasis. the client's lungs are clear. what is the best intervention to prevent pneumonia and atelectasis? 3. a client who suffered a stroke with persistent unconsciousness has a nursing diagnosis of risk for impaired skin integrity related to unconsciousness. what is the best outcome? 4. complications of immobility are which of the following? 5. a client in traction is on enforced bed rest and has reddened non-blanchable intact skin over the coccyx. what pressure ulcer stage is the wound

1. the nursing staff will ambulate the client twice a day 2. deep breathing and coughing 3. the client will continue to have intact skin over bony prominences for the next 6 weeks 4. Pressure ulcers, pneumonia, Deep vein thrombosis, pulmonary embolism, atelectasis, constipation, urinary retention, depression 5. stage 1

Objective: Discuss Pharmacokinetics basics: Pharmacokinetics...continued Metabolism: After a medication reaches its action site, it becomes metabolized into a less active/inactive form that is easier to excrete.

Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove biologically active chemicals. Most biotransformation occurs in the live, but lungs, kidneys, blood, and intestines also metabolize meds. -The liver degrades many harmful chemicals before distributed to tissues through oxidizing and transforming toxic substances. -Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly because medications will be eliminated more slowly.

Discuss O2 therapy -O2 toxicity

CNS Manifestations: Pallor or sweating, N/V, Seizures, Muscle twitching, Vertigo, Tinnitus, Hallucinations, Visual changes, Anxiety, Respiratory changes, Decreased LOC Pulmonary Manifestations: Substernal chest pain, SOB, Dry cough, Pulmonary edema,Pulmonary fibrosis

Objective: Discuss Pharmacokinetics basics: Pharmacokinetics...continued Distribution=After medication is absorbed, it is distributed within the body to tissues and organs and ultimately, to the specific site of action. The rate and extent of distribution depend on the physical and medications chemical properties and the physiology of the person taking it.

Circulation: once a medication enters the bloodstream, it is carried throughout the tissues and organs. How fast it reaches a site depends on the vascularity of various tissues and organs. -Conditions that limit blood flow/perfusion inhibit medication distribution Membrane permeability= medications ability to pass through tissues and membranes to enter a target cell. -To be distributed to an organ, a medication passes through the tissues and biological membranes of that organ. -Some membranes serve as barriers to passage of medication, like blood-brain barrier. Therefore, CNS infections often require antibiotic treatment to be injected directly into subarachnoid space in spinal cord. Protein binding: The degree medications bind to serum proteins affect their distribution -most medications partially bind to albumin, reducing drugs ability to exert pharmacological activity. The unbound or "free" medication is its active form. Adults with liver disease have less albumin in the bloodstream and because more medication is unbound in these patients, they are at risk for increased medication toxicity, activity, or both.

Develop a plan of care to treat pressure ulcers complications of wound healing

Hemorrhage= bleeding from a wound site (normal during and immediately after initial trauma) Hematoma= localized collection of blood underneath tissues. Infection -Wound infection is the second most common health care-associated infection. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent and causes a yellow, green, or brown color, depending on the causative organism. Dehiscence -Dehiscence is the partial or total separation of wound layers. A patient who is at risk for poor wound healing is at risk for dehiscence. Evisceration -With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency that requires surgical repair.

Describe normal oxygenation physiology O2 intake

Oxygen from the atmosphere is delivered to the blood stream; this requires: functioning respiratory system and cardiovascular system The respiratory system requires 3 things: 1. an open airway 2. adequate breathing 3. gas exchange at the alveolar-capillary interface The cardiovascular system requires: 1. adequate blood supply 2. adequate blood volume 3. adequate RBCs & hemoglobin 4. adequate cardiac output (heart pumping) 5. adequate heart rate (HR) 6. adequate blood pressure (BP) 7. adequate blood flow through the lungs

Develop a plan of care to treat pressure ulcers PU staging

Staging of Pressure Ulcers: Stage I= Intact skin with non-blanchable redness Stage 2: Partial-thickness skin loss involving epidermis, dermis, or both (abrasion, blister, shallow crater) Stage 3: Full-thickness tissue loss with visible fat (deep crater with or without undermining) Stage 4: Full-thickness tissue loss with exposed bone, muscle, or tendon (necrosis, undermining, sinus tracts) Unstageable: Full-thickness tissue loss with exposed bone, muscle, or tendon Suspected Deep Tissue Injury= Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue. -is painful, mushy, warmer, or cooler to adjacent tissue

Describe normal oxygenation physiology -O2 transport -SP02 -P02

Oxygen is transported in the blood in 2 ways 1. red blood cells (RBC) -RBCs contain hemoglobin (Hg) molecules -Hg molecules carry oxygen -each Hg molecule carries up to four O2 molecules (the technical explanation: there are 4 heme groups per Hg molecule each heme group carries an O2 molecule) -lab testing for RBCs, Hemoglobin, & Hematocrit is important= tells us about the O2 carrying capacity of the blood -98.5% of Oxygen in the blood is carried by RBCs -Oxygen carried by RBCs is measured as SpO2 (O2 saturation) -95% SpO2 means 95% of the O2 binding sites (heme groups) contains O2 -SpO2 normal range is 94%-99% 2. blood plasma -Oxygen dissolved in blood plasma is 1.5% of the O2 in the blood -O2 dissolved in blood plasma is measured as partial pressure (PO2) -PO2 normal range is 80 to 100 mmHg

Utilize therapeutic communication to promote effective nurse-client relationsip concepts of communication

How do nurses express caring? The #1 way a nurse shows caring is by being competent! A competent nurse cares enough about future clients to build a solid knowledge base, refine psychomotor skills, and develop critical thinking skills. Communication= Essential to nursing practice, Lifelong learning process for professional nurses, Relationship building among patients, families, nurse, and multidisciplinary team, and Helping-trust relationships Effective Communication= Essential for nurse-patient relationship, nurse-family relationship, and nurse-health care team relationships. it Sets the tone of care experience, is Essential for the quality of care (reduce the risk of error and promote improved patient outcomes), and makes an Impact on patient satisfaction Poor communication= #1 contributor to errors in the workplace Caring Expressions by Nurses: -accepting of others -developing sensitivity to self and others -promoting and accepting expressions of feelings -developing helping-trust relationships -instilling faith and hope -promoting interpersonal teaching and learning -providing a supportive environment -assisting with gratification of human needs -allowing for spiritual expression -being competent

Describe nursing interventions used to promote oxygenation in the acute care setting

Interventions are focused on: 1. Halting the pathological process 2. Shortening the duration and severity of illness 3.Symptom management 3. Preventing complications from pathological process or treatments -Dyspnea management -Airway management -Secretion management Dyspnea management: -Treatment of underlying pathology=Ex. Antibiotics; thoracentesis to drain fluid -Oxygen=Can relieve dyspnea symptoms related to hypoxia -Medications=Ex. Bronchodilators; steroids; anxiety medication -Breathing techniques=Ex. Pursed lip breathing; abdominal or diaphragmatic breathing Airway and secretion managment: -Positioning=45 degree position best-promotes lung expansion and relieves abdominal pressure and Tripod positioning -Cough and deep breathing=Clears secretions and increases lung volume -Suctioning=Oral; nasotracheal; tracheal -Hydration=Keeps secretions thin and easier to clear -Humidification (especially when on oxygen) -Medications=Ex. Bronchodilators; steroids Incentive spirometry: -Encourages voluntary deep breathing -Prevents or treats atelectasis in the postoperative patient -Encourages patients to use visual feedback to maximally inflate their lungs and sustain that inflation -Must inhale slowly and hold their breath for 3-5 seconds and exhale slowly=Order will usually read: IS x10 qh Oxygen therapy: -Classified as a medication -Must have a physician's order -Widely available -Relieves or prevents tissue hypoxia -Dosage or concentration is monitored continuously (oxygen delivery device and amount delivered) -Can be very drying to mucosa Measurement of oxygen saturation: -Pulse oximetry=The measurement of oxygen saturation indirectly via a finger or earlobe attached to an oximeter device -The reading is conveyed in SpO2 percentage -Normal reading is >95-100% -The oximeter will also give a reading for the patient's pulse -Oxygen is NOT combustible. However, it greatly amplifies combustion. Compressing, stomping, squeezing, concentrating, shooting O2 will not cause combustion. However, combustion from any source is much greater in an oxygen-rich atmosphere. Striking a match where oxygen is being used will cause a large flame and if the flame enters the O2 tank, it will explode. NO SMOKING around O2. NO FLAMES around O2 Oxygen safety precautions: -Keep source a minimum of 10 feet away of flame -No smoking!! -Monitor cylinder positioning (upright and secured) -Ensure all equipment is functioning and tubing is connected -Can cause drying of the nasal and oral mucosa -Tubing can be a risk for falling and injury -Oxygen toxicity is a complication of high levels of oxygen over an extended length of time

Discuss means to secure client safety interventions to prevent falls

Interventions to Prevent Falls: -Identifying fall risk patient with arm band, foot wear, signage and communicate with all staff -Keep bed as low as possible and locked -Orient as needed -Keep room free of obstacles -Keep all belongings within reach -Side rails up as appropriate -Education patient and family -Observe frequently -Regular toileting schedule(stay with high risk patients when toileting) -Use gait belt when transferring -Bed/chair alarms -Use of assistive devices (walkers, transfer devices) -PT and OT consults -Moving patient location -Fall mats

Develop a plan of care to treat pressure ulcers risk factors of PU

Intrinsic Factors: -Nutritional debilitation -Advanced age -Stress -Hypotension -Smoking -Elevated body temperature

Identify oxygen administration devices

Low flow: 1. Nasal cannula: 1-6L/minute (FIO2 of 24-44%) -You will see High flow nasal cannulas in the hospital that can go up to 15L/minute -When you are using a nasal cannula you should put humidification on liter flows >4L/minute 2. Simple face mask: 5-8L/minute (FIO2 of 35-50%) -Not good to use for patients with carbon dioxide retention 3. Nonrebreather mask: 10-15L/minute (FiO2 60-80%) -Ensure that the reservoir bag is inflated -Will frequently hear it called 100%nonrebreather mask High flow: -Venturi mask: 4-12 L/minute with FIO2 of 24-60% Has a venturi barrel that allows you to dial in a specific FiO2. Has holes on side of mask to allow for exhaled air to escape

develop a plan of care to prevent complications of immobility intervention to prevent complications of immobility

Nursing Diagnosis: -Impaired physical mobility -Ineffective airway clearance -Risk for injury -Risk for impaired skin integrity -Insomnia -Social isolation Interventions: -Increase the patient's activity= Use lifts to get patients out of bed -Respiratory Exercises= Turn, cough and deep breath; Incentive spirometer; Chest physiotherapy -Increase fluid intake unless contraindicated -Monitor I/O -Follow prophylaxis program for preventing thrombus formation= Sequential compression devices (SCDs); Medications; Antiembolic stockings -Turn and reposition frequently (every 2 hours)= Use of trapezes -Perform ROM exercises -Use therapeutic devices to help prevent pressure ulcers= SCD's -Continually assess for complications associated with immobility -Involve patients in their care=Talk and listen to the patient -OT (Occupational Therapy)/PT (Physical Therapy) Referal GOAlS: -To maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance -To prevent complications related to the effects of immobility -To restore patient's ability to perform ADLs (activities of daily living) as well as IADLs (activities that are necessary to be independent in society)= ADL's - physical self care such as eating, grooming, transferring, and toileting AND IADL's - physical self care, shopping, preparing meals, banking, and taking medication

Describe normal oxygenation physiology -O2 uptake into cells

Oxygen moves into the cells via the capillaries: 1. the cardiovascular system delivers the O2 enriched blood to the capillary beds 2. the RBCs give up some O2 3. the newly released O2 goes swimming in the blood plasma 4. O2 moves from the blood plasma into the cells 5. the O2 is used by the cell to create energy in the Kreb cycle Oxygen moves into the cells via the capillaries 1. CO2 is created during the Kreb cycle 2. CO2 moves from the cell into the blood plasma 3. CO2 attaches to the O2 binding sites (heme groups) in the RBCs 4. CO2 is delivered to the lungs for excretion O2 uptake into the cells can be altered: 1. pH of the blood -normal arterial blood pH is 7.35 to 7.45 -acidosis is pH < 7.35 -alkalosis is pH > 7.45 -the further away from normal pH range, the worse the condition of the client -the body's enzyme systems work in a narrow range of pH -the more acidotic or alkalotic the blood the worse the body's function -in the presence of acidosis the RBCs will give up more O2 into the capillary beds, therefore there is more O2 available for the cells -in the presence of alkalosis RBCs will hold onto the O2 and give up less O2 into the capillary beds, therefore there is less O2 available for the cells -pH is part of Arterial Blood Gas (ABG 2. poisons like cyanide

Describe normal oxygenation physiology -O2 alterations

Oxygenation of the blood is decreased when there are: 1. pulmonary system problems 2. cardiovascular system problems Oxygenation of the blood is decreased when there is: 1. ineffective airway clearance (obstructed airway) 2. altered breathing pattern 3. impaired gas exchange at the alveolar-capillary interface Oxygenation is decreased when there is 1. low blood volume 2. anemia 3. poor heart function 4. slow or fast HR 5. low BP 6. obstructed blood flow through the lungs O2 uptake into the cells can be altered 2. poisons like cyanide block the uptake of O2 into the cells at the capillary level Hypoxia 94% to 99% is normal 92% to 93% is mild hypoxia 90% to 91% is moderate hypoxia < 90% is severe hypoxia -decisions to treat hypoxia with oxygen therapy depends on professional judgement COPD Clients: -Maintain SpO2 level at 88%-92% -Adding oxygen therapy and driving the SpO2 above 92% will harm COPD clients -Add oxygen therapy for SpO2 levels below 88%

Health promotion and illness prevention

Primary prevention=it precedes disease and is applied to healthy patients (physically and emotionally). Focus on improving the general health of individual, families, and communities ex. health education, immunization, helmets & seat belts Secondary Prevention=people who are experiencing health problems and are at risk for developing complicaiton/conditions. Activities are directed at diagnosis and prompt interventions, thereby reducing and enabling patients to return to a normal level of health as early as possible. ex. BP screening, mammography, annual physical examination Tertiary Prevention=occurs when a defect or disability is permanent or irreversible. Involved minimizing effects of long term disease by interventions directed at preventing complications and deterioration. Helps the patient achieve the highest level of functioning despite limitations caused by illness or impairment. ex. rehabilitation, disease-specific education, CHF weight loss program Risk factors =any situation or variable that increases vulnerability to an illness or accident; modifiable vs. non-modifiable

Utilize the principles of heat transfer to increase or decrease body temperature

Radiation= promote heat loss by removing clothing or blankets Conduction= gains heat by making contact with materials warmer than skin temp=aquathermia pad/bear Convection=promote heat loss with fan Evaporation=transfer of heat energy when a liquid is changed to a gas

Utilize ISBARR tool to prepare for collaboration with other health care professionals

SBAR promotes better communication in healthcare. In most cases nurses and physicians communicate in very different ways. Nurses are taught to report in narrative form, providing all details known about the patient. Physicians are taught to communicate using brief "bullet points" that provide key information to the listener. Introduction= Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital about your patient Jane Smith Situation=Mrs. Smith is having increasing dyspnea and is complaining of chest pain. Background=She had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath. Assessment=My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism. Recommendation=I recommend that you see her immediately and that we start her on 02 stat. Do you agree? Read Back Verify Orders=Your orders are to start O2 and maintain SpO2 between 94% and 99% ASAP and get chemical profile lab tests STAT. -communication with other members of the health care team affects patient safety and the work environment. -the use of common language such as SBAR from communication critical info improves the perception of communication and information about patients between HCPS. The use of ISBARR is to relay information in structured and timely manner. Consults - consultants go to the client. Referals - the client must take initiative to see the professional RN may delegate to= UAPs, Unit secretaries, Other RNs

develop a plan of care to prevent complications of immobility complications of immobility

Safety Issues with Immobility: -The ability to transfer and ambulate safely decreases as patients become more sedentary and less mobile -Falls are more likely to occur when immobile patients are trying to access the bathroom -Requires the use of more equipment when transferring= Gait belts, walkers, lift equipment Assessment of Mobility: -Range of Motion (ROM) -Gait -Look at balance, safety, use of assistive devices -Exercise and activity tolerance -Body alignment

Identify alterations in respiratory function including signs/symptoms and causes

The three primary alterations are: Hypoventilation, Hyperventilation, Hypoxia Hypoventilation=Occurs when alveolar ventilation is inadequate to meet the oxygen (O2)demands or eliminate sufficient carbon dioxide (CO2) -Signs and symptoms= Mental status changes; dysrhythmias; convulsions -Causes=Atelectasis; sedation; chronic lung disease Hyperventilation=A state of ventilation in which the lungs remove carbon dioxide faster than it is produced -Signs and Symptoms=Rapid respirations; light headedness; "sighing" breaths; numbness or tingling in hands and feet -Causes=Anxiety; infection; drugs; body's compensation for acidosis Hypoxia=inadequate tissue oxygenation at the cellullar level and is a life-threatening condition resulting from a deficiency in oxygen delivery or oxygen use at the cellular level -Can be life threatening and cause fatal dysrhythmias -EARLY SIGNS=Restlessness, Confusion, Anxiety, Difficulty concentrating, Elevated blood pressure, Increased heart rate, Increased respiratory rate, Dyspnea - difficult or labored breathing -LATE SIGNS=Decreased level of consciousness, Decreased activity level, Decreased respiratory rate as patient fatigues, Hypotension -BP will lower , Bradycardia - slow heart rate (<60), Acidosis (pH < 7.35), Cyanosis, Central Cyanosis: observed in the tongue, soft palate, and conjunctiva of the eye Peripheral cyanosis: observed in the extremities, nail beds and ear lobes

Identify the correct health care worker for delegation of tasks and collaboration Delegation and Collaboration

Typically there is a nurse manager, RNs, certified nurses aides (CNA), nurse technicians and unit secretaries. The RNs may be further distinguished as charge nurses or team leaders and staff nurses. Sometimes a clinical pharmacist is assigned to a unit. The following descriptions are general and do not reflect the precise duties at any one hospital. 1. Nurse managers are responsible for the quality of care provided on the unit. That entails: budget, staffing, supplies & equipment, policy adherence, and other duties defined by the hospital. 2. Charge nurses/team leaders are responsible for coordinating the shift unit staff and act as an information resource. 3. Staff nurses are responsible for the care of assigned clients including coordinating the care activities on behalf of the client, ensuring accuracy and execution of orders, and collaborating with other health care professionals. 4. CNAs typically get vital signs; provide blood glucose testing, provide client hygiene, position change, and ambulation; assist clients with meals; and other duties as defined by the hospital. Sometimes CNAs are called patient care assistants (PCA). 5. Nurse tech duties are those of a CNA plus some technical skills as defined by the hospital. The technical skills may include discontinuing indwelling urinary catheters, discontinuing IVs, phlebotomy, tube feedings. Sometimes nurse techs are called patient care technicians (PCT). 6. Some hospitals hirer student nurses whose duties are defined the hospital and are often those of a nurse tech. 7. Unit secretaries are in charge of record keeping, admissions, answering phone calls, and providing information to visitors and staff. 8. Clinical pharmacists prepare medication mixtures and medication information. Delegation: Staff nurses are responsible for all aspects of care of assigned clients. Therefore, RNs cannot do everything and need to delegate to the appropriate team member. Knowing and understanding the specific duties of the team members is important. Please refer to hospital job descriptions. Collaboraton: Staff RNs collaborate with other health care professionals. Knowing the roles and scope of practice of health care professionals is important. An earlier assignment covered a basic list of health professionals and their roles. For example, any medication request is referred to a physician or nurse practitioner. lung issues go to respiratory therapy, nutrition questions go to dieticians, etc.

Nontherapeutic Communication

WHY questions "I think you should..." "Let's not talk about this..." "Everything will be Ok" "I can't believe you did..." "There must be a reason for..." "Why are you so angry?..." "I am so sorry this happened to you" -Ask personal questions (nosy, invasive, unnessesary) -Give personal opinions (problem and solution belong to the other person) -Change the subject (rude, shows lack of empathy) -Give automatic responses or false reassurance (can seem uncaring/unapproachable) -Sympathy - " I am sorry!" (prevents clear perspective of issues confronting that person) -Ask for explanations (cause resentment, insecurity, mistrust) -Give approval or disapproval (patient has right to be themselves and make own decisions) -Provide defensive responses (implies person has no right to opinion) -Provide passive/aggressive responses (reflect anger/frustration) -False assurances (discourages open communication)

Utilize therapeutic communication to promote effective nurse-client relationship HIPPA

What rights does a patient have? -Privacy: the right of patients to keep information about themselves from being disclosed -Confidentiality: how health care provides treat patient private information once it has been disclosed to others What rights does a patient have? -To consent to use and disclose protected health information -To inspect and copy one's medical record -To amend mistaken or incomplete information -Limits who is able to access a patient's record -Establishes the basis for privacy and confidentiality concerns -Privacy -Confidentiality PHI= -Demographic data (birth date, social security number, address, medical record number) -Diagnosis -Prognosis -Laboratory/test results -Current treatment -Past, present, or future physical or mental health or condition When can you share PHI? PHI can be shared only if the information is necessary in the course of providing care Patient confidentiality is a sacred trust Do - only review medical information in reference to patients you are caring for. Do - be aware of PHI on the nursing unit. Do not - leave computer unattended before you sign off. Do not - discuss patients in public areas. What is is HIPPA? Health Insurance Portability and Accountability Act of 1996 -Goal= Protect a patient's health information while allowing for flow of health information needed to provide and promote high-quality health care -Confidential information=Patient, financial, and personnel information (date of birth, SS #, credit card #) HIPPA: -Provides rights to patients and protects employees -Protects individuals from losing their health insurance when changing jobs -Via the privacy rule, protects all individually identifiable health information -Violations have civil and criminal sanctions

Develop a plan of care to treat pressure ulcers Healing 1 degree an second degree

Wounds: 1. Classification 2. Wound healing 3. Repair -Partial-thickness wound repair -Full-thickness wound repair -Hemostasis (fibrin) -Inflammatory phase -Proliferative phase (epithelialization) -Remodeling Partial Thickness: -Inflammatory -Epithelial proliferation (reproduction) and migration -Reestablishment of epidermal layers Full Thickness: 1. Hemostasis- control blood loss, establish bacterial control 2. Inflammatory Phase 3. Proliferative Phase 4. Remodeling Primary Intention (first degree)=sutures and fine scar - Wound healing from surgical incision. Wound healing edges are pulled together and approximated with sutures or staples; healing occurs by connective tissue deposition. Secondary Intention (second degree) =epithelial cells and scar tissue, scar -Wound edges are not approximated and healing occurs by formation of granulation tissue and contraction of wound edges.

Internal and External variables of Helalth

internal variables= developmental stage, intellectual bachground, preceptions of functioning, emotional factors, spiritual factors external varaibles= family practices, psychosocial and socioeconomic factors, cultural

Objective: Discuss Pharmacokinetics basics: Medication Actions

medications vary considerably in the way they act and their types of action 1) Therapeutic effect= the expected or predicted physiological response caused by a medication. Some meds have more than one therapeutic effect. -Knowing the desired therapeutic effect for each medication allows you to provide education and accurately evaluate the desired effect of a medication 2) Adverse effects= undesired, unintended, and unpredictable responses to medication. Can be mild or severe. Some happen immediately, whereas others develop over time. -At risk for adverse medication effects=very young and older adults, women, patients taking multiple medications, patients extremely underweight/overweight, and patients with renal or liver disease. Types of adverse effects: 1. side effects=predictable and the unavoidable adverse effect produced at a usual therapeutic dose. Can range from being harmless to causing serious symptoms/injury 2. Toxic effects often develop after prolonged intake of medication or when a medication accumulated in blood because of impaired metabolism/excretion. Can have lethal effects depending on medication action. 3. Idiosyncratic reactions=a patient overreacts or underreacts to a medication or has a reaction different than normal. 4. Allergic Reactions= unpredictable response to a medication. Some patients become immunologically sensitized to a medications initial dose. 3) Medication Interactions= occurs when one medication modifies the action of another. Some medications increase or diminish the action of others or alter the way another medication is absorbed, metabolized, or eliminated from the body. When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately.

Describe normal oxygenation physiology

oxygenation=It is vital for the body to have consistent delivery of oxygen to the cells for energy production. This requires functioning pulmonary and cardiovascular systems. -Vital signs are an assessment of the pulmonary and cardiovascular systems functioning metabolic oxygen need, and how much O2 is being carried in the blood: -pulmonary system: respirations -cardiovascular system: pulse & BP -metabolic need: temperature -O2 supply: SpO2 Respiration is the process of: -moving atmospheric oxygen into the body -delivery of oxygen to the cells, -uptake of O2 into the cells -use of oxygen to produce energy in the Kreb's cycle -delivery & exhalation of CO2 to the lungs This involves: pulmonary system cardiovascular system cellular metabolism

Describe Physiology of altered temperature Normal thermoregulation

physiological and behavioral mechanisms regulate the balance between heat loss and heat produced. For body temperature to stay constant and within acceptable various mechanisms maintain the relationship between heat production and that loss.