Study Guide // Topics

r/t

"related to" (r/t) statement (Ackley 4)

inflammatory response

After tissues are injured, a series of well-coordinated events occurs. The inflammatory response includes the following: 1 Vascular and cellular responses 2 Formation of inflammatory exudates (fluid and cells that are discharged from cells or blood vessels [e.g., pus or serum]) 3 Tissue repair (Potter 403) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. An infection does not always present with typical signs and symptoms in all patients. For example, some older adults have an advanced infection before it is identified. Because of the aging process, there is a reduced inflammatory and immune response. Older adults have increased fatigue and diminished pain sensitivity. A reduced or absent fever response often occurs from chronic use of aspirin or nonsteroidal antiinflammatory drugs. (Potter 406) Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness (Fardo, 2009). (Potter 406) Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers. Tissue trauma causes the inflammatory response, which in turn causes redness and swelling to the area with a moderate amount of serous exudate. This response is generally limited to the first 24 hours after wounding. The epithelial cells begin to regenerate, providing new cells to replace the lost cells. The epithelial proliferation and migration start at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells only migrate across a moist surface. In a dry wound the cells migrate down into a moist level before migration can occur (Doughty and Sparks-Defriese, 2012). New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers. The cells slowly reestablish normal thickness and appear as dry, pink tissue. (Potter 1181-1182) Inflammatory Phase In the inflammatory stage damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues. This results in localized redness, edema, warmth, and throbbing. The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment (e.g., ankle or neck). Leukocytes (white blood cells) reach the wound within a few hours. The primary-acting white blood cell is the neutrophil, which begins to ingest bacteria and small debris. The second important leukocyte is the monocyte, which transforms into macrophages. The macrophages are the "garbage cells" that clean a wound of bacteria, dead cells, and debris by phagocytosis. Macrophages continue the process of clearing the wound of debris and release growth factors that attract fibroblasts, the cells that synthesize collagen (connective tissue). Collagen appears as early as the second day and is the main component of scar tissue. In a clean wound the inflammatory phase establishes a clean wound bed. The inflammatory phase is prolonged if too little inflammation occurs, as in a debilitating disease such as cancer or after administration of steroids. Too much inflammation also prolongs healing because arriving cells compete for available nutrients. An example is a wound infection in which the increased metabolic energy requirements present in an infected wound compete for the available calorie intake. (Potter 1182-1183) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

SBAR

An effective and efficient way to communicate important information\allows parties to have common expectations related to what is to be communicated and how the communication is structure. S=Situation (a concise statement of the problem) B=Background (pertinent and brief information related to the situation) A=Assessment (analysis and considerations of options — what you found/think) R=Recommendation (action requested/recommended — what you want

Systemic Infection

An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated. (Potter 401)

fever

Any condition (e.g., pain or fatigue) that depletes a person's energy also impairs the ability to learn. For example, a patient who spends a morning having rigorous diagnostic studies is unlikely to be able to learn because of fatigue. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. After working with a patient, assess the patient's energy level by noting the patient's willingness to communicate, the amount of activity initiated, and his or her responsiveness toward questions. Temporarily stop teaching if the patient needs rest. You achieve greater teaching success when patients are physically able to actively participate in learning. (Potter 334) An infection does not always present with typical signs and symptoms in all patients. For example, some older adults have an advanced infection before it is identified. Because of the aging process, there is a reduced inflammatory and immune response. Older adults have increased fatigue and diminished pain sensitivity. A reduced or absent fever response often occurs from chronic use of aspirin or nonsteroidal antiinflammatory drugs. (Potter 406) An infection does not always present with typical signs and symptoms in all patients. For example, some older adults have an advanced infection before it is identified. Because of the aging process, there is a reduced inflammatory and immune response. Older adults have increased fatigue and diminished pain sensitivity. A reduced or absent fever response often occurs from chronic use of aspirin or nonsteroidal antiinflammatory drugs. (Potter 406) Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness (Fardo, 2009). (Potter 406)

transmission based precautions

Barrier precautions include the appropriate use of personal protective equipment (PPE) such as gowns, gloves, masks, eyewear, and other protective devices or clothing. The choice of barriers depends on the task being performed. Barrier protection applies to all patients because every patient has the potential to transmit infection via blood and body fluids and the risk for infection transmission is unknown. The CDC issued new isolation guidelines in 2007 that build on the two-tiered approach established in the 1996 guidelines. The first and most important tier is standard precautions. The second tier addresses isolation precautions, which are based on the mode of transmission of a disease (see Table 28-6). Isolation precautions are termed airborne, droplet, contact, and protective environment. The precautions are for patients with highly transmissible pathogens. The protective environment category is designed for patients who have undergone transplants and gene therapy (CDC, 2007). • Contact precautions: Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and handling of contaminated body fluids. An example includes blood or other body fluids from an infected patient that enter the health care worker's body through direct contact with compromised skin or mucous membranes. Indirect contact involves the transfer of an infectious agent through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if hand hygiene is not performed between patients (CDC, 2007). • Droplet precautions: Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. An example is a patient with influenza. • Airborne precautions: Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. This requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. All health care personnel wear an N95 respirator every time they enter the room. • Protective environment: Focuses on a very limited patient population. This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms (CDC, 2007). • When using the isolation guidelines of the CDC, refer to additional CDC documents to prevent health care-associated aspergillosis and Legionnaires' disease in immunocompromised patients and the spread of multidrug-resistant organisms (CDC, 2007). Regardless of the type of isolation system, follow these basic principles: • Use thorough hand hygiene before entering and leaving the room of a patient in isolation. • Dispose of contaminated supplies and equipment in a manner that prevents spread of microorganisms to other persons as indicated by the mode of transmission of the organism. • Apply knowledge of a disease process and the mode of infection transmission when using protective barriers. • Protect all persons who might be exposed during transport of a patient outside the isolation room. (Potter 415-416) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

effects of immobility and interventions

Bed Rest, Prolonged: Deficient Diversional Activity r/t prolonged bed rest Impaired bed Mobility r/t neuromuscular impairment Risk for Loneliness: Risk factor: prolonged bed rest (Ackley 29) Immobility: Ineffective Breathing Pattern r/t inability to deep breathe in supine position Acute Confusion: elderly r/t sensory deprivation from immobility Constipation r/t immobility Adult Failure to Thrive r/t limited physical mobility Impaired physical Mobility r/t medically imposed bed rest Ineffective peripheral Tissue Perfusion r/t interruption of venous flow Powerlessness r/t forced immobility from health care environment Impaired Walking r/t limited physical mobility, deconditioning of body Risk for Disuse Syndrome: Risk factor: immobilization Risk for impaired Skin Integrity: Risk factors: pressure on immobile parts, shearing forces when moved Readiness for enhanced Knowledge: expresses an interest in learning (Ackley 63) • Encourage ambulation as tolerated. Immobility is harmful to the elderly because it decreases ventilation and increases stasis of secretions. • Encourage elderly clients to sit upright or stand and to avoid lying down for prolonged periods during the day. Thoracic aging results in decreased lung expansion; an erect position fosters maximal lung expansion. (Ackley 177) NOTE: Complications from immobility can include pressure ulcer, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection and/or retention, decreased strength or endurance, orthostatic hypotension, decreased range of joint motion, disorientation, disturbed body image, and powerlessness. (Ackley 309) Maintain full range of motion in joints • Maintain intact skin, good peripheral blood flow, and normal pulmonary function • Maintain normal bowel and bladder function • Express feelings about imposed immobility • Explain methods to prevent complications of immobility (Ackley 309) Suggested NIC Interventions Energy Management, Exercise Therapy: Joint Mobility, Muscle Control (Ackley 309) When client's condition is stable, screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement (Sedlak et al, 2009). EB: In healthy adults, muscle strength declines by 1% per day of strict bed rest ( De Jonghe et al, 2009). • Assess the level of assistance needed by the client and express in terms of amount of effort expended by the person assisting the client. The range is as follows: total assist, meaning client performs 0% to 25% of task and, if client requires the help of more than one caregiver, it is referred to as a dependent transfer; maximum assist, meaning client gives 25% of effort while caregiver performs majority of the work; moderate assist, meaning client gives 50% of effort; minimal assist, meaning client gives 75% of effort; contact guard assist, meaning no physical assist is given but caregiver is physically touching client for steadying, guiding, or in case of loss of balance; stand by assist, meaning caregiver's hands are up and ready in case needed; supervision, meaning supervision of task is needed even if at a distance; modified independent, meaning client needs assistive device or extra time to accomplish task; and independent, meaning client is able to complete task safely without instruction or assistance. EB & CEB: There are guideliness on how to determine the amount of care the client will need ( Granger, 2011; Uniform Data System, 1997). ▴ Request a referral to a physical therapist as needed so that client's range of motion, muscle strength, balance, coordination, and endurance can be part of the initial evaluation. • Incorporate bed exercises such as flexing and extending feet and quadriceps or use of Thera-Bands for upper extremities into nursing care to help maintain muscle strength and tone (Koenig, Teixeira, & Yetzer, 2012). ▴ If not contraindicated by the client's condition, obtain a referral to physical therapy for use of tilt table to help determine the cause of syncope. Use of the tilt table can help determine if the cause of syncope is autonomic or from another cause ( Low & Engstrom, 2012). • Perform range of motion exercises for all possible joints at least twice daily; perform passive or active range of motion exercises as appropriate. If not used, muscles weaken and shorten from fibrosis of the muscle ( Wagner et al, 2008). EBN: Range of motion exercises are effective in maintaining joint mobility and muscle integrity ( Gillis & MacDonald, 2008; Summers et al, 2009). • Use specialized boots to prevent pressure ulcers on the heels and footdrop; remove boots twice daily to provide foot care. Boots hopefully help keep the foot in normal anatomical alignment to prevent footdrop and prevent pressure ulcer formation on the heel. EB: A Cochrane review found that there is not a good evidence base to determine which boots or pressure redistribution system is most effective in preventing heel pressure ulcers ( McGinnis & Stubbs, 2011). EBN: A study found that use of a wedge-shaped viscoelastic bed-sized support surface was more effective than use of a pillow to prevent heel ulcers ( Heyneman et al, 2009). • When positioning a client on the side, tilt client 30 degrees or less while lying on side. Full (versus tilt) side-lying position places higher pressure on trochanter, predisposing to skin breakdown although more evidence is needed to fully determine the impact of full versus tilted positioning ( van Rijswijk, 2009). • Assess skin condition at least daily and more frequently if needed. Utilize a risk assessment tool such the Braden Scale or the Norton Scale to predict the risk of developing pressure ulcers. EBN: Use of a risk assessment tool is possibly effective to predict the risk of developing a pressure ulcer ( Gillis & MacDonald, 2008). Refer to care plan for Risk for impaired Skin Integrity. • Discuss with staff and management a "safe handling" policy that may include a "no lift" policy. Benefits of a safe handling policy include decreased injury to workers, increased safety and comfort for clients, decreased litigation related to injuries, and decreased lost work and wages due to injury, as well as decreased workers' compensation claims ( Nelson et al, 2008). • Turn clients at high risk for pressure/shear/friction frequently. Turn clients at least every 2 to 4 hours on a pressure-reducing mattress/every 2 hours on standard foam mattress. These are general guidelines given for turning, but they do not have a good evidence base. Preferably base the turning schedule on close assessment of the client's condition and predisposing conditions ( Krapfl & Gray, 2008; van Rijswijk, 2009). • Provide the client with a pressure-relieving horizontal support surface. For further interventions on skin care, refer to the care plan for Impaired Skin Integrity. • Help the client out of bed as soon as able. Early mobilization reduces risk of atelectasis, pneumonia, venous thromboembolism (VTE) and pulmonary embolism, and decreases orthostatic hypotension ( Summers et al, 2009) as well as reducing risk of skeletal muscle atrophy, joint contractures, insulin resistance, microvascular dysfunction, systemic inflammation, and pressure ulcers ( Brower, 2009). Bed rest is almost always harmful to clients; early mobilization is better than bed rest for most health conditions ( Perme & Chandrashekar, 2009). • When getting the client up after bed rest, do so slowly and watch for signs of postural (orthostatic) hypotension, tachycardia, nausea, diaphoresis, or syncope. Take the blood pressure lying, sitting, and standing, waiting 2 minutes between each reading. Consequences of bed rest are increased systemic vascular resistance, muscle atrophy, joint contracture, thromboembolic disease, and insulin resistance as well as microvascular dysfunction ( Brower, 2009). Suggest waist-high elastic hosiery such as an elastic "belly binder" and/or bilateral lower extremity ace wraps over TED hose to facilitate venous return if hypotension is an issue ( McPhee & Papadakis, 2009). • Obtain assistive devices such as braces, crutches, or canes to help the client reach and maintain as much mobility as possible. Assistive devices can help increase mobility ( Yoem, Keller, & Fleury, 2009). ▴ Apply graduated compression stockings as ordered. Ensure proper fit by measuring accurately. Remove the stockings at least twice a day, in the morning with the bath and in the evening to assess the condition of the extremity, then reapply. Knee length is preferred rather than thigh length. EBN & EB: Effectiveness of knee-high compression stockings is equal to thigh-high compression stockings, and knee-high stockings are more comfortable and fit better, adding to client compliance as stockings are most effective when worn continuously during the at-risk period; on during day and off at night ( Hilleren-Listerud, 2009; McCaffrey & Blum, 2009). The American College of Chest Physicians ( ACCP, 2012) recommends pharmacological or mechanical prophylaxis such as the use of graduated compression stockings to reduce the incidence of venous thromboembolism in clients who have undergone high-risk orthopedic surgical procedures clients older than 70 years of age or are at high risk for VTE for multiple reasons ( Kahn et al, 2012). Please refer to the ACCP guidelines for use of mechanical prophylaxis for specific client situations. • Observe for signs of VTE, including pain, tenderness, and swelling in the calf and thigh. Also observe for new onset of breathlessness. Clients commonly complain of a cramp in their lower calf that persists and becomes more painful with time. Symptoms of existing deep vein thrombosis are nonspecific and cannot be used alone to determine the presence of VTE. New onset of breathlessness is commonly associated with development of a pulmonary embolism ( Goldhaber, 2012). • Have the client cough and deep breathe or use incentive spirometry every 2 hours while awake. Bed rest compromises breathing because of decreased chest expansion, decreased cilia activity, pooling of mucus, the effects of organ shift (such the diaphragm and heart as well as pressure on the esophagus when in the supine position) and leads to partial or complete atelectasis usually of the left lower lobe ( Brower, 2009). • Monitor respiratory functions, noting breath sounds and respiratory rate. Percuss for new onset of dullness in lungs. • Note bowel function daily. Provide increased fluids, fiber, and natural laxatives such as prune juice as needed. Constipation is common in immobilized clients because of decreased activity and fluid and food intake. Refer to care plan Constipation. • Increase fluid intake to 2000 mL/day within the client's cardiac and renal reserve. Adequate fluids helps prevent kidney stones and constipation, both of which are associated with bed rest. • Encourage intake of a balanced diet with adequate amounts of fiber and protein. Consider recommending Practical Interventions to Achieve Therapeutic Lifestyle Changes (TLC), which includes monounsaturated and polyunsaturated fats, oils, margarines, beans, peas, lentils, soy, skinless poultry, lean fish, trimmed cuts of meat, fat-free and low-fat daily foods, omega-3 polyunsaturated fat sources, and whole grains including soluble fiber sources such as oats, oat bran, and barley ( Tucker, 2010). (Ackley 309-311) Implications for Practice • Evaluate patterns of daily living and culturally prescribed activities before suggesting specific forms of exercise to patients. • Help patients plan physical activities that are culturally acceptable. • Exercise programs need to be flexible and accommodate family and community responsibilities of the culture. • Encourage culturally specific and individually tailored interventions to facilitate commitment to exercise. • Educate patients of all ages on the importance of exercise in preserving health and correct any misconceptions. (Potter 1147) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

stages of infection

Box 28-2 Course of Infection by Stage Incubation Period Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 10 to 21 days after exposure; common cold, 1 to 2 days; influenza, 1 to 5 days; mumps, 12 to 26 days). Prodromal Stage Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears. Illness Stage Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling. Convalescence Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.) (Potter 401) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. An infection does not always present with typical signs and symptoms in all patients. For example, some older adults have an advanced infection before it is identified. Because of the aging process, there is a reduced inflammatory and immune response. Older adults have increased fatigue and diminished pain sensitivity. A reduced or absent fever response often occurs from chronic use of aspirin or nonsteroidal antiinflammatory drugs. (Potter 406) Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness (Fardo, 2009). (Potter 406)

Precautions when using needles (best practice is...)...

Box 31-23 Recommendations for Prevention of NeedlEStick Injuries • Avoid using needles when effective needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices are available. • Do not recap any needle. • Plan safe handling and disposal of needles before beginning the procedure. • Immediately dispose of needles, needleless systems, and SESIP into puncture-proof and leak-proof sharps disposal containers. • Maintain a sharps injury log that includes the following: type and brand of device involved in the incident; location of the incident (e.g., department or work area); description of the incident; privacy of the employees who have had sharps injuries. (Potter 609) Insulin... Some agencies use lancet devices with an automatic blade retraction system. This reduces the possibility of self-sticks, preventing exposure to bloodborne pathogens. Place blood-letting device firmly against side of finger and push release button, causing needle to pierce skin (see illustration). (Potter 1037) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. All needles and other sharp items must be handled carefully and discarded in puncture-resistant containers. Needles should not be recapped, broken, bent, or removed from a syringe to avoid the risk of puncturing the finger or hand. All needle sticks need to be reported and followed up with appropriate testing for infectious disease. Special reusable needles are placed in metal containers for transport to a designated area for sterilization or disinfection.

Identify culturally appropriate health promotion and disease and injury prevention interventions

Collaborate with other nurses and educators to present appropriate teaching approaches, and ask the people in the cultural group to help by sharing their values and beliefs. Ethnic nurses are excellent resources who are able to provide input through their experiences to improve the care provided to members of their own community (Bastable, 2008). When patients cannot understand English, use trained and certified health care interpreters to provide health care information. (Potter 343) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Patient Education Patient education needs to be patient-centered and culturally sensitive for learning to occur. Assessing patients' preferred learning approaches and adapting education to meet patients' needs facilitates the attainment of educational outcomes. Sociocultural norms, values, and traditions often determine the importance of different health education topics and the preference of one learning approach over another. Educational efforts are especially challenging when patients and educators do not speak the same language or when written materials are not culturally sensitive and are written above patients' reading abilities. (Potter 343) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Using Teaching Tools Many teaching tools are available for patient education. Selection of the right tool depends on the instructional method, the patient's learning needs, and his or her ability to learn (Table 25-3). For example, a printed pamphlet is not the best tool to use for a patient with poor reading comprehension, but an audiotape is a good choice for a patient with visual impairment. (Potter 343) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Consider cultural implications as well. For example, Arab women frequently do not have breast examinations, mammograms, and cervical cancer screening because of religious and cultural beliefs about modesty (Cohen and Azaiza, 2010). Develop a therapeutic relationship with patients and provide culturally sensitive education that is written at an appropriate reading level (see Chapter 25). Encourage patients to find health care providers that they can trust and help patients who are uninsured or underinsured locate resources that can help them pay for important sexual health screenings (Hogben and Leichliter, 2008). (Potter 686) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Implications for Practice • Use culturally appropriate assessment tools to assess pain such as tools written in the patient's native language (Pasero and McCaffery, 2011). (Potter 969) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Use materials and teaching techniques that are culturally relevant and language appropriate to communicate and assess the non-English-speaking patient regarding factors such as pain, general comfort, temperature, and need to void. (Potter 1263) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

QSEN

DEFINITIONS AND PRE-LICENSURE KSAS: Patient-Centered Care Teamwork and Collaboration Evidence-based Practice (EBP) Quality Improvement (QI) Safety Informatics knowledge, skills, attitudes

How often are rounds in best practice?

Every-2-hour rounds entail rounding every 2 hours throughout the entire 24-hour period. Evidence-based nursing rounds influence safety outcomes such as checking patients for the 5 Ps: pain, potty, position, possessions, and plan of care. (Potter 384) Application to Nursing Practice • Implementation of purposeful, hourly nursing rounds improves outcomes in reducing patient falls (Weisgram and Raymond, 2008; Ford, 2010). However, in one study every-2-hour rounds did not significantly reduce falls (Meade et al., 2006). • Implementation of hourly nursing rounds also reduces patient development of pressure ulcers (Studer Group, 2007). • Purposeful rounding includes specific nursing actions such as addressing toileting, turning, and ensuring that possessions are within reach. • Nurses and NAPs often share rounding responsibilities. (Potter 384)

QSEN Teamwork and Collaboration definition

Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

write an outcome/goal for a nursing diagnosis

Guidelines for Writing Goals and Expected Outcomes There are seven guidelines for writing goals and expected outcomes. Patient-Centered Outcomes and goals reflect patient behaviors and responses expected as a result of nursing interventions. Write a goal or outcome to reflect a patient's specific behavior, not to reflect your goals or interventions. (Potter 240-241) Singular Goal or Outcome You want to be precise when you evaluate a patient's response to a nursing action. Each goal and outcome should address only one behavior or response. If an outcome reads, "Patient's lungs will be clear to auscultation, and respiratory rate will be 20 breaths per minute by 8/22," your measurement of outcomes will be complicated. When you evaluate that the lungs are clear but the respiratory rate is 28 breaths per minute, you do not know if the patient achieved the expected outcome. By splitting the statement into two parts, "Lungs will be clear to auscultation by 8/22," and "Respiratory rate will be 20 breaths per minute by 8/22," you are able to determine if and when the patient achieves each outcome. Singularity allows you to decide if there is a need to modify the plan of care. A goal also contains only one behavior or response. The example, "Patient will administer a self-injection and demonstrate infection control measures," is incorrect because the statement includes two different behaviors, administer and demonstrate. Instead word the goal as follows, "Patient will administer a self-injection by discharge." The specific criteria you use to measure success of the goal are the singular expected outcomes. For example, "Patient will prepare medication dose correctly," and "Patient uses medical asepsis when preparing injection site." Observable You need to be able to observe if change takes place in a patient's status. Observable changes occur in physiological findings and in the patient's knowledge, perceptions, and behavior. You observe outcomes by directly asking patients about their condition or using assessment skills. For example, you observe the goal, "Patient will be able to self-administer insulin," through the outcome of watching, "Patient prepares insulin dosage correctly by 8/30." For the outcome, "Lungs will be clear on auscultation by 8/31," you auscultate the lungs following any therapy. The outcome statement, "Patient will appear less anxious," is not correct because there is no specific behavior observable for "will appear." A more correct outcome is, "Patient will show better eye contact during conversations." Measurable You learn to write goals and expected outcomes that set standards against which to measure the patient's response to nursing care. Examples such as, "Body temperature will remain 98.6° F," and, "Apical pulse will remain between 60 and 100 beats per minute," allow you to objectively measure changes in the patient's status. Do not use vague qualifiers such as "normal," "acceptable," or "stable" in an expected outcome statement. Vague terms result in guesswork in determining a patient's response to care. Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. Time-Limited The time frame for each goal and expected outcome indicates when you expect the response to occur. It is very important to collaborate with patients to set realistic and reasonable time frames. Time frames help you and the patient to determine if the patient is making progress at a reasonable rate. If not, you must revise the plan of care. Time frames also promote accountability in delivering and managing nursing care. Mutual Factors Mutually set goals and expected outcomes ensure that the patient and nurse agree on the direction and time limits of care. Mutual goal setting increases the patient's motivation and cooperation. As a patient advocate, apply standards of practice, evidence-based knowledge, safety principles, and basic human needs when assisting patients with setting goals. Your knowledge background helps you select goals and outcomes that should be met on the basis of typical responses to clinical interventions. Yet you must consider patients' desires to recover and their physical and psychological condition to set goals and outcomes to which they can agree. Realistic Set goals and expected outcomes that a patient is able to reach based on your assessment. This is a challenge when the time allotted for care is limited. But it also means that you must communicate these goals and outcomes to caregivers in other settings who will assume responsibility for patient care (e.g., home health, rehabilitation). Realistic goals provide patients a sense of hope that increases motivation and cooperation. To establish realistic goals, assess the resources of the patient, health care facility, and family. Be aware of the patient's physiological, emotional, cognitive, and sociocultural potential and the economic cost and resources available to reach expected outcomes in a timely manner. (Potter 241) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

bloodborne pathogens

Hepatitis B and C are the infections most commonly transmitted by contaminated needles (Box 28-16). Report any contaminated needlestick immediately. (Potter 424-425) Testing the exposed employee at the time of the exposure is not needed immediately unless required by the state testing law. If the patient tests positive for a bloodborne pathogen or if the source patient is unknown, prophylactic treatment is recommended for the employee. (Potter 425) Exposure to bloodborne pathogens is one of the deadliest hazards to which nurses are exposed on a daily basis. Most needlestick injuries are preventable with the implementation of safe needle devices. The Needlestick Safety and Prevention Act mandates the use of special needle safety devices to reduce the frequency of needlestick injuries. (Potter 608) Operating Room Patient Care • Use nonlatex gloves. (Use caution: Not all substitutes are equally impermeable to bloodborne pathogens; care and investigation should be taken in the selection of substitute gloves.) (Potter 1273)

landmarks for injections

If a nurse does not administer injections correctly, negative patient outcomes result. Failure to select an injection site in relation to anatomical landmarks results in nerve or bone damage during needle insertion. Inability to maintain stability of the needle and syringe unit can result in pain and tissue damage. If you fail to aspirate the syringe before injecting an IM medication, the medication may accidentally be injected directly into an artery or vein. Injecting too large a volume of medication for the site selected causes extreme pain and results in local tissue damage. (Potter 604) The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs (Fig. 31-17). The site most frequently recommended for heparin injections is the abdomen (Fig. 31-18). Alternative subcutaneous sites for other medications include the scapular areas of the upper back and the upper ventral or dorsal gluteal areas. The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves. (Potter 604-605) Assess the muscle before giving an injection. Properly identify the site for the IM injection by palpating bony landmarks, and be aware of the potential complications associated with each site (Nicoll and Hesby, 2002). It needs to be free of tenderness. Repeated injections in the same muscle cause severe discomfort. With the patient relaxed, palpate the muscle to rule out any hardened lesions. Minimize discomfort during an injection by helping the patient assume a position that helps to reduce muscle strain. Other interventions such as distraction and applying pressure to the IM site decrease pain during an IM injection. Sites When selecting an IM site, consider the following: Is the area free of infection or necrosis? Are there local areas of bruising or abrasions? What is the location of underlying bones, nerves, and major blood vessels? What volume of medication is to be administered? Each site has different advantages and disadvantages. Ventrogluteal The ventrogluteal muscle involves the gluteus medius; it is situated deep and away from major nerves and blood vessels. This site is the preferred and safest site for all adults, children, and infants, especially for medications that have larger volumes and are more viscous and irritating (Hockenberry and Wilson, 2009; Nicoll and Hesby, 2002). The ventrogluteal site is recommended for volumes greater than 2 mL (Nicoll and Hesby, 2002). Research shows that injuries such as fibrosis, nerve damage, abscess, tissue necrosis, muscle contraction, gangrene, and pain are associated with all the common IM sites except the ventrogluteal site. Actually the only published case study of a complication at the ventrogluteal site reported a local reaction to the medication, which is not a complication associated with the site itself (Nicoll and Hesby, 2002). Locate the ventrogluteal muscle by positioning the patient in a supine or lateral position. Flexing the knee and hip helps to relax this muscle. Place the palm of your hand over the greater trochanter of the patient's hip with the wrist perpendicular to the femur. Use the right hand for the left hip and use the left hand for the right hip. Point the thumb toward the patient's groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle (Fig. 31-20, A to C). FIG. 31-20 A, Landmarks for ventrogluteal site. B, Locating ventrogluteal site in patient. C, Giving intramuscular injection in ventrogluteal muscle using the Z-track method. Vastus Lateralis The vastus lateralis muscle is another injection site for adults and children. The muscle is thick and well developed, is located on the anterior lateral aspect of the thigh, and extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur (Fig. 31-21, A and B). Use the middle third of the muscle for injection. The width of the muscle usually extends from the midline of the thigh to the midline of the outer side of the thigh. With young children or FIG. 31-21 A, Landmarks for vastus lateralis site. B, Giving intramuscular injection in vastus lateralis muscle. cachectic patients, it helps to grasp the body of the muscle during injection to be sure that the medication is deposited in muscle tissue. To help relax the muscle, ask the patient to lie flat with the knee slightly flexed or in a sitting position. The vastus lateralis site is often used for infants, toddlers, and children receiving biologicals (e.g., immunoglobulins, vaccines, or toxoids) (Nicoll and Hesby, 2002). Deltoid Although the deltoid site is easily accessible, this muscle is not well developed in many adults. There is a potential for injury because the axillary, radial, brachial, and ulnar nerves, as well as the brachial artery, lie within the upper arm under the triceps and along the humerus. Use this site for small medication volumes (2 mL or less) (Nicoll and Hesby, 2002). Carefully assess the condition of the deltoid muscle, consult medication references for suitability of the medication, and carefully locate the injection site using anatomical landmarks (Fig 31-22, A). Use this site only for small medication volumes, when giving immunizations (e.g., hepatitis B, flu shots), or when other sites are inaccessible because of dressings or casts (Nicoll and Hesby, 2002). To locate the muscle, fully expose the patient's upper arm and shoulder. Do not roll up a tight-fitting sleeve. Have the patient relax the arm at the side and flex the elbow. The patient may sit, stand, or lie down (Fig. 31-22, B). Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. You can also locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process. (Potter 606-607)

principles of body mechanics

In the discussion of body mechanics, two of these functions (i.e., support and movement) are most important (see Chapter 47). Bones serve as support by providing the framework and contributing to the shape, alignment, and positioning of the body parts. Bones, together with their joints, constitute levers for muscle attachment to provide movement. As muscles contract and shorten, they pull on bones, producing joint movement (Patton and Thibodeau, 2010). (Potter 747) Body Mechanics The U.S. Occupational Safety and Health Administration released federal ergonomic guidelines to prevent musculoskeletal injuries in the workplace (OSHA, 2009). Half of all back pain is associated with manual lifting tasks (Box 38-10). Coordinated musculoskeletal activity is necessary when positioning and transferring patients. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Injury to these areas affects the ability to bend forward, backward, and from side to side. The ability to rotate the hips and lower back is also decreased (Nelson and Hughes, 2009). Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients (Table 38-1). Before lifting, assess the weight to be lifted, determine the assistance needed, and evaluate available resources. Use safe patient-handling equipment when the patient is unable to assist in transfer. Lift teams, consisting of two physically fit people competent in lifting techniques, reduce the risk of injury to the patient and members of the health care team (Baptiste et al., 2006; Pelczarski, 2007). Use manual lifting only as a last resort when you need to lift a small portion of the patient's weight (Nelson and Baptiste, 2004; Nelson et al., 2008; Tullar et al., 2010). Teaching health care workers about patient-handling equipment, proper body mechanics, and the use of lift teams is most effective in preventing injury (Nelson and Baptiste, 2004; Nelson et al., 2008). (Potter 758) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems. Although nurses need to understand the physics surrounding body mechanics, lifting techniques historically used in nursing practice that emphasize body mechanics often cause debilitating injuries to nursing and other health care staff (de Castro et al., 2006). Today nurses use information about body alignment, balance, gravity, and friction when implementing nursing interventions such as positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients. (Potter 1127-1128) Nurses spend time in many activities bending and twisting, which also cause injury. Examples of such activities include lifting objects; pushing beds; and bathing, feeding, dressing, and undressing patients (Nelson et al., 2009). Therefore, in addition to knowing how to move patients safely, nurses also need to apply concepts related to body mechanics in the workplace. Before beginning a task, know your individual capabilities for activities such as lifting and moving objects. If providing care (e.g., bathing) to a patient, consider his or her condition and whether or not he or she can assist you. When you cannot safely complete a task (e.g., moving a bed from one room to another), assess the number of people you will need to help you and do not start until the task can be completed safely to prevent injury to you, the other members of the health care team, and the patient. Follow these steps to prevent injury: 1 Keep the weight to be lifted as close to the body as possible; this action places the object in the same plane as the lifter and close to the center of gravity for balance. 2 Bend at the knees; this helps to maintain the center of gravity and uses the stronger leg muscles to do the lifting (Fig. 47-17). 3 Tighten abdominal muscles and tuck the pelvis; this provides balance and helps protect the back. 4 Maintain the trunk erect and knees bent so multiple muscle groups work together in a coordinated manner (see Chapter 38); do not allow the trunk to twist. (Potter 1147) Weight is the force exerted on a body by gravity. The force of weight is always directed downward, which is why an unbalanced object falls. Unsteady patients fall if their center of gravity becomes unbalanced because of the gravitational pull on their weight. To lift safely the lifter has to overcome the weight of the object and know its center of gravity. In symmetrical inanimate objects the center of gravity is at the exact center of the object. However, people are not geometrically perfect; their centers of gravity are usually at 55% to 57% of standing height and are in the midline, which is why only using principles of body mechanics in lifting patients often leads to injury of the nurse or health care professional. (Potter 1128) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

QSEN EVIDENCE-BASED PRACTICE (EBP) defintion

Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

QSEN SAFETY Definition:

Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

QSEN SAFETY definition:

Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

Modes of Transmission

Modes of Transmission Each disease has a specific mode of transmission. Many times you are able to do little about the infectious agent or the susceptible host, but by practicing infection prevention and control techniques such as hand hygiene, you interrupt the mode of transmission (Box 28-1). The same microorganism is sometimes transmitted by more than one route. For example, varicella zoster (chickenpox) is spread by the airborne route in droplet nuclei or by direct contact. Box 28-1 Modes of Transmission Contact Direct • Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming contaminated food) Indirect • Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment) Droplet • Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host Airborne • Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles Vehicles • Contaminated items • Water • Drugs, solutions • Blood • Food (improperly handled, stored, or cooked; fresh or thawed meats) Vector • External mechanical transfer (flies) • Internal transmission such as parasitic conditions between vector and host such as: • Mosquito • Louse • Flea • Tick (Potter 400-401) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

medical and surgical asepsis

Procedures used to reduce the number of microorganisms and prevent their spread. (Potter 1305) . Asepsis is the absence of pathogenic (disease-producing) microorganisms. Aseptic technique refers to practices/procedures that help reduce the risk for infection. The two types of aseptic technique are medical and surgical asepsis. Medical asepsis, or clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Principles of medical asepsis are also commonly followed in the home; hand hygiene with soap and water before preparing food is an example. It is also important to include cultural, religious, or social beliefs of the patient and family. After an object becomes unsterile or unclean, it is considered contaminated. In medical asepsis an area or object is considered contaminated if it contains or is suspected of containing pathogens. For example, a used bedpan, the over-bed table, and a used dressing are considered to be contaminated items. (Potter 410) When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform (Fig. 39-11). Place soiled linen in special linen bags before placing in a hamper. To avoid air currents that spread microorganisms, never shake the linen. To avoid transmitting infection, do not place soiled linen on the floor. If clean linen touches the floor or any unclean surface, immediately place it in the dirty linen container. (Potter 793) Surgical Asepsis Surgical asepsis or sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area (Rutala and Weber, 2008, 2009). In surgical asepsis an area or object is considered contaminated if touched by any object that is not sterile. It demands the highest level of aseptic technique and requires that all areas be kept free of infectious microorganisms. Use surgical asepsis in the following situations: • During procedures that require intentional perforation of the patient's skin such as insertion of IV catheters or central lines • When the integrity of the skin is broken as a result of trauma, surgical incision, or burns • During procedures that involve insertion of catheters or surgical instruments into sterile body cavities such as insertion of a urinary catheter Although surgical asepsis is common in the operating room, labor and delivery area, and major diagnostic areas, you also use surgical aseptic techniques at the patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and reapplying sterile dressings). (Potter 421) A nurse in an operating room follows a series of steps to maintain sterile technique, including applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and gloves. In contrast, a nurse performing a dressing change at a patient's bedside only performs hand hygiene and applies sterile gloves. For certain procedures (e.g., changing a central line dressing) the nurse also uses a mask. Regardless of the procedures followed or the setting, the nurse always recognizes the importance of strict adherence to aseptic principles (Iwamoto, 2009). (Potter 421) Because surgical asepsis requires exact techniques, you need to have the patient's cooperation. Certain patients fear moving or touching objects during a sterile procedure, whereas others try to assist. Explain how you will perform a procedure and what the patient can do to avoid contaminating sterile items, including the following: • Avoid sudden movements of body parts covered by sterile drapes. • Refrain from touching sterile supplies, drapes, or the nurse's gloves and gown. • Avoid coughing, sneezing, or talking over a sterile area. Certain sterile procedures last an extended time. The nurse assesses a patient's needs and anticipates factors that may disrupt a procedure. If a patient is in pain, administer ordered analgesics about a half an hour before a sterile procedure begins. Ask a patient if he or she needs to use the bathroom or a bedpan. Often patients have to assume relatively uncomfortable positions during sterile procedures. Help a patient assume the most comfortable position possible. Finally, a patient's condition sometimes results in actions or events that contaminate a sterile field. For example, a patient with a respiratory infection transmits organisms by coughing or talking. Anticipate such a problem and place a surgical mask on him or her before the procedure begins. (Potter 421) Review Principles of a Sterile Procedure on 421 etc.

isolation

Psychological Implications of Isolation When a patient requires isolation in a private room, a sense of loneliness sometimes develops because normal social relationships become disrupted. This situation can be psychologically harmful, especially for children. A recent study noted that patients in isolation suffered more depression and anxiety and were less satisfied with their care (Abad et al., 2010). Patients' body images become altered as a result of the infectious process. Some feel unclean, rejected, lonely, or guilty. Infection prevention and control practices further intensify these beliefs of difference or undesirability. Isolation disrupts normal social relationships with visitors and caregivers. Take the opportunity to listen to a patient's concerns or interests. If you rush care or show a lack of interest in a patient's needs, he or she feels rejected and even more isolated. Before you institute isolation measures, the patient and family need to understand the nature of the disease or condition, the purposes of isolation, and steps for carrying out specific precautions. If they are able to participate in maintaining infection prevention and control practices, the chances of reducing the spread of infection increase. Teach the patient and family to perform hand hygiene and use barrier protection if appropriate. Demonstrate each procedure; be sure to give the patient and family an opportunity for practice. It is also important to explain how infectious organisms are transmitted so the patient and family understand the difference between contaminated and clean objects. Explaining and demonstrating these procedures, especially hand hygiene, helps the family to consistently practice correct hand hygiene and prescribed isolation measures (Gould et al., 2011). Take measures to improve the patient's sensory stimulation during isolation. Make sure that the room environment is clean and pleasant. Open drapes or shades and remove excess supplies and equipment. Listen to the patient's concerns or interests. Mealtime is a particularly good opportunity for conversation. Providing comfort measures such as repositioning, a back massage, or a warm sponge bath increase physical stimulation. Depending on the patient's condition, encourage him or her to walk around the room or sit up in a chair. Recreational activities such as board games or cards are an option to keep the patient mentally stimulated. Explain to the family the patient's risk for depression or loneliness (Abad et al., 2010). Encourage visiting family members to avoid expressions or actions that convey revulsion or disgust related to infection prevention and control practices. Discuss ways to provide meaningful stimulation. The Isolation Environment Private rooms used for isolation sometimes provide negative-pressure airflow to prevent infectious particles from flowing out of a room to other rooms and the air handling system. Special rooms with positive-pressure airflow are also used for highly susceptible immunocompromised patients such as recipients of transplanted organs. On the door or wall outside the room the nurse posts a card listing precautions for the isolation category in use according to health care facility policy. The card is a handy reference for health care personnel and visitors and alerts anyone who might enter the room accidentally that special precautions must be followed. The isolation room or an adjoining anteroom needs to contain hand hygiene and PPE supplies. Soap and antiseptic (antimicrobial) solutions need to be available. Personnel and visitors perform hand hygiene before approaching the patient's bedside and again before leaving the room. If toilet facilities are unavailable, there are special procedures for handling portable commodes, bedpans, or urinals. All patient care rooms, including those used for isolation; contain an impervious bag for soiled or contaminated linen and a trash container with plastic liners. Impervious receptacles prevent transmission of microorganisms by preventing leaking and soiling of the outside surface. A disposable rigid container needs to be available in the room to discard used sharps such as safety needles and syringes. Remain aware of infection prevention and control techniques while working with patients in protected environments. You need to feel comfortable performing all procedures and yet remain conscious of infection prevention and control principles. Depending on the microorganism and mode of transmission, evaluate which articles or equipment to take into an isolation room. For example, the CDC (2007) recommends the dedicated use of articles such as stethoscopes, sphygmomanometers, or rectal thermometers in the isolation room of a patient infected or colonized with vancomycin-resistant enterococci. Do not use these devices on other patients unless they are first adequately cleaned and disinfected. Box 28-12 describes the procedures to perform when using shared equipment. (Potter 416) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

QSEN QUALITY IMPROVEMENT (QI) Definition

QUALITY IMPROVEMENT (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

QSEN Patient Centered Care definition

Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.

Falls: Morse Fall Scale

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a resident's likelihood of falling. The MFS is used widely in acute care settings. Variables; History of Falling, Secondary diagnosis, Ambulatory aid, IV or IV access, Gait, Mental Status. Risk Level; No risk, Low to moderate risk, High risk.

Alternatives to Restraints

The hierarchy of intervention is: promote a milieu that provides structure and calmness, with negotiation and collaboration taking precedence over control; maintain vigilance of the unit and respond to behavioral changes early; talk with client to calm and promote understanding of emotional state; use chemical restraints as ordered; increase to manual restraint if needed; increase to mechanical restraint and seclusion as a last resort. (Ackley 852) Allow, encourage, and assist the client to verbalize feelings appropriately either one-on-one or in a group setting. Actively listen to the client; explore the source of the client's anger, and negotiate resolution when possible. Teach healthy ways to express feelings/anger, appropriate gender roles, and how to communicate needs appropriately. (Ackley 853) Have the client keep an anger diary and discuss alternative responses together. Teach cognitive-behavioral techniques. (Ackley 853) Avoid use of restraints if at all possible. Restraint-free is now the standard of care for hospitals and long-term care facilities. Obtain a physician's order if restraints are necessary. (Ackley 487) • In place of restraints, use the following: ▪ Well-staffed and educated nursing personnel with frequent client contact ▪ Continuity of care with familiar staff ▪ Nursing units designed to care for clients with cognitive or functional impairments ▪ Avoiding use of IVs or tubes that are susceptible to being removed ▪ Alarm systems with ankle, above-the-knee, or wrist sensors ▪ Bed or wheelchair alarms ▪ Increased observation of the client ▪ Providing exercise to diffuse and deflect client behavior ▪ Low or very-low height beds ▪ Border-defining pillow/mattress to remind the client to stay in bed ▪ Mobility exercise to strength muscles and steady gait ▪ Floor mats and transfer poles for client safety These alternatives to restraints can be helpful to prevent falls (Ackley 487-488) Ackley, Betty J., Gail Ladwig. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 10th Edition. Mosby, 2014. VitalBook file.

When MUST you WASH hands?

Transient microorganisms attach to the skin when a person has contact with another person or object during normal activities. The friction of rubbing hands together removes soil and transient organisms from the hands. (Potter 410) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition. Mosby, 2013. VitalBook file.

QSEN INFORMATICS definition:

Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

Exudate

exudate Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes. (Potter 1301)

standard precautions

standard precautions: Guidelines recommended by the Centers for Disease Control and Prevention (CDC) to reduce risk of transmission of bloodborne and other pathogens in hospitals. (Potter 1310) Contaminated hands of health care workers are a primary source of infection transmission in health care settings. (Potter 410) It is recommended that health care workers have well-manicured nails and refrain from wearing artificial nails (Box 28-8) to reduce microorganism transmission. For example, you are performing a dressing change, and the patient's roommate asks for assistance with a blocked IV line. If you do not perform hand hygiene before handling the IV line, you transfer organisms from the patient's wound to the roommate's IV site. TJC has identified compliance with proper hand hygiene as a National Patient Safety Goal (TJC, 2011). (Potter 410-411) The CDC (2002; WHO, 2009) recommends the following: 1 When hands are visibly dirty, when soiled with blood or other body fluids, before eating, and after using the toilet, wash hands with either a nonantimicrobial soap or antimicrobial soap and water. 2 Wash hands if exposed to spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Standard Precautions (Tier One) for Use with All Patients • Standard precautions apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes. • Perform hand hygiene before, after, and between direct contact with patients. (Examples of between-contact activities are cleaning hands after a patient care activity, moving to a nonpatient care activity, and cleaning hands again before returning to perform patient contact.) • Perform hand hygiene after contact with blood, body fluids, mucous membranes, nonintact skin, secretions, excretions or wound dressings; after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. • When hands are visibly soiled or contaminated with blood or body fluids, wash them with either a nonantimicrobial soap or an antimicrobial soap and water. • When hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based, waterless antiseptic agent to perform hand hygiene (WHO, 2009). • Wash hands with nonantimicrobial soap and water if contact with spores (e.g., Clostridium difficile) is likely to have occurred. • Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes. • Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces is likely. Remove gloves and perform hand hygiene between patient care encounters and when going from a contaminated to a clean body site. • Wear personal protective equipment when the anticipated patient interaction indicates that contact with blood or body fluids may occur. • A private room is unnecessary unless the patient's hygiene is unacceptable (e.g., uncontained secretions, excretions, or wound drainage). • Discard all contaminated sharp instruments and needles in a puncture-resistant container. Health care facilities must make available needleless devices. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping. • Respiratory hygiene/cough etiquette: Have patients cover the nose/mouth when coughing or sneezing; use tissues to contain respiratory secretions and dispose in nearest waste container; perform hand hygiene after contacting respiratory secretions and contaminated objects/materials; contain respiratory secretions with procedure or surgical mask; sit at least 3 feet away from others if coughing. Modified from Centers for Disease Control and Prevention, Hospital Infection Control Practice Advisory Committee: Guidelines for isolation precautions in hospitals, MMWR Morb Mortal Wkly Rep 57/RR-16:39, 2007. MRSA, Methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococcus. (Potter 414) Serous fluids such as pleural, peritoneal, amniotic, cerebrospinal, and synovial fluids are included. Semen and vaginal secretions should also be considered hazardous. Other clinical specimens (e.g., sputum, stool, urine) are of less concern, and the Standard Precautions apply only if these specimens contain visible amounts of blood. (Pagana 5) These precautions require the use of protective barriers (gloves, gowns, masks, protective eyewear) to avoid skin and mucous membrane exposure to blood and body fluids. A fundamental principle of Standard Precautions is frequent handwashing between patients and when gloves are changed. All specimens should be collected and transported in containers that prevent leakage. Blood or body fluid spills must be decontaminated immediately. All needles and other sharp items must be handled carefully and discarded in puncture-resistant containers. Needles should not be recapped, broken, bent, or removed from a syringe to avoid the risk of puncturing the finger or hand. All needle sticks need to be reported and followed up with appropriate testing for infectious disease. Special reusable needles are placed in metal containers for transport to a designated area for sterilization or disinfection. Vaccination against HBV is another safety precaution recommended by the CDC. (Pagana 5) BOX 1-1 Standard Precautions These precautions have been mandated by the Occupational Safety and Health Administration (OSHA). Their purpose is to protect health care workers from contracting illnesses from the specimens they handle, the patients they care for, and the environment in which they work. The precautions are as follows: • Wear gowns, gloves, protective eyewear, face masks, and protective clothing (including laboratory coat) whenever exposed to blood or other body fluids. • If the health care worker's skin is opened, gloves should be worn whenever direct patient care is performed. • Mouth-to-mouth emergency resuscitation equipment should be available in strategic locations. The mouthpieces should be individualized for each health care worker. Ambu bags are preferable. Saliva is considered an infectious fluid. • Dispose of all sharp items in puncture-resistant containers. • Do not "recap," bend, break, or remove needles from syringes. • Immediately remove gloves that have a hole or tear in them. • All disposed patient-related wastes must be labeled as a "biohazard." • All specimens must be transported in leak-proof containers. • Eating, drinking, applying cosmetics, or handling contact lenses is prohibited in patient care areas. • Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting. • Implement respiratory hygiene/cough etiquette instructions to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection. These include posting signs with instructions about covering mouths/noses, using and disposing of tissues, and hand hygiene. Offer masks to coughing patients and encourage them to keep a distance of at least three feet from others. • If a health care worker has experienced an exposure incident to blood or other body fluids (e.g., needle stick), testing of the health care worker and the patient for HBV and HIV is necessary. Data from Centers for Disease Control and Prevention, 2007. (Pagana 6) Pagana, Kathleen, Timothy Pagana. Mosby's Manual of Diagnostic and Laboratory Tests, 5th Edition. Mosby, 2014. VitalBook file.