NU 311 Final Exam
medications that require a double check by another nurse
-narcotics -insulin
Infiltration
-pain, swelling, coolness to touch, or presence of blanching (white, shiny appearance at or above IV site) or redness • Stop infusion and remove IV catheter at first sign • Elevate affected extremity. • Avoid applying pressure, which can force solution into contact with more tissue, causing tissue damage. • Use standard scale for assessing and documenting it
Sudden infusion of large volume of solution occurs
-patient develops dyspnea, crackles in lung, dependent edema (edema in legs), and increased urine output, indicating FVE. • Slow infusion rate: KVO rates must have specific rate ordered by health care provider. • Notify health care provider immediately. • Place patient in high-Fowler's position. • Anticipate new IV orders. • Anticipate administration of oxygen per order. • Administer diuretics if ordered.
What best determines the the type of effluent from an ostomy?
-placement -The character of the output of a bowel stoma (called effluent) is influenced by a patient's medications and hydration status and the foods eaten. Diet and fluid therapy are important therapies in managing ostomy effluent.
ANA Code of Ethics Provision 8
"The nurse collaborates with other health professionals and the public to protect and promote human rights, health diplomacy, and health initiatives."
ANA Code of Ethics Provision 6
"The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care."
Avoid vein selection
(1) Areas with pain on palpation, compromised areas, sites distal to compromised areas (e.g., open wounds, bruising, infection, infiltration, or extravasation) (2) Upper extremity on side of breast surgery with axillary node dissection or lymphedema or after radiation, arteriovenous (AV) fistulas/grafts; or affected extremity from cerebrovascular accident (CVA) (3) Site distal to previous venipuncture site, sclerosed or hardened veins, previous infiltrations or extravasations, areas of venous valves, or phlebitic vessels. (4) Fragile dorsal hand veins in older adults. Veins of lower extremities should not be used for routine IV therapy in adults because of risk of tissue damage and thrombophlebitis (5) Areas of flexion such as wrist or antecubital area (6) Ventral surface of wrist (10-12.5 cm [4-5 inches]) (7) Choose site that will not interfere with patient's activities of daily living (ADLs), use of assist devices, or planned procedures.
Three-point gait (crutches)
(1) Begin in tripod position (see illustration A), with patient standing on weight-bearing foot. (2) Advance both crutches and involved leg, keeping foot of involved leg off floor (see illustration B). (3) Move weight-bearing leg forward, stepping on floor (see illustration C). (4) Repeat sequence.
Two-point gait (crutches)
(1) Begin in tripod position (see illustration A). (2) Move left crutch and right foot forward (see illustration B). (3) Move right crutch and left foot forward (see illustration C). (4) Repeat sequence.
Four-point gait (crutches)
(1) Begin in tripod position (see illustration). Have patient place the crutch tips about 4 to 6 inches (10 to 15 cm) to the side and in front of each foot (American College of Foot and Ankle Surgeons, 2016). Have patient place weight on handgrips, not under arms. (2) Move right crutch forward 10 to 15 cm (4 to 6 inches) (see illustration A). (3) Move left foot forward to level of left crutch (see illustration B). (4) Move left crutch forward 10 to 15 cm (4 to 6 inches) (see illustration C). (5) Move right foot forward to level of right crutch (see illustration D). (6) Repeat above sequence.
Swing-to gait (crutches)
(1) Begin in tripod position. (2) Move both crutches forward. (3) Lift and swing legs through and beyond crutches. (4) Repeat previous steps.
Before initiating transfusion check the following
(1) Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's medication administration record (MAR) or medical record. (2) Transfusion record number and patient's identification number match. (3) Patient's name is correct on all documents. Check patient identification number and date of birth on identification band and patient record. (4) Check unit number on blood bag with blood bank form to ensure that they are the same. Check expiration date and time. (5) Blood type matches on transfusion record and blood bag. Verify that component received from blood bank is same component that health care provider ordered (e.g., packed red cells, platelets) (6) Check that patient's blood type and Rh type are compatible with donor blood type and Rh type (e.g., Patient A+: Donor A+ or 0+). (7) Check expiration date and time on unit of blood. (8) Just before initiating transfusion, check patient identification information with blood unit label information (see illustration). Do not administer blood to patient without identification bracelet or blood identification bracelet (see agency policy). (9) Both individuals verify patient and unit identification record process as directed by agency policy.
RACE
(1) Rescue patient from immediate injury by removing from area or shielding from fire to avoid burns. (2) Activate fire alarm immediately. Follow agency policy for alerting staff to respond. (In many situations perform Steps (1) and (2) simultaneously by using call system to alert staff while you help patients at risk.) (3) Contain the fire by: (a) Closing all doors and windows. (b) Turning off oxygen and electrical equipment. (c) Placing wet towels along base of doors. (4) Evacuate patients: (a) Direct ambulatory patients to walk by themselves to a safe area. Know the fire exits and emergency evacuation route. (b) If patient is on life support, maintain respiratory status manually (Ambu bag) until you remove him or her from fire area. (c) Move bedridden patients by stretcher, bed, or wheelchair. (d) For patients who cannot walk or ambulate use these options: (i) Place on blanket and drag patient out of area of danger. (ii) Use two-person swing: Place patient in sitting position and have two staff members form a seat by clasping forearms together. Lift patient into "seat" and carry out of area of danger
Behavior and level of consciousness
(1) Restlessness and mild confusion (2) Decreased level of consciousness (lethargy, confusion, coma)
Clinical markers of interstitial volume
(1) Skin turgor (Pinch skin over sternum or inside of forearm.) (2) Dependent edema (pitting or nonpitting) (3) Oral mucous membrane between cheek and gum
Clinical markers of vascular volume
(1) Urine output (decreased, dark yellow) (2) Vital signs: blood pressure, respirations, pulse, temperature (3) Distended neck veins (Normally veins are full when person is supine and flat when person is upright.) (4) Auscultation of lungs (5) Capillary refill
liquid medications
(1) Use unit-dose container with correct amount of medication. Gently shake container. Administer medication packaged in a single-dose cup directly from the single-dose cup. Do not pour medicine into another cup. (2) Administer medications in only oral use syringes prepared by pharmacy. Do not use hypodermic syringe or syringe with needle or syringe cap
fecal diversions
-colostomy -ileostomy
why the a catheter should be secured to the leg
Reduces risk of urethral erosion, CAUTI, or accidental catheter removal
Administering Medications Through a Feeding Tube
1. Perform hand hygiene. Prepare medications for instillation into feeding tube (see Skill 21.1). Check medication label against MAR 2 times. Fill graduated container with 50 to 100 mL of tepid water. Use sterile water for immunocompromised or critically ill patients a. Tablets: Crush each tablet into a fine powder, using pill-crushing device or two medication cups (see Skill 21.1). Dissolve each tablet in separate cup of 30 mL of warm water. b. Capsules: Ensure that contents of capsule (granules or gelatin) can be expressed from covering (consult with pharmacist). Apply gloves and open capsule or pierce gel cap with sterile needle and empty contents into 30 mL of warm water (or solution designated by drug company). Gel caps dissolve in warm water, but this may take 15 to 20 minutes. c. Prepare liquid medication according to Skill 21.1. 2. Take medication(s) to patient at correct time (see agency policy). Medications that require exact timing include stat, first-time or loading doses, and 1-time doses. Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents) at exact time ordered (no later than 30 minutes before or after scheduled dose). Give non-time-critical scheduled medications within a range of 1 or 2 hours of scheduled dose (ISMP, 2011). During administration, apply six rights of medication administration. Perform hand hygiene. 3. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's MAR or medical record. 4. At patient's bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if he or she has allergies. 5. Explain procedure to patient and discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about the drugs. 6. Assist patient to sitting position. Elevate head of bed to minimum of 30 degrees and preferably 45 degrees (unless contraindicated) or sit patient up in a chair (Malone, 2014). 7. If continuous enteral tube feeding is infusing, adjust infusion pump setting to hold tube feeding. 8. Apply clean gloves. Check placement of feeding tube (see Skill 32.2) by observing gastric contents and checking pH of aspirate contents. Gastric pH less than 5.0 is a good indicator that tip of tube is correctly placed in stomach (Clifford et al., 2015). 9. Check for gastric residual volume (GRV). Draw up 10 to 30 mL of air into a 60-mL syringe and connect syringe to feeding tube. Flush tube with air and pull back slowly to aspirate gastric contents (see illustration). Determine GRV using either scale on syringe or a graduate container. Return aspirated contents to stomach unless a single GRV exceeds 250 mL (see agency policy). When GRV is excessive, hold medication and contact health care provider. 10. Irrigate the tubing. a. Pinch or clamp enteral tube and remove syringe. Draw up 30 mL of water into syringe. Reinsert tip of syringe into tube, release clamp, and flush tubing. Clamp tube again and remove syringe. b. Using the appropriate enteral connector (see Fig. 21.1), attach to enteral tube. 11. Remove bulb or plunger of syringe and reinsert syringe into tip of feeding tube. 12. Administer dose of first liquid or dissolved medication by pouring into syringe (see illustration). Allow to flow by gravity. a. If giving only one dose of medication, flush tubing with 30 to 60 mL of water after administration. b. To administer more than one medication, give each separately and flush between medications with 15 to 30 mL of water. c. Follow last dose of medication with 30 to 60 mL of water. 13. Clamp proximal end of feeding tube if tube feeding is not being administered and cap end of tube. 14. When continuous tube feeding is being administered by infusion pump, follow medication administration. If medications are not compatible with feeding solution, hold feeding for additional 30 to 60 minutes (Klang et al., 2013). 15. Help patient to comfortable position and keep head of bed elevated for 1 hour (see agency policy). 16. Dispose of soiled supplies, rinse graduated container and syringe with tap water, remove and dispose of gloves, and perform hand hygiene.
Right Task
Is it safe to delegate? Requires little supervision
information included in discharge summary
•Use clear, concise descriptions in patient's own language. •Provide step-by-step description of how to perform a procedure (e.g., home medication administration). Reinforce explanation with printed instructions for the patient to take home. •Provide a detailed list of all prescribed medications. •Identify precautions to follow when performing self-care or administering medications. •Review any restrictions that may relate to activities of daily living (e.g., bathing, ambulating, and driving). •Review signs and symptoms of complications to report to health care provider. •List names and phone numbers of health care providers and community resources for the patient to contact. •Identify any unresolved problem, including plans for follow-up and continuous treatment. •List actual time of it, mode of transportation, and who accompanied patient.
safety equipment
•Validated fall risk assessment tool •Hospital bed with side rails; option: low bed •Wedge cushion •Call-light intercom system •Gait belt for assisting with ambulation •Wheelchair and seat belt (as needed) •Additional safety devices •Bed alarm •Pad
Self charting
•never chart for someone else, only chart for yourself •You are accountable for the information you enter into a chart
Goal of therapeutic communication
•to promote wellness and personal growth in patients
single order
(one-time) orders are common for preoperative medications or medications given before diagnostic procedures. The medication is ordered to be given only once at a specified time.
Planning
-3rd part of nursing process -Goals and Expected Outcomes -Establishing Priorities -Nursing Actions Establish Goals Set Expected outcomes Prescribe Specific Nursing Interventions Set Priorities These actions are documented as your PLAN of CARE -Include the patient in the process Patient-Centered Care!
Defining Characteristics
-3rd part of the nursing diagnosis What evidence leads you to 1 & 2? (As evidenced by)
Quality Improvement Data, Risk management Data
-Health care agency trending information about clinical conditions and problems -Tier VII on the Heirarchy of Evidence
Discontinuing a non-tunneled CVAD
- A nurse can perform this procedure
Phlebitis
-(i.e., vein inflammation): pain, redness, warmth, swelling, induration, or presence of palpable cord along course of vein. Rate of infusion may be altered. • Notify health care provider. • Determine cause (i.e., chemical, mechanical, bacterial) and consider removal or replacement of VAD. • Chemical: Apply heat, elevate limb, consider slowing infusion rate, and determine if catheter removal is necessary • Mechanical: Apply heat, elevate limb, monitor for 24-48 hours, consider catheter removal if signs and symptoms persist • Bacterial: Remove IV catheter • Document phlebitis using a standardized scale, including nursing interventions per agency policy and procedure
Diagnostic Label
-1st part of the nursing diagnosis -What is the problem; potential or actual? -Examples: impaired gas exchange, activity intolerance, hypothermia
Pre-interactive phase
-1st phase of the therapeutic relationship - Here the nurse gathers information about the patient prior to having direct contact.
Assessment
-1st step of the nursing process -Ultimate goal is to decide on a course of treatment -Three Activities: Gathering the Data Sorting and organizing the collected data Documenting the data in a retrievable format -Primary source of data is the Patient -Secondary Sources of data are the: Family, Friends, Healthcare Providers, and Medical Record -Subjective Data (verbal description) -Objective Data (observation or measurement) -Comprehensive ones are guided by databases -Databases are different depending on the setting -Collect of data should be broad and specific
parts of a nursing diagnosis
-2nd part of nursing process -All found in Doenges Pocket Guide 1. Diagnostic Label (What is the problem; potential or actual?) 2. Etiology (What is the probable cause?) (Related to) 3. Defining Characteristics (What evidence leads you to 1 & 2?)(As evidenced by)
Etiology
-2nd part of the nursing process -What is the probable cause -Related factors
Orientation phase
-2nd phase of the therapeutic relationship - The goal of this phase is to develop rapport and trust. It begins with an introduction and ends when the relationship has been defined.
Working phase
-3rd phase of the therapeutic relationship - During this phase, caring is communicated, thoughts and feelings are expressed, mutual respect is maintained, and honest verbal and nonverbal expression occurs. The key goal is to help the patient to clarify feelings and concerns. A professional relationship is courteous, trustworthy, and confidential and accomplished by active listening and the use of therapeutic communication techniques.
implementation
-4th part of nursing process -When the plan of care is put into action -When the nurse performs the interventions -Use concept maps Clinical guidelines, protocols or clinical pathways Remember that assessment is ongoing! Patient condition changes! Revision of the Nursing Care Plan is ongoing Direct vs. indirect (delegation) care
Termination phase
-4th phase of the therapeutic relationship - concludes the relationship. This could occur at the end of a shift or discharge from the facility, etc. Note that therapeutic relations have an end.
Evaluation
-5th part of nursing process -Addresses whether established goals are met It is an ongoing process to determine effectiveness of the plan of care Appropriateness of nursing actions Need to revise assessments/interventions Development of new client needs Need for referral to other resources Need to rearrange priorities -Should directly address the goal statement and the expected outcomes ... NOT the nursing intervention If goal and expected outcomes met ... either continue or establish a new goal If goal unmet - modify either the goal or interventions
Use medicines safely
-A National Patient Safety Goal -Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. -Take extra care with patients who take medicines to thin their blood. -Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Identify patient safety risks
-A National Patient Safety Goal -Find out which patients are most likely to try to commit suicide.
Improve staff communication
-A National Patient Safety Goal -Get important test results to the right staff person on time.
Use alarms safely
-A National Patient Safety Goal -Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Prevent mistakes in surgery
-A National Patient Safety Goal -Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. -Mark the correct place on the patient's body where the surgery is to be done. -Pause before the surgery to make sure that a mistake is not being made.
Identify patients correctly
-A National Patient Safety Goal -Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. -Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Prevent infection
-A National Patient Safety Goal -Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. -Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent infection of the blood from central lines. -Use proven guidelines to prevent infection after surgery. -Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
confirm position of central catheter tip
-A chest x-ray verifies appropriate placement. Although chest x-ray is still the gold standard for determining placement, the use of transesophageal echocardiography, fluoroscopy, and C-arm can detect a catheter tip more readily and accurately compared with chest x-ray
orthostatic hypotension
-A drop in blood pressure that occurs when a patient changes from a horizontal to a vertical position. -A drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, and fainting
Case Control Study
-A group of subject with a certain condition is compared to another group without the condition -Tier IV on the Heirarchy of Evidence
ileostomy
-A stoma placed in the transverse or ascending colon, which drains fecal effluent that is watery-to-thick and contains some digestive enzymes -yellow-brown fluid
5 on phlebitis scale
-All of the following signs are evident and extensive: • Pain along the path of cannula • Erythema • Induration • Palpable venous cord • Pyrexia
The Professional Nurse
-Always looks for a Win-Win or a Win-lose/Win-lose Solution -Image: Research indicates more sexualized work attire lessens respect for female workers in responsible jobs causing others to see them as less intelligent
Ongoing assessments
-Are actions included in the Planning Process -MUST include a frequency of action: a. every 6 hours b. every AM before breakfast c. 30 minutes after pain medications -Examples Assess wound for drainage every 6 hours Reassess patient pain score 30 minutes after giving pain medications Monitor intake and output every hour Weigh patient every morning before breakfast
Professional Boundaries in Nursing
-Are the spaces between the nurse's power and the patient's vulnerability. -Crossings are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. -Violations can result when there is confusion between the needs of the nurse and those of the patient. -Professional sexual misconduct is an extreme form of violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient.
External Tunneled (Hickman, Broviac, Groshong)
-CVAD -Long-term device -placed under skin • Length of dwell: Considered permanent • Insertion sites: Chest region through subclavian or jugular vein • Insertion technique: Surgery required; tunneling of proximal end subcutaneously from insertion site and bringing it out through skin at an exit site • Held in place by a Dacron cuff coated in antimicrobial solution; in approximately 2-3 weeks scar tissue forms around cuff, fixing catheter in place
Implanted Venous Ports
-CVAD -Long-term device • Length of dwell: Considered permanent • Insertion sites: Chest, abdomen, or inner aspect of forearm • Insertion techniques: Requires surgery; catheter placed via subclavian or jugular vein and attached to reservoir located within a surgically created subcutaneous pocket • Sutured in place within surgically created pocket and accessed using a noncoring needle through the skin
Peripherally Inserted Central Catheters (PICCs)
-CVAD -Short-term device -Use engineered stabilization device (if not sutured) when cleaning • Length of dwell: As long as they function properly with no evidence of intravenous (IV)-related complications • Insertion sites: Antecubital fossa or upper arm (basilic or cephalic vein) and advanced until catheter tip reaches superior vena cava (SVC) • Insertion technique: Not surgically placed; can be done at bedside, in home setting, or in radiology setting • Held in place with sutures or engineered securement device
Nontunneled Percutaneous
-CVAD -Short-term device • Length of dwell: Days to several weeks • Insertion sites: Subclavian, external/internal jugular, and femoral veins • Insertion technique: Not surgically placed; can be done at bedside; direct puncture into intended vein without passing through subcutaneous tissue • Held in place with sutures or engineered securement device
Central Line Complications
-Catheter damage, breakage -Occlusion: thrombus, fibrin sheath, fibrin tail, precipitation, malposition -Infection and sepsis: catheter skin junction, tunnel, thrombus, port pocket, CLABSI -Dislodgement -Catheter migration (e.g., length of catheter moved from original position), pinch-off syndrome (e.g., compression of catheter between clavicle and first rib), port separation or catheter fracture (e.g., internal fracture or separation of catheter) -Skin erosion (e.g., mechanical loss of skin tissue), hematomas (e.g., local collection of blood), cuff extrusion (e.g., tissue at edges of insertion site separate), scar tissue formation over port -Infiltration, extravasation -Pneumothorax, hemothorax, air emboli, hydrothorax -Incorrect placement
Catheter-related sepsis or bacteremia
-Cause: Catheter hub contamination; contamination of infusate; spread of bacteria through bloodstream from distant site -Symptoms: Systemic: Isolation of same microorganism from blood culture and catheter segment, with patient showing fever, chills, malaise, elevated white blood cell count -Immediate Action: Systemic: Do not exceed hang time of 24 hours for PN that contains dextrose and amino acids either alone or with fat emulsion added as a 3-in-1 formulation (INS, 2016). Administer antibiotics intravenously; remove catheter by proper professional (CRNP, PA-C, or MD). -Prevention: Use full sterile-barrier precautions during catheter insertion and dressing change. Consider the use of antibiotic-impregnated catheters (INS, 2016). Do not disconnect tubing unnecessarily. Replace IV tubing and filter every 24 hours. In some selected situations it is necessary to change administration sets with each new PN container (INS, 2016).
Air embolism
-Cause: IV tubing disconnected; part of catheter system open or removed without being clamped -Symptoms: Sudden respiratory distress: decreased oxygen saturation levels, shortness of breath, coughing, chest pain, decreased blood pressure -Immediate Action: Clamp catheter; position patient in left Trendelenburg's position; call health care provider; administer oxygen as needed. -Prevention: Make sure that all catheter connections are secure; clamp catheter when not in use. Never use a stopcock with a CVC. Unless contraindicated, instruct patient in Valsalva maneuver for tubing changes.
Hypoglycemia
-Cause: PN abruptly discontinued; too much insulin -Symptoms: Patient shaky, dizzy, nervous, anxious, hungry, blood glucose level <80 mg/100 dL -Immediate Action: Call health care provider; if PN discontinued abruptly, may need to restart D10W at previous PN rate. If patient has oral intake, give cup fruit juice. Perform blood glucose monitoring; retest in 15 to 30 min. -Prevention: Decrease PN, "tapering" gradually until discontinued; blood glucose monitoring is used to ensure adequate insulin.
written errors
-DO NOT erase, apply correction fluid, or scratch out __________ made while recording -Draw a single line through the error, write the word "error" above it, and sign your name or initials
patient behavior
-DO NOT write retaliatory or critical comments about patient or care by other health care professionals -Enteronlyobjective descriptions of patient's conduct, use quotations for patients comments
Social media Guidelines for nurses
-Don't post about patients -Don't post defamatory comments -Don't follow patients on it -Can be subject to disciplinary actions
Localized infection (exit site or tunnel)
-Cause: Poor aseptic technique in removal of skin flora during site preparation and dressing care -Symptoms: Exit site: Erythema, tenderness, induration, or purulence within 2 cm (0.8 inches) of skin at exit site Tunnel: Same as above but extends beyond 2 cm from exit site -Immediate Action: Call health care provider. Exit: Apply warm compress, daily care of site, oral antibiotics. Infection: Collaborate with health care provider regarding removal of catheter. Tunnel: Remove catheter. -Prevention: Provide catheter site care using aseptic technique, visually inspect site (including cleaning site), applying new stabilization device, and applying sterile dressing. Change transparent dressings at least every 5-7 days and gauze dressings every 48 hours. Change dressing if damp, loosened, or soiled or when inspection of site is necessary. Use chlorhexidine wipes to cleanse site. For adults, consider the use of chlorhexidine-impregnated dressings.
Hyperglycemia
-Cause: Possible blood-draw error, confirm with bedside glucose device; patient receiving too little insulin in PN solution; receiving steroids; new-onset infection -Symptoms: Excessive thirst, urination, blood glucose greater than 160 mg/100 dL, confusion -Immediate Action: Call health care provider; may need to slow infusion rate (health care provider order). -Prevention: Review medical history for blood drawn through central line with PN infusing (repeat peripheral blood draw or obtain fingerstick), glucose intolerance or diabetes, new infection, new medication such as steroids; keep rate as ordered; never increase PN to "catch up." Maintain blood glucose in range ordered by health care provider. Use aseptic technique and routine blood glucose monitoring.
Pneumothorax
-Cause: Tip of catheter enters pleural space during insertion, causing lung to collapse -Symptoms: Sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, tachycardia -Immediate Action: Per health care provider's order, the proper professional (CRNP, PA-C, or MD) may remove the central catheter. Administer oxygen via nasal cannula. Insert chest tube to remove air under water-seal drainage or dry one-way valve system. -Prevention: Medical personnel should be properly trained to insert central catheters. Researchers suggest use of ultrasound when placing CVCs. Catheter should be secured properly to prevent migration, movement.
Catheter migration
-Central Line/CVAD Complication -(e.g., length of catheter moved from original position), pinch-off syndrome (e.g., compression of catheter between clavicle and first rib), port separation or catheter fracture (e.g., internal fracture or separation of catheter) -Assess for patient complaints of gurgling sounds. -Assess for change in patency of catheter by evaluating change in flow rate, local irritation, swelling, occlusion, tenderness, pain, inability to aspirate fluid and/or blood. -Pain at site when flushed or symptoms of embolus. -Obtain x-ray film examination. -Assess edema of arm and hand on side of insertion. -Assess for distended neck veins. -Assess for inability to infuse solutions. -Assess length of catheter daily.
Skin erosion
-Central Line/CVAD Complication -(e.g., mechanical loss of skin tissue), hematomas (e.g., local collection of blood), cuff extrusion (e.g., tissue at edges of insertion site separate), scar tissue formation over port -Assess for loss of viable tissue over septum site. -Assess for separation of exit site edges. -Assess for drainage at catheter skin junction. -Assess for redness. -Assess for edema, contusions. -Note if tunneled catheter is exposed (Dacron cuff is visible.)
Incorrect placement
-Central Line/CVAD Complication -Assess for cardiac dysrhythmias. -Assess for hypotension. -Assess for neck distention. -Assess for narrow pulse pressure. -Assess for inadequate blood withdrawal. -Assess for retrograde flow of blood (flow of blood back into tubing usually caused by decreased pressure gradient between venous system and access device unit [e.g., IV infusion, heparin lock]).
Infiltration, extravasation
-Central Line/CVAD Complication -Assess for erythema. -Assess for edema. -Assess for spongy feeling. -Assess for swelling around IV site and at termination of catheter tip. -Assess for labored breathing. -Assess for aspiration of fluid and/or blood. -Assess for complaints of pain with infusion of solutions or medications (e.g., burning). -Assess for no free-flow IV drip.
Pneumothorax, hemothorax, air emboli, hydrothorax
-Central Line/CVAD Complication -Assess for subcutaneous emphysema by inspecting and palpating skin around insertion site and along arm. -Inspection may reveal edema where air is located, and air may travel if skin is loose. -Palpation reveals a crackling sensation such as popping plastic bubble wrap. -Assess for chest pain. -Assess for dyspnea, apnea, hypoxia, tachycardia, hypotension, nausea, confusion.
Dislodgement
-Central Line/CVAD Complication -Assess length of catheter daily. -Inform patient of possible catheter dislodgement. -Identify edema at catheter skin junction or drainage. -Palpate catheter skin junction and tunnel for coiling (catheter can feel cordlike underneath the skin). -Assess for distended neck veins.
Catheter damage, breakage
-Central Line/CVAD Complication -Every shift observe for pinholes, leaks, tears. -Assess for drainage from site after flushing.
Infection and sepsis
-Central Line/CVAD Complication -catheter skin junction, tunnel, thrombus, port pocket, CLABSI -Assess catheter skin junction for redness, drainage, edema, or tenderness. -Assess for signs of systemic infection. -Monitor laboratory findings.
Occlusion
-Central Line/CVAD Complication -thrombus, fibrin sheath, fibrin tail, precipitation, malposition -Assess insertion site and sutures. -Assess for blood return. -Assess for ability to infuse fluid. -Assess equipment. -If port is in place, reassess and verify noncoring needle placement. -Assess with syringe directly on catheter. -Assess for discomfort or pain in shoulder, neck, ear, or arm at insertion site. -Assess for neck or shoulder edema.
Empathy
-Characteristic of therapeutic communication -Is the desire to understand and be sensitive to the feelings, beliefs and situations of another person (Put yourself in the other's place.)
Genuineness
-Characteristic of therapeutic communication - Be honest. Be authentic
Concreteness and Confrontation
-Characteristic of therapeutic communication - Offer understandable responses to a client's questions or concerns. Construct messages in a manner that is suitable for the patient. Conversely, if a patient is unable to express thoughts clearly, be willing and able to request clarification or to ____________ the patient, as needed.
indwelling catheter
-Double-lumen catheters, designed for ________________ catheters, provide one lumen for urinary drainage and a second lumen to inflate a balloon that keeps the catheter in place -Triple-lumen catheters are used for continuous bladder irrigation or when it becomes necessary to instill medications into the bladder. One lumen drains the bladder, a second lumen is used to inflate the balloon, and a third lumen delivers irrigation fluid into the bladder.
Treatment Errors
-Error in the performance of an operation, procedure, or test -Error in administering the treatment -Error in the dose or method of using a drug -Avoidable delay in treatment or in responding to an abnormal test -Inappropriate (not indicated) care
Diagnostic Errors
-Error or delay in diagnosis -Failure to employ indicated tests -Use of outmoded tests or therapy -Failure to act on results of monitoring or testing
1 on phlebitis scale
-Erythema at access site with or without pain -One of the following signs is evident: Slight pain near IV site or slight redness near IV site
Clinical Experts
-Experts on a nursing unit -Tier VIII on the Heirarchy of Evidence
Other Errors
-Failure of communication Equipment failure -Other system failure
Preventive Errors
-Failure to provide prophylactic treatment -Inadequate monitoring or follow-up of treatment
Adverse Transfusion Reactions
-Febrile, nonhemolytic -Acute hemolytic transfusion reaction -Delayed hemolytic transfusion reaction (extravascular) -Allergic reaction (mild-to-moderate) -Allergic reaction (severe) -Graft-versus-host disease -Circulatory overload -Infectious disease transmission -Iron overload
Regulate EID (infusion pump or smart pump)
-Follow manufacturer guidelines for setup. Be sure you are using infusion tubing compatible with it. a. Close roller clamp on primed IV infusion tubing. b. Insert infusion tubing into chamber of control mechanism (see manufacturer directions). Roller clamp on IV tubing goes between it and patient. c. Secure part of IV tubing through "air in line" alarm system. Close door and turn on power button, select required drops per minute or volume per hour, close door to control chamber, and press start button . If infusing medication, access the library of medications and set appropriate rate and dose limits. If smart pump alarms immediately and shuts down, your settings were outside unit parameters. d. Open infusion tubing drip regulator completely while it is in use. e. Monitor infusion rate and IV site for complications according to agency policy. Use watch to verify rate of infusion, even when using one. f. Assess IV system from container to VAD insertion site when alarm signals.
absorption rate factors
-From fastest to slowest IV, IM, SubQ, Oral -Topical applications on skin absorb slowly. -Medications applied to mucous membranes and respiratory airways absorb quickly. -Oral medications pass through the gastrointestinal tract and absorb slowly. -The intravenous route produces the most rapid absorption because the medication is available immediately when it enters the systemic circulation. -Solutions and liquid suspensions absorb more readily than tablets or capsules. -Acidic medications pass through the gastric mucosa rapidly and absorb rapidly, whereas basic medications (pH greater than 7.0) do not absorb before reaching the small intestine. -When the administration site contains a rich blood supply, medications absorb rapidly. -A medication in contact with a large surface area (e.g., small intestine) absorbs faster than one in contact with smaller surface area (e.g., stomach). -Medications that are highly lipid soluble absorb more readily.
complications due to immobility
-Functional decline, the loss of the ability to perform self-care or activities of daily living, may result not only from illness or adverse treatment effects, but also can be the result of deconditioning. -Deconditioning -DVT -Older adults are at greater risk for a reduction of muscle mass, strength, and power, and for developing orthostatic hypotension, syncope, confusion, increased risk for fractures, and functional incontinence as a result of decreased mobility from bed rest.
When should enteral feedings be held?
-GVR greater than 500mL 1. Feeding tube becomes clogged. 2. Patient develops large amount of diarrhea (more than three loose stools in 24 hours). 3. Patient develops nausea and vomiting. 4. Patient aspirates formula (auscultation of crackles or wheezes, dyspnea, or fever).
Evaluation example
-Goal: By 1400 on 10/2, the patient will ambulate half the length of the hallway w/assist 3 x's a day -10/2 goal partially met; Pt. refused to ambulate in the morning but did walk to the BR once in the afternoon with one assist. Continue POC, but review rationale for progressive ambulation with patient; assess motivation to increase independence.
incentive spirometer (IS)
-Helps a patient deep breathe. It works by providing visual feedback that helps encourage the patient to take long, deep, slow breaths. The use of one alone is not recommended to prevent postoperative pulmonary complications. -Flow-oriented ones have one or more plastic chambers with freely movable colored balls. The advantage of a flow-oriented one is the slow, steady expansion of the lung. As a patient inhales slowly, the balls elevate to a premarked area. A patient's goal is to keep the balls elevated for as long as possible to ensure maximal sustained inhalation. Even if a very slow inspiration does not elevate the balls, this pattern helps a patient improve lung expansion -Volume-oriented devices use a bellows that a patient must raise to a predetermined volume by inhaling slowly. The advantage of the volume-oriented one is that a patient can achieve a known inspiratory volume and measure it with each breath.
Venturi mask
-High-flow delivery device -FiO2 delivered: 24%-50% -Advantages: Provides specific amount of O2 with humidity added Administers low, constant O2 -Disadvantages: Mask and humidity may irritate skin Interferes with eating, drinking, and talking
High-flow nasal cannula
-High-flow delivery device -FiO2 delivered: Adjustable FiO2 (0.21-1.0) with a modifiable flow (up to 60 L/min) -Advantages: Wide range of FiO2; can use on adults, children, and infants -Disadvantages: FiO2 dependent on patient respiratory pattern and input flow; risk for infection
Non-verbal communication
-Includes personal appearance and body language such as facial expression, posture and gait, gestures and touch. -It is important that nurses recognize that this behavior accounts for 85% of communication. These messages are more likely to convey how someone truly feels. -If there is incongruence between the spoken and non-spoken message, the non-spoken message is heard loudest. • Nurses must be aware of personal style and how their non-spoken behavior affects messages sent. • When interpreting messages from others, it is important to watch for both verbal and non-spoken cues. When there is a discrepancy, between what is said and what is seen, the nurse seeks clarification before assigning judgment. It is careless to make a quick assumption as to the meaning of the behavior. Remember, cultural beliefs are strongly reflected in behavior. For example, when a Chinese female does not make eye contact, one may misinterpret the behavior as reflecting a poor self concept or perhaps see the behavior as representing dishonesty; however, in the Chinese culture, direct eye contact is considered rude behavior. The response of the female may simply be a courteous or respectful social act. To make clinical inferences about discrepancies, nurses must have an understanding of cultural variations and be willing to ask probing questions to validate speculations. • Touch
Methods to improve vascular distention
-Increased volume of blood in vein at venipuncture site makes vein more visible. (1) Position extremity lower than heart, have patient open and close fist slowly, and lightly stroke vein downward. (2) Apply dry heat to extremity for several minutes.
Randomized Control Trial
-Intervention tested against usual standard of care, participants randomly assigned -Tier II on the Heirarchy of Evidence
SBAR
-Is an effective tool for all types of communication handoffs •is a simple method to help standardize communication •Allows all parties to have common expectations: -What is going to be communicated -How the communication is structured -Required elements •Focuses on the problem, not the people
chest physiotherapy
-Is external chest wall manipulation, which includes one of a combination of or all of percussion, vibration, and postural drainage (PD) therapy to loosen and remove secretions from patients' airways. Is usually followed by productive coughing or suctioning to remove secretions.
Right Circumstances
-Long term vs. acute vs home health? -Knowledge and skill of delegatee -Verification of clinical competence -Stability of patient's condition -Availability of resources (including human)
closed system with parenteral nutrition
-Maintains sterility
The Needle Safety and Prevention Act of 2001
-Mandates that health care agencies use safe needle devices and manufactured needleless systems to reduce needlestick injury. Systems with catheter ports or Y-connector sites are designed to contain a needle housed in a protective covering. Needleless infusion lines allow a direct connection with the IV line via a recessed connection port, a blunt-ended cannula, or shielded-needle device, eliminating the risk for exposure to an IV needle.
Delayed hemolytic transfusion reaction (extravascular)
-Mechanism: ABO, Rh incompatibility. Caused by donor plasma incompatible with recipient's red cells, usually the result of improperly identified blood sample, blood unit, or patient -Onset: Several hours after transfusion -S&S: Unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, jaundice -Prevention: Proper patient identification; proper labeling of blood sample -Nursing Intervention: Stop transfusion if in progress. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank immediately. Monitor laboratory values for anemia. (Recognition is important because subsequent transfusions may cause an acute hemolytic reaction.) Most delayed hemolytic reactions require no treatment.
Acute hemolytic transfusion reaction
-Mechanism: Caused by ABO, Rh incompatibility; donor red cells incompatible with recipient's plasma that can be potentially fatal with as little as 10-15 mL of incompatible blood; usually caused by administration of blood with wrong ABO blood group as a result of misidentification or improper labeling -Onset: Within minutes of transfusion initiation -S&S: Fever with or without chills, tachycardia, hypotension, lumbar/flank pain, hemoglobinemia, hemoglobinuria, dyspnea, shock, oliguria or anuria, abnormal bleeding -Prevention: Proper patient identification; proper labeling of blood sample; meticulous verification of ABO/Rh compatibility between donor and recipient before administration -Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Monitor vital signs at least every 15 min. Administer ordered therapy to correct arterial blood pressure and coagulopathy. Insert Foley catheter. Monitor intake and output hourly. Assess for shock. Dialysis may be required. Obtain blood and urine samples and send to laboratory with unused part of unit of blood. Document reaction according to agency policy.
Allergic reaction (severe)
-Mechanism: Caused by recipient allergy to a donor antigen (usually IgA). Agglutination of RBCs obstructing capillaries and blocking blood flow, causing symptoms to all major organ systems -Onset: Within minutes of transfusion initiation -S&S: Coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, possible cardiac arrest -Prevention: Transfusion of saline-washed or leukocyte-depleted RBCs -Nursing Intervention: Stop transfusion. This is a life-threatening reaction. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Administer antihistamines, corticosteroids, epinephrine, and antipyretics as ordered. Monitor and document vital signs until stable. Initiate cardiopulmonary resuscitation if necessary.
Graft-versus-host disease
-Mechanism: Donor lymphocytes destroyed by recipient's immune system In immunocompromised patients the donor lymphocytes are identified as foreign; however, patient's immune system is not capable of destroying, and in turn patient's lymphocytes are destroyed. -Onset: 8 to 10 days after transfusion -S&S: Skin rash, diarrhea, fever, jaundice caused by liver dysfunction, bone marrow suppression -Prevention: Administration of irradiated blood and leukocyte-depleted RBC products as prescribed -Nursing Intervention: Administer methotrexate and corticosteroids as ordered for treatment of symptoms.
Iron overload
-Mechanism: Iron from donated blood binds to protein and is not eliminated -Onset: May occur with multiple transfusions or chronic transfusion therapy -S&S: Cardiac dysfunction, SOB, arrhythmias, HF, increased serum transferrin, increased liver enzymes, jaundice -Prevention: Chelation, phlebotomy, monitoring of serum iron levels -Nursing Intervention: Monitor patient for heart failure, cardiac disorder, liver disorder, serum transferrin.
Infectious disease transmission
-Mechanism: Microorganism contamination of infused product -Onset: During transfusion to 2 h after transfusion. Complete transfusion within 4 h -S&S: High fever, chills, abdominal cramping, vomiting, diarrhea, profound hypotension, flushed skin, back pain -Prevention: Proper care of blood or blood product from time of procurement through end of administration -Nursing Intervention: Stop transfusion. Change administration set and maintain patent IV access. Notify health care provider and blood bank. Monitor and document vital signs. Obtain samples for blood culture and Gram stain from recipient. Administer IV fluids, broad-spectrum antimicrobials, vasopressors, and steroids as ordered.
Febrile, nonhemolytic
-Mechanism: Most common type of transfusion reaction; caused by WBC antigen-antibody reaction -Onset: May begin early in transfusion or as long as several hours after completion -S&S: Temperature increase of 1°C (2°F) or more above baseline, chills, rigors, general malaise -Prevention: Premedicate as ordered with antipyretics if prior history of reaction. Use leukocyte-reduced blood products -Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Institute transfusion reaction protocol. Administer antipyretics as ordered to treat fever. Document clinical symptoms, when transfusion was stopped, notification of health care provider and blood bank, nursing interventions and response to interventions, and patient teaching.
Circulatory overload
-Mechanism: Occurs with transfusion of excessive volume or excessively rapid rate; can lead to pulmonary edema -Onset: Anytime during or within 1-2 h after transfusion -S&S: Dyspnea, cough, crackles at lung bases, tachypnea, headache, hypertension, tachycardia, increased central venous pressure, distended neck veins -Prevention: Administration of blood or component at prescribed rate, usually no greater than 2-4 mL/kg/h; particular attention paid to rate and volume in older adults, young children, and patients with cardiac and renal disorders Administration of PRBCs instead of whole blood Minimizing amount of saline infused with transfusion -Nursing Intervention: Slow or stop transfusion as ordered. Elevate patient's head. Notify health care provider. Administer oxygen and diuretics as ordered. Monitor and document vital signs, including a cardiac and respiratory assessment.
Allergic reaction (mild-to-moderate)
-Mechanism: Thought to be caused by sensitivity reaction to foreign plasma protein in transfused product -Onset: Within minutes of transfusion initiation -S&S: Local erythema; hives; and urticaria, itching, or pruritus -Prevention: May administer antihistamines before transfusion if prescribed -Nursing Intervention: Stop transfusion. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Administer antihistamines as ordered. Monitor and document vital signs every 15 min. Transfusion may be restarted if fever, dyspnea, and wheezing are not present.
frequency of monitoring while patients receive blood
-Monitor patient's vital signs every 15 minutes or per agency policy if you susupect a transfusion reaction -before, during, and after transfusion
0 on phlebitis scale
-No symptoms -IV site appears healthy
RNs cannot delegate
-Nursing Process: Assessment, Diagnosis, Planning, and Evaluation -Patient Education (LPNs may reinforce education) -Tasks that require clinical judgment and critical thinking
3 on phlebitis scale
-Pain at access site with erythema and/or edema -Streak formation -Palpable venous cord -All of the following signs are evident: • Pain along the path of cannula • Induration
4 on phlebitis scale
-Pain at access site with erythema and/or edema -Streak formation -Palpable venous cord >2.5 cm (1 inch) in length -Purulent drainage -All of the following signs are evident and extensive: • Pain along the path of cannula • Erythema • Induration • Palpable venous cord
2 on phlebitis scale
-Pain at access site with erythema and/or edema -Two of the following signs are evident: • Pain at IV site • Erythema • Swelling
Systematic review
-Panel of experts reviews all of the evidence from RCTs and summarizes the data! A meta-analysis adds statistical analysis combining all data from the studies. -Tier I on the Heirarchy of Evidence
High Risk Priorities
-Part of Planning -A Nursing Diagnosis, if untreated, may cause harm to the patient Risk for other-directed violence Impaired gas exchange Decreased cardiac output -Be careful....the current patient condition, behavior, and circumstances rearrange priorities -For example, risk for fall may supersede an impaired gas exchange
Independent Nursing Actions
-Part of Planning -Are autonomous actions by the nurse -Do not require a medical order/prescription -Examples Elevate an edematous extremity while sitting in chair Turn a patient side to side every 2 hours Assess for side effects of digoxin toxicity (nausea, diarrhea, visual changes) Instruct patient to dorsiflex feet 10 times every hour while lying in bed Observe for signs of hypoglycemia (i.e., confusion, diaphoresis, irritability
Collaborative Actions
-Part of Planning -Interdependent therapies that require the knowledge and skill of other disciplines -Examples Consult diabetic educator for new diabetic education Consult dietician for renal diet instructions Consult social work services for discharge planning Consult the Wound Care Nurse for pressure ulcer
Nursing Actions
-Part of Planning -Ongoing assessments: prioritize -Interventions: prioritize Types of Actions - Independent - Dependent - Collaborative Include all three types in your Nursing Care Plan Select Carefully When selecting... consider 6 important factors: 1. Nursing diagnosis 2. Established PATIENT goals and desired outcomes 3. Ability of the nurse to implement the assessment/interventions 4. Willingness of the patient to participate 5. Patient age, situation, individual strengths 5. RESEARCH (evidence based)
Dependent Actions
-Part of Planning -Require an order from a care provider -Examples Administer Darvocet-N 100 mg PO q4 hours as needed Perform fingerstick BG at 7a-11a - 4p - 9p Administer 10 units of Humulin N insulin SC q am after fingerstick BG Irrigate wound with room temperature sterile NS at 9a - 4p - 10p
Setting Priorities
-Part of Planning -are a moving target and change as the patient's condition changes Safety Airway Breathing Circulation Pain High Risk Intermediate Risk Low Risk
Goals
-Part of Planning -statements of patient and family behaviors that are measurable or observable -Time Limited -Individualized or client-centered and realistic
Background
-Part of SBAR - brief, related, to the point • State the admission diagnosis and date of admission • State the pertinent medical history • A Brief Synopsis of the treatment to date
Situation
-Part of SBAR - the problem • State: your name and unit • I am calling about:: (Patient Name & Room Number) • The problem: The reason I am calling .....
Assessment
-Part of SBAR - what you found, what you think • Pertinent objective & subjective information - Most recent vitals - Mental status - Respiratory rate and quality - B/P, pulse rate & quality - Pain - Neuro changes - Skin color - Rhythm changes
Recommendation
-Part of SBAR - what you want • State what you would like to see done: - Transfer the patient? - Change treatment? - Come to see the patient at this time? - Talk to the family and patient about....? - Ask for a consulting physician to see the patient? - Other suggestions - CXR ABG EKG - CBC Other? - If a change in treatment is ordered, ask: "How often?" - Ask: "If the patient does not improve, when would you want to be called again?"
Touch
-Part of non-verbal communication -Can be highly therapeutic. Can convey caring, concern, and encouragement. Is particularly comforting to the elderly or those who are grief stricken. However, one must carefully consider how another may interpret touch before using this therapeutic skill. -Instances when it may be inappropriate include when interacting with an: • Angry person • Mentally ill person Also, it is not appropriate if another may possibly infer the act as a sexual gesture. Along those same lines, some cultures prohibit an individual of the opposite sex to be alone with another. Sensitivity to these situations are essential to avoid misinterpretations or ______________.
Expected Outcomes
-Part of planning -measurable criteria used to evaluate goal achievement -Example: Patient will achieve improved pain control by 1400 on 10/19 (overall goal) a.e.b. a. Patient will rate pain < 3 on a scale of 0-10. b. Verbalize 2 nonpharmacological methods that provide pain relief
Plan of Care
-Part of problem-oriented medical records -All disciplines involved in a patient's care contribute to the development of an interprofessional _______________ for a specific problem. For example, for a patient having a nutritional deficit, a nurse recommends feeding approaches, and a registered dietitian recommends types of dietary supplements. Standards require that it be developed for all patients on admission to a health care agency. Generally these plans include nursing diagnoses, expected outcomes, interventions, and evaluations.
Progress Notes
-Part of problem-oriented medical records -Health care team members use them to monitor and record the progress of a patient's problem. Narrative notes, flow sheets, and discharge summaries are formats used to document patient progress.
Database
-Part of problem-oriented medical records -contains all available information pertaining to a patient. This section is the foundation for identifying patient problems and planning care. Remains active and current for each patient and is revised as new data become available.
Problem List
-Part of problem-oriented medical records -includes the patient's physiological, psychological, sociocultural, spiritual, developmental, and environmental needs. Develop a patient's _____________ after analyzing the assessment data. Identify and list priority ones in chronological order to serve as an organizing guide for the patient's care. Add new ones as they are identified during the ongoing nursing assessment. When one is resolved, record the date and draw a line through it and its number. In an electronic system it is marked as resolved.
Transmission
-Part of the chain of infection -means of spread
Infectious agent
-Part of the chain of infection -pathogenic organism capable of causing disease
Host
-Part of the chain of infection -patient
Reservoir
-Part of the chain of infection -site or source of microorganism growth
Portal of entry
-Part of the chain of infection -site through which microorganism enters a host
Portal of exit
-Part of the chain of infection -means by which microorganisms leave a site
Active listening
-Part of therapeutic communication - The active listener focuses on the sender and attends to both verbal and non-verbal communication. This requires full attention and the use of all senses. This type of comunication begins conversations with open ended questions such as "What brings you to the hospital" and seeks clarification through more direct (closed) and probing questions.
Restate/Reflection
-Part of therapeutic communication - Use patient's own words to ask for the patient to elaborate.
Clarify
-Part of therapeutic communication - Use when a patient's words or messages are ambiguous or confusing. "Do I understand you correctly when you say...."
Establish Trust
-Part of therapeutic communication -Good communication originates with a trusting relationship. Can be enhanced through the use of active listening, honesty, and the provision of competent, compassionate care.
Be Assertive
-Part of therapeutic communication -Is the expression of beliefs or feelings without infringing on another's right. - Make "I" statements - State facts, avoid judgments - Ask directly for what you need; don't make another guess as what you want. - Use body language (eye contact and speak clearly) -____________ people look for win-win solutions. Some confuse being __________ with being aggressive. An aggressive person looks for a win- lose solution. -Commonly, nurses begin early in their career by being passive (not speaking up) and move over time towards becoming passive-aggressive (quietly sabotage). Beware, don't fall prey to these type behaviors.
Use silence
-Part of therapeutic communication -Very uncomfortable for most, but respectful and highly effective in promoting communication
Truthful
-Part of verbal communication - A response such as "I don't know but I'll find out is far more credible than providing incorrect information." Furthermore, a nurse should never lie to a patient; lying destroys trust. For example, when a nurse tells a patient she will be right back with pain medication and fails to return until later reminded, the patient loses confidence in the nurse.
Relevant information
-Part of verbal communication - Extraneous information blurs the intended message
Appropriate timing
-Part of verbal communication - When information is sent while the receiver is distracted, the receiver may either not hear the message or may received a distorted version of the message.
Humor
-Part of verbal communication - can be positive and contribute to a patient's well being. However, humor must be used cautiously. The patient should never be left feeling like the brunt of a joke. Furthermore, the use of humor at the wrong time conveys a lack of caring and concern.
assess for pressure on dark skinned patients
-Patients with _____________________ cannot be assessed for pressure injury risk by examining only skin color. Changes in sensation, temperature, or tissue consistency may precede visual skin changes. 1. Use natural lighting, but note that visual inspection techniques to identify pressure injuries are ineffective in ________________. Skin inspection techniques for individuals with ______________________ must include assessment of temperature, edema, and changes in tissue consistency as compared with the surrounding skin. 2. Assess localized skin color changes. Any of the following may appear: •Color remains unchanged when pressure is applied. •Color changes occur at site of pressure, which differ from patient's usual skin color. •If patient previously had a pressure injury, that area of skin may be lighter than original color. •Localized area of skin may be purple/blue or violet instead of red. Purple or maroon discoloration may indicate deep tissue injury. 3. Circumscribed area of intact skin may be warm to touch. As tissue changes color, intact skin will feel cool to touch. NOTE: Gloves may decrease sensitivity to changes in skin temperature. •Localized heat (inflammation) is detected by making comparisons to surrounding skin. Localized area of warmth eventually will be replaced by area of coolness, which is a sign of tissue devitalization. 4. Edema may occur with induration of more than 15 mm in diameter and may appear taut and shiny. 5. Palpate tissue consistency in surrounding tissues to identify any changes in tissue consistency between area of injury and normal tissue. 6. Patient complains of discomfort at a site that is predisposed to pressure injury development (e.g., bony prominence, under medical devices).
Complications of Parenteral Nutrition
-Pneumothorax -Air embolism -Localized infection (exit site or tunnel) -Catheter-related sepsis or bacteremia -Hyperglycemia -Hypoglycemia
ink color
-Record all entries legibly and in black or blue ink (check institution's policy) -DO NOT chart with a pencil or a felt tip pen
Responsible
-The individual receiving the assignment is ____________ for the performance of the task. -Can delegate this but not accountibility
how to prevent pressure injury
-Reposition patients every 1 to 2 hours -Assess for pressure injury risk using Braden Scale -Use dressings on bony prominences if ordered by physician -Assess for pressure injuries created by medical devices
COPD
-Require oxygen 24 hours a day; therefore care is taken to plan administration around patient needs. -Patients with decreased tissue oxygenation benefit from controlled oxygen administration. Long-term oxygen treatment can improve survival in it.
Quasi-Experimental Study
-Research approach tries to show an intervention causes a particular outcome
straight catheter
-Single-lumen catheters are used for intermittent catheterization (i.e., the insertion of a catheter for one-time bladder emptying). -No balloon
Descriptive Study
-Study describes the concepts of the study -Tiers V (systematic review of many studies) and Tier VI (single study) on the Heirarchy of Evidence
Qualitative Study
-Study examines health experiences or life experiences -Tiers V (systematic review of many studies) and Tier VI (single study) on the Heirarchy of Evidence
Can be delegated to nursing assistive personnel (NAP)
-Tasks they can be delegated change all the time -Know their certifications -Examples of Tasks Delegated to LPN 1. Monitoring client findings as input to the RN's ongoing assessment 2. Reinforcement of client teaching from standard care plan 3. Insertion of urinary catheter 4. Medication administration (IV meds) -Examples of Tasks Delegated to CNA 1. Activities of daily lining (ADLs): Bathing, Grooming, Dressing, Toileting, Ambulating, Feeding (without swallowing precautions), positioning, bedmaking 2. Specimen collection (non-sterile) 3. Intake and output 4. Vital signs (on stable clients)
Do Not Use list
-The Joint Commission issued a minimum list of dangerous abbreviations, symbols, and acronyms that must be included on a this list by every organization it accredits. -U or u write out unit
ANA Code of Ethics Provision 1
-The Professional Nurse practices with compassion and respect for the inherent dignity, worth, and unique attribute of EVERY person -The professional nurse maintains compassionate and caring relationships with colleagues and others with a commitment for the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict.
principles of delegation
-The RN takes responsibility and accountability for the provision of nursing practice. -The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care. -The RN may delegate components of care but does not delegate the nursing process itself. The practice pervasive functions of assessment, planning, evaluation and nursing judgment cannot be delegated. -The decision of whether or not to delegate or assign is based upon the RN's judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated. -The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures. -The RN individualizes communication regarding the delegation to the nursing assistive personnel and client situation and the communication should be clear, concise, correct and complete. The RN verifies comprehension with the nursing assistive personnel and that the assistant accepts the delegation and the responsibility that accompanies it. -Communication must be a two-way process. Nursing assistive personnel should have the opportunity to ask questions and/or for clarification of expectations. -The RN uses critical thinking and professional judgment when following the Five Rights of Delegation, to be sure that the delegation or assignment is: 1. The right task 2. Under the right circumstances 3. To the right person 4. With the right directions and communication; and 5. Under the right supervision and evaluation. -Chief Nursing Officers are accountable for establishing systems to assess, monitor, verify and communicate ongoing competence requirements in areas related to delegation. -There is both individual accountability and organizational accountability for delegation. Organizational accountability for delegation relates to providing sufficient resources, including: o Sufficient staffing with an appropriate staff mix o Documenting competencies for all staff providing direct patient care and for ensuring that the RN has access to competence information for the staff to whom the RN is delegating care o Organizational policies on delegation are developed with the active participation of all nurses, and acknowledge that delegation is a professional right and responsibility.
Verbal communication
-The conscious use of spoken or written word. Choice of words can reflect age, education, developmental level, or culture. Feelings can be expressed through the tone and pace of words. This means that the emotional meaning of words are altered by how things are said. Nurses need to remember this important message when giving or receiving information. -The most effective messages consist of: • Clearly selected wording • The use of a few words, not dissertations • Relevant information • Appropriate timing • Truthful • Humor
Accountability
-The individual delegating the task retains ____________________ for the outcome. -Can delegate responsiblity but not this
therapeutic range
-The minimum effective concentration (MEC) is the plasma level of the medication below which the effect of the medication does not occur. The toxic concentration is the level at which toxic effects occur. Is between the MEC and the toxic concentration. -ratio of the Lethal Dose in 50% of the population to the Effective Dose in 50% of the population -= LD50 / ED50 -a very low value means that there is a small difference between the doses of a drug which produce therapeutic vs. lethal effects
ANA Code of Ethics Provision 5
-The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. -Duties to Self and Others: -INTEGRITY is an aspect of wholeness of character and is primarily a self-concern of the individual nurse. -Nurses have a responsibility to remain consistent with both their personal and professional values
ANA Code of Ethics Provision 3
-The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. -Promotes, advocates for, and strives to protect the health, safety, and rights of the patient -This means: •Participate in review and development of policies •Reporting errors and near misses per facility policy (whether you or other made error) •Disclosing errors to patients •Use the Chain of Command
ANA Code of Ethics Provision 2
-The nurse's primary commitment is to the patient, whether an individual, family, group, or population -When acting within one's role as a professional, the nurse recognizes and maintains boundaries that establish appropriate limits to relationships.
Can't be delegated to NAP
-The skill of initiating transfusion therapy -After the transfusion has been started and the patient is stable, monitoring a patient by __________ does not relieve a registered nurse (RN) of the responsibility to continue to assess the patient during the transfusion.
licensed practical nurse (LPN)
-The skill of initiating transfusion therapy by a _______________________ varies by State Practice Acts. -The skill of monitoring for adverse blood transfusion reactions by a _______________________ varies by state Nurse Practice acts.
viscous
-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 thicker and irritating. -Muscle is less sensitive to irritating and thick medications
Why use a Central Line over a Peripheral Line
-To prevent infusion-related complications, solutions and medications with an osmolarity greater than 900 mOsm/L are infused through a CVAD. Short-peripheral catheters should not be used for vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900 mOsm/L. In addition, solutions or medications with low or high pH have the potential to cause infusion-related complications such as phlebitis when administered with a short-peripheral or midline catheter
Principles for Vein selection
-Veins on dorsal and ventral surfaces of arms (e.g., metacarpal, cephalic, basilic, or median) are preferred in adults. image - Use most distal site in nondominant arm if possible. Patients with VAD placement in their dominant hand have decreased ability to perform self-care. - With your fingertip, palpate vein at intended insertion site by pressing downward. Note resilient, soft, bouncy feeling while releasing pressure - Select well-dilated vein
how to clean a wound
-When a drain is present, clean the drain site using a circular stroke, starting with the area immediately next to the drain. Using a new swab, clean immediately next to the drain and attempt to clean a little farther out from the drain. a. Perform hand hygiene and apply clean gloves. Use gauze or cotton ball moistened in saline or antiseptic swab (per health care provider order) for each cleaning stroke or spray wound surface with wound cleaner. b. Clean from least to most contaminated area. c. Clean around any drain (if present), using circular strokes starting near drain and moving outward and away from insertion site. d. Use sterile dry gauze to blot wound bed in same manner as above.
Oxygen-conserving cannula (Oxymizer)
-low flow delivery device -FiO2 delivered: 8 L/min: up to 30%-60% -Advanatges: Indicated for long-term O2 use in the home Allows increased O2concentration and lower flow -Disadvantages: Cannula cannot be cleaned More expensive than standard cannula
respiratory tasks that cannot be delegated to Assistive Personnel (AP)
-administering oxygen therapy to a patient with an artificial airway -caring for a patient receiving noninvasive ventilation -caring for a patient on a mechanical ventilator -performing oropharyngeal suctioning for patients with oral or neck surgery in the immediate postoperative period -artificial airway suctioning of newly inserted artificial airways -airway suction with a closed (in-line) suction catheter -performing ET care -performing tracheostomy care (not usually)
respiratory tasks that can be delegated to Assistive Personnel (AP)
-applying a nasal cannula or oxygen mask -helping a patient to use incentive spirometry -PD -using an Acapella device -performing percussion and vibration -performing oropharyngeal suctioning -suction a patient with a well-established tracheostomy -performing tracheostomy care in some settings (patients who have well-established TTs)
Lipoatrophy
-breakdown of subcutaneous fat at the site of repeated insulin injections -use site rotation to prevent
lipohypertrophy
-buildup of subcutaneous fat at the site of repeated injections -use site rotation to prevent
slough
-can be yellow; cream colored; or gray, which is usually accompanied by purulent drainage -Usually indicates infection
Catheter occlusion
-can occur from bent catheter, positional catheter (catheter resting against catheter wall), kink or knot in infusion tubing, clot formation, or precipitate formation from administration of incompatible medications or solutions • Determine cause and consider catheter removal. • Positional catheters can be repositioned to improve IV flow. • Remove occluded IV catheter. Blocked catheters should not be flushed because an embolus can result from dislodging a clot
Catheter-related infection
-can present as redness, swelling around or above IV site, pain, purulent drainage at insertion site, and body temperature elevations • Notify health care provider. Obtain order to culture drainage • Remove IV catheter and culture purulent drainage from around IV site
Jackson-Pratt (JP) drain
-collects fluid that is in the range of 100 to 200 mL/24 -Relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device. The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects in a closed reservoir or a suction bladder. The closed system collects fluid but operates only if the tubing is patent and a vacuum exists. If drainage device is half full, empty the chamber and measure the drainage. After measurement reestablish the vacuum and ensure that all drainage tubes are patent.
Nerve injuries
-during short-peripheral IV insertion can occur. Be alert for patient complaints of paresthesias, including shocklike pain, tingling or pins and needles, burning, or numbness on insertion. • Notify health care provider of any signs and symptoms injury • Immediately stop VAD insertion and remove device if patient complains of symptoms of paresthesias • Continue to monitor neurovascular status
importance of mobility
-exercise and physical activity can help older adults maintain an active lifestyle, improve quality of life, and prevent injury -prevents deconditioning, DVTs -better patient outcomes, recover faster
safety measures that a nurse applies when bathing a patient in the bed, tub, or shower
-installation of grab bars in shower, adhesive strips applied to shower or tub floor, addition of a shower chair or placement of a chair or stool.
Levin tube
-is an NG tube used for gastric decompression -is a single-lumen tube with holes near the tip You connect it to a drainage bag or an intermittent suction device to drain stomach secretions.
Hematoma
-is bleeding under skin caused by trauma to vessel wall. It can occur during short-peripheral IV insertion if needle punctures either adjacent vessels or posterior vein wall or can be seen with multiple venipuncture attempts • Remove IV catheter immediately and apply pressure and dry, sterile. • Monitor for additional bleeding. • Elevate extremity and monitor for circulatory, neurological, or motor dysfunction
Hemovac or ConstaVac drainage system
-is used for larger amounts of drainage (500 mL/24 h -Relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device. The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects in a closed reservoir or a suction bladder. The closed system collects fluid but operates only if the tubing is patent and a vacuum exists. If drainage device is half full, empty the chamber and measure the drainage. After measurement reestablish the vacuum and ensure that all drainage tubes are patent.
Partial nonrebreather
-low flow delivery device -Bag should always remain partially inflated. Therefore flow rate must be high enough to prevent collapse of bag. -FiO2 delivered: 10-15 L/min; 60%-90% -Advantages: Useful for short periods Delivers increased FiO2 Easily humidifies O2 Does not dry mucous membranes -Disadvantages: Hot and confining May cause skin irritation Interferes with eating, drinking, and talking Bag may twist and deflate
Nasal cannula
-low flow delivery device -FiO2 Delivered: 1-6 L/min: 24%-44% -Advanatges: Safe and simple Easily tolerated Effective for low concentrations Does not impede eating or talking Inexpensive, disposable -Disadvantages: Unable to use with nasal obstruction Drying of mucous membranes Can dislodge easily May cause skin irritation or breakdown Patient's breathing pattern affects exact FiO2
Simple face mask
-low flow delivery device -FiO2 delivered: 6-12 L/min: 35%-50% -Advantages: Useful for short periods of time such as patient transportation -Disadvanatges: Contraindicated for patients who retain CO2 May induce feelings of claustrophobia Therapy interrupted with eating or drinking Increased risk for aspiration
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
-protects patients' private protected health information. HIPAA governs all areas of health information management (e.g., reimbursement, coding, security, and patient records). -The Security Rule provides standards for the protection of electronic health information. Numerous nursing and medical professional organizations have developed guidelines and strategies for safe computer charting. -It is against it to share information with caregivers not involved in the patient's care -Three key concepts are: (1) agencies are required to inform patients of the privacy rights they have and how the agency will handle their PHI; (2) the agency and the health care providers are to use or disclose a patient's PHI only for the purposes of treatment, payment, or health care operations; and (3) health care providers disclose only the minimum amount of PHI necessary, on a need-to-know basis, to accomplish the purpose of the use.
graduated compression (elastic) stockings
-rationale for use: preventing distension of veins which can lead to DVT -application: a. Use tape measure to measure patient's leg to determine proper elastic stocking size (follow package directions). b. Option: Apply a small amount of powder or cornstarch to legs provided patient does not have sensitivity. c. Turn elastic stocking inside out: place one hand into stocking, holding heel of stocking. Take other hand and pull stocking inside out until reaching the heel (see illustration). d. Place patient's toes into foot of elastic stocking up to the heel, making sure that stocking is smooth (see illustration). e. Slide remaining part of stocking over patient's foot, making sure that toes are covered. Make sure that foot fits into toe-and-heel position of stocking. Stocking will now be right side out (see illustration). f. Slide stocking up over patient's calf until sock is completely extended. Be sure that stocking is smooth and that no ridges or wrinkles are present (see illustration). g. Instruct patient not to roll stockings partially down, to avoid wrinkles and crossing legs, and to elevate legs while sitting. -assessment: 1. Assess patient for risk factors for developing DVT 2. Assess for contraindications for use of elastic stockings or SCDs: a. Dermatitis or open skin lesions on area to be covered by stockings/SCD b. Recent skin graft to lower leg c. Decreased arterial circulation in lower extremities as evidenced by cyanotic, cool extremities and/or gangrenous conditions affecting the lower limb(s) d. If signs/symptoms of a DVT are present, do not manipulate the leg to apply stockings. 3. Assess condition of patient's skin (area to be covered by stockings) and circulation to the legs. Palpate pedal pulses, note any palpable veins, and inspect skin over lower extremities for edema, skin discoloration, warmth, presence of lesions. 4. Obtain health care provider's order. 5. Assess patient's or family caregiver's knowledge of previous use of elastic or sequential compression stockings. -care: keep two pair and wash one daily -safety measures related to use: 1. Remove compression stockings or SCD sleeves at least once per shift (e.g., long enough to inspect skin for irritation or breakdown and determine patient's comfort level). 2. Evaluate skin integrity and circulation to patient's lower extremities as ordered (see agency policy). 3. Educate patient/family caregiver about how to care for elastic stockings (keep two pair and wash one daily) and precautions to take to prevent DVT at home (CDC, 2015): •Stay active and move around as much as possible. •When sitting for long periods of time such as when traveling for more than 4 hours: •Get up and walk around every 2 to 3 hours. •Drink plenty of water. •Exercise your legs while you're sitting by raising and lowering your heels while keeping your toes on the floor, raising and lowering your toes while keeping your heels on the floor, tightening and releasing your leg muscles. •Wear loose-fitting clothes.
Sequential Compression Devices (SCD)
-rationale for use: pump blood into deep veins, thus removing pooled blood and preventing venous stasis -application: a. Remove SCD sleeve from plastic cover; unfold and flatten on bed. b. Arrange SCD sleeve under patient's leg according to leg position indicated on inner lining of sleeve. c. Place patient's leg on SCD sleeve. Back of ankle should line up with ankle marking on inner lining of sleeve. d. Position back of knee with popliteal opening on inner sleeve (see illustration). e. Wrap SCD sleeve securely around patient's leg. Check fit of SCD sleeve by placing two fingers between patient's leg and sleeve (see illustration). f. Attach SCD sleeve connector to plug on mechanical unit. Arrows on connector line up with arrows on plug from mechanical unit (see illustration). g. Turn on mechanical unit. Green light indicates that unit is functioning. Monitor functioning SCD through one full cycle of inflation and deflation. -assessment, care, and safety measures related to use: 1. Remove compression stockings or SCD sleeves at least once per shift (e.g., long enough to inspect skin for irritation or breakdown and determine patient's comfort level). 2. Evaluate skin integrity and circulation to patient's lower extremities as ordered (see agency policy). 3. Educate patient/family caregiver about how to care for elastic stockings (keep two pair and wash one daily) and precautions to take to prevent DVT at home (CDC, 2015): •Stay active and move around as much as possible. •When sitting for long periods of time such as when traveling for more than 4 hours: •Get up and walk around every 2 to 3 hours. •Drink plenty of water. •Exercise your legs while you're sitting by raising and lowering your heels while keeping your toes on the floor, raising and lowering your toes while keeping your heels on the floor, tightening and releasing your leg muscles. •Wear loose-fitting clothes.
IV Discontinuation Documentation
-states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if fluids are prescribed -intactness of catheter tip
IV Start Documentation
-states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if fluids are prescribed • Record in nurses' notes in electronic health record (EHR) or chart the number of attempts (successful and unsuccessful) and sites of insertion; precise description of insertion site (e.g., cephalic vein on dorsal surface of right lower arm, 2.5 cm [1 inch] above wrist); flow rate; method of infusion (gravity or EID); size and type, length, and brand of catheter; and time infusion started and patient's response to insertion. Use an infusion therapy flow sheet when available. • If using an EID, document type and rate of infusion and device identification number. • Record patient's status, IV fluid, amount infused, integrity and patency of system according to agency policy. • Record patient's and family caregiver's level of understanding following instruction in nurses' notes in EHR or chart. • Report to oncoming nursing staff: type of fluid, flow rate, status of VAD, amount of fluid remaining in present solution, expected time to hang subsequent IV container, and patient condition. • Report to health care provider any signs and symptoms of IV-related complications. • Record signs and symptoms of IV-related complications, including interventions and patient response to treatments.
ID injections
-syringe size: 0.3-1 mL -needle length: 3/8 to 5/8 inch -gauge: greater viscosity greater gauge
IM injections
-syringe size: 1-3 mL -needle length: 1- 1 1/2 inch -gauge: greater viscosity greater gauge
Subq injections
-syringe size: 1-3 mL -needle length: 3/8 to 5/8 inch -gauge: greater viscosity greater gauge
evisceration
-total separation of wound layers and protrusion of viscera through wound opening -If internal abdominal pressure is increased (like when sneezing) the patient will report a pop and then some type of wet weight in their lap.
Best Evidence
-up to date information from relevant, valid research -Comes from well designed, systematically conducted research studies
blue pigtail on a salem sump
-ventilation -don't clamp or irrigate
Nasotracheal Suctioning
1. (without applying suction): As patient takes deep breath, advance catheter following natural course of naris. Advance catheter slightly slanted and downward to just above entrance into larynx and then trachea. While patient takes deep breath, quickly insert catheter: for adults insert approximately 16-20 cm (6-8 inches) into trachea (see illustration). Patient will begin to cough; then pull back catheter 1-2 cm (image inch) before applying suction. NOTE: In older children, 16-20 cm (6-8 inches); in infants and young children, 8-14 cm (3-image inches). 2. Positioning option: In some instances turning patient's head helps you suction more effectively. If you feel resistance after insertion of catheter, use caution; it has probably hit the carina. Pull catheter back 1-2 cm (0.4-0.8 inches) before applying suction (AARC, 2004). 3. Apply intermittent suction for no more than 10-15 seconds by placing and releasing nondominant thumb over catheter vent. Slowly withdraw catheter while rotating it back and forth between thumb and forefinger.
Nasopharyngeal suctioning
1. (without applying suction): As patient takes deep breath, insert catheter following natural course of naris; slightly slant catheter downward and advance to back of pharynx. Do not force through naris. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8-12 cm (3 to 5 inches); in infants and young children, 4-7.5 cm (1.5-3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible. 2. Apply intermittent suction for no more than 10-15 seconds by placing and releasing nondominant thumb over catheter vent. Slowly withdraw catheter while rotating it back and forth between thumb and forefinger.
Examples of Tasks Delegated to CNA
1. Activities of daily lining (ADLs): Bathing, Grooming, Dressing, Toileting, Ambulating, Feeding (without swallowing precautions), positioning, bedmaking 2. Specimen collection (non-sterile) 3. Intake and output 4. Vital signs (on stable clients)
Ongoing assessment and evaluation of restraints
1. After application, evaluate patient for signs of injury every 15 minutes (e.g., circulation, vital signs, ROM, physical and psychological status, and readiness for discontinuation). Perform visual checks if patient is too agitated to approach (TJC, 2015). 2. Evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours. 3. Evaluate patient for any complications of immobility. 4. The licensed health care provider or registered nurse trained according to CMS requirements needs to evaluate patient within either 1 or 4 hours after initiation of restraints, depending on Medicare status of hospital (see agency policy). 5. After 24 hours, before writing a new order, health care provider who is responsible for patient's care must see and reassess patient. 6. Observe IV catheters, urinary catheters, and drainage tubes to determine that they are positioned correctly and that therapy remains uninterrupted. 7. Observe patient's behavior and reaction to presence of restraint.
principles of sterile technique (surgical asepsis)
1. All items used within a sterile field must be sterile. 2. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. 3. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. 4. Tables draped as part of a sterile field are considered sterile only at table level. 5. If there is any question or doubt about the sterility of an item, the item is considered to be unsterile. 6. Sterile people or items contact only sterile areas; unsterile people or items contact only unsterile areas. 7. Movement around and in the sterile field must not compromise or contaminate the field. 8. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 9. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible.
steps to prepare and maintain a sterile field
1. Apply PPE as needed (consult agency policy). 2. Select a clean, flat, dry work surface above waist level. 3. Perform hand hygiene. 4. Prepare sterile work surface. a. Use sterile commercial kit or pack containing sterile items. (1) Place sterile kit or pack on the prepared work surface. (2) Open outside cover and remove package from dust cover. Place on work surface. (3) Grasp outer surface of tip of outermost flap. (4) Open outermost flap away from body, keeping arm outstretched and away from sterile field. (5) Grasp outside surface of edge of first side flap. (6) Open side flap, pulling to side, allowing it to lie flat on table surface. Keep arm to side and not over sterile surface. (7) Repeat Step (6) for second side flap. (8) Grasp outside border of last and innermost flap. Stand away from sterile package and pull flap back, allowing it to fall flat on table. Kit is ready to be used. b. Open sterile linen-wrapped package. (1) Place package on clean, dry, flat work surface above waist level. (2) Remove sterilization tape seal and unwrap both layers following same steps (see Steps 4a [2] through 4a [8]) as for sterile kit (see illustration). (3) Use opened package wrapper as sterile field. c. Prepare sterile drape. (1) Place pack containing sterile drape on flat, dry surface and open as described (see Steps 4a [2] through 4a[8]) for sterile package. (2) Apply sterile gloves (optional, see agency policy). You may touch outer 2.5-cm (1-inch) border of drape without wearing gloves. (3) Using fingertips of one hand, pick up folded top edge of drape along 2.5 cm (1-inch) border. Gently lift drape up from its wrapper without touching any object. Discard wrapper with other hand. (4) With other hand, grasp an adjacent corner of drape and hold it straight up and away from body. Allow drape to unfold, keeping it above waist and work surface and away from body. (Carefully discard wrapper with other hand.) (5) Holding drape, position bottom half over top half of intended work surface (see illustration). (6) Allow top half of drape to be placed over bottom half of work surface. 5. Add sterile items to sterile field. a. Open sterile item (following package directions) while holding outside wrapper in nondominant hand. b. Carefully peel wrapper over nondominant hand. c. Be sure that the wrapper does not fall down onto the sterile field. Place the item onto the field at an angle. Do not hold arms over sterile field. d. Dispose of outer wrapper. 6. Pour sterile solutions. a. Verify contents and expiration date of solution. b. Place receptacle for solution near table/work surface edge. Sterile kits have cups or plastic molded sections into which fluids can be poured. c. Remove sterile seal and cap from bottle in upward motion. d. With solution bottle held away from field and bottle lip 2.5 to 5 cm (1 to 2 inches) above inside of sterile receiving container, slowly pour needed amount of solution into container. Hold bottle with label facing palm of hand.
how to perform oropharyngeal suctioning
1. Apply clean gloves. Apply mask or face shield if splashing is likely. Wear gown if isolation precautions are indicated. 2. Fill cup or basin with approximately 100 mL of water or normal saline. 3. Connect one end of connecting tubing to suction machine and other to Yankauer suction catheter. Turn on suction machine; set vacuum regulator to appropriate setting (infants 80-100 mm Hg; children 100-120 mm Hg; adults 100-150 mm Hg). 4. Check that suction machine is functioning properly by placing tip of catheter in water or normal saline and suctioning small amount from cup or basin. 5. Remove patient's oxygen mask if present. Nasal cannula may remain in place. Keep oxygen mask near patient's face. 6. Insert catheter into mouth along gum line to pharynx. Move catheter around mouth until secretions have cleared. Encourage patient to cough. Replace oxygen mask. 7. Rinse catheter with water or normal saline in cup or basin until connecting tubing is cleared of secretions. Turn off suction. Place catheter in clean, dry area. 8. Wash face if secretions are present on patient's skin. 9. Observe respiratory status. Repeat procedure if indicated. May need to use standard suction catheter to reach into trachea if respiratory status not improved. 10. Remove towel, cloth, or disposable drape and place in trash or in laundry if soiled. Reposition patient; Sims' or side-lying position encourages drainage and should be used if patient has decreased level of consciousness. 11. Discard remainder of water or normal saline into appropriate receptacle. Rinse basin in warm soapy water and dry with paper towels (check agency policy). Discard disposable cup into appropriate receptacle.
apply sterile gloves
1. Apply sterile gloves. a. Perform thorough hand hygiene. Place glove package near work area. b. Remove outer glove package wrapper by carefully separating and peeling apart sides (see illustration). c. Grasp inner package and lay on clean, dry, flat surface at waist level. Open package, keeping gloves on inside surface of wrapper (see illustration). d. Identify right and left glove. Each glove has a cuff approximately 5 cm (2 inches) wide. Glove dominant hand first. e. With thumb and first two fingers of nondominant hand, grasp glove for dominant hand by touching only inside surface of cuff. f. Carefully pull glove over dominant hand, leaving a cuff and being sure that cuff does not roll up wrist. Be sure that thumb and fingers are in proper spaces (see illustration). g. With gloved dominant hand, slip fingers underneath cuff of second glove (see illustration). h. Carefully pull second glove over fingers of nondominant hand (see illustration). i. After second glove is on, interlock hands together and hold away from body above waist level until beginning procedure (see illustration). 2. Perform procedure. 3. Remove gloves. a. Grasp outside of one cuff with other gloved hand; avoid touching wrist. b. Pull glove off, turning it inside out, and place it in gloved hand. c. Take fingers of bare hand and tuck inside remaining glove cuff (see illustration). Peel glove off inside out and over previously removed glove. Discard both gloves in receptacle. d. Perform thorough hand hygiene.
Steps of EBP
1. Ask a clinical question. 2. Search for the most relevant and best evidence that applies to the question. 3. Critically appraise the evidence. 4. Apply or integrate evidence along with your clinical expertise, patient preferences, and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Communicate and disseminate results.
steps of the nursing process
1. Assessment 2. Nursing Diagnosis 3. Planning 4. Implementation 5. Evaluation
Changing Intravenous Solutions
1. Change solution when fluid remains only in neck of container (about 50 mL) or when new type of solution has been ordered. 2. Perform hand hygiene. 3. Prepare new solution for changing. If using plastic bag, hang on IV pole and remove protective cover from IV tubing port. If using glass bottle, remove metal cap and metal and rubber disks. 4. Close roller clamp on existing solution to stop flow rate. Remove IV tubing from EID (if used). Then remove old IV solution container from IV pole. Hold container with tubing port pointing upward. 5. Quickly remove spike from old solution container and, without touching tip, insert spike into new container. 6. Hang new container of solution on IV pole. 7. Check for air in IV tubing. If air bubbles have formed, remove them by closing roller clamp, stretching tubing downward, and tapping tubing with finger (bubbles rise in fluid to drip chamber). 8. Make sure that drip chamber is one-third to one-half full. If drip chamber is too full, level can be decreased by removing bag from IV pole, pinching off IV tubing below drip chamber, inverting container, squeezing drip chamber, releasing and turning solution container upright, and releasing pinch on tubing. 9. Regulate flow to ordered rate by opening and adjusting roller clamp on IV tubing or by opening roller clamp and programming and turning on EID. 10. Place time label on side of container and label with time hung, time of completion, and appropriate intervals. If using plastic bags, mark only on label and not container. 11. Instruct patient on purpose of new IV solution, additives, flow rate, potential side effects, how to avoiding occluding tubing, and what to report.
indications for discontinuing trach care
1. Cuff leak develops. 2. Accidental decannulation/dislodgement 3. Respiratory distress from mucus plugs in cannula.
Changing a Short-Peripheral Intravenous Dressing Pre-assessments
1. Determine when dressing was last changed. Dressing should be labeled to include date and time applied, size and type of vascular access device (VAD) insertion date. 2. Perform hand hygiene and apply clean gloves. Observe present dressing for moisture and intactness. Determine if moisture is from site leakage or external source. 3. Inspect and gently palpate skin around and above IV site over dressing. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing). Remove and discard gloves. 4. Assess patient's understanding of need for continued IV infusion.
Types of Errors
1. Diagnostic -Error or delay in diagnosis -Failure to employ indicated tests -Use of outmoded tests or therapy -Failure to act on results of monitoring or testing 2. Treatment -Error in the performance of an operation, procedure, or test -Error in administering the treatment -Error in the dose or method of using a drug -Avoidable delay in treatment or in responding to an abnormal test -Inappropriate (not indicated) care 3. Preventive -Failure to provide prophylactic treatment -Inadequate monitoring or follow-up of treatment 4. Other -Failure of communication Equipment failure -Other system failure
Nurse of Excellence
1. Empathy 2. Detail Oriented 3. Communication 4. Intuition 5. Physical Endurance 6. Emotional Stability 7. Critical Thinking 8. Coordinator of Services 9. Patience 10. Dedication
Changing a Short-Peripheral Intravenous Dressing Post-evaluations
1. Evaluate function, patency of IV system, and flow rate after changing dressing. 2. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV line-related complications. 3. Use Teach-Back: "I want to be sure that I explained reasons for why we change the IV dressing. Tell me in your own words the problems that you would report that would require us to change the dressing." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.
nasal
1. Gently roll or shake container. Instruct patient to clear or blow nose gently unless contraindicated (e.g., risk of increased intracranial pressure or nosebleed). 8. Administer drops. a. Help patient to supine position and position head properly (ASHP, 2013c). (1) For access to posterior pharynx, tilt patient's head backward. (2) For access to ethmoid or sphenoid sinus, tilt head back over edge of bed or place small pillow under patient's shoulder and tilt head back (see illustration). (3) For access to frontal and maxillary sinus, tilt head back over edge of bed or pillow with head turned toward side to be treated (see illustration). b. Support patient's head with nondominant hand. c. Instruct patient to breathe through mouth. d. Hold dropper 1 cm ( inch) above nares and instill prescribed number of drops toward midline of ethmoid bone. e. Have patient remain in supine position 5 minutes. f. Offer facial tissue to blot runny nose but caution patient against blowing nose for several minutes. 9. Administerspray. a. Help patient into upright position with head tilted slightly forward. b. Instruct or assist patient to insert tip of nasal spray into appropriate nares and occlude other nostril with finger (see illustration). Point spray tip toward side and away from center of nose (ASHP, 2013d). c. Have patient spray medication into nose while inhaling. Help him or her remove nozzle from nose and instruct to breathe out through mouth. d. Offer facial tissue to blot runny nose but caution patient against blowing nose for several minutes.
Putting on Personal Protective Equipment (PPE)
1. Hand Hygiene 2. Cap if required 3. Gown-ties in the back; if too small, use two 4. Mask-tie top tie first, then bottom. Metal piece goes over nose. Use two fingers to gently shape metal strip to nose. Pull down over chin 5. Goggles-should fit securely 6. Gloves-extend gloves over cuffs of gown
how to perform CPT
1. Help patient to desired position to drain congested areas. Place pillows for support and comfort. Drape patient appropriately. 2. Have patient maintain position for 10 to 15 minutes. 3. After 10 to 15 minutes of drainage in selected postures, perform chest percussion and vibration over affected lung region. 4. After 10 to 15 minutes of drainage in first posture, have patient sit up and cough. If indicated, save expectorated secretions in clear container. If patient cannot cough, suctioning is necessary 5. Have patient rest briefly if necessary between positions. Note pulse oximeter readings. 6. Have patient take sips of water. 7. Repeat Steps 3 to 8 until all affected areas selected are drained. Make sure that each treatment does not exceed 30 to 60 minutes.
care of dentures
1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2016). 2. Assess environment for safety (e.g., check room for spills; make sure that equipment is working properly and that bed is in locked, low position). 3. Perform hand hygiene. 4. Ask patient if dentures fit and if there is any gum or mucous membrane tenderness or irritation. Ask patient about denture care and product preferences. 5. Determine if patient has necessary dexterity to clean dentures independently or requires help. 6. Position patient comfortably sitting up in bed or help him or her walk from bed to chair placed in front of sink. 7. Fill emesis basin with tepid water. (If using sink, place washcloth in bottom of sink and fill sink with approximately 2.5 cm [1 inch] of water.) 8. Apply clean gloves. 9. Ask patient to remove dentures. If patient is unable to do this independently, grasp upper plate at front with thumb and index finger wrapped in gauze and pull downward. Gently lift lower denture from jaw and rotate one side downward to remove from patient's mouth. Place dentures in emesis basin or sink lined with washcloth and 2.5 cm (1 inch) of water. 10. Apply cleaning agent to brush and brush surfaces of dentures (see illustration). Hold dentures close to water. Hold brush horizontally and use back-and-forth motion to clean biting surfaces. Use short strokes from top of denture to biting surfaces to clean outer teeth surfaces. Hold brush vertically and use short strokes to clean inner teeth surfaces. Hold brush horizontally and use back-and-forth motion to clean undersurface of dentures (see Skill 18.2). 11. Rinse thoroughly in tepid water. If water is too cold, dentures can crack. If it is too hot, dentures can become warped and no longer fit. 12. Some patients use an adhesive to seal dentures in place. Apply a thin layer to undersurface before inserting. 13. If patient needs help with inserting dentures, moisten upper denture and press firmly to seal it in place. Insert moistened lower denture (if applicable). Ask if denture(s) feel comfortable. 14. Some patients prefer to store their dentures to give gums a rest and reduce risk for infection. Store in tepid water in enclosed, labeled denture cup. Keep denture cup in a secure place labeled with patient's name to prevent loss when not worn (e.g., at night, during surgery). 15. Dispose of supplies. Remove and discard gloves and perform hand hygiene. 16. Return patient to a comfortable position. Leave call light in reach.
how to perform a wound assessment
1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. 2. Examine the medical record for the last wound assessment to use as a comparison for this wound assessment. Review the record to determine the etiology of the wound. 3. Determine agency-approved wound assessment tool and review the frequency of assessment. Examine the last wound assessment to use as comparison for this assessment. 4. Assess comfort level or pain on a scale of 0 to 10 and identify symptoms of anxiety. Offer pain medication if indicated. 5. Perform hand hygiene. Close room door or bed curtains and position patient. a. Position comfortably to permit observation of wound in well-lighted room. b. Expose only the area of the wound. 6. Explain procedure of wound assessment to patient. 7. Form a cuff on waterproof biohazard bag and place near bed. 8. Apply clean gloves and remove soiled dressings. 9. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Discard gloves. 10. Perform hand hygiene and apply clean gloves. 11. Inspect wound and determine type of wound healing (e.g., primary or secondary intention). 12. Use agency-approved assessment tool and assess the following: a. Wound healing by primary intention (surgical wound): (1) Assess anatomical location of wound on body. (2) Note if incisional wound margins are approximated or closed together. The wound edges should be together with no gaps. (3) Observe for presence of drainage. A closed incision should not have any drainage. (4) Look for evidence of infection (presence of erythema, odor, or wound drainage). (5) Lightly palpate along incision to feel a healing ridge. The ridge will appear as an accumulation of new tissue presenting as firmness beneath the skin, extending to about 1 cm (1/2 inch) on each side of the wound between 5 and 9 days after the incision had been created. This is an expected positive sign. b. Wound healing by secondary intention (e.g., pressure injury or contaminated surgical or traumatic wound: (1) Assess anatomical location of wound. (2) Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide. Measure length by placing a ruler over wound at the point of greatest length (or head to foot). Measure width from side to side. Measure depth by inserting cotton-tipped applicator in area of greatest depth and placing a mark on applicator at skin level. Discard measuring guide and cotton-tipped applicator in a biohazard bag. (3) Assess for undermining: Use cotton-tipped applicator to gently probe wound edges. Measure depth and note location using the face of a clock as a guide. The 12 o'clock position (top of wound) would be the head of patient, and the 6 o'clock position would be the bottom of the wound toward patient's feet. Document the number of centimeters that area extends from wound edge (e.g., underneath intact skin). (4) Assess extent of tissue loss: If wound is a pressure injury, determine the deepest viable tissue layer in wound bed and determine stage. If necrotic tissue does not allow visualization of base of wound, the stage cannot be determined. If the wound is not a pressure injury, determine if there is partial-thickness loss (epidermis and part of the dermis) or full-thickness loss (loss of both the epidermis and the dermis). If it is a pressure injury, use the staging system of the National Pressure Ulcer Advisory Panel. (5) Observe tissue type, including percentage of granulation, slough, and necrotic tissue. (6) Note presence of exudate: amount, color, consistency and odor. Indicate amount of exudate by using part of dressing saturated (completely or partially saturated or in terms of quantity (e.g., scant, moderate, or copious). (7) Note if wound edges are rounded toward wound bed; this may be an indication of delayed wound healing. Describe presence of epithelialization at wound edges (if present) because this indicates movement toward healing. 13. Inspect the periwound skin, including color, texture, and temperature; and describe skin integrity (e.g., open macerated areas, blistering). Periwound assessment provides clues about the effectiveness of wound treatment and possible wound extension. 14. Apply dressings per order. Place time, date, and initials on new dressing. 15. Reassess patient's pain and level of comfort, including pain at wound site, using a scale of 0 to 10, after dressing is applied. 16. Discard biohazard bag, soiled supplies, and gloves per agency policy. Perform hand hygiene. 17. Record wound assessment findings and compare assessment with previous wound assessments to monitor wound healing.
how to assess stoma
1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number), according to agency policy. 2. Perform hand hygiene and apply clean gloves. 3. Observe existing skin barrier and pouch for leakage and length of time in place. Pouch should be changed every 3 to 7 days, not daily (Carmel et al., 2016). If an opaque pouch is being used, remove it to fully observe stoma. Dispose of such a pouch in proper receptacle. 4. Observe amount of effluent in pouch and empty it if it is more than full by opening the pouch and draining it into a container for measurement of output. Note consistency of effluent and record intake and output. 5. Observe stoma for type, location, color, swelling, presence of sutures, trauma, and healing or irritation of peristomal skin. 6. Observe placement of stoma in relation to abdominal contours and presence of scars or incisions. Remove and dispose of gloves; perform hand hygiene. 7. Explore patient's attitudes, perceptions, knowledge, and acceptance of stoma; discuss interest in learning self-care. Identify others who will be helping patient after leaving hospital.
National Patient Safety Goals
1. Identify patients correctly -Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. -Make sure that the correct patient gets the correct blood when they get a blood transfusion. 2. Improve staff communication -Get important test results to the right staff person on time. 3. Use medicines safely -Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. -Take extra care with patients who take medicines to thin their blood. -Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. 4. Use alarms safely -Make improvements to ensure that alarms on medical equipment are heard and responded to on time. 5. Prevent infection -Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. -Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent infection of the blood from central lines. -Use proven guidelines to prevent infection after surgery. -Use proven guidelines to prevent infections of the urinary tract that are caused by catheters. 6. Identify patient safety risks -Find out which patients are most likely to try to commit suicide. 7. Prevent mistakes in surgery -Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. -Mark the correct place on the patient's body where the surgery is to be done. -Pause before the surgery to make sure that a mistake is not being made.
Writing an Incident Report
1. Identify the electronic patient record using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. 2. Use clinical reasoning skills to systematically and carefully determine what was involved in the event. Either report the event as witnessed or determine from NAP specifically what occurred. Record the exact sequence of events involved, including time and type of event; injury to patient, nurse, or other staff; and observation of factors that possibly contributed to the event (e.g., wet floor discovered in area of patient fall). Notify risk management per agency protocol. 3. Assess extent of any injury to patient or others, including patient's subjective report and objective physical examination findings. 4. If the adverse event involves an injury, take steps to restore individual's safety such as stabilizing patient's position after a fall and assessing for further injuries. 5. When patient sustains an injury, call the health care provider immediately. 6. When visitor or staff member sustains an injury, refer to emergency department or appropriate treatment setting. 7. Complete adverse event report form. a. Record time of event and describe exactly what occurred or was observed, using objective findings and observations. Use language that does not allow for subjective interpretation. Do not include personal opinions or feelings. Document victim's interpretation of event by using quotes. b. Objectively describe patient's or staff member's condition when event was discovered or observed. c. Describe measures taken by any caregivers at time of event. d. Send completed report to designated department. 8. When patient is involved, document events of incident in patient's chart. a. Only enter objective description of what happened. b. Record any assessment and intervention activities initiated as a result of event. c. Do not duplicate all information from report. d. Do not record that report was completed. 9. Submit the report properly with the risk-management department or designated people.
Examples of Tasks Delegated to LPN
1. Monitoring client findings as input to the RN's ongoing assessment 2. Reinforcement of client teaching from standard care plan 3. Insertion of urinary catheter 4. Medication administration (IV meds?)
Handwashing using regular or antimicrobial soap
1. Inspect surface of hands for breaks or cuts in skin or cuticles. Cover any skin lesions with a dressing before providing care. If lesions are too large to cover, you may be restricted from direct patient care. a. Stand in front of sink, keeping hands and uniform away from sink surface. (If hands touch sink during handwashing, repeat sequence.) b. Turn on water. Turn on faucet (see illustration) or push knee pedals laterally or press pedals with foot to regulate flow and temperature. c. Avoid splashing water against uniform. d. Regulate flow of water so temperature is warm. e. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. f. Apply 3 to 5 mL of antiseptic soap and rub hands together (see illustration). g. Perform hand hygiene using plenty of lather and friction for at least 15 seconds. Interlace fingers and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. h. Areas underlying fingernails are often soiled. Clean them with fingernails of other hand and additional soap or with disposable nail cleaner. i. Rinse hands and wrists thoroughly, keeping hands down and elbows up (see illustration). j. Dry hands thoroughly from fingers to wrists with paper towel, single-use cloth, or warm air dryer. k. If used, discard paper towel in proper receptacle. l. To turn off hand faucet, use clean, dry paper towel; avoid touching handles with hands (see illustration). Turn off water with foot or knee pedals (if applicable). m. If hands are dry or chapped, use small amount of lotion or barrier cream dispensed from individual-use container.
Ways to Protect Privacy
1. Make sure no one gets private and protected health or personal information by not talking about patients in public places like the cafeteria, elevator, by the water cooler, in lounges, waiting rooms or parking garages. 2. Make sure no one gets private and protected health or personal information by being sure no one can see your computer screen while you are working. 3. Make sure no one gets private and protected health or personal information by Never sharing your access codes. 4. Make sure no one gets private and protected health or personal information by logging off when not working on your computer. 5. Make sure no one gets private and protected health or personal information by changing your code and notifying your supervisor if your code becomes known by anyone else. 6. Make sure no one gets private and protected health or personal information by not leaving information on answering machines or E-mails because you don't know who can get your messages. 7. Make sure no one gets private and protected health or personal information by leaving only your name and your number on message machines when you are asking patients to call you back. 8. Make sure no one gets private and protected health or personal information by being sure you are in a private area when listening to or reading your messages. 9. Make sure no one gets private and protected health or personal information by knowing who you are speaking to on the phone if not sure - get a name and number to call back after you find out it is OK to do so. 10. Make sure no one gets private and protected health or personal information by being sure no one around you can overhear your conversation, especially in an office or waiting room. 11.Make sure no one gets private and protected health or personal information by using ONLY a standard phone because cellular phones can be scanned. 12.Make sure no one gets private and protected health or personal information by never leaving documents unattended. - Store, file, shred or destroy according to your departmental policy. 13.Make sure no one gets private and protected health or personal information by making sure Fax numbers are correct and use a cover sheet with a confidentiality statement. 14.Make sure no one gets private and protected health or personal information by giving your supervisor any papers or materials with patient information you find anywhere such as - a classroom or lounge - cafeteria, floor or wastebasket.
risk diagnosis
1. NANDA Diagnostic Label: Risk for deficient fluid volume 2. Evidenced by risk factors of: -increased intestinal losses (vomiting and diarrhea) and decreased fluid intake Example: -Risk for deficient fluid volume as evidenced by risk factors of increased intestinal losses (vomiting and diarrhea) and decreased fluid intake
Changing Infusion Tubing Pre-assessments
1. Note date and time when IV tubing was last changed 2. Perform hand hygiene. Assess IV tubing for puncture, contamination, or occlusion that requires immediate change. 3. Determine patient understanding of need for continued IV therapy.
Regulating Intravenous Flow Rates Post-evaluations
1. Observe patient every 1 to 2 hours (see agency policy), noting volume of IV fluid infused and rate of infusion. 2. Look at patient's response to therapy (e.g., laboratory values, input and output [I&O], weights, vital signs, postprocedure assessments). 3. Look at patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications. 4. Use Teach-Back: "I want to be sure that I explained the importance of your IV fluids running on time at the rate ordered. Tell me what you think may cause the pump to alarm and what you would do." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.
Insertion of a Short-Peripheral Intravenous Device Post-evaluations
1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system and for correct infusion rate and accurate type/amount of IV solution infused by observing level in IV container. 2. Look at patient to determine response to therapy (e.g., laboratory values, input and output [I&O]), weights, vital signs, postprocedure assessments). 3. Look at patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications by inspecting and gently palpating skin around and above IV site over the dressing. 4. Use Teach-Back: "I want to make sure that I explained the problems that can happen with your IV. Tell me the signs or symptoms that you should tell me or the other nurses about." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.
Changing Infusion Tubing Post-evaluations
1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system and leaking at connection sites. 2. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications. 3. Use Teach-Back: "Let's go over what we talked about earlier regarding the problems that can occur with your IV line. Tell me how you can prevent the tubing from being pinched off and which signs and symptoms you would report to me or another nurse." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.
Changing Intravenous Solutions Post-evaluations
1. Observe patient every 1 to 2 hours or at established intervals per agency policy and procedure for function, intactness, and patency of IV system; correct infusion rate; and type/amount of IV solution infused. 2. Evaluate patient to determine response to therapy (e.g., laboratory values, input and output [I&O], weights, vital signs, postprocedure assessments). 3. Monitor patient for signs of fluid volume excess (FVE), fluid volume deficit (FVD), or signs and symptoms of electrolyte imbalances. 4. Evaluate patient at established intervals per agency policy and procedure for signs and symptoms of IV-related complications. 5. Use Teach-Back: "We talked about the importance of your IV solutions running continuously. I want to be sure I explained this clearly. Tell me in your own words what you should do if you notice that the IV is not dripping." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly.
procedure for giving a bedbath
1. Offer patient bedpan or urinal. Apply clean gloves to help patient as needed. Provide toilet tissue and dispose of any excrement properly. Dispose of gloves if applied and perform hand hygiene. Provide patient towel and moist washcloth. 2. Perform hand hygiene. If patient has nonintact skin or skin is soiled with drainage, excretions, or body secretions, apply new pair of clean gloves before beginning bath. 3. Raise bed to comfortable working height. Lower side rail closest to you and help patient assume comfortable supine position, maintaining body alignment. Bring patient toward side closest to you (staying supine). 4. Place bath blanket over patient. Have patient hold top of bath blanket and remove top sheet from under bath blanket without exposing patient. Place soiled linen in laundry bag. 5. Remove patient's gown or pajamas. a. If gown has snaps on sleeves, simply unsnap and remove gown without pulling IV tubing (if present). b. If gown has no snaps and if an extremity is injured or has reduced mobility, begin removal from unaffected side first. c. If patient has an IV line and gown with no snaps, remove gown from arm without IV line first. Then remove gown from arm with IV line (see illustration). Pause IV fluid infusion by pressing appropriate sensor on IV pump. Remove IV tubing from pump; use regulator to slow IV infusion. Remove IV bag from pole (see illustration) and slide IV bag and tubing through arm of patient's gown (see illustration). Rehang IV bag (see illustration), reconnect tubing to pump, open regulator clamp, and restart IV fluid infusion by pressing appropriate sensor on IV pump. If IV fluids are infusing by gravity, check IV flow rate and regulate if necessary. Do not disconnect IV tubing to remove gown. 6. Raise side rail. Lower bed temporarily to lowest position and raise on return after you fill wash basin two-thirds full with warm water. Place basin along with supplies on over-bed table and position over patient's bed. Check water temperature and have patient place fingers in water. 7. Lower side rail. Remove pillow (if tolerated). Raise head of bed 30 to 45 degrees if allowed. Place bath towel under patient's head. Place second bath towel over patient's chest. 8. Wash face. a. Inquire if patient is wearing contact lenses. You may choose to remove at this time. b. Form a mitt with washcloth (see illustration); immerse in water and wring thoroughly. c. Wash patient's eyes with plain warm water, using a clean area of cloth for each eye and bathing from inner to outer canthus (see illustrations). Soak any crusts on eyelid for 2 to 3 minutes with warm, damp cloth before attempting removal. Dry around eyes thoroughly but gently. d. Ask if patient prefers to use soap on face. Otherwise wash, rinse, and dry forehead, cheeks, nose, neck, and ears without using soap. Ask men if they want to be shaved. e. Provide eye care for unconscious patient. (1) Instill eyedrops or ointment per health care provider's order. (2) In the absence of blink reflex, keep eyelids closed. Close eye gently, using back of your fingertip, before placing eye patch or shield. Place tape over patch or shield. Do not tape eyelid. 9. Wash upper extremities and trunk. Option: Change bath water at this time. Obtain new 6-quart basin and mix contents of a 4-ounce bottle of 4% CHG with warm water. a. Remove bath blanket from patient's arm that is closest to you. Place bath towel lengthwise under arm using long, firm strokes from distal to proximal (fingers to axilla). b. Raise and support arm above head (if possible) to wash axilla, rinse, and dry thoroughly (see illustration). Apply deodorant to underarms as needed or desired. c. Move to other side of bed and repeat steps with other arm. d. Cover patient's chest with bath towel and fold bath blanket down to umbilicus. Bathe chest with long, firm strokes. Take special care with skin under female patient's breasts, lifting breast upward if necessary while bathing underneath breast. Rinse if using soap and water and dry well. 10. Wash hands and nails. a. Fold bath towel in half and lay it on bed beside patient. Place basin on towel. Immerse patient's hand in water. Allow hand to soak for 3 to 5 minutes before cleaning fingernails (see Skill 18.4). NOTE: Do not soak fingers of patient with diabetes mellitus. Remove basin and dry hand well. Repeat for other hand. 11. Check temperature of bath water and change water if necessary; otherwise continue. 12. Wash abdomen. a. Place bath towel lengthwise over chest and abdomen. (You may need two towels.) Fold bath blanket down to just above pubic region. Bathe, rinse, and dry abdomen with special attention to umbilicus and skinfolds of abdomen and groin. Keep abdomen covered between washing and rinsing. Dry well. b. Apply clean gown or pajama top by dressing affected side first. Option: You may omit this step until completion of bath. 13. Wash lower extremities. a. Cover chest and abdomen with top of bath blanket. Expose near leg by folding blanket toward midline. Be sure that other leg and perineum remain draped. Place bath towel under leg as you support patient's knee and ankle. b. Wash leg using long, firm strokes from ankle to knee and knee to thigh (see illustration). Assess condition of extremities. c. Clean foot, making sure to bathe between toes. Clean and file nails as needed (check agency policy) (see Skill 18.4). Dry toes and feet completely. d. Raise side rail; remove towel; move to opposite side of bed, lower side rail, place dry towel under second leg, and repeat steps 13b and c for other leg and foot. Apply light layer of moisturizing lotion to both feet. When finished, remove used towel. e. Cover patient with bath blanket, raise side rail, and change bath water (if using plain soap and water). 14. Wash back. a. Apply clean gloves (if not already applied). Lower side rail. Help patient assume prone or side-lying position, using safe patient-handling techniques (see Chapter 11) (as applicable). Place towel lengthwise along patient's side. b. If fecal material is present, enclose in fold of underpad or toilet tissue and remove with disposable wipes. c. Keep patient draped by sliding bath blanket over shoulders and thighs during bathing. Wash, rinse, and dry back from neck to buttocks with long, firm strokes. Pay special attention to folds of buttocks and anus. d. Clean buttocks and anus, washing front to back (see illustration). Clean, rinse, and dry area thoroughly. If needed, place clean, absorbent pad under patient's buttocks. 15. While patient is supine, provide perineal care (see Procedural Guideline 18.1). 16. Massage back if patient desires. 17. Apply body lotion to skin and topical moisturizing agents to dry, flaky, reddened, or scaling areas. NOTE: If using CHG solution for bathing, only use a product compatible with CHG (AHRQ, 2013b). 18. Remove and dispose of gloves and perform hand hygiene before helping patient complete grooming (e.g., combing hair, shaving). 19. Check function and position of external devices (e.g., indwelling catheters, nasogastric tubes, IV tubes, braces). 20. Replace top bed linen by pulling sheet and bedspread from foot of bed to cover patient before removing bath blanket. Apply gloves if linen is soiled. Option: Make occupied bed at this time (see Procedural Guideline 18.6). 21. Place bed in low, locked position and raise appropriate number of side rails so they do not restrain patient from exiting bed safely. Make sure that patient is in comfortable position with call light and personal possessions in reach. 22. Disinfect/rinse and dry bed basin according to agency policy. This is especially important if using CHG solution. DO NOT use basin for CHG as storage container for supplies (Petlin et al., 2014). 23. Perform hand hygiene and leave room.
indications for discontinuing suctioning
1. Patient has decrease in overall cardiopulmonary status as evidenced by decreased SpO2, increased ETCO2, continued tachypnea, continued increased work of breathing, and cardiac dysrhythmias. 2. Bloody secretions are returned after suctioning. 3. Patient has paroxysms of coughing or bronchospasm. 4. Inability to obtain secretions during suction procedure.
mid-stream catch urine specimen
1. Perform hand hygiene, check labels, and complete laboratory requisition for specimen container. 2. Provide privacy for patient; close curtains around bed or close room door. Allow mobile patients to collect specimen in bathroom. 3. Collect clean-voided urine specimen. a. Apply clean gloves. Give patient cleaning towelette or towel, washcloth, and soap to clean perineum or help with cleaning perineum. Help bedridden patient onto bedpan to facilitate access to perineum. Remove and dispose of gloves. b. Using aseptic technique, open outer package of commercial specimen kit. Maintains sterility of equipment. c. Apply clean gloves. d. Pour antiseptic solution over cotton balls (unless kit contains prepared antiseptic towelettes). e. Open specimen container, maintaining sterility of inside specimen container, and place cap with sterile inside up. Do not touch inside of cap or container. f. Use aseptic technique to help patient or allow patient to independently clean perineum and collect specimen. Amount of help needed varies with each patient. Inform patient that antiseptic solution will feel cold. Maintains patient's dignity and comfort. (1) Male: (a) Hold penis with one hand; using circular motion and antiseptic towelette, clean meatus, moving from center to outside 3 times with different towelettes (see illustration). Have uncircumcised male patient retract foreskin for effective cleaning of urinary meatus and keep retracted during voiding. Return foreskin when done. (b) If agency procedure indicates, rinse area with sterile water and dry with cotton balls or gauze pad. (c) After patient initiates urine stream into toilet or bedpan, have him pass urine specimen container into stream and collect 90 to 120 mL of urine (Pagana and Pagana, 2015) (see illustration). (2) Female: (a) Either nurse or patient spreads labia minora with fingers of nondominant hand. Provides access to urethral meatus. (b) With dominant hand clean urethral area with antiseptic swab (cotton ball or gauze). Move from front (above urethral orifice) to back (toward anus). Use fresh swab each time; clean 3 times; begin with labial fold farthest from you, then labial fold closest, and then down center (see illustration). (c) If agency procedure indicates, rinse area with sterile water and dry with cotton ball. (d) While continuing to hold labia apart, patient initiates urine stream into toilet or bedpan; after stream is achieved, pass specimen container into stream and collect 90 to 120 mL of urine (Pagana and Pagana, 2015) (see illustration). g. Remove specimen container before flow of urine stops and before releasing labia or penis. Patient finishes voiding into bedpan or toilet. Offer to help with personal hygiene as appropriate. h. Replace cap securely on specimen container, touching only outside. i. Clean urine from exterior surface of container.
how to irrigate a wound
1. Perform hand hygiene. 2. Form cuff on waterproof biohazard bag and place near bed. 3. Apply gown, mask, goggles as indicated; apply clean gloves and remove old dressing. 4. Discard old dressing and gloves in biohazard bag. Perform hand hygiene. 5. Apply clean or sterile gloves (check agency policy). Perform wound assessment and examine recent charted assessment of patient's open wound. 6. Expose area near wound only. 7. Irrigate wound with wide opening: a. Fill 35-mL syringe with irrigation solution. b. Attach 19-gauge angiocatheter. c. Hold syringe tip 2.5 cm (1 inch) above upper end of wound and over area being cleaned. d. Using continuous pressure, flush wound; repeat Steps 7a to 7c until solution draining into basin is clear. 8. Irrigate deep wound with very small opening: a. Attach soft catheter to filled irrigation syringe. b. Gently insert tip of catheter into opening about 1.3 cm (0.5 inch). c. Using slow, continuous pressure, flush wound. d. While keeping catheter in place, pinch it off just below syringe. e. Remove and refill syringe. Reconnect to catheter and repeat until solution draining into basin is clear. 9. Clean wound with handheld shower: a. With patient seated comfortably in shower chair or standing if condition allows, adjust spray to gentle flow; make sure that water is warm. b. Shower for 5 to 10 minutes with shower head 30 cm (12 inches) from wound. 10. When indicated, obtain cultures after cleaning with nonbacteriostatic saline. 11. Dry wound edges with gauze; dry patient after shower. 12. Remove and dispose of gloves. Perform hand hygiene. Apply clean or sterile gloves (see agency policy). Apply appropriate dressing and label with time, date, and nurse's initials. 13. Remove mask, goggles, and gown. 14. Dispose of equipment and soiled supplies; remove and dispose of gloves. Perform hand hygiene. 15. Help patient to comfortable position.
how to use an incentive spirometers
1. Position patient in most erect position (e.g., high-Fowler's if tolerated) in bed or chair. 2. Instruct patient to hold IS upright, exhale normally and completely through mouth, and place lips tightly around mouthpiece 3. Instruct patient to take a slow, deep breath and maintain constant flow, like pulling through a straw. If flow-oriented IS, inhalation should raise the ball. If volume-oriented IS, inhalation should raise the piston. Remove mouthpiece at point of maximal inhalation; then have patient hold his or her breath for 3 seconds and exhale normally. 4. Have patient repeat maneuver, encouraging him or her to reach prescribed goal. 5. Encourage patient to independently use IS at prescribed frequency.
Insertion Nasogastric Tube for Gastric Decompression
1. Position patient upright in high-Fowler's position unless contraindicated. If patient is comatose, raise head of bed as tolerated in semi-Fowler's position with head tipped forward, chin to chest. 2. Place bath towel over patient's chest; give facial tissues to patient. Allow to blow nose if necessary. Place emesis basin within reach. 3. Pull curtain around bed or close room door. 4. Wash bridge of nose with soap and water or alcohol swab. Dry thoroughly. 5. Stand on patient's right side if right-handed, left side if left-handed. Lower side rail. 6. Instruct patient to relax and breathe normally while occluding one naris. Then repeat this action for other naris. Select nostril with greater airflow. 7. Measure distance from tip of patient's nose to earlobe to xiphoid process of sternum (see illustration). 8. With small piece of tape placed around tube, mark length that will be inserted. 9. Prepare materials for tube fixation. Tear off a 7.5-10 cm (3-4 inch) length of hypoallergenic tape or open membrane dressing or other fixation device (see Step 24a[2]). 10. Perform hand hygiene and apply clean gloves. 11. Apply pulse oximetry/capnography device and measure vital signs. Monitor oximetry/capnography during insertion. 12. Option: Dip tube with surface lubricant into glass of room temperature water or lubricate 7.5-10 cm (3-4 inches) end of tube with water-soluble lubricant (see manufacturer directions). 13. Hand an alert patient a cup of water if able to hold cup and swallow. Explain that you are about to insert tube. 14. Explain next steps. Insert tube gently and slowly through naris to back of throat (posterior nasopharynx). Aim back and down toward patient's ear. 15. Have patient relax and flex head toward chest after tube is passed through nasopharynx. 16. Encourage patient to swallow by taking small sips of water when possible. Advance tube as patient swallows, Rotate tube gently 180 degrees while inserting. 17. Emphasize need to mouth breathe during procedure. 18. Do not advance tube during inspiration of coughing because it will likely enter respiratory tract. Monitor oximetry/capnography. 19. Advance tube each time patient swallows until you reach desired length. 20. Using penlight and tongue blade, check to be sure that tube is not positioned in back of throat. 21. Temporarily anchor tube to nose with small piece of tape. 22. Verify tube placement. Check agency policy for recommended methods of checking tube placement. a. Follow order for bedside x-ray film and notify radiology for examination of chest and abdomen. b. While waiting for x-ray film to be performed, follow these procedures: Attach Asepto or catheter-tipped syringe to end of tube. Aspirate gently back on syringe to obtain gastric contents, observing amount, color, and quality of return (see illustration). c. Use pH test paper to measure aspirate for pH with color-coded pH paper. Be sure that paper range of pH is at least from 1.0 to 11.0 (see illustration). 23. Anchor tube with a fixation device, avoiding pressure on the nares. Select one of the following fixation methods. a. Apply tape. (1) Apply tincture of benzoin or other skin adhesive on bridge of patient's nose and allow it to become "tacky." (2) Tear small horizontal slits at and length of tape without splitting tape (see illustration). Fold middle sections toward one another to form a closed strip. (3) Print date and time on tape and place top end of tape over bridge of patient's nose. (4) Wrap bottom end of tape around tube as it exits nose (see illustration). b. Apply tube fixation device using shaped adhesive patch (see manufacturer directions). (1) Apply wide end of patch to bridge of nose (see illustration). (2) Slip connector around tube as it exits nose (see illustration). 24. Fasten end of nasogastric tube to patient's gown with piece of tape (see illustration). Do not use safety pins to fasten tube to gown. 25. Keep head of bed elevated at least 30 degrees (preferably 45 degrees) unless contraindicated (Metheny and Franz, 2013). 26. Assist radiology as needed in obtaining ordered x-ray film of chest and abdomen. 27. Remove gloves, perform hand hygiene, and help patient to comfortable position. 28. Once placement is confirmed, measure amount of tube that is external and mark exit of tube at nares with indelible marker as guide for any tube displacement. Record this information in nurses' notes in electronic health record (EHR) or chart. 29. Attach NG tube to suction as ordered.
Administering Central Parenteral Nutrition
1. Perform hand hygiene. 2. Check label on bag with health care provider's order on MAR or computer printout and patient's name. Also check any additives and note solution expiration date. 3. Inspect 2 : 1 solution for particulate matter; inspect 3 : 1 solution for separation of fat into layer. 4. Before leaving medication room, check IV solution second time using six rights of medication administration. Check label of bag against MAR or computer printout. 5. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's MAR or medical record. 6. Take solution to patient in advance of previous solution emptying. Compare names of solution and additives with MAR at bedside. 7. Apply clean gloves. Prepare IV tubing for solution: a. Attach appropriate filter to IV tubing. b. Prime tubing with solution, making sure that no air bubbles remain, and turn off flow with roller clamp. Some infusion pumps and IV tubing require that priming be done on pump rather than by gravity. 8. Wipe end port of central vascular access device (CVAD) with alcohol swab, allow to dry, then attach syringe of 0.9% normal saline (NS) solution to needleless port, aspirate for blood return, and flush saline per agency policy. 9. Remove syringe. Connect Luer-Lok end of IV tubing to end port of CVAD; for multilumen lines label tubing used for it. 10. Place IV tubing in EID. Open roller clamp. Set and regulate flow rate as ordered. a. Continuous infusion (optional): Flow rate is immediately set at ordered rate and given over 24-hour period. b. Cycle infusion (optional): Flow rate is initiated at about 40 to 60 mL/hr, and the rate is gradually increased until patient's nutritional needs are met. Before completion of infusion, rate is decreased at about the same milliliter per hour until it is completed. The infusion is usually given over a shorter time frame (12 to 18 hours). 11. Infuse all IV medications or blood through alternative IV site or multilumen device. Do not obtain blood samples or central venous pressure readings through same lumen used for it. 12. Do not interrupt infusion (e.g., during showers, transport to procedure, blood transfusion) and be sure that rate does not exceed ordered rate. 13. Solution containing dextrose and amino acids alone or with fat emulsion added as a 3 : 1 formulation should have a hang time not to exceed 24 hours. Fat emulsions alone should have a hang time not to exceed 12 hours. 14. Change IV administration sets for it every 24 hours and immediately on suspected contamination. Discard used supplies and perform hand hygiene.
Administering Peripheral Parenteral Nutrition With Lipid (Fat) Emulsion
1. Perform hand hygiene. 2. Compare label of bag and bottle with MAR or computer printout; check for correct additives and solution expiration date. Also check patient's name. 3. Examine solution for separation of it into layers or globules or presence of froth. 4. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. Compare identifiers with information on patient's MAR or medical record. 5. Compare identifiers with information on solution bag label and patient's MAR or medical record at the bedside. 6. Measure patient's vital signs. 7. Apply clean gloves. Prepare IV tubing for solution; run solution through tubing to remove excess air. Turn roller clamp to "off" position. Some infusion pumps and tubing require priming through infusion pump. Add sterile capped needle or place sterile cap on end of tubing. Follow same procedure with separate infusion set for infusion. 8. Wipe end port of peripheral IV infusion tubing with antimicrobial swab and allow to dry. Connect needleless connector at end of tubing to end port of patient's functional peripheral IV line. Gently disconnect old tubing from IV site and insert adapter of new infusion tubing. Open roller clamp on new tubing. Allow solution to run to ensure that tubing is patent; regulate IV drip rate using electronic infusion pump. 9. Clean needleless peripheral line tubing injection cap with antimicrobial swab. 10. Attach it to infusion tubing to injection cap of IV line. Y-connector may be used if patient is receiving separate ____________________ and ____________________ infusions. Label tubing. 11. Open roller clamp completely on infusion and check flow rate on infusion pump. 12. Infuse lipids initially at 1 mL/min for adults and 0.1 mL/min for child for first 15 to 30 minutes; increase rate as ordered. 13. Begin at ordered rate. 20% fats are infused over at least 8 hours. All can hang for 12 hours as a separate infusion. 14. Remove and discard gloves and supplies and perform hand hygiene.
Making an Unoccupied Bed
1. Perform hand hygiene. Arrange supplies at beside. 2. Assess environment for safety (e.g., check room for spills; make sure that equipment is working properly and that bed is in locked, low position). 3. Pull room divider curtain or close room door to provide privacy. Follow steps for transferring patient to bedside chair or recliner (see Chapter 11). 4. Lower remaining side rails on bed and raise bed to comfortable working position. 5. Apply clean gloves if linen is soiled with body fluids. Remove all linen, hold away from uniform, and place in laundry bag. Avoid shaking or fanning linen. 6. Straighten mattress and wipe off any moisture with a washcloth moistened in antiseptic solution (consult agency housekeeping guidelines). Dry thoroughly. 7. Apply all bottom linen on one side of bed before moving to opposite side. a. For fitted sheet: Make sure that fitted sheet is placed smoothly over mattress and top and bottom mattress edge. Fit corners on one end and then the other. b. For flat sheet: Place sheet over mattress. Allow about 25 cm (10 inches) to hang over side mattress edge. Lower hem of sheet should lie seam down, even with bottom edge of mattress. Pull remaining top part of sheet over top edge of mattress. While standing at head of bed, miter top corner of bottom sheet (see Procedural Guideline 18.6, Step16a-f). Tuck remaining part of flat bottom sheet under mattress. c. Optional: Apply drawsheet and/or waterproof pad laying centerfold along middle of bed lengthwise. Smooth drawsheet/pad over mattress. Tuck excess edge of drawsheet under mattress, keeping palms down. 8. Move to opposite side of bed. Repeat Step 7. 9. Place top sheet over bed with vertical centerfold lengthwise down middle of bed. Open sheet out from head to foot, being sure that top edge of sheet is even with top edge of mattress. Optional: Spread a blanket or bedspread evenly over top sheet in same fashion. 10. Standing on one side at foot of bed, lift mattress corner slightly with one hand and with other hand tuck top sheet and blanket or spread under mattress. 11. Make modified mitered corner with top sheet, blanket, and spread. After making triangular fold, leave tip of triangle untucked (see Procedural Guideline 18.6, Step 36). 12. Make cuff by turning edge of top sheet down over top edge of blanket and spread. 13. Standing on one side at foot of bed, lift mattress corner slightly with one hand and with other hand tuck top sheet, blanket, and spread under mattress. Be sure that toe pleats are not pulled out. 14. Make modified mitered corner with top sheet, blanket, and spread. After making triangular fold, do not tuck tip of triangle (see Procedural Guideline 18.6, Step 36). 15. Go to other side of bed. Spread sheet, blanket, and spread out evenly. Make cuff with top sheet and blanket (closed bed). Make modified corner at foot of bed. Alternatively, fanfold sheet, blanket, and spread at foot of bed, with top layer ready to be pulled up (this leaves an open bed). Optional: Make horizontal toe pleat; stand at foot of bed and fanfold in sheet 5 to 10 cm (2 to 4 inches) across bed. Pull sheet up from bottom to make fold approximately 15 cm (6 inches) from bottom edge of mattress. 16. Apply clean pillowcase. 17. Place call light within patient's reach on bedrail or pillow and return bed to lowest position, allowing for patient transfer. Help patient to bed. 18. Place linen bag in dirty laundry bag. Remove and dispose of gloves. 19. Arrange and organize patient's room and perform hand hygiene.
Changing Infusion Tubing
1. Perform hand hygiene. Open new infusion set and connect add-on pieces (e.g., filters, extension tubing) using aseptic technique. Keep protective coverings over infusion spike and distal adapter. Place roller clamp about 2-2.5 cm (1-2 inches) below drip chamber and move roller clamp to "off" position. Secure all connections. 2. Apply clean gloves. If patient's IV cannula hub is not visible, remove IV dressing (see Skill 29.5). Do not remove tape securing cannula to skin. 3. Prepare IV tubing with new IV container. 4. Prepare IV tubing with existing continuous IV infusion bag. a. Move roller clamp on new IV tubing to "off" position. b. Slow rate of infusion through old tubing to keep vein open (KVO) rate using EID or roller clamp. c. Compress and fill drip chamber of old tubing. d. Invert container and remove old tubing. Keep spike sterile and upright. e. Insert spike of new infusion tubing into solution container. Hang solution bag on IV pole, compress drip chamber on new tubing, and release, allowing it to fill one-third to one-half full. f. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end of tubing and slowly open roller clamp to allow solution to flow from drip chamber to distal end of IV tubing. If tubing has Y connector, invert Y connector when solution reaches it to displace air. Return roller clamp to "off" position after priming tubing (filled with IV solution). Replace protective cover on end of IV tubing. Place end of adapter near patient's IV site. g. Stop EID or turn roller clamp on old tubing to "off" position. Prevents fluid spillage. 5. Prepare tubing with extension set or saline lock. a. If short extension tubing is needed, use sterile technique to connect new injection cap to new extension set or IV tubing. b. Scrub injection cap with antiseptic swab for at least 15 seconds and allow to dry completely. Attach syringe with 3 to 5 mL of NS flush solution and inject through injection cap into extension set. 6. Reestablish infusion. a. Gently disconnect old tubing from extension tubing (or from IV catheter hub) and quickly insert Luer-Lok end of new tubing or saline lock into extension tubing connection (or IV catheter hub) (see illustrations for example of connecting tubing to short extension set). b. For continuous infusion, open roller clamp on new tubing and regulate drip rate using roller clamp or insert tubing into EID, program to desired rate, and push on. c. Attach piece of tape or preprinted label with date and time of IV tubing change onto tubing below drip chamber. d. Form loop of tubing and secure it to patient's arm with strip of tape. 7. Remove and discard old IV tubing. If necessary, apply new dressing. Remove and dispose of gloves. Perform hand hygiene. 8. Teach patient how to move and turn properly with IV tubing.
Friction and Shear
1. Problem: Requires moderate-to-maximum help to move. Complete lifting without sliding against sheets impossible Frequently slides down in bed or chair; repositioning with maximal help Spasticity, contractions, or agitation leads to almost constant friction 2. Potential problem: Moves feebly or requires minimal help. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down 3. No apparent problem: Moves in bed and chair independently and has sufficient muscle strength to sit up completely during move. Maintains good position in bed or chair
Regulating Intravenous Flow Rates
1. Regulate gravity infusion 2. Regulate EID 3. Attach label to IV solution container with date and time container changed (check agency policy). 4. Teach patient purpose of EID if infusion therapy is delivered by EID, purpose of alarms, to avoid raising hand or arm that affects flow rate, and to avoid touching control clamp. 5. Remove and dispose of any used supplies; perform hand hygiene.
Regulating Intravenous Flow Rates Pre-assessments
1. Review accuracy and completeness of health care provider order in patient's medical record for patient name and correct solution: type, volume, additives, infusion rate, and duration of IV therapy. Follow six rights of drug administration 3. Apply clean gloves; inspect and gently palpate skin around and above IV site over dressing. Ask patient how IV site feels. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing). Dispose of gloves; perform hand hygiene. 4. Check IV system for patency from IV container to insertion site. 5. Identify patient risk for fluid and electrolyte imbalance given type of IV solution (e.g., neonate, history of cardiac or renal disease). 6. Check patient's knowledge of how positioning of IV site affects flow rate.
Changing Intravenous Solutions Pre-assessments
1. Review accuracy and completeness of health care provider's order in patient's medical record for patient name and correct solution: type, volume, additives, rate, and duration of IV therapy. Follow rights of drug administration 2. Note date and time when IV tubing and solution were last changed. 3. Determine patient understanding of need for continued IV therapy. 4. Perform hand hygiene and apply clean gloves; inspect and gently palpate skin around and above IV site over dressing. Assess VAD for patency and signs and symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or leaking under dressing). 5. Check infusion system from solution container down to VAD insertion site for integrity, including but not limited to discoloration, cloudiness, leakage, expiration date. Determine compatibility of all IV solutions and additives by consulting approved online database, drug reference, or pharmacist. Discard gloves and perform hand hygiene. 6. Check pertinent laboratory data such as potassium level.
Insertion of a Short-Peripheral Intravenous Device Pre-assessments
1. Review accuracy of health care provider's order: date and time, IV solution, route of administration, volume, rate, duration, and signature of ordering health care practitioner. Follow rights of medication administration. a. Check approved online database, drug reference book, or pharmacist about IV solution composition, purpose, potential incompatibilities, adverse reactions, and side effects. 3.Check patient's knowledge of procedure, reason for prescribed therapy, and arm placement preference. 4. Check for clinical factors/conditions that will respond to or be affected by administration of IV solutions. a. Body weight b. Clinical markers of vascular volume c. Clinical markers of interstitial volume d. Thirst e. Behavior and level of consciousness 4. Determine if patient is to undergo any planned surgeries or procedures. 5. Check available laboratory data (e.g., hematocrit, serum electrolytes, arterial blood gases, and kidney functions [blood urea nitrogen, urine specific gravity, and urine osmolality]). 6. Check patient's history of allergies, especially to iodine, adhesive, or latex.
Procedural Steps for CPM
1. Review medical record and assess nature of patient's condition and ROM limits prescribed by health care provider. Be sure that order designates cycles per minute and time on machine. 2. Assess CPM machine for electrical safety. If you suspect a problem, notify the electrical safety department in your agency. 3. Assess setup of machine before placing on bed: check stability of frame, flexion/extension controls, padding of exposed metal parts or hard surfaces, and on/off switch. 4. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2016). 5. Perform hand hygiene. 6. Establish a baseline by assessing patient's pain on a scale of 0 to 10 (10 being the worst pain) before and during use. 7. Assess patient's heart rate, blood pressure, and respirations to establish baseline for exercise tolerance. 8. Assess patient's knowledge about CPM and ability and willingness to learn about the CPM machine. 9. Explain procedure and demonstrate CPM machine, turning machine on for patient to observe a cycle before placing on bed. 10. Help patient to comfortable supine position. Before placing patient in a CPM device, attend to his or her elimination needs and, if ordered, provide an analgesic 30 minutes before a new treatment begins. 11. Apply clean gloves if wound drainage is present. 12. Place elastic compression stockings on patient (if ordered) to promote venous return (see Procedural Guideline 12.3). 13. Place CPM machine on bed. Set limits of flexion and extension as ordered. Set speed control to slow or moderate range as ordered; turn machine on for it to run one full cycle. 14. Stop CPM machine when in extension. Place padding on CPM machine. 15. Support patient's affected joint while placing extremity in CPM machine frame. 16. Adjust CPM machine to patient's extremity. Lengthen and shorten appropriate sections of frame while centering patient's extremity on it. Align patient's joint with mechanical joint of CPM. 17. Secure patient's extremity on CPM machine with Velcro straps (see illustration). Apply loosely. image STEP 17 Patient's extremity properly placed and secured on CPM machine. 18. Press power switch to start machine. When it reaches flexed position, stop it and check degree of flexion. Then observe patient and affected extremity for two full cycles. 19. Ask if patient feels comfortable; evaluate pain severity on pain scale. 20. Be sure that CPM on/off power switch is within patient's reach. Instruct patient to turn CPM machine off if malfunctioning or if he or she is experiencing pain. Instruct him or her to notify nurse immediately. 21. Discard gloves and perform hand hygiene. 22. Use Teach-Back: "I want to be sure you understand what the CPM machine is supposed to do for you. In your own words, tell me the purpose of the CPM machine." Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly. 23. Inspect bony prominences and areas of skin in contact with machine at least every 2 hours; looking for breakdown. 24. Check patient's alignment and positioning at least every 2 hours. 25. Continue to evaluate patient for presence of pain. If patient is on a continuous cycle, provide analgesic at next scheduled dose. 26. Observe patient and CPM machine with each increase in flexion and extension. 27. Record in the nurses' notes in electronic health record (EHR) or chart patient's tolerance for CPM machine, rate of cycles per minute, degree of flexion and extension used, condition of extremity and skin, condition of operative site if present, and length of time CPM machine is in use. 28. Report immediately to nurse in charge or health care provider any resistance to ROM; increased pain; swelling, heat, or redness in joint.
Making an Occupied Bed
1. Review medical record and assess restrictions in mobility/positioning of patient. 2. Organize supplies and close room door or divider curtain to provide privacy. 3. Assess environment for safety (e.g., check room for spills; make sure that equipment is working properly and that bed is in locked position and appropriate number of side rails are raised). 4. Perform hand hygiene. Apply clean gloves if patient has been incontinent or if drainage is present on linen. 5. Explain procedure to patient, noting that patient will be asked to turn over layers of linen. 6. Raise bed to a comfortable working height; lower head of bed (HOB) as tolerated, keeping patient comfortable. Remove call light. 7. Lower side rail on side where you are standing. Loosen all top linen. Remove bedspread and blanket separately, leaving patient covered with top sheet. If blanket or spread is soiled, place in linen bag. If to be reused, fold into square and place over back of chair. 8. Cover patient with clean bath blanket by unfolding it over top sheet. Have patient hold top edge of bath blanket or tuck blanket under shoulders. Grasp top sheet under bath blanket at patient's shoulders and bring sheet down to foot of bed. Remove sheet and discard in dirty laundry bag. 9. Position patient on far side of bed, turned onto side and facing away from you. NOTE: This is when another caregiver can help you by standing at bedside across from you. Encourage patient to use side rail to turn. Adjust pillow under patient's head. 10. Assess to make sure that there is no tension on any external medical devices. 11. Loosen bottom linens, moving from head to foot. Fanfold or roll any cloth pads, drawsheet (if present), and bottom sheet (in that order) toward patient. Tuck edges of old linen just under patient's buttocks, back, and shoulders (see illustration). Do not fanfold mattress pad (if it is to be reused). Remove any disposable pads and discard in receptacle. 12. Clean, disinfect, and dry mattress surface if it is soiled or has moisture (see agency policy). 13. Apply clean linens to the exposed half of bed in separate layers. When needed, start with a new mattress pad by placing it lengthwise with center crease in middle of bed. Fanfold pad to center of bed alongside patient. Repeat process with bottom sheet. 14. Pull new fitted sheet smoothly over mattress corner at top and bottom of bed. If using a flat sheet, allow edge of sheet to hang about 25 cm (10 inches) over mattress edge at head of bed. Be sure that lower hem of bottom flat sheet lies seam down and with bottom edge of mattress. 15. If bottom sheet is flat, miter top corner at HOB. Face HOB diagonally. Place hand away from HOB under top corner of mattress, lift, and with other hand tuck edge of bottom sheet smoothly under mattress so side edges of sheet above and below mattress meet when brought together. 16. If bottom sheet is flat, miter top corner at HOB. a. Face HOB diagonally. Place hand away from HOB under top corner of mattress, near mattress edge, and lift. b. With other hand, tuck top edge of bottom sheet smoothly under mattress so side edges of sheet above and below mattress meet when brought together. c. To miter a corner, pick up top edge of sheet at about 45 cm (18 inches) from top end of mattress (see illustration). d. Lift sheet and lay it on top of mattress to form a neat triangular fold with lower base of triangle even with mattress side edges (see illustration). e. Tuck lower edge of sheet, which is hanging free below the mattress, under the mattress. Tuck with palms down, without pulling triangular fold. f. Hold part of sheet covering side of mattress in place with one hand (see illustrations). With other hand pick up top of triangular linen fold and bring it down over side of mattress. Tuck under mattress with palms down without pulling fold (see illustration). 17. Tuck remaining part of sheet under mattress, moving toward foot of bed. Keep linen smooth. 18. Place new drawsheet along middle of bed lengthwise. Fanfold or roll drawsheet on top of clean bottom sheet. Tuck under patient's buttocks and torso without touching old linen. 19. Add waterproof pad (absorbent side up) over drawsheet with seam side down. Fanfold toward patient. Continue to keep clean and soiled linen separate. Also keep linen under patient as flat as possible because patient will need to roll over old and new layers of linen when you are ready to make other side of bed. 20. Advise patient that he or she will be rolling over a thick layer of linens. Keeping patient covered; ask him or her to roll toward you slowly over layers of linen and to not raise the hips (see illustration). Stress the need to roll while staying aligned. 21. You will now raise side rail and move to opposite side of bed. Option: The caregiver helping you will help position patient. Have patient roll away from you toward other side of bed, over all of the folds of linen. Again have patient keep hips still. 22. Loosen edges of soiled linen from under mattress. Remove soiled linen by folding into a bundle or square. 23. Hold linen away from your body and place it in laundry bag. 24. Clean, disinfect, and dry other half of mattress as needed. 25. Pull clean, fanfolded or rolled mattress pad; sheet; drawsheet; and pad out from beneath patient toward you. Smooth all linen out over mattress from head to foot of bed. Help patient roll back to supine position and reposition pillow. 26. If bottom sheet is fitted, pull corners over mattress edges. If flat sheet is used, miter top corner of bottom flat sheet (see Steps 16a-f). 27. Facing side of bed, grasp remaining edge of bottom flat sheet. Lean back slightly, keep back straight, and pull while tucking excess linen under mattress from HOB to foot of bed. Avoid lifting mattress during tucking. 28. Smooth fanfolded drawsheet over bottom sheet (tucking is optional). Smooth waterproof pads, making sure that bed surface is wrinkle free. 29. Place top sheet over patient with vertical centerfold lengthwise down middle of bed and with seam side of hem facing up. Open sheet out from head to foot and unfold over patient. Be sure that top edge of sheet is even with top edge of mattress. 30. Place clean or reused bed blanket on bed over patient. Make sure that top edge is parallel with top edge of sheet and 15 to 20 cm (6 to 8 inches) from edge of top sheet. Raise side rail. 31. Go to other side of bed. Lower side rail. Spread sheet and blanket out evenly. 32. Have patient hold onto sheet and blanket while you remove bath blanket; discard in linen bag. 33. Make cuff by turning edge of top sheet down over top edge of blanket. 34. Make horizontal toe pleat; stand at foot of bed and fanfold in sheet and blanket 5 to 10 cm (2 to 4 inches) across bed. Pull sheet and blanket up from bottom to make fold approximately 15 cm (6 inches) from bottom edge of mattress. 35. Standing at side of bed, tuck in remaining part of sheet and blanket under foot of mattress. Tuck top sheet and blanket together. Be sure that toe pleats are not pulled out. 36. Make modified mitered corner with top sheet and blanket. Follow Steps 16a-f). After making triangular fold, do not tuck tip of triangle 37. Go to other side of bed. Repeat Steps 35 and 36. 38. Change pillowcase. Have patient raise head. While supporting neck with one hand, remove pillow. Allow patient to lower head. Remove soiled case and place in linen bag. Grasp clean pillowcase at center of closed end. Gather case, turning it inside out over the hand holding it. With the same hand, pick up middle of one end of pillow. Pull pillowcase down over pillow with other hand. Do not hold pillow against your uniform. Be sure that pillow corners fit evenly into corners of case. Reposition pillow under patient's head. 39. Place call light within patient's reach on bedrail or pillow; return bed to locked, low position; and raise side rail (as needed). 40. Place all linen in dirty laundry bag. Remove and dispose of gloves. 41. Arrange and organize patient's room and perform hand hygiene. 42. During procedure inspect skin for areas of irritation. Observe patient for signs of fatigue, dyspnea, pain, or other sources of discomfort.
Five Rights of Delegation
1. Right Direction/Communication-Clear, concise, correct, and complete initial and ongoing directions. (Include time, expectations, follow-up communication etc.) 2. Right Supervision-Oversee assigned/delegated tasks (Huddles/checkpoints - solicit team members opinion; credit team for accomplishments 3. Right Circumstances-Long term vs. acute vs home health? -Knowledge and skill of delegatee -Verification of clinical competence -Stability of patient's condition -Availability of resources (including human) 4. Right Task-Is it safe to delegate? Requires little supervision 5. Right Person-License, certification and role description; strengths, experience, competence?
6 rights of medication administration
1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation
Starting and IV Implementation
1. Swabs injection cap and primes saline lock leaving syringe attached. Loosens protector cap (maintain sterility). Removes over needle catheter (ONC) and transparent dressing from wrappers. 2. Applies tourniquet 4 - 6 inches above selected site (check radial pulse) and assesses vein for appropriateness. If need additional prep time may release tourniquet temporarily. 3. Applies clean gloves 4. Moves saline lock nearby, on over-the-bed table, maintaining in sterile package. 5. Cleanses site with Chlorhexidine - using friction horizontal, vertical, and circular. Cleanse for at least 30 seconds and allow site to completely dry. Do not touch site! 6. Performs venipuncture: Anchors vein 1.5-2 inches below insertion site by gently stretching the skin against the direction of insertion site. Be sure not to touch the cleansed site or allow the ONC to touch the anchoring thumb; advises patient to remain still and that there will be a quick stick; inserts ONC with bevel up at 10-30 ° angle in the direction parallel to the vein. 7. Observes for blood return. Lowers needle and advances 1/4 inch. 8. Continues to hold skin and advances catheter all the way to hub without advancing the stylet/needle. Stabilizes catheter with one hand and releases tourniquet with the other hand. (Push and pop) 9. Apply gentle/firm pressure 1 1⁄4 inch above insertion site and removes stylet/needle of ONC. Disposes of stylet in sharps container if close or temporarily places on bedside table away from patient. 10. Removes cap and maintains sterility; quickly connects end of saline lock to catheter. Secures temporarily with tape. 11. Reassesses for blood return with gentle aspiration and flushes the vein with remaining saline, observing site for swelling. Removes flush syringe and places in sharps container. 12. Applies a sterile transparent dressing up to the hub of the catheter (leave connection below the extension set and hub uncovered) without touching under the dressing. 13.. Secures IV and IV tubing (Does not place tape under or over the transparent dressing). Allow saline lock tubing to assume a natural position prior to taping. 14. Disposes of equipment safely. Properly removes and disposes of gloves. 15. Writes date, time, gauge, and initials on tape/label before applying to edge of dressing. 16. Repositions patient for comfort and safety (lowers bed/raises siderail). Instructs patient how to prevent dislodging IV and s/s of IV related complications. (See book/video) 17. Performs hand hygiene. 18. Documentation: states date, time, describes location, # attempts, catheter gauge and length, patient tolerance, presence of saline lock or flow rate and method of infusion if fluids are prescribed.
TJC Guidelines for restraint orders
1. To ensure the immediate physical safety of the patient, a staff member, or others. 2. When less restrictive interventions have been ineffective. 3. In accordance with a written modification to the patient's plan of care. 4. When it is the least restrictive intervention that will be effective to protect the patient, staff members, or others from harm. 5. In accordance with safe and appropriate restraint techniques as determined by hospital policies. 6. It is discontinued at the earliest possible time.
Official "Do Not Use" list
1. U, u (unit) Mistaken for "0" (zero), the number "4" (four), or "cc" Write "unit" 2. IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write "International Unit" 3. Q.D., QD, q.d., qd (daily) Mistaken for one another Write "daily" 4. Q.O.D., QOD, q.o.d, qod (every other day) Period after the Q mistaken for "I" and the "O" mistaken for "I" Write "every other day" 5. Trailing zero (X.0 mg) Decimal point is missed Write X mg 6. Lack of leading zero (.X mg) Write 0.X mg 7. MS Can mean morphine sulfate or magnesium sulfate Write "morphine sulfate" 8. MSO4 and MgSO4 Confused for one another Write "magnesium sulfate"
how to give a Change of Shift Report
1. Use an organized format for delivering report that provides a description of patient needs and problems. SBAR (Situation, Background, Assessment, Recommendation) can be used to organize and streamline report. 2. Identify the electronic patient record using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. 3. Gather information from documentation sources, NAP report, or other relevant documents. 4. Prioritize information on the basis of patient's needs and problems. 5. For each patient include the following: S Situation: Patient's name, gender, age, chief complaint on admission, and current situation B Background information: Allergies, emergency code status (i.e., do not resuscitate [DNR]), medical and surgical histories, special needs as related to any physical challenges (e.g., blind, hearing deficit, amputee), and vaccinations A Assessment data: Objective observations and measurements made by the nurse during the shift; emphasis on any recent changes. Include any relevant information reported by patient, family caregiver, or health care team members such as laboratory data and diagnostic test results. Include therapies or treatments administered during shift and expected outcomes (e.g., medication changes, use of oxygen, referral visits). Describe education given in the teaching plan and patient's/family caregiver's ability to demonstrate learning. Report on evaluation by explaining patient's response and whether outcomes are met. Review patient's progress toward discharge during each change-of-shift report. R Recommend: Explanation of the priorities to which oncoming nurse must attend, including referrals, nursing orders, and core measures. Ask staff from oncoming shift if they have any questions regarding information provided.
legal medication order
1. date: required for controlled substances a. Schedules III-V: valid for 6 months from date written b. Schedule II: valid for several days to 6 months depending on individual state regulations c. prescriptions for noncontrolled medications valid for one year from date of issuance (generally accepted practice) 2. name and address of patient a. required for controlled substances b. age and weight helpful for pediatric patients 3. superscription - Rx 4. inscription - drug name and strength 5. subscription - directions to pharmacist 6. signatura - directions to patient; transcribed by pharmacist onto label of dispensed medication 7. refill information a. Schedule II - no refills allowed b. Schedule III-V - maximum of 5 refills (or 6 months from date written, whichever comes first)c. no limit on refills of noncontrolled drugs in Alabama; however, after one year, prescription should be renewed. Other states do place limits on refills; "prn" (as needed) refills may not be allowed.
how to shave a patient
1. disposable razor: a. Place bath towel over patient's chest and shoulders. b. Run warm water in washbasin. Check water temperature. c. Place washcloth in basin and wring out thoroughly. Apply cloth over patient's entire face for several seconds. d. Apply approximately image inch shaving cream or soap to patient's face. Smooth cream evenly over sides of face, on chin, and under nose. e. Hold razor in dominant hand at 45-degree angle to patient's skin. Begin by shaving across one side of patient's face using short, firm strokes in direction that hair grows (see illustration). Use nondominant hand to gently pull skin taut while shaving. Ask patient if he feels comfortable. f. Dip razor blade in water because shaving cream accumulates on edge of blade. g. After all facial hair is shaved, rinse face thoroughly with warm, moistened washcloth. h. Dry face thoroughly and apply aftershave lotion if desired. Remove towel. 2. electric razor: a. Place bath towel over patient's chest and shoulders. b. Apply skin conditioner or preshave preparation. c. Turn razor on and begin by shaving across side of face. Gently hold skin taut while shaving over surface of skin. Use gentle downward stroke of razor in direction of hair growth. d. After completing shave, remove towel and apply aftershave lotion as desired unless contraindicated.
Changing a Short-Peripheral Intravenous Dressing
2. Remove existing dressing: TSM or Gauze 3. Assess VAD insertion site for signs and symptoms of IV-related complications. If complication exists, determine if VAD requires removal. Remove catheter if ordered by health care provider 4. If catheter is to remain in place, assess integrity of engineered stabilization device. Continue to stabilize catheter and remove as recommended by manufacturer directions for use. Inspect for signs of adhesive-related skin injury from adhesive-based engineered stabilization devices. NOTE: Some stabilization devices are designed to remain in place for length of time VAD is in as long as adequate stabilization is evident. 5. While stabilizing IV line, perform skin antisepsis to insertion site with CHG solution using friction in back-and-forth motion for 30 seconds and allow to dry completely. If using alcohol or povidone-iodine, clean in concentric circle, moving from insertion site outward with the swab. Allow antiseptic solution to dry completely. 6. Optional: Apply skin protectant to area where you will apply tape, dressing, or engineered stabilization device. Allow to dry. 7. While stabilizing catheter, apply sterile dressing over site (procedures differ; follow agency policy). a. TSM dressing b. Sterile gauze dressing 8. Option. Secure with new engineered catheter stabilization device 9. Remove and discard gloves and used equipment. Perform hand hygiene. 10. Optional: Apply site protection device (e.g., I.V. House Ultra Protective Dressing®). 11. Anchor extension tubing or IV tubing alongside dressing on arm and secure with tape directly over tubing. When using TSM dressing, avoid placing tape over dressing. 12. Label dressing per agency policy. Information on label includes date and time of IV insertion, VAD gauge size and length, and your initials. 13. Perform hand hygiene.
how to give feedings and medications through a feeding tube
3. Prepare formula for administration, following manufacturer guidelines. a. Have formula at room temperature. b. Use aseptic technique to connect tubing to container as needed. Use proper ENFit connecter and avoid handling feeding system or touching can tops, container openings, spike, and spike port. c. Shake formula container well. Clean top of canned formula with alcohol swab before opening it. d. For closed systems connect administration tubing to container. If using open system, pour formula from brick pack or can into administration bag (see illustration). image 4. Open roller clamp and allow administration tubing to fill. Clamp off tubing with roller clamp. Hang container on intravenous (IV) pole. 5. Place patient in high-Fowler's position or elevate head of bed at least 30 degrees (preferably 45 degrees). For patient forced to remain supine, place in reverse Trendelenburg's position, which raises head. 6. Verify tube placement (see Skill 32.2). Observe appearance of aspirate and note pH. a. Nasoenteric tube: Attach ENFit syringe and aspirate gastric contents. Observe appearance of aspirate and note pH. b. Gastrostomy tube: Attach ENFit syringe and aspirate gastric contents. Observe appearance of aspirate and note pH. c. Jejunostomy tube: Attach syringe and aspirate intestinal secretions. Observe appearance; if significant amounts are returned or resemble gastric secretions, check pH. 7. Check gastric residual volume (GRV) before each feeding (for bolus and intermittent feedings) and every 4 to 6 hours (for continuous feedings). a. Draw up 10 to 30 mL air into ENFit syringe and connect to end of feeding tube. Inject air slowly into tube. Pull back slowly and aspirate total amount of gastric contents you can aspirate. b. Return aspirated contents to stomach slowly unless volume exceeds 250 mL (see agency policy) (Metheny, 2010). c. GRVs in range of 200 to 500 mL should raise concern and lead to implementation of measures to reduce risk of aspiration. Automatic cessation of feeding shouldn't occur for GRV less than 500 mL in absence of other signs of intolerance. d. Flush feeding tube with 30 mL water.
care for a gastrotomy or jejunostomy tube
4. Remove old dressing. Fold dressing with drainage contained inside; remove gloves inside out over dressing. Discard in appropriate container. 5. Assess exit site for evidence of tenderness, leakage, swelling, excoriation, infection, bleeding, or excessive movement (more than image inch or 6 mm) of the tube in or out of the stomach. 6. Clean skin around stoma site with warm water and mild soap or saline (according to agency policy) with 4 × 4-inch gauze. (If drainage is present, apply clean gloves.) Clean starting next to the stoma site and work outwards using circular strokes. 7. Rinse and dry site completely. 8. Apply thin layer of protective skin barrier to exit site if indicated (e.g., site excoriated). 9. If dressing is ordered, place a drain-gauze dressing over external bar or disk. NOTE: Do not place dressing under external bar; this can cause gastric tissue erosion or internal abdominal wall pressure. 10. Secure dressing with tape. 11. Place date, time, and initials on new dressing. 12. Remove gloves and dispose of supplies in appropriate receptacle. Perform hand hygiene. 13. Evaluate condition of site routinely (see agency policy) 14. Document in nurse's notes in electronic health record (EHR) or chart appearance of exit site, drainage noted, and dressing application. 15. Report to health care provider any exit site complications.
vaginal
7. Have patient void (using bathroom facilities or bedpan). Help her lie in dorsal recumbent position. Patients with restricted mobility in knees or hips may lie supine with legs abducted. 8. Keep abdomen and lower extremities draped. 9. Be sure that vaginal orifice is well illuminated by room light. Otherwise position portable gooseneck lamp. 10. Insert vaginal suppository. a. Remove suppository from wrapper and apply liberal amount of water-soluble lubricant to smooth or rounded end (see illustration). Be sure that suppository is at room temperature. Lubricate gloved index finger of dominant hand. b. With nondominant gloved hand gently separate labial folds in front-to-back direction. c. With dominant gloved hand insert rounded end of suppository along posterior wall of vaginal canal the entire length of finger (7.5 to 10 cm [3 to 4 inches]) (see illustration). d. Withdraw finger and wipe away remaining lubricant from around orifice and labia with tissue or cloth. 11. Apply cream or foam. a. Fill cream or foam applicator following package directions. b. With nondominant gloved hand gently separate labial folds. c. With dominant gloved hand gently insert applicator approximately 5 to 7.5 cm (2 to 3 inches). Push applicator plunger to deposit medication into vagina (see illustration). d. Withdraw applicator and place on paper towel. Wipe off residual cream from labia or vaginal orifice with tissue or cloth. 12. Administer irrigation or douche. a. Place patient on bedpan with absorbent pad underneath. b. Be sure that irrigation or douche fluid is at body temperature. Run fluid through container nozzle (priming the tubing). c. Gently separate labial folds and direct nozzle toward sacrum, following floor of vagina. d. Raise container approximately 30 to 50 cm (12 to 20 inches) above level of vagina. Insert nozzle 7 to 10 cm (3 to 4 inches). Allow solution to flow while rotating nozzle. Administer all irrigating solution. e. Withdraw nozzle and help patient to comfortable sitting position. f. Allow patient to remain on bedpan for a few minutes. Clean perineum with soap and water. g. Help patient off bedpan. Dry perineal area. 13. Instruct patient who received suppository, cream, or tablet to remain on her back for at least 10 minutes. 14. If using an applicator, wash with soap and warm water, rinse, air dry, and then store for future use. 15. Offer perineal pad when patient resumes ambulation.
rectal
7. Help patient assume left side-lying Sims' position with upper leg flexed upward. 8. If patient has mobility impairment, help into lateral position. Obtain help to turn patient and use pillows under upper arm and leg. 9. Keep patient draped with only anal area exposed. 10. Examine condition of anus externally. Option: Palpate rectal walls as needed (e.g., if impaction is suspected) (see Chapter 6). If you palpate rectal walls, dispose of gloves by turning them inside out and placing them in proper receptacle if they become soiled. Otherwise keep gloves on your hands and proceed to Step 12. 11. Perform hand hygiene and apply new pair of clean gloves (if previous gloves were soiled and discarded). 12. Remove suppository from foil wrapper and lubricate rounded end with water-soluble lubricant. Lubricate gloved index finger of dominant hand. If patient has hemorrhoids, use liberal amount of lubricant and touch area gently. 13. Ask patient to take slow, deep breaths through mouth and relax anal sphincter. 14. Retract patient's buttocks with nondominant hand. With gloved index finger of dominant hand, insert suppository gently through anus, past internal sphincter, and against rectal wall, 10 cm (4 inches) in adults (see illustration) or 5 cm (2 inches) in infants and children. You should feel rectal sphincter close around your finger. 15. Option: A suppository may be given through a colostomy (not ileostomy) if ordered. Patient should lie supine. Use small amount of water-soluble lubricant for insertion. 16. Withdraw finger and wipe patient's anal area. 17. Ask patient to remain flat or on side for 5 minutes. 18. Discard gloves by turning them inside out and dispose of them and used supplies in appropriate receptacle. Perform hand hygiene. 19. If suppository contains laxative or fecal softener, place call light within reach so patient can obtain help to reach bedpan or toilet. 20. If suppository was given for constipation, remind patient not to flush commode after bowel movement.
ear (otic)
7. Position patient on side (if not contraindicated) with ear to be treated facing up, or patient may sit in chair or at bedside. Stabilize patient's head with his or her own hand. Option: Apply clean gloves if ear drainage present. 8. Straighten ear canal by pulling pinna up and back to 10 o'clock position (adult or child older than age 3) (see illustration) or down and back to 6 to 9 o'clock position (child under age 3). 9. If cerumen or drainage occludes outermost part of ear canal, wipe out gently with cotton-tipped applicator (see illustration). Take care not to force cerumen into canal. 10. Instill prescribed drops holding dropper 1 cm (image inch) above ear canal. 11. Ask patient to remain in side-lying position for a few minutes. Apply gentle massage or pressure to tragus of ear with finger (see illustration). 12. If ordered, gently insert part of cotton ball into outermost part of canal. Do not press cotton into canal. 13. Remove cotton after 15 minutes. Help patient to comfortable position after drops are absorbed.
PI(C)OT
= Comparison with the intervention (Does a comparison intervention exist? Which standard of care or current intervention do you usually now use in practice? practice?)
P(I)COT
= Intervention or issue of interest (Which intervention do you think is worthwhile to use in practice? It can be a treatment; a clinical, educational, or administrative intervention; a process of care, an education strategy; or an assessment approach)
PIC(O)T
= Outcome (that is MEASURABLE) (Which result do you wish to achieve or observe as a result of an intervention (e.g., change in patient's behavior, quality of life, physical finding, change in patient's perception, rate of adverse events, costs)?)
(P)ICOT
= Patient, population or problem (Identify your patients by age, gender, ethnicity, disease, or symptoms)
PICO(T)
= Time (an optional component for a clinical question) (How long does it take for an intervention to achieve outcome?)
colostomy
=A stoma in the large intestine or colon, which is usually placed in the descending colon and results in a stool similar to that normally passed through the rectum. -soft or formed stool
prn order
A medication can be ordered to be given only when a patient requires or requests it. You must assess a patient thoroughly to determine whether he or she needs the medication. This type of order usually has a minimum interval set for the time of administration.
Admission History
A nurse completes a comprehensive nursing history form or screen to gather baseline assessment data when a patient is admitted to a nursing care unit. You use the data to form a plan of care and compare it to any changes in a patient's condition. The nursing history guides the admitting nurse through a complete assessment to identify relevant nursing diagnoses or problems for the patient's care plan. Examples of information included in the nursing history are patient allergies, primary spoken/written language, advance directives, disabilities, and mobility/fall risk and medication reconciliation.
ph value of stomach
A pH value of pH 5.5 or below will exclude 100% of pulmonary placements and more than 93.9% of placements in small intestine.
First priority is aspiration
A patient in the nursing home has Chronic COPD. The patient is unable to turn or feed self. The patient has difficulty swallowing and is placed on tube feedings. The patient has lost 10 lbs over the last month. What is the priority nursing diagnosis?
First priority is to get patient stable
A patient is admitted for chest pain. Following a diagnostic workup, the patient is scheduled for open heart surgery. The patient has an unstable irregular heart rhythm and low BP. The patient is fearful about having the surgery. What is the priority nursing diagnosis?
First priority is foot ulcer
A patient with a history of cardiovascular disease (↑BP and previous CABG) comes into the hospital with a foot ulcer. The patient's cardiac condition is stable. What is the priority?
idiosyncratic reactions
A reaction is an unpredictable effect in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have this response is impossible. For example, lorazepam is an antianxiety medication that may cause agitation and delirium when given to an older adult.
z track
A technique for pulling the skin during an injection, is recommended for IM injections. It prevents leakage of medication into subcutaneous tissues, seals medication in the muscle, and minimizes irritation. To use it, apply the appropriate-size needle to the syringe and clean and select an IM site, preferably in a large, deep muscle such as the ventrogluteal. Pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to image inches) laterally to the side with the ulnar side of the nondominant hand. Hold the skin in this position until you have administered the injection. Inject the needle deeply into the muscle. To reduce injection site discomfort, the CDC (2015) recommends there is no longer any need to aspirate after the needle is injected when administering vaccines (CDC, 2015). However, follow agency policy for aspirating vaccines after injecting an IM needle. Keep the needle inserted for 10 seconds to allow the medication to disperse evenly. Release the skin after withdrawing the needle. This leaves a zigzag path that seals the needle track wherever tissue planes slide across one another. The medication is sealed in the muscle tissue.
Mobility
Ability to change and control body position 1. Completely immobile: Does not make even slight changes in body or extremity position without help 2. Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently 3. Slightly limited: Makes frequent, although slight, changes in body or extremity position independently 4. No limitations: Makes major and frequent changes in position without help
Sensory Perception
Ability to respond meaningfully to pressure-related discomfort 1. Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli because of diminished level of consciousness or sedation or Limited ability to feel pain over most of body 2. Very limited: Responds only to painful stimuli Cannot communicate discomfort except by moaning or restlessness or Has a sensory impairment that limits the ability to feel pain or discomfort over half of body 3. Slightly limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned or Has some sensory impairment, which limits ability to feel pain or discomfort in one or two extremities 4. No impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort
Right documentation
Accurate notation allows nurses and other health care providers to communicate with one another and improves medication safety. Many medication errors result from inaccurate notation. Therefore always note accurately at the time of administration and verify any inaccurate notation before administering medications. To ensure the right notation, first make sure that the information on your patient's MAR corresponds exactly with the health care provider's order and the label on the medication container. Never note that you have administered a medication until you have actually given it. Record the name of the medication, the dose, the time of administration, and the route on the patient's MAR as soon as it is administered. Also note the site of any injections and the patient's response to medications. You need to note response to drugs such as therapeutic or if ADE or side effects occur.
distribution
After a medication is absorbed, it is passed out to tissues and organs and finally to the site of drug action. The rate and extent of it depends on circulation, cell membrane permeability, and protein binding. Poor perfusion (e.g., heart failure) alters it. A medication must pass through biological membranes to reach certain organs. Some membranes are barriers to the passage of medications. For example, the blood-brain barrier allows only fat-soluble medications to pass into the brain and cerebrospinal fluid. The degree to which medications bind to serum proteins such as albumin affects it. Most medications bind to albumin to some extent. When this happens, they are unable to exert pharmacological activity. Only the unbound, or "free," medication is active. Older adults and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity.
metabolism
After a medication reaches its site of action, it is processed into a less active or inactive form. Biotransformation occurs under the influence of enzymes that detoxify, degrade (break down), and remove biologically active chemicals. Most biotransformation occurs in the liver; although the lungs, kidneys, blood, and intestines also play a role. Patients (e.g., older adults and those with chronic disease) are at risk for medication toxicity if their organs cannot process medications effectively.
Measles, chickenpox (varicella), disseminated varicella zoster, pulmonary or laryngeal tuberculosis
Airborne precautions (droplet nuclei smaller than 5 microns) Barrier Protection: Private-room, negative-pressure airflow of at least 6 to 12 exchanges per hour via HEPA filtration; mask or respiratory protection device, N95 respirator (depending on condition)
allergic reactions
Also are adverse unpredictable responses to a medication. Exposure to an initial dose of a medication causes a patient to become sensitized immunologically. The medication acts as an antigen, which causes antibodies to be produced. With repeated administration a patient develops one to the drug, its chemical preservatives, or a metabolite. Ranges from mild to severe, depending on the patient and the medication. Among the different classes of medications, antibiotics cause a high incidence of them. Severe or anaphylactic reactions, which are life threatening, are characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath. Some patients become severely hypotensive, necessitating emergency resuscitation measures. It is common practice for hospitalized patients with them to have their allergy information recorded in a clearly identifiable place.
Kardex
Also known as a"cardboard flip-over" file is kept at the nurses' station provides information for daily patient care needs. It has two parts: an activity and treatment section and a nursing care plan section. The updated information eliminate the need for repeated referral to the chart for routine information throughout the day. The forms do not always become part of the permanent record. Information commonly found on the it includes the following: •Basic demographic data (e.g., age, religion) •Primary medical diagnosis •Current health care provider's orders (e.g., diet, activity, dressing changes) •Plan of care •Nursing orders or interventions (e.g., intake and output, comfort measures, teaching) •Scheduled tests and procedures •Safety precautions used in the patient's care •Factors related to activities of daily living •Nearest relative/guardian or person to contact in an emergency •Emergency code status •Allergies
Braden Scale for Predicting Pressure Ulcer Risk
Analyzes: Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear
Focus or DART
Another narrative format is ________________ or (Data, Action, Response, Teaching). One distinction of it is that it places less importance on patient problems and focuses on patient concerns such as a sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in condition. Each entry includes data (both subjective and objective), actions or nursing interventions, and patient response (e.g., evaluation of effectiveness). Saves time because it is easy for caregivers to understand, is adaptable to most health care settings, and enables all caregivers to track a patient's condition and progress.
isometric exercises
Are contractions of a particular muscle or group of muscles. Muscle doesn't noticeably change length and the affected joint doesn't move. Help maintain strength.
ET Tubes
Are flexible, plastic tubes placed in the mouth or through the nose and advanced down into the trachea to establish short-term artificial airways to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration, and clear secretions. Routine care maintains correct position of the tube and good hygiene. After insertion, the cuff is inflated, and the tube is secured with tape or a commercially available device. A cuff prevents the escape of air between the tube and the walls of the trachea and reduces the risk of aspiration when a patient is receiving mechanical ventilation. The amount of air or water inserted in a cuff is based on two factors (i.e., the size of the patient's trachea and the external diameter of the artificial airway). If the cuff pressures are too high, permanent damage to the tracheal mucosa occurs, leading to complications such as tracheomalacia; tracheoesophageal fistula; or erosion of the innominate artery, which is rare but almost always fatal. If the cuff pressure is too low, the mechanical ventilation will not be effective; and the patient has an increased risk of aspiration, which increases the risk of developing ventilator-associated pneumonia (VAP).
intestinal or pulmonary pH value
Are more basic than stomach contents. A pH greater than 6.0 indicates _________________ placement
adverse effects (AEDs)
Are unintended, undesirable, and often unpredictable. Although sometimes they are apparent immediately, unfortunately they often take weeks or months to develop. Early clinical recognition of them is the important first step in identification. Range from mild (e.g., rashes or photosensitivity to light) to potentially fatal (anaphylaxis). Prompt recognition and reporting of them prevent serious injury to patients. Always assess patients who may be at high risk for one such as pregnant women and patients with chronic disorders (e.g., hypertension, epilepsy, heart disease, psychoses). Health care providers report them to the Food and Drug Administration (FDA) using the MedWatch program.
Right medication
At the time of admission, when transferring to a different unit, and when discharging patients from a hospital, assess their medication regimen, especially if they were admitted to the hospital because of a problem with medication self-administration. Medication reconciliation helps prevent errors. Patients often leave the hospital with a basic knowledge of their medications but are unable to safely self-administer them once they return home. When patients enter a health care agency, it is critical for health care providers to have an accurate list of the medications they are currently prescribed to take and any OTC medications being used. A medication order is required for every medication that you administer to a patient. Regardless of how an order is received, you compare the health care provider's orders with the MAR or electronic MAR (eMAR) when the medication is ordered initially. Nurses verify medication information whenever new MARs are written or distributed or when patients transfer from one nursing unit or health care setting to another.
Restraint free goal
Because physical and chemical restraints restrict a patient's physical activity or normal access to the body, serious and often fatal complications can develop, especially when patients try to get out of restraints. Creating a restraint-free environment allows you to have interventions in place to reduce wandering and risk of patient falls. A restraint-free environment is the _____________ of care for all patients.
necrosis
Black or brown wounds/eschars which represents full-thickness tissue destruction. Black is used to describe _____________ tissue or desiccated tissue such as tendon. It is also related to gangrenous lesions secondary to peripheral vascular disease.
How much time do you have to hang the blood after the unit is received from the blood bank?
Blood transfusion should be initiated within 30 minutes from time of release from blood bank. If this cannot be completed because of factors such as an elevated temperature, immediately return the blood to the blood bank and retrieve it when you can administer it. It is important that the blood bag not be spiked until you ensure that no factors exist preventing transfusion.
Right Direction/Communication
Clear, concise, correct, and complete initial and ongoing directions. (Include time, expectations, follow-up communication etc.)
how to write an appropriate nursing diagnosis example
Constipation R/T insufficient physical activity a.e.b. inability to pass stool X 3 days
Colonization or infection with multidrug-resistant organisms such as VRE and MRSA, Clostridium difficile, shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); respiratory syncytial virus in infants, young children or immunocompromised adults
Contact precautions (direct patient or environmental contact) Barrier Protection: Private-room or cohort patients (see agency policy), gloves, gowns; patients may leave their room for procedures or therapy if infectious material is contained or covered and placed in a clean gown and hands cleaned
ampule
Contain single doses of injectable medication in a liquid form and are available in sizes from 1 to 10 mL or more. Is made of glass with a constricted, prescored neck that is snapped off to allow access to a medication. A colored ring around the neck indicates where it is prescored to be broken easily. Medication is easily withdrawn from it by aspirating with a filter needle and syringe. Use filter needles when preparing medication from a glass one to prevent glass particles from being drawn into the syringe. Do not use the filter needle to administer the medication. Place an appropriate-size needle on the syringe after withdrawing the medication.
Activity
Degree of it 1. Bedfast: Confined to bed 2. Chairfast: Ability to walk severely limited or nonexistent Cannot bear own weight and/or must be helped into chair or wheelchair 3. Walks occasionally: Walks occasionally during day but for very short distances with or without help. Spends most of each shift in bed or chair 4. Walks frequently: Walks outside room at least twice a day and inside room at least once every 2 hours during waking hours
Moisture
Degree to which skin is exposed to it 1. Constantly: Skin kept wet almost constantly by factors such as perspiration and urine Dampness detected every time patient is moved or turned 2. Very: Skin often but not always wet Linen must be changed at least once a shift 3. Occasionally: Skin occasionally wet, requiring extra linen change approximately once a day 4. Rarely: Skin usually dry; linen requires changing only at routine intervals
toxic effects
Develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Excess amounts of a medication within the body sometimes have lethal effects, depending on the action of the medication. For example, high levels of morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity.
Hip ROM exercises
Flexion: Move leg forward and up. Extension: Move leg back beside other leg. Abduction: Move leg laterally away from body. Adduction: Move leg back toward midline position and beyond if possible. Internal rotation: Turn foot and leg toward other leg. External rotation: Turn foot and leg away from other leg. Circumduction: Move leg in circle.
crushable medications
Do not _______ sublingual, sustained-release, chewable, long-acting, or enteric-coated medications. Consult with the hospital pharmacist about whether you can ________ or dissolve a medication. Always verify correct placement of a nasogastric tube before administering medications
What if an oral medication is ordered for a patent who has a nasogastric tube ordered to suction? How would you administer the med?
Do not administer medications into nasogastric tubes that are inserted for decompression.
Over what period of time should a unit of blood be infused?
Do not let a unit of blood hang for more than 4 hours because of danger of bacterial growth. When a longer transfusion time is indicated clinically, the unit may be divided by the blood bank, and the part not being transfused can be properly refrigerated. Administration sets should be changed at the completion of each unit or every 4 hours to reduce bacterial contamination. Blood should only be stored in a refrigerator specific for blood or blood products to maintain appropriate temperature controls.
Ankle ROM exercises
Dorsal flexion: Move foot so toes are pointed upward. Plantar flexion: Move foot so toes are pointed downward.
Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mumps, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague
Droplet precautions (droplets larger than 5 microns; being within 3 feet of patient) Barrier Protection: Private-room or cohort patients; mask or respirator (refer to agency policy)
how to apply a urinary pouch
Each type of one comes with a connector for the bedside drainage bag. Incorrect pouch placement, large volumes of urine in the bag, or one without an antireflux valve promotes reflux of urine back into the urostomy and ureters, causing the risk of infection. You reduce the risk of reflux by attaching one to straight drainage when high urinary output is expected. A patient must understand the importance of draining the pouch frequently and using clean technique during stomal and skin care.
Thumb ROM exercises
Flexion: Move thumb across palmar surface of hand. Extension: Move thumb straight away from hand. Abduction: Extend thumb laterally (usually done when placing fingers in abduction and adduction). Adduction: Move thumb back toward hand. Opposition: Touch thumb to each finger of same hand.
Continuous infusion of CPN
Flow rate is immediately set at ordered rate and given over 24-hour period.
side effects
Every medication has the potential for harm. No medication is totally safe and absolutely free of nontherapeutic effects. Are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. They are either harmless or cause injury. The intensity of side effects is often dose dependent. If they are serious enough to outweigh the benefits of the therapeutic action of a medication, the health care provider will likely discontinue the medication. Patients commonly stop taking medications because of ones such as anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, constipation, and diarrhea. Report any to the health care provider to ensure that it is not incorrectly interpreted as a more serious adverse medication reaction.
Wrist ROM exercises
Flexion, move palm toward inner aspect of forearm. Extension: Move fingers and hand posterior to midline. Hyperextension: Bring dorsal surface of hand back as far as possible. Radial deviation: Bend wrist medially toward thumb. Ulnar deviation: Bend wrist laterally toward fifth finger.
Elbow ROM exercises
Flexion: Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder. Extension: Straighten elbow by lowering hand.
Neck, cervical spine ROM exercises
Flexion: Bring chin to rest on chest. Extension: Return head to erect position. Hyperextension: Bend head back as far as possible. Lateral flexion: Tilt head as far as possible toward each shoulder. Rotation: Turn head as far as possible in circular movement.
Knee ROM exercises
Flexion: Bring heel back toward back of thigh. Extension: Return leg to floor.
Toes ROM exercises
Flexion: Curl toes downward. Extension: Straighten toes. Abduction: Spread toes apart. Adduction: Bring toes together.
Fingers ROM exercises
Flexion: Make fist. Extension: Straighten fingers. Hyperextension: Bend fingers back as far as possible. Abduction: Spread fingers apart. Adduction: Bring fingers together.
Cycle infusion
Flow rate is initiated at about 40 to 60 mL/hr, and the rate is gradually increased until patient's nutritional needs are met. Before completion of infusion, rate is decreased at about the same milliliter per hour until it is completed. The infusion is usually given over a shorter time frame (12 to 18 hours).
Stage 4 Pressure Injury
Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury.
Stage 3 Pressure Injury
Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
buccal
Have patient place medication in mouth against mucous membranes of cheek and gums until it dissolves.
sublingual
Have patient place medication under tongue and allow it to dissolve completely (see illustration). Caution patient against swallowing tablet.
oral
Help patient to sitting or Fowler's position. Use side-lying position if he or she is unable to sit. Have patient stay in this position for 30 minutes after administration.
Shoulder ROM exercises
Horizontal flexion: swing arm horizontally forward Horizontal extension: Swing arm horizontally backward Abduction: Bring arm up sideways Adduction: Bring arm toward midline of the body Shoulder extension: Move arm behind body, keeping elbow straight. Circumduction: Move arm in full circle (circumduction is combination of all movements of ball-and-socket joint).
How do you remove a gown from a patient with an IV?
If patient has an IV line and gown with no snaps, remove gown from arm without IV line first. Then remove gown from arm with IV line (see illustration). Pause IV fluid infusion by pressing appropriate sensor on IV pump. Remove IV tubing from pump; use regulator to slow IV infusion. Remove IV bag from pole (see illustration) and slide IV bag and tubing through arm of patient's gown (see illustration). Rehang IV bag (see illustration), reconnect tubing to pump, open regulator clamp, and restart IV fluid infusion by pressing appropriate sensor on IV pump. If IV fluids are infusing by gravity, check IV flow rate and regulate if necessary. Do not disconnect IV tubing to remove gown.
Charting by Exception
Is a system of documentation that aims to eliminate redundancy, makes documentation of routine care more concise, emphasizes abnormal findings, and identifies trends in clinical care. Is a shorthand method for documenting on the basis of clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. This system involves completing a flow sheet that incorporates standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. You write a narrative nurse's note only when there is an exception to the established standard or abnormal data are present. Assessments are standardized on forms so all health care providers evaluate and document findings consistently. The presumption with it is that the nurse assessed the patient and all standards are met unless otherwise documented. Changes in a patient's condition require thorough and precise descriptions of what happened, actions taken, and patient response to treatment. Legal risks in using it include difficulty in proving safe care if nurses are not disciplined in documenting exceptions.
Discharge Summary Forms
Includes essential information for the patient, family caregiver, and health care agency and is based on data obtained from the _____________________ planning process. Is a comprehensive process with emphasis placed on preparing a patient for ______________________ from a health care agency. Nurses enhance ______________ planning when they are responsive to changes in a patient's condition and involve the patient and family caregiver in the planning process. There must be evidence of the involvement of the patient and family caregiver in the planning process so the patient and family have the necessary information and resources to return home . TJC has standards for patient and family education necessary for effective ________________ planning. When a patient is ______________________ from a health care agency, the members of the health care team prepare one. It provides important information relating to the patient's ongoing health problems and need for health care after it. Planning achieves specific outcomes that include identifying patients with ongoing health needs, collaborating with other health care professions to determine level of care, matching patients with appropriate referrals and resources, and streamlining the transition to the next level of care. Include in it the reason for hospitalization; significant findings; current status of the patient; and the teaching plan that is given to the patient or family caregiver, home care, rehabilitation, or long-term care facility. Make the summary concise and instructive. They emphasize previous learning by the patient and family caregiver and care that needs to continue in any restorative care setting.
measure for crutches
Includes three areas: patient's height, distance between pad and axilla, and angle of elbow flexion. (1) Standing: Position tips at 15 cm (6 inches) to side and 15 cm in front of patient's feet (tripod position). Pads should be 5 cm (image to 2 inches (3.75 to 5 cm) or 2-3 finger widths) under axilla (2) Supine: Pad is approximately 5 cm (2 inches) or two-to-three finger widths under axilla with crutch tips positioned 15 cm (6 inches) lateral to patient's heel (3) Height of handgrip must be adjusted so patient's elbow is flexed 15 to 30 degrees or it sits at approximately height of wrist crease. Both height of it and handgrip dimensions are adjustable on a well-made one.
pediatric considerations for nose meds
Infants are nose breathers, and the possible congestion caused by nasal medications may inhibit their sucking. Administer nose drops if ordered 20 to 30 minutes before feedings
Chain of Infection
Infectious agent (pathogenic organism capable of causing disease) Reservoir (site or source of microorganism growth) Portal of exit (means by which microorganisms leave a site) Transmission (means of spread) Portal of entry (site through which microorganism enters a host) Host (patient)
pediatric considerations for ear meds
Insert cotton pledgets loosely into ear canal to prevent medication from flowing out. To prevent cotton from absorbing medication, premoisten it with a few drops of medication
Foot ROM exercises
Inversion: Turn sole of foot medially. Eversion: Turn sole of foot laterally.
inline closed suctioning
Is a method of suctioning an artificial airway. It involves the use of a multiuse suction catheter that is housed within a plastic sleeve and is attached to a patient's artificial airway. This method of suctioning is associated with decreased risk of hypoxia and cardiovascular complications when compared to open suctioning. It is also the recommended method of suctioning for patients who cannot tolerate loss of positive end-expiratory pressure (PEEP) such as those with severe respiratory disorders who require high amounts of PEEP or oxygen requirements.
trach tube
Is a surgical or percutaneous creation of a stoma through the neck and into the trachea that allows for the insertion of an artificial airway. Are placed in patients who require long-term airway management because of airway obstruction, airway clearance needs, and/or long-term need for mechanical ventilation. Offers advantages over long-term endotracheal tube (ET) placement such as decreased risk of laryngeal and tracheal injury, less sedation, shorter ventilator weaning time (time it takes to get a patient off a ventilator), and improved comfort for the patient. Some even allow more patient freedom in the performance of activities of daily living such as feeding, speaking, and mobility
Suprapubic Catheter
Is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis (Fig. 34.7). The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon similar to an indwelling catheter. Are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urologic surgery) and when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning.
Continuous Passive Motion (CPM) Machine
Is designed to exercise various joints such as the hip, ankle, knee, shoulder, and wrist. It is used most commonly after knee surgery. However, questions have been raised about benefits. A recent review of research involving knee arthroplasty surgery show that the device probably improves the ability of a patient to bend the knee slightly but may not ease pain or improve function. Prescribed from the first to fourth day following surgery for 1.5 to 24 hours a day. An initial setting is typically 20 to 30 degrees of flexion and full extension at two cycles per minute.
now order
Is more specific than a one-time order and is used when a patient needs a medication quickly but not as soon as a stat order. When you receive one, you have up to 90 minutes to give the drug.
pulse oximeters
Is the noninvasive measurement of arterial blood oxygen saturation, the percent to which hemoglobin is filled with oxygen. Is a probe with a light-emitting diode (LED) connected by cable to an oximeter. The LED emits light wavelengths that are absorbed differently by the oxygenated and deoxygenated hemoglobin molecules. The more hemoglobin saturated by oxygen, the higher the oxygen saturation. Normally oxygen saturation (SpO2) is greater than 95%. A saturation less than 90% is a clinical emergency. Measurement of SpO2 is simple and painless and has few of the risks associated with more invasive measurements of oxygen saturation such as arterial blood gas sampling. A vascular, pulsatile area is needed to detect the change in the transmitted light when making measurements with a finger or earlobe probe. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Factors that affect light transmission such as outside light sources or patient motion also affect the measurement of oxygen saturation. Carbon monoxide in the blood, jaundice, and intravascular dyes can influence the light reflected from hemoglobin molecules.
absorption
Is the passage of medication molecules into the blood from the site of administration. Factors that influence the rate of it include the administration route, ability of a medication to dissolve, blood flow to the administration site, body surface area, and lipid solubility of a medication
Right Person
License, certification and role description; strengths, experience, competence?
stat order
Means that you give a single dose of medication immediately and only once. Are used for emergencies when a patient's condition changes suddenly.
Right patient
Medication errors often occur because one patient gets a drug intended for another patient. It is difficult to remember every patient's name and face. Before giving a medication to a patient, always use at least two patient identifiers. To identify a patient correctly in an acute care setting, at the patient's bedside compare the patient identifiers on the MAR with those on his or her identification bracelet
If you were drawing up medication from both a multi-dose vial and ampule into the same syringe; what would you draw up first?
Medication from the vial
trough
Minimum blood serum concentration of medication reached just before the next scheduled dose
nasogastric (NG) tubes
Nasally placed feeding tubes (8 to 12 French [Fr]) are referred to as _____________________; but some types, which are larger and more rigid, are used for gastric decompression instead of feeding
Stage 1 Pressure Injury
Nonblanchable erythema of intact skin: Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Indications for Parenteral Nutrition
Nonfunctional GI Tract • Small bowel resection • Small bowel surgery or GI bleed • Paralytic ileus • Intestinal obstruction • Trauma to abdomen, head, or neck • Severe malabsorption • Intolerant of slow rates of enteral tube feeding • Chemotherapy, radiation therapy, bone marrow transplantation • Severely catabolic patients when GI tract is not functioning for more than 7 days Nonfunctional GI Tract • Enterocutaneous fistula • Inflammatory bowel disease • Severe diarrhea • Moderate-to-severe pancreatitis Preoperatively • Preoperative bowel rest • Severe malnutrition before surgery
Patient is walking without an assertive device
Nurse stands on strong side
Unstageable Pressure Injury
Obscured Full-Thickness Skin and Tissue Loss: full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
primary intention healing
Occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells regenerate quickly, and capillary walls stretch across under the suture line to form a smooth surface as they join.
SOAP
One way to structure narrative notes to document patient progress is the Subjective data, Objective data, Assessment, and Plan format. Some agencies add an I and E. The I stands for intervention, and the E represents evaluation. The logic for these notes is similar to that of the nursing process: collect data about a patient's problems, draw conclusions, and develop a plan of care. Number each note and title it according to the problem on the list.
Right Supervision
Oversee assigned/delegated tasks (Huddles/checkpoints - solicit team members opinion; credit team for accomplishments
Stage 2 Pressure Injury
Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
why you perform oropharyngeal suctioning
Perform when a patient is able to cough effectively but is unable to clear secretions such as for a patient with a neuromuscular injury who cannot manage his or her own oral secretions. Patients with artificial airways and impaired swallowing require use to provide oral hygiene.
Flow and Graphic Sheets
Permit concise documentation of nursing information and patient data over time. They are especially useful for the documentation of routine observations or repeated specific measurements for a patient such as vital signs, intake and output, hygiene measures, medication administration, and pain assessment. Use a format or system for entry of information, usually every 24 hours. When documenting a significant change that you recognize on one, describe the change in the progress notes, including the patient's response to nursing interventions. For example, if a patient's blood pressure becomes dangerously low, record in the progress notes the blood pressure, relevant assessment such as pallor or dizziness, and any interventions to raise the blood pressure. Also include an evaluation of the interventions such as repeated blood pressures and relief of dizziness. Other health care providers such as nursing assistants may have the responsibility to document on nursing _________________________ or screens.
Allogeneic hematopoietic stem cell transplants
Protective environment Barrier Protection: Private room; positive airflow with ≥12 air exchanges per hour; HEPA filtration for incoming air; mask to be worn by patient when out of room during times of construction in area
Deep Tissue Pressure Injury
Persistent nonblanchable deep red, maroon, or purple discoloration: Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3 or 4). Do not use this classification to describe vascular, traumatic, neuropathic, or dermatological conditions.
gastric residual volume
Return aspirated contents to stomach unless a single one exceeds 250 mL . When it is excessive, hold medication and contact health care provider.
Right time
Safe medication administration involves adherence to prescribed doses and dosage schedules. Some agencies set schedules for medication administration. However, nurses are able to alter this schedule based on knowledge about a medication.
measure for canes
Should extend from greater trochanter of the hip to floor while it is held 15 cm (6 inches) from foot. Allow 15- to 30-degree elbow flexion. Handle should fit comfortably in palm of hand.
signs and symptoms of a DVT
Signs include swelling in the affected leg (rarely swelling in both legs); warm, cyanotic skin; and pain in the leg which often starts in the calf and can feel like cramping or a soreness. One calf can appear larger than the other or if it is red or hot, or if the patient complains of calf pain
SBAR
Situation, Background, Assessment, Recommendation is a concrete approach for framing conversations, especially critical ones that require a nurse's immediate attention and action. It allows for an easy and focused way to set expectations for what the team will communicate. Promotes the provision of safe, efficient, timely, and patient-centered communication. This method is used for written and verbal communication when a patient's condition changes, for a brief targeted report (e.g., as a preprocedure or postprocedure report) or as a change-of-shift report.
nasointestinal (NI) tubes
Small-bowel _______________ such as nasojejunal (NJ) are also used for enteral tube feedings, and these are advanced into the jejunum of the small intestine by way of the nose.
interventions to prevent VAP
Some patients require mouth care as often as every 1 to 2 hours until the mucosa returns to normal. Proper hygiene requires keeping the mucosa moist and removing secretions as they accumulate in the back of the throat. The Institute for Healthcare Improvement and the American Academy of Critical Care Nursing have recommended use of 0.12% chlorhexidine gluconate (CHG) as part of daily oral care (CDC, 2015; Wiech and Bayer, 2012) in critically ill patients. Many hospitals use an oral care bundle to reduce incidence of it, including toothbrushing every 12 hours before the application of CHG; CHG 0.12% rinse every 12 hours; and keeping the head of bed (HOB) elevated 30 to 45 degrees or more unless contraindicated to prevent aspiration of oral secretions.
tertiary intention healing
Sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed.
Removing gauze dressing
Stabilize catheter hub while loosening tape and removing old dressing one layer at a time by pulling toward insertion site. Be cautious if tubing becomes tangled between two layers of dressing.
Removing TSM (tegaderm) dressing
Stabilize catheter with nondominant hand. Remove dressing by pulling up one corner and gently pulling straight out and parallel to skin. Repeat on all sides until dressing has been removed.
What side should a patient's cane be on?
Strong side
Forearm ROM exercises
Supination: Turn lower arm and hand so palm is up. Pronation: Turn lower arm so palm is down.
Never events
The Centers for Medicare and Medicaid Services (CMS) have identified select serious adverse events _________________ (e.g., adverse events that should never occur in a health care setting). One of these is hospital-acquired injury from external causes (e.g., fractures, head injury, crushing injury), as in the case of falls. The CMS denies hospitals higher payment for any hospital-acquired condition resulting from or complicated by the occurrence of one.
PIE
The Problem, Intervention, Evaluation note format of documentation is similar to that of SOAP charting in its problem-oriented nature. However, it differs from the SOAP method in that this type of charting has a nursing origin, whereas SOAP originated from a medical model. This format simplifies documentation by combining the care plan and progress note into one record. It differs from that of SOAP because there are no assessment data in the narrative note. Assessment data are included in documentation on the flow sheets of each shift. You number or label the notes according to a patient's problems. Resolved problems are dropped from daily documentation after your review. Continuing problems are documented daily.
You are walking with a patient who has a cane.
The cane should be on the string side. The nurse should be on the weak side.
excretion
The final aspect of pharmacokinetics is this, the process by which medications exit the body through the lungs, exocrine glands, bowel, kidneys, and liver. The chemical makeup of a medication determines the organ of exit. For example, gaseous and volatile compounds such as alcohol and nitrous oxide exit through the lungs. The site of it poses implications for nursing care. For example, when medications exit through sweat glands, you provide skin care to reduce irritation. You must know if a drug exits through the intestines because the administration of laxatives or enemas increases peristalsis, accelerates it, and thus lessens the time for drug effects. When patients have reduced renal function, they are at risk for medication toxicity since kidneys are the main organs for medication exit.
Right route
The health care provider's order must designate a way of administration. If the way of administration is missing or if the specified one is not the recommended one, consult the health care provider immediately.
ANA Code of Ethics Provision 4
The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care
ANA Code of Ethics Provision 5
The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
ANA Code of Ethics Provision 3
The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
ANA Code of Ethics Provision 7
The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
ANA Code of Ethics Provision 9
The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
Standardized Care Plans
The trend among many health care agencies is to computerize care plans. These systems provide daily computer-generated care plans, which incorporate several nursing diagnoses or problems in a single nursing or interprofessional plan. These systems improve documentation and facilitate high-quality care that is based on scientific evidence and proven experience. Are based on agency standards of clinical practice and are established guidelines used to care for patients with similar health problems. After completing a nursing assessment, identify the patient's nursing diagnosis or health problem and select an appropriate one for the patient medical record. Always individualize it for each patient. Most allow for the addition of patient-specific outcomes and target dates for achieving these outcomes. One advantage is the establishment of evidence-based standards of care. By using them nurses learn to recognize the accepted requirements of care for patients. Implementation of digital ones improves continuity of care among professional nurses. One disadvantage is an increased risk that the unique, individualized therapies needed by patients will go unrecognized. Do not replace professional judgment and decision making. In addition, care plans need to be updated on a regular basis to ensure that content is current and appropriate.
Right dose
The unit-_________ system is designed to minimize errors. When a medication is prepared from a larger volume or strength than needed or when the health care provider orders a system of measurement different from that which the pharmacist supplies, the chance of error increases. After calculating them for high-risk medications such as insulin or warfarin, compare the calculation with one done independently by a second nurse. This is especially important if it is an unusual calculation or involves a potentially toxic drug.
Nasogastric Tube for Gastric Decompression
There are times following major surgery or with conditions affecting the gastrointestinal (GI) tract when normal peristalsis is altered temporarily. Because peristalsis is slowed or absent, a patient cannot eat or drink fluids without causing abdominal distention. The temporary insertion of a ________________________ into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. The Levin and Salem sump tubes are the most common.
health insurance portability
This means that if you want to change your health insurance in any way or change insurance companies, it is easy to do so. For example, maybe your family is going to have a baby or you lost your job and now have to get insurance from your husband's or wife's insurance company. HIPAA makes it easy.
health insurance accountability
This means that your health information is kept private and secure. Only those people who must have information about you to provide care or to process your records should know your private health information.
peak action
Time it takes for a medication to reach its highest effective peak concentration
lovenox
To minimize the pain and bruising associated with LMWH, it is given subcutaneously on the right or left side of the abdomen, at least 5 cm (2 inches) away from the umbilicus (the patient's "love handles"). Administer LMWH in its prefilled syringe with the attached needle and do not expel the air bubble in the syringe before giving the medication. There is some new evidence to support a slower injection rate of 30 seconds to reduce bruising and pain
Bladder Scan
To obtain the most reliable reading, measure PVR within 5 to 15 minutes of voiding. A volume less than 50 mL is considered normal. Two or more PVR measurements greater than 100 mL require further investigation. If one is not available, obtain a PVR by measuring urine emptied from the bladder after a straight catheterization.
document care of a wound
Type: serous, serosanguineous, sanguineous, purulent Amount: saturation Color: goes with type Consistency Odor: yes/no Size: number Tissue type: Black: nercrotic/eschar, yellow/gray: slough, red/pink: granulation good Healing: Primary, Secondary, and Tertiary Staging: I-IV and Unstageable
Safety measures for shaving a patient
Use an electric razor for any patient who is at risk for bleeding tendencies
Narrative documentation
Uses a storylike format to document specific information about a patient's conditions and nursing care, usually presented in chronological order. It is useful in emergency situations when the time and order of events are important. Organize one in a clear, concise way (e.g., by using the nursing process to order the data).
Nutrition
Usual food intake pattern 1. Very poor: Never eats a complete meal Rarely eats more than one third of any food offered Eats two servings or less of protein (meat or dairy products) per day. Takes fluids poorly; does not take a liquid dietary supplement or Is NPO and/or maintained on clear liquids or IV infusions for more than 5 days 2. Probably inadequate: Rarely eats a complete meal and generally eats only about half of any food offered Protein intake includes only three servings of meat or dairy products per day Occasionally takes a dietary supplement or Receives less than optimal amount of liquid diet or tube feeding 3. Adequate: Eats over half of most meals Eats a total of four servings of protein (meat, dairy products) each day Occasionally refuses a meal but usually takes a supplement when offered or Is on a tube-feeding or TPN regimen that probably meets most of nutritional needs 4. Excellent: Eats most of every meal Never refuses a meal. Usually eats a total of four or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation
Examples of Measurable Verbs for Goal Setting
Verbalize Perform Discuss State Apply Identify List Explain Demonstrate Describe Ambulate
pediatric considerations for delivering meds through feeding tube
Volumes for instillation of medications or for irrigation of enteral tubes should be small enough to clear tubing
Reporting Medication Errors
When one occurs, the patient's safety and well-being become the top priority. A nurse assesses and examines the patient's condition and notifies the health care provider of the incident as soon as possible. Once the patient is stable, the nurse reports the incident to the appropriate person in the agency (e.g., manager or supervisor). As a nurse you are responsible for preparing a written incident or occurrence report that must be filed usually within 24 hours of an incident. The incident report is an internal audit tool and not a permanent part of the medical record. To legally protect the health care professional and agency, do not refer to an incident report in the nurses' notes in the EHR or chart. Agencies use incident reports to track incident patterns and initiate performance improvement programs as needed. Depending on the circumstances and the severity of the outcome, the nurse or agency may be responsible for reporting the incident to TJC, MedWatch (FDA Medical Products Reporting Program), or USP Medication Errors Reporting Program. It is good risk management to report all of them, including mistakes that do not cause obvious or immediate harm or near misses. You should feel comfortable in reporting one and not fear repercussions from managerial staff. Even when a patient suffers no harm from it, the agency can still learn why the mistake occurred and what to do in the future to avoid similar ones.
pediatric considerations for rectal meds
With children it is often necessary to gently hold or tape the buttocks together for 5 to 10 minutes to relieve pressure on the anal sphincter until the urge to expel the suppository is gone
secondary intention healing
Wounds that are left open and allowed to heal by scar formation. There is tissue loss and open wound edges. Granulation tissue gradually fills in the area of the defect. This process is typical of severe laceration or massive surgical intervention with skin loss. There is a gap between the edges. Connective tissue develops, which supports new capillaries. This form of healing results in the formation of scar tissue to close the wound. The slowness of this process places a patient at greater risk for infection because there is no epidermal barrier until later in the healing process.
standing order
You carry out this type of order until the health care provider cancels it by another order or until a prescribed number of days elapse. Sometimes indicates a final day or number of doses. Many agencies have a policy for automatically discontinuing them.
care of contacts
a. Apply 1 or 2 drops of cleaning solution to lens in palm of hand. Using index finger (soft lenses) or little finger (rigid lenses), rub lens gently but thoroughly on both sides for 20 to 30 seconds. b. Holding lens over emesis basin, rinse thoroughly with recommended rinsing solution. Clinical Decision Point Do not use tap water, bottled water, homemade saline, or distilled water for cleaning, rinsing, or storage ( FDA, 2015 ). Tap water contains microbes and may be absorbed into the lenses, making them uncomfortable to wear. Tap and distilled water have been associated with Acanthamoeba keratitis, a corneal infection that is resistant to treatment and cure ( FDA, 2015 ).
eye (ophthalmic)
a. Ask patient to lie supine or sit back in chair with head slightly hyperextended, looking up. b. If drainage or crusting is present along eyelid margins or inner canthus, gently wash away. Soak any dried crusts with warm, damp washcloth or cotton ball over eye for several minutes. Always wipe clean from inner to outer canthus (see illustration). Remove gloves and perform hand hygiene. c. Explain that there might be temporary burning sensation from drops. d. Instill eyedrops. (1) Option: Apply clean gloves if eye drainage present. Hold clean cotton ball or tissue in nondominant hand on patient's cheekbone just below lower eyelid. (2) With tissue or cotton ball resting below lower lid, gently press downward with thumb or forefinger against bony orbit, exposing conjunctival sac. Never press directly against patient's eyeball. (3) Ask patient to look at ceiling. Rest dominant hand on patient's forehead; hold filled medication eyedropper approximately 1 to 2 cm (image to image inch) above conjunctival sac. (4) Drop prescribed number of drops into conjunctival sac (see illustration). (5) If patient blinks or closes eye, causing drops to land on outer lid margins, repeat procedure. (6) When administering drops that may cause systemic effects, apply gentle pressure to patient's nasolacrimal duct with clean tissue for 30 to 60 seconds over each eye, one at a time (see illustration). Avoid pressure directly against patient's eyeball. (7) After instilling drops, ask patient to close eyes gently. e. Instill ointment. (1) Option: Apply clean gloves if eye drainage present. Holding applicator above lower lid margin, apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva (see illustration) from inner to outer canthus. (2) Have patient close eye and rub lid lightly in circular motion with cotton ball if not contraindicated. Avoid placing pressure directly against patient's eyeball. (3) If excess medication is on eyelid, gently wipe it from inner to outer canthus. (4) If patient needs an eye patch, apply clean one by placing it over affected eye so entire eye is covered. Tape securely without applying pressure to eye. f. Insert intraocular disk. (1) Apply clean gloves. Open package containing disk. Gently press your fingertip against disk so it adheres to your finger. It may be necessary to moisten gloved finger with sterile saline. Position convex side of disk on your fingertip. (2) With your other hand gently pull patient's lower eyelid away from eye. Ask patient to look up. (3) Place disk in conjunctival sac so it floats on sclera between iris and lower eyelid (see illustration). (4) Pull patient's lower eyelid out and over disk (see illustration). You should not be able to see disk at this time. Repeat if you can see disk. 8. After administering eye medications, remove and dispose of gloves and soiled supplies; perform hand hygiene. 9. Remove intraocular disk. a. Perform hand hygiene and apply clean gloves. Gently pull downward on lower eyelid using your nondominant hand. b. Using forefinger and thumb of your dominant hand, pinch disk and lift it out of patient's eye (see illustration).
Prepare IV tubing and solution for continuous infusion.
a. Check IV solution using six rights of medication administration and review label for name and concentration of solution, type and concentration of any additives, volume, beyond-use and expiration dates, and sterility state. If using bar code, scan code on patient's wristband and then on IV fluid container. Be sure that prescribed additives such as potassium and vitamins have been added. Check solution for color and clarity. Check bag for leaks. b. Open IV infusion set, maintaining sterility. NOTE: EIDs sometimes have a dedicated administration set; follow manufacturer's instructions. c. Place roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber and move roller clamp to "off" position. d. Remove protective sheath over IV tubing port on plastic IV solution bag or top of IV solution bottle while maintaining sterility. e. Remove protective cover from IV tubing spike while maintaining sterility of spike. Insert spike into port of IV bag using a twisting motion. If solution container is glass bottle, clean rubber stopper on glass-bottled solution with antiseptic swab and insert spike into rubber stopper of IV bottle. Bottles require vented tubing. f. Compress drip chamber and release, allowing it to fill one-third to one-half full g. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end of IV tubing (some tubing can be primed without removing protective cover) and slowly open roller clamp to allow fluid to flow from drip chamber to distal end of IV tubing. If tubing has a Y connector, invert Y connector when fluid reaches it to displace air. Return roller clamp to "off" position after priming tubing (filled with IV fluid). Replace protective cover on distal end of tubing. Label IV tubing with date according to agency policy and procedure. h. Be certain that IV tubing is clear of air and air bubbles. To remove small air bubbles, firmly tap tubing where they are located. Check entire length of tubing to ensure that all air bubbles are removed. i. If using optional long extension tubing (not short tubing in Step 7), remove protective cover and attach it to distal end of IV tubing, maintaining sterility. Then prime long extension tubing. Insert tubing into EID with power off.
Regulate gravity infusion
a. Ensure that IV container is at least 76.2 cm (30 inches) above IV site for adults and increase height for more viscous fluids b. Slowly open roller clamp on tubing until you can see drops in drip chamber. Hold a watch with second hand at same level as drip chamber and count drip rate for 1 minute. Adjust roller clamp to increase or decrease rate of infusion. c. Monitor drip rate at least hourly.
topical
a. Expose affected area while keeping unaffected areas covered. b. Wash, rinse, and dry affected area before applying medication if not done earlier (see Assessment, Step 3). c. If skin is excessively dry and flaking, apply topical agent while skin is still damp. d. After washing, remove gloves, perform hand hygiene, and apply new clean or sterile gloves. e. Place required amount of medication in palm of gloved hand and soften by rubbing briskly between hands. f. Tell patient that initial application of agent may feel cold. Once medication is softened, spread it evenly over skin surface, using long, even strokes that follow direction of hair growth. Do not vigorously rub skin. Apply to thickness specified by manufacturer instructions. g. Explain to patient that skin may feel greasy after application.
SC
a. For average-size patient, hold skin across injection site or pinch skin with nondominant hand. b. Inject needle quickly and firmly at 45- to 90-degree angle (see illustration). Release skin if pinched. Option: When using injection pen or giving heparin, continue to pinch skin while injecting medicine. c. For obese patient pinch skin at site and inject needle at 90-degree angle below tissue fold. d. After needle enters site, grasp lower end of syringe barrel with nondominant hand to stabilize it. Move dominant hand to end of plunger and slowly inject medication over several seconds (see illustration). When giving heparin, inject over 30 seconds (Akbari Sari et al., 2014; Sanofi-Aventis, 2014). Avoid moving syringe. image e. Withdraw needle quickly while placing antiseptic swab or gauze gently over site.
What would you do if a patient you were ambulating began to fall
a. Grasp patient's gait belt with both hands around his or her waist with palms up. b. Stand with feet apart for a broad base of support (see illustration A). c. Extend one leg, pull patient against you, and let him or her slide down your leg as you ease him or her to the floor (see illustration B). Caution: If patient is obese, do not risk personal injury. d. Bend your knees and lower your body as patient slides to floor (see illustration C). image e. Stay with patient until help arrives.
instruct patient on use of canes
a. Have patient hold cane on strong side. Direct patient to place cane forward 10 to 15 cm (4 to 6 inches) and slightly to the side of the foot, keeping body weight on both legs. Allow approximately 15- to 30-degree elbow flexion. b. To begin, have patient move cane forward about 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. c. Instruct patient to advance involved leg forward, even with the cane. The cane and affected leg swing and strike the ground at the same time. d. Have patient advance strong leg 15 to 25 cm (6 to 10 inches) past cane. e. Have patient move involved leg forward, even with strong leg, which can go as far forward as bad leg or slightly past it. f. Repeat sequences as patient tolerates. Once comfortable, have patient advance cane and weak leg together.
instruct patient on the use of walkers
a. Have patient stand straight in center of walker and grasp handgrips on upper bars. b. Have patient move walker comfortable distance forward, about 15 to 20 cm (6 to 8 inches). Patient then takes step forward with involved leg first and follows through with good leg. Instruct patient not to advance leg past the front bar of walker. If patient has equal strength in both legs, it makes no difference which leg advances first. c. If patient is unable to bear weight on involved leg, have him or her slowly hop to center of walker using strong leg, supporting weight on hands. d. Instruct patient not to try to climb stairs with walker unless he or she has specific walker for steps.
perineal care for male
a. If patient is able to maneuver and handle washcloth, allow him to clean perineum on his own. b. Help patient to supine position. Note restriction in mobility. c. Fold lower half of bath blanket up to expose upper thighs. Wash and dry thighs. d. Cover thighs with bath towels. Raise bath blanket to expose genitalia. Gently raise penis and place bath towel underneath. Gently grasp shaft of penis. If patient is uncircumcised, retract foreskin. If patient has an erection, defer procedure until later. e. Wash tip of penis at urethral meatus first. Using circular motion, clean from meatus outward (see illustration). Discard washcloth and repeat with clean cloth until penis is clean. Rinse and dry gently and thoroughly. (Exception: do not rinse if using CHG.) f. Return foreskin to its natural position.
perineal care for female
a. If patient is able to maneuver and handle washcloth, allow to clean perineum on own. b. Help patient assume dorsal recumbent position. Note restrictions or a limitation in patient's positioning. Position waterproof pad under patient's buttocks. c. Drape patient with bath blanket placed in shape of a diamond. d. Fold both outer corners of bath blanket up around patient's legs onto abdomen and under hip (see illustration). Lift lower tip of bath blanket when you are ready to expose the perineum. e. Wash and dry patient's upper thighs. (NOTE: If agency uses CHG solution for perineal care, do not rinse; allow to dry.) f. Wash labia majora. Use nondominant hand to gently retract labia from thigh. Use dominant hand to wash carefully in skinfolds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth or new washcloth. Rinse and dry area thoroughly. g. Gently separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand wash downward from pubic area toward rectum in one smooth stroke (see illustration). Use separate section of cloth for each stroke. Clean thoroughly over labia minora, clitoris, and vaginal orifice. Avoid tension on indwelling catheter if present and clean area around it thoroughly. h. Rinse and dry area thoroughly, using front-to-back method. i. If patient uses bedpan, pour warm water over perineal area and dry thoroughly. (Exception: do not rinse if using CHG.) j. Fold lower corner of bath blanket back between patient's legs and over perineum. Ask patient to lower legs and assume comfortable position.
If you suspect transfusion reaction
a. Immediately stop transfusion. b. Remove blood component and tubing containing blood product. Replace them with new bag of 0.9% sodium chloride (normal saline [NS]) and tubing. Connect tubing directly to hub of vascular access device (VAD). -Exception: If patient symptoms suggest mild allergic reaction, stop transfusion, administer antihistamine, and restart or discontinue transfusion per health care provider's order. c. Maintain patent VAD using 0.9% sodium chloride (NS) at rate prescribed by health care provider. d. Obtain vital signs. Remain with patient for continuous monitoring and assessment. Do not leave patient alone. e. Notify health care provider. f. Notify blood bank. g. Obtain blood samples (if needed) from extremity opposite extremity receiving transfusion. Check agency policy regarding number and type of tubes to be used. h. Return remainder of blood component and attached blood tubing to blood bank according to agency policy. i. Monitor patient's vital signs every 15 minutes or per agency policy. j. Administer prescribed medications according to type and severity of transfusion reaction. (1) Epinephrine (2) Antihistamine (3) Antibiotics (4) Antipyretics/analgesics (5) Diuretics/morphine (6) Corticosteroids (7) Intravenous (IV) fluids k. In event of cardiac arrest, initiate cardiopulmonary resuscitation l. Obtain first voided urine sample and send to laboratory. You may need to insert Foley catheter to obtain urine.
Blood Transfusion Preadministration protocol
a. Obtain blood component from blood bank following agency protocol b. Check blood bag for any signs of contamination (i.e., clumping/clots, gas bubbles, purplish color) and presence of leaks. c. Verbally compare and correctly verify patient, blood product, and type with another person considered qualified by your agency (e.g., RN or LPN) before initiating transfusion. d. Review purpose of transfusion and ask patient to report any changes that he or she may feel during the transfusion. e. Have patient void or apply clean gloves and empty urine drainage collection container.
care of hearing aids
a. Patient or nurse turns hearing aid(s) volume off, usually by turning volume control to left or toward patient's nose. Then grasp aid securely and gently remove device following natural ear contour. b. Hold aid over towel and wipe exterior with tissue to remove cerumen. c. Inspect all openings in aid for accumulated cerumen. Carefully remove cerumen with wax loop or other device supplied with hearing aid. d. Inspect ear mold for rough edges or any frays in cords. e. Open battery door, place hearing aid in labeled storage container, and allow it to air dry. f. Assess ear for redness, tenderness, discharge, or odor. g. Repeat procedure for other hearing aid if bilateral. h. Place towel beneath patient's ear(s). Wash ear canal(s) with washcloth moistened in soap and water. Rinse and dry. i. Dispose of towels, remove gloves, and perform hand hygiene. j. If storing hearing aid(s), place each in dry storage case with desiccant material. Label case with patient's name and room number. If more than one aid, note right or left. Indicate in patient's medical record where aid is stored.
IM
a. Position ulnar side of nondominant hand just below site and pull skin laterally approximately 2.5 to 3.5 cm (1 to image inches). Hold position until medication is injected. With dominant hand inject needle quickly at 90-degree angle into muscle (see Fig. 22.16A). b. Option: If patient's muscle mass is small, grasp body of muscle between thumb and forefingers. c. After needle pierces skin, still pulling on skin with nondominant hand, grasp lower end of syringe barrel with fingers of nondominant hand to stabilize it. Move dominant hand to end of plunger. Avoid moving syringe. d. Pull back on plunger 5 to 10 seconds. If no blood appears, inject medication slowly at rate of 10 sec/mL (Nicoll and Hesby, 2002). e. Once medication is injected, wait 10 seconds, then smoothly and steadily withdraw needle, release skin, and apply gauze gently over site (see Fig. 22.16B).
Nasogastric Tube for Gastric Decompression Irrigation
a. Perform hand hygiene and apply clean gloves. b. Check for tube placement in stomach by disconnecting NG tube, connecting irrigating syringe, and aspirating contents (see Step 22b). Temporarily clamp NG tube or reconnect to connecting tube and remove syringe. c. Empty syringe of aspirate and use it to draw up 30 mL of normal saline. d. Disconnect NG from connecting tubing and lay end of connection tubing on towel. e. Insert tip of irrigating syringe into end of NG tube. Remove clamp. Hold syringe with tip pointed at floor and inject saline slowly and evenly. Do not force solution. f. If resistance occurs, check for kinks in tubing. Turn patient onto left side. Repeated resistance should be reported to health care provider. g. After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. If amount aspirated is greater than amount instilled, record difference as output. If amount aspirated is less than amount instilled, record difference as intake. h. Use an Asepto syringe to place 10 mL of air into blue pigtail. i. Reconnect NG tube to drainage or suction. (Repeat irrigation if solution does not return.)
Blood Transfusion Administration
a. Perform hand hygiene. Apply clean gloves. Reinspect blood product for signs of leakage or unusual appearance. b. Open Y-tubing blood administration set for single unit. Use multiset if multiple units are to be transfused. c. Set all clamp(s) to "off" position. d. Use aseptic technique and spike bag of 0.9% sodium chloride (NS) IV bag with one of Y-tubing spikes. Hang bag on IV pole and prime tubing. Open upper clamp on normal saline side of tubing and squeeze drip chamber until fluid covers filter and one third to one half of drip chamber. e. Maintain clamp on blood product side of Y-tubing in "off" position. Open common tubing clamp to finish priming tubing to distal end of tubing connector. Close tubing clamp when tubing is filled with saline. All three tubing clamps should be closed. Maintain protective sterile cap on tubing connector. f. Prepare blood component for administration. Gently invert bag two or three times, turning back and forth. Remove protective covering from access port. Spike blood component unit with other Y-connection. Close normal saline clamp above filter, open clamp above filter to blood unit, and prime tubing with blood. Blood will flow into drip chamber. Tap filter chamber to ensure that residual air is removed. g. Maintaining asepsis, attach primed tubing to patient's VAD by first cleansing the catheter hub with an antiseptic swab. Then quickly connect NS-primed blood administration tubing directly to patient's VAD. h. Open common tubing clamp and regulate blood infusion to allow only 2 mL/min to infuse in initial 15 minutes. Remain with patient during first 15 minutes of transfusion. Initial flow rate during this time should be 1-2 mL/min or 10-20 gtt/min (using macrodrip of 10 gtt/mL). i. Monitor patient's vital signs within 5 to 15 minutes of initiating transfusion and at completion of transfusion or according to agency policy. j. If there is no transfusion reaction, regulate rate of transfusion according to health care provider's orders based on drop factor for blood administration tubing. k. After blood has infused, clear IV line with 0.9% sodium chloride (NS) and discard blood bag according to agency policy. When consecutive units are ordered, line patency with 0.9% sodium chloride (NS) at keep vein open (KVO) rate as ordered by health care provider and retrieve subsequent unit for administration. l. Appropriately dispose of all supplies. Remove gloves and perform hand hygiene.
how to remove staples
a. Place lower tips of staple extractor under first staple. As you close handles, upper tip of extractor depresses center of staple, causing both ends of staple to be bent upward and simultaneously exit their insertion sites in dermal layer. b. Carefully control staple extractor. c. As soon as both ends of staple are visible, move it away from skin surface and continue until staple is over refuse bag. d. Release handles of staple extractor, allowing staple to drop into refuse bag. e. Repeat Steps a through d until all staples are removed.
CVAD Insertion site care and dressing change
a. Position patient in comfortable position with head slightly elevated. Have arm extended. b. Prepare dressing materials. -TSM dressing: change at least every 5-7 days -Gauze dressing: change at least every 2 days -Gauze under TSM: change at least every 2 days c. Perform hand hygiene and apply mask. Instruct patient to turn head away from site during dressing change or provide mask for patient. d. Apply clean gloves. Remove old TSM dressing by stabilizing catheter with nondominant hand. Remove dressing by pulling up one corner and gently pulling straight out and parallel to skin. Repeat on all sides until dressing has been removed. e. Remove catheter stabilization device if used and requires changing. Must use alcohol to remove adhesive stabilization devices. f. Inspect catheter, insertion site, and surrounding skin. Measure external CVAD length and compare to measurement from insertion if dislodgement is suspected. For PICC and midlines, measure upper-arm circumference 10 cm above antecubital fossa if clinically indicated and compare to baseline. g. Remove and discard clean gloves; perform hand hygiene. Open CVAD dressing kit using sterile technique and apply sterile gloves. Area to be cleaned should be same size as dressing. h. Clean site: (1) Perform skin antisepsis with CHG solution using friction in back-and-forth motion for 30 seconds and allow to dry completely. (2) Povidone-iodine and alcohol may be used in some settings or if patient is sensitive to CHG (see agency policy). If using alcohol or povidone-iodine, clean in concentric circle, moving from insertion site outward with swab. Allow to dry completely. i. Apply skin protectant to area and allow to dry completely so skin is not tacky. Skin protectant must be used if adhesive stabilization device will be used. j. Option: Use CHG-impregnated dressing for short-term CVADs. k. Apply sterile TSM dressing or gauze dressing over insertion site l. Apply new catheter stabilization device according to manufacturer directions for use if catheter is not sutured in place m. Apply label to dressing with date, time, and your initials. n. Dispose of soiled supplies and used equipment. Remove gloves and perform hand hygiene.
Implementation: Partial or general seizure response
a. Position patient safely. (1) If patient is standing or sitting, guide him or her to floor and protect head by cradling in your lap or place pillow under head. Position patient so as to keep head tilted to maximize breathing (if able). Try to position patient on side but do not force. Do not lift patient from floor to bed during seizure. (2) If patient is in bed, turn him or her onto side (do not force) and raise side rails. b. Note time seizure began and call for help immediately to have staff member bring emergency cart to bedside and clear surrounding area of furniture. Provide airway protection and gas exchange by positioning head. Have health care provider notified immediately. c. Keep patient in side-lying position (if possible), supporting head and keeping it flexed slightly forward. d. Do not restrain patient; if patient is flailing limbs, hold them loosely. Loosen restrictive clothing/gown to aid breathing. e. Never force any object into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. f. If possible, provide privacy. Have staff control flow of visitors in area. g. Observe sequence and timing of seizure activity. Note type of seizure activity (tonic, clonic, staring, blinking); whether more than one type of seizure occurs; sequence of seizure progression; level of consciousness; character of breathing; presence of incontinence; presence of autonomic signs of lip smacking, mastication, or grimacing; rolling of eyes. h. As patient regains consciousness, assess vital signs and reorient and reassure him or her. Explain what happened and answer patient's questions. Stay with patient until fully awake.
pour a sterile solution into a container on a sterile field
a. Verify contents and expiration date of solution. b. Place receptacle for solution near table/work surface edge. Sterile kits have cups or plastic molded sections into which fluids can be poured. c. Remove sterile seal and cap from bottle in upward motion. d. With solution bottle held away from field and bottle lip 2.5 to 5 cm (1 to 2 inches) above inside of sterile receiving container, slowly pour needed amount of solution into container. Hold bottle with label facing palm of hand.
ID
a. With nondominant hand stretch skin over site with forefinger or thumb. Needle pierces tight skin more easily. b. With needle almost against patient's skin, insert it slowly at 5- to 15-degree angle until resistance is felt. Advance needle through epidermis to approximately 3 mm (image inch) below skin surface. You will see bulge of needle tip through skin (see illustration). c. Inject medication slowly. Normally you feel resistance. If not, needle is too deep; remove and begin again. d. While injecting medication, note that small bleb (approximately 6 mm [image inch]) resembling mosquito bite appears on skin surface (see illustration). e. After withdrawing needle, apply alcohol swab or gauze gently over site.
p
after
pc
after meals
nursing interventions
are informed by the results of nursing assessments. While the ultimate goal of an assessment is to decide on a course of treatment, an _________________ in many cases is the treatment. Go beyond simply "fixing" a patient medically.
Seizure
are sudden, abnormal, electrical discharges in the brain causing alterations in behavior, sensation, or consciousness.
a
before
ac
before meals
copious, moderate, scant amounts of drainage
completely or partially saturated or in terms of quantity
trade name
has the symbol™ at the upper right of the name, indicating a manufacturer trademark of the name (e.g., Panadol™, Tempra™, Tylenol™). Many companies choose names that are easy to remember and can be very similar, which contributes to medication errors. May look different from generic.
Virchow's triad
hypercoagulability of the blood, venous wall damage, and blood flow stasis
vial
is a single- or multi-dose plastic or glass container with a rubber seal at the top (see Fig. 22.10B). After you open a single-dose one discard it, regardless of the amount of medication used. A multi-dose one contains several doses of a medication and thus can be used several times, although only for a single patient. When using a multi-dose one, write the date that it is opened on the label.
Problem-oriented medical records
is a structured method of documenting narratives that emphasizes a patient's problems. This method organizes data using the nursing process, which facilitates communication about patient needs. Data are organized by problem or diagnosis. Ideally all members of the health care team contribute to the list of identified patient problems. This approach helps to coordinate an individualized plan of care with the following sections: database, problem list, care plan, and progress notes.
Incident Reports
is any event not consistent with the routine operation of a health care unit or routine care of a patient. Examples include patient falls, needlestick injuries, medication errors, or a visitor becoming ill. The National Quality Forum identified a standardized list of preventable, serious adverse events that facilitate reporting of such events. Completion of an occurrence report happens when there is actual or potential patient injury (near miss) that is not part of the patient record. Document in the patient's record an objective description of what you observed and follow-up actions taken without reference to it. Reporting helps to identify high-risk trends in nursing care or daily unit operations that warrant correction. You complete the report even if an injury does not occur or is not apparent. The information from the reports helps nursing staff find solutions to prevent repeated incidents. The reports are an important part of the quality improvement program of a unit. Are important sources of data for enhancing understanding of underlying causes of events that, when analyzed, can improve patient safety. Nurses are active participants in examining the cause of errors and redesigning systems to minimize the same type of errors in the future. By focusing on systems rather than individual failures, there is greater opportunity to improve patient safety. For example, a patient is administered the wrong medication by a nurse. A review of the event focuses primarily on the medication process as opposed to blaming the nurse for the error.
Individually identifiable health information
is information that is a subset of health information, including demographic information (e.g., age, social security number, electronic mail address) collected from an individual.
Therapeutic communication
is patient centered, purposeful, and time limited. This differs from social communication which is casual and comfortable. In this kind of relationship, the nurse recognizes the patient as a unique individual and establishes a goal to help the patient. One does not form a social relationship with the patient, such as dating, confiding personal information, etc.
Salem sump tube
is preferable for stomach decompression. The tube has two lumens: one for removal of gastric contents and one to provide an air vent, which prevents suctioning of gastric mucosa into eyelets at the distal tip of a tube. A blue "pigtail" is the air vent that connects with the second lumen. When the main lumen of the tube is connected to suction, the air vent permits free, continuous drainage of secretions. Never clamp off the air vent, connect to suction, or use for irrigation.
generic
is the name that is listed in official publications such as the United States Pharmacopeia (USP). Many companies names that are easy to remember and can be very similar, which contributes to medication errors. Are often prescribed as a more cost-efficient substitution for brand-name medications. However, there may be dramatic differences in appearance of drugs, depending on the manufacturer.
protected health information (PHI)
refers to any information (oral or recorded) in any form that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse and relates to the past, present, or future physical or mental health or condition of any individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual
hazards of immobility
often restricts a patient's ability to change and control body position, thus increasing the pressure over bony prominences which can lead to pressure ulcers
5 P's
pain, potty, possessions, pathway, pumps
dehiscence
partial or total separation of wound layers
therapeutic effects
the intended or desired physiological response of a medication
sanguineous drainage
which indicates fresh bleeding, bright red
serous drainage
which is a clear, watery plasma
serosanguineous drainage
which is a pale, red, more watery drainage than sanguineous drainage
purulent drainage
which is a thick, yellow, green, tan, or brown drainage
overlined c
with
overlined s
without
Postictal
—meaning after the attack. Refers to the aftereffects of a seizure (e.g., arm numbness, altered consciousness, partial paralysis).
Ictus
—meaning attack ____________ is another word for the physical seizure involving a series of muscle contractions, called tonic and clonic contractions.
Aura
—the start of a partial seizure. If it is the only phase a patient experiences, the patient has had a simple partial seizure. If the seizure spreads and affects consciousness, it is a complex partial seizure. If the seizure spreads to the rest of the brain, it becomes a generalized seizure.
Regulating Intravenous Flow Rates Geriatric Considerations
• Use an EID and microdrip tubing to administer IV solutions. Monitor vital signs, electrolyte levels, blood urea nitrogen (BUN), creatinine, urine output, and body weight
pediatric considerations for inhalers
• A spacer is of benefit to young children because they have difficulty coordinating inhaler activation and inhaling (Hockenberry and Wilson, 2015). • Educate child and parent about the need to use the inhaler during school hours. Help family find resources within the school or day care facility. Many school systems do not permit self-administration of MDIs. Follow school policy regarding having the MDI available for use during school hours. A health care provider's order may be necessary.
Professional Nursing Organizations
• American Nurses Association (ANA) • International Council of Nursing (ICN) • National Student Nurses Association (NSNA) • National League for Nursing (NLN) • Specialty organizations
aspiration risk patients
• Assess patient's ability to swallow and cough and check for presence of gag reflex. • Prepare oral medication in form that is easiest to swallow. • Allow patient to self-administer medications if possible. • If patient has unilateral (one-sided) weakness, place medication in stronger side of mouth. • Administer pills one at a time, ensuring that each medication is properly swallowed before next one is introduced. • Thicken regular liquids or offer fruit nectars if patient cannot tolerate thin liquids. • Avoid straws because they decrease control patient has over volume intake, which increases risk of aspiration. • Have patient hold and drink from a cup if possible. • Time medications to coincide with meals or when patient is well rested and awake if possible. • Administer medications using another route if risk of aspiration is severe.
Infusion Nursing Society (INS) standards for reducing infection related to IV Therapy
• Assess the VAD catheter-skin junction site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Assess short-peripheral catheters minimally at least every 4 hours or more if clinically indicated and daily for outpatient or home care patients. CVADs should be assessed at least daily. • Change the dressing immediately to assess, clean, and disinfect the site in the event of drainage, tenderness, other signs of infection or if dressing becomes loose or dislodged. • Perform hand hygiene before placing and providing any VAD-associated interventions. • Perform dressing changes at a frequency based on the type of catheter and dressing. Short-peripheral catheter dressings are changed if the dressing becomes damp, loosened, and/or visibly soiled; if there is blood or drainage under the dressing; and at least every 5-7 days. Change CVAD dressings at least every 5-7 days for TSM dressings and at least every 2 days for gauze dressings that cover a catheter site or are under a TSM. • Use approved antiseptic agents before venipuncture and when performing skin antisepsis. The preferred skin antiseptic is >0.5% chlorhexidine gluconate (CHG) in alcohol solution. Tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may be used if CHG solution is contraindicated. • Allow skin antiseptic to dry fully before dressing placement; alcoholic chlorhexidine solutions, for at least 30 seconds; iodophors, for at least 1.5-2 minutes. • Use catheter stabilization device that allows visual inspection of access site. • Use vigorous mechanical scrubbing methods when disinfecting needleless connectors before each access using 70% isopropyl alcohol, iodophors, or >0.5% chlorhexidine alcoholic solution. Disinfect before each access when multiple accesses are required. • Change needleless connectors using aseptic no-touch technique no more frequently than 96-hour intervals. • Use passive disinfection caps (e.g., isopropyl alcohol). • Change administration sets based on solution administered and frequency of the infusion and immediately on suspected contamination or when integrity has been compromised. CVAD, Central vascular access device; INS, Infusion Nurses Society; TSM, transparent semipermeable membrane; VAD, vascular access device.
Recommendations for the 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 after medication administration. • Plan safe handling and disposal of needles before beginning a procedure. • Immediately dispose of needles, needleless systems, and SESIP into puncture-proof and leak-proof sharps disposal containers. • Maintain a sharps injury log that reports 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; and privacy of the employees who have had sharps injuries. • Attend education offerings on bloodborne pathogens and follow recommendations for infection prevention, including receiving the hepatitis B vaccine. • Participate in the selection and evaluation of SESIP devices with safety features within your agency whenever possible.
Primary and Secondary Continuous Infusions
• Change no more frequently than every 96 hours for solutions other than lipid, blood, or blood products. • In addition to routine changes, change the administration set whenever the short-peripheral IV site is changed or a new CVAD is placed. • If the second set is removed from the first set, the second set is now an intermittent set and should be changed every 24 hours.
IV solution runs slower than ordered
• Check for positional change that affects rate, height of IV container, kinking of tubing, or obstruction. • Check VAD site for complications. • Consult health care provider for new order to provide necessary fluid volume.
IV patency is lost subsequent to IV solution container running empty.
• Discontinue present IV infusion and restart new short-peripheral catheter in new site.
Regulating Intravenous Flow Rates Pediatric Considerations
• Do not use containers exceeding 150 mL in children younger than 2 years of age, exceeding 250 mL in children younger than 5 years of age, or exceeding 500 mL in children younger than 10 years of age. Always use tamper-resistant volume-controlled EIDs to ensure accurate fluid delivery
Characteristics of Therapeutic Communication
• Empathy - Empathy is the desire to understand and be sensitive to the feelings, beliefs and situations of another person (Put yourself in the other's place.) • Respect for the patient • Genuineness - Be honest. Be authentic. • Concreteness and Confrontation - Offer understandable responses to a client's questions or concerns. Construct messages in a manner that is suitable for the patient. Conversely, if a patient is unable to express thoughts clearly, be willing and able to request clarification or to confront the patient, as needed.
Characteristics of a Profession
• Extensive education • Theoretical body of knowledge • Specific service • Autonomy in decision making • Code of ethics • Define their scope and standards • Code of Behavior • Duty to the Public • Emphasis is on service rather than mere economic gain • Acceptance of accountability • Pride about the it • Pursuit of quality • Willingness to pursue development within it
Can be delegated to NAP
• Frequency of vital sign monitoring needed. • What to observe such as complaints of shortness of breath, hives, and/or chills and reporting this information to the nurse. • Obtaining blood components from the blood bank (check agency policy).
additional information
•DO NOT try to add ______________- to a previously made entry •If _____________________ needs to be added to an existing entry, write the date and time of the new entry on the next available space, and mark it as an addendum
VAP Prevention
• Good hand hygiene • Internal endotracheal cuff pressure at 25 to 30 cm H2O every 2 hours • Head of bed at 30 to 45 degrees • Prophylaxis for deep vein thrombosis and peptic ulcer disease • Daily interruptions of sedation to assess accurately for readiness to extubate • Oral care with chlorhexidine 0.12% every 12 hours and general oral care every 2 hours secondary to microbial colonization within the mouth • Complete subglottal suctioning to decrease risk of oral fluid aspiration • Accurate and timely documentation • Timely ventilator circuit changes and removal of condensation • Provide for mobility through turning and repositioning every 2 hours
Safe Medication Administration
• Identify patient correctly. Use at least two patient identifiers (neither can be patient's room number) when providing care, treatment (e.g., medications), or services. • Improve the effectiveness of communication among caregivers. • Verbal or telephone orders require a verification "read-back" of the complete order or test result by the person receiving the order/test result. • Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout an organization. • Improve the safety of using medications. • Identify and at a minimum annually review a list of look-alike/sound-alike drugs used by the organization. • Before a procedure, label all medications and medication containers (e.g., syringes) that are not labeled. Do this in areas where medicines and supplies are set up, such as on and off the sterile field in perioperative and other procedural settings. Labels include drug name, strength, amount, expiration date when not used within 24 hours, and expiration time when expiration occurs in less than 24 hours. • Take extra care with patients who take anticoagulants. Use only oral unit-dose products and premixed infusions. When heparin is administered intravenously and continuously, use programmable infusion pumps. • Maintain and communicate accurate patient medication information. • Accurately and completely reconcile medications across the continuum of care. • There is a process for comparing the patient's current medications with those ordered for the patient while under the care of the health care organization. • Communicate a complete list of the patient's medications to the next provider of service when a patient is referred or transferred to another setting, service, or level of care. Also provide the complete list to the patient on discharge from the agency. • Encourage patients' active involvement in their own care as a patient safety strategy.
pediatric considerations for eye meds
• Infants often clench the eyes tightly to avoid eyedrops. Place the drops at the nasal corner where the lids meet with the infant supine. When the infant opens the eye, the medication will flow into it. • If the eye ointment is to be given once a day, administer at bedtime because it will blur the child's vision
pediatric considerations for oral medication
• Liquid forms of medication are safer to swallow to avoid aspiration of small pills. • Children refuse bitter or distasteful oral preparations. Mix the drug with a small amount (about 1 tsp) of a sweet-tasting substance such as jam, applesauce, sherbet, ice cream, or fruit puree. Do not use honey for infants because of the risk of botulism. Offer the child juice or a flavored ice pop after medication administration. Do not place medication in an essential food item such as milk or formula; the child may refuse the food at a later time. • Measure the liquid medications with a plastic calibrated oral dosing syringe or a spoon. Calibrated spoons have proven to be most accurate for the pediatric population
Changing a Short-Peripheral Intravenous Dressing Pediatric Considerations
• Patients are not always able to understand explanations fully. Presence of parent or security toy during procedure helps to decrease fear and increase cooperation. Perform procedure on patient's toy or doll first. • Help is necessary to keep patient still and protect IV catheter from dislodgement. • Use commercially available IV site protectors to cover and protect the IV site in young active children. • Use CHG with care in premature infants and those under 2 months of age due to the risks of skin irritation and chemical burns • Dried povidone-iodine should be removed with sodium chloride or sterile water for neonates with compromised skin integrity
Insertion of a Short-Peripheral Intravenous Device Pediatric Considerations
• Perform venipuncture in a neutral space to allow the child's room to be a safe place. • In addition to the usual venipuncture sites, the four scalp veins are used in infants and toddlers and, if not walking, the dorsum of the foot. • Needle selection is based on age: 26- to 24-gauge for neonates, 24- to 22-gauge for children. • Use local anesthetics and distraction strategies to minimize distress associated with venipuncture. • Apply latex-free tubing or use a blood pressure cuff inflated to just below diastolic blood pressure. • Allow older children to select IV site to increase cooperation so they believe that they have some control over their treatment. • To maintain safety in positioning, have extra help when starting an IV line on a child. Use therapeutic hugging, usually in a sitting position, to provide close contact. NAP can help with positioning. • Choose age-appropriate activities compatible with the maintenance of the IV infusion to maintain normal growth and development.
IV catheter is removed or dislodged accidentally.
• Restart new short-peripheral IV line in other extremity or above previous insertion site if continued therapy is necessary.
Primary Intermittent Infusions
• Should be changed every 24 hours because of increased risk of infection with repeatedly disconnecting and reconnecting administration set. • Aseptically attach a new, sterile covering device to the Luer end of the administration set after each use. Avoid attaching the exposed end of the administration set to port on the same set (e.g., looping).
Use of Add-on Devices
• Should be minimized because each is a potential source of contamination and disconnection. • Use of administration sets with devices as part of the set is preferred. • Aseptically change with insertion of new VAD or with each administration set replacement. • Change if the integrity of the product is compromised or suspected of being compromised.
Changing a Short-Peripheral Intravenous Dressing Geriatric Consideration
• Some older adults have fragile skin; therefore prevent skin tears by minimizing the use of tape or an engineered stabilization device directly on the skin and applying skin protectant before applying tape. • Infiltration may go unnoticed because of the decreased elasticity of skin and loose skinfolds. Because of decreased tactile sensation, a large amount of fluid may infiltrate before pain occurs.
pediatric considerations for nebulizers
• Use a mask for the nebulizer treatment if child is too young to hold mouthpiece correctly for the duration of the treatment (Hockenberry and Wilson, 2015). • Instruct child to breathe normally with mouth open to provide a direct route to the airways for the medication. • Educate child and parent about the need to use the nebulizer during school or day care hours. Help family find resources within the school or day care facility. Follow school policy regarding having the nebulizer and medication available for use during school hours. A health care provider's order may be necessary.
interventions for the prevention of CAUTI
• Use aseptic catheter insertion with sterile equipment (Fekete et al., 2015; TJC, 2016). • Use only trained, dedicated personnel to insert urinary catheters (Lo et al., 2014). • Use smallest catheter possible. • Remove catheter as soon as possible (Meddings et al., 2013). • Secure indwelling catheters to prevent movement and pulling on the catheter. • Maintain a closed urinary drainage system. • Maintain an unobstructed flow of urine through the catheter, drainage tubing, and drainage bag. • Keep the urinary drainage bag below the level of the bladder at all times. • When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. • Perform routine perineal hygiene daily and after soiling. • Quality improvement/surveillance programs should be in place that alert providers that a catheter is in place and include regular educational programming about catheter care.
Insertion of a Short-Peripheral Intravenous Device Geriatric Considerations
• Veins of the older population are very fragile; they have less subcutaneous support tissue, and their skin is thinning. Avoid sites that are easily moved or bumped. Use a commercial protective device to protect the site and reduce manipulation • In older patients the use of a 22- or 24-gauge catheter is appropriate for most therapies. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of the IV solutions or medications • If possible, avoid the back of the older adult's hand or the dominant arm for venipuncture because use of these sites interferes with their independence. • As older adults lose subcutaneous tissue, the veins lose stability and roll away from the needle. To stabilize the vein, pull the skin taut and toward you with your nondominant hand and anchor the vein with your thumb.
Hypotonic solutions
•0.45% sodium chloride (half NS) •0.33% sodium chloride (one-third NS)
generalized terms
•AVOID using them, or empty phrases such as "status unchanged" or "had a good day" •Use complete and concise descriptions of care
guidelines for administering controlled substances
•All are stored in a securely locked, substantially constructed cabinet (i.e., automated medication dispensing system [AMDS]) or a locked room. •Authorized nurses carry a set of keys or an individual computer entry code for the AMDS. •An inventory record is used each time one is dispensed. Records are often kept electronically and provide an accurate ongoing account of the medications used, wasted, and remaining. If you find a discrepancy, correct and report it immediately. •Use a special inventory record to document a patient's name, date, name of medication, dose, time of medication administration, and signature of nurse dispensing the medication. •A second nurse witnesses disposal of the unused part if a nurse gives only part of a dose of one. Computerized systems record the nurses' names electronically. If paper records are kept, both nurses sign their names on the form. Follow agency policy for appropriate waste of them. Do not place wasted part of medications in sharps containers.
3 phases of a seizure
•Aura—the start of a partial seizure. If the aura is the only phase a patient experiences, the patient has had a simple partial seizure. If the seizure spreads and affects consciousness, it is a complex partial seizure. If the seizure spreads to the rest of the brain, it becomes a generalized seizure. •Ictus—meaning attack Ictus is another word for the physical seizure involving a series of muscle contractions, called tonic and clonic contractions. •Postictal—meaning after the attack. Postictal refers to the aftereffects of a seizure (e.g., arm numbness, altered consciousness, partial paralysis).
Databases that contain searchable scientific literature
•CINAHL •Cochrane Database of Systematic Reviews •PubMed •MEDLINE •EMBASE •Psyc INFO •National Guidelines Clearinghouse
Which database can I find a systematic review
•CINAHL •Cochrane Database of Systematic Reviews •PubMed •MEDLINE •EMBASE •Psyc INFO •National Guidelines Clearinghouse
Assertiveness
•Choose appropriate location •Maintain eye contact •Establish trust •Be sensitive to cultural differences •Use "I" statements •Avoid "You" statements that indicate blame •State concerns using open, honest, and direct statements •Convey empathy •Focusing on the issue of conflict; avoid personal attacks •Concluding with a statement that describes a fair solution •Nonthreatening •Respects others •Direct statement of feelings
Fall prevention interventions
•Correction of environmental hazards •Identification armbands and bed and door signs for high-risk patients •Bedrails and bed height kept at the lowest level •Nurse call bell explained and within reach •Unsafe footwear replaced and/or nonskid footwear provided •Individualized patient and caregiver education and written instructions (preferably prescribed on the basis of risk factors) •Staff assignments in close proximity (assigned to patients in adjacent rooms) •Improving staff communication by including nonlicensed staff •Improving patient hand-off communication •Advising patients on changing position slowly •Encouraging patients to use eye glasses, hearing aids, footwear, and mobility devices •Nurse toilet and turn or comfort and care safety rounds (conducted hourly) •Supervision and assistance with transfer and toilet use •Toileting before pain medication •Medical referral for abnormal blood pressure •Medication review for sedatives, antidepressants, diuretics, and polypharmacy •Ophthalmology referral for poor eyesight and optician visit if lost glasses
computer use
•DO NOT leave a computer screen unattended if you are logged on •Always keep your password to yourself to help maintain security and confidentiality
blank spaces
•DO NOT leave them in nurses' notes •Chart consecutively, line by line; if space is left draw a line horizontally through it, and sign your name at the end
Physician mistakes
•DO NOT record "physician made error." Instead chart that "Dr. Smith was called to clarify order for analgesic." •If an order is questioned, record that you sought clarification
time management when charting
•DO NOT rush to complete charting; make sure information is accurate •Correct ALL errors promptly
guessing
•DO NOT speculate or _________ while making entries, make sure to state the facts •Record ALL the facts, so that the information is accurate and reliable
charting throughout the day
•DO NOT wait until the end of the shift to record important changes that occurred several hours earlier, be sure to sign each entry •Begin each entry with time, and end with your signature and title
how to reduce risks associated with orthostatic hypotension
•Dangling on the side of the bed and making sure legs are touching the floor can minimize it by allowing the circulatory system to equilibrate. •After dangling, have the patient stand and if he or she tolerates standing without dizziness, proceed with ambulation. •Use safety precautions before and during ambulation to control for it and subsequent falling.
Hypertonic solutions
•Dextrose 10% in water •Dextrose 50% in water •3%-5% sodium chloride •Dextrose 5% in 0.9% sodium chloride •Dextrose 5% in 0.45% NaCl sodium chloride •Dextrose 5% in Lactated Ringer's
Isotonic solutions
•Dextrose 5% in water -Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments so it acts like a hypotonic solution •0.9% sodium chloride† (NS) •Lactated Ringer's‡ -Has multiple electrolytes
restraints alternatives
•Distraction •Social interaction •Regular exercise •Circular design of a patient care unit •More frequent observation of patients -hourly rounding 5 P's (pain, potty, possessions, pathway, pumps) •Involvement of family during visitation •Frequent reorientation •Provide for patient needs and keep them comfortable
Strategy for Improvement
•Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety. •Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organi zations and practitioners to develop and participate in voluntary reporting systems. •Raising performance standards and expectations for improve ments in safety through the actions of oversight organizations, professional groups, and group purchasers of health care. •Implementing safety systems in health care organizations to en- sure safe practices at the delivery level.
Electrical Safety
•If patient receives an electrical shock, immediately unplug the electrical source and assess for presence of a pulse. Caution: When disengaging electrical source, check for presence of water on floor. •Do not touch a person who is being shocked while he or she is still engaged with the electrical source. If unable to disconnect source, call emergency number for assistance. •Prevention -Make sure electrical equipment is in good working order -All electrical equipment should have an unexpired hospital biomedical sticker on it -Patient's personal electrical devices must be inspected by hospital engineers -All devices should have a 3-prong electrical plug
Types of Conflict
•Intrapersonal •Interpersonal •Intergroup Conflict •Organizational Conflict
parameters included in a wound assessment
•Location: Note the anatomical position of the wound. •Type of wound: If possible, note the etiology of the wound (i.e., surgical, pressure, trauma). •Extent of tissue involvement: Full-thickness wound involves both the dermis and epidermis. Partial-thickness wound involves only the epidermal layer. If it is a pressure injury, use the staging system of the National Pressure Ulcer Advisory Panel. •Type and percentage of tissue in wound base: Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount. •Wound size: Follow agency policy to measure wound dimensions, which includes width, length, and depth. •Wound exudate: Describe the amount, color, and consistency. Serous drainage is clear like plasma; sanguineous or bright red drainage indicates fresh bleeding; serosanguinous drainage is pink; and purulent drainage is thick and yellow, pale green, or white. •Presence of odor: Note the presence or absence of odor, which may indicate infection. •Periwound area: Assess the color, temperature, and integrity of the skin. •Pain: Use a validated pain assessment scale to evaluate pain.
Guidelines for Verbal and Telephone Orders
•Only authorized staff receive and record verbal or telephone orders. Agency identifies in writing the staff who are authorized. •Clearly identify patient's name, room number, and diagnosis. •Read back all orders to health care provider. •Use clarification questions to avoid misunderstandings. •Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse. •Follow agency policies; some agencies require documentation of the "read-back" or two nurses to review and sign telephone or verbal orders. •Health care provider co-signs the order within the time frame required by the agency (usually 24 hours; verify agency policy).
Developing a PICO Question
•P = Patient, population or problem (Identify your patients by age, gender, ethnicity, disease, or symptoms) •I = Intervention or issue of interest (Which intervention do you think is worthwhile to use in practice? It can be a treatment; a clinical, educational, or administrative intervention; a process of care, an education strategy; or an assessment approach) •C = Comparison with the intervention (Does a comparison intervention exist? Which standard of care or current intervention do you usually now use in practice? practice?) •O = Outcome (that is MEASURABLE) (Which result do you wish to achieve or observe as a result of an intervention (e.g., change in patient's behavior, quality of life, physical finding, change in patient's perception, rate of adverse events, costs)?) •T = Time (an optional component for a clinical question) (How long does it take for an intervention to achieve outcome?)
Phases of the therapeutic relationship
•Pre-interactive phase - Here the nurse gathers information about the patient prior to having direct contact. • Orientation phase - The goal of this phase is to develop rapport and trust. It begins with an introduction and ends when the relationship has been defined. • Working phase - During this phase, caring is communicated, thoughts and feelings are expressed, mutual respect is maintained, and honest verbal and nonverbal expression occurs. The key goal is to help the patient to clarify feelings and concerns. A professional relationship is courteous, trustworthy, and confidential and accomplished by active listening and the use of therapeutic communication techniques. • Termination phase - concludes the relationship. This could occur at the end of a shift or discharge from the facility, etc. Note that therapeutic relations have an end.
removing personal protective equipment (PPE)
•Take off alphabetically -Gloves-remove flove to glove and skin to skin pointing hand down toward the trash can -Goggles -Gown-untie and pull off touching the inside of the gown only and roll it up with outside in -Mask -Hand Hygiene
Applying Physical Restraints
•Teach patient & family •Use least restrictive restraint •Attach restraint straps to a part of the bedframe that moves with the patient; never the siderail •Secure restraints on bedframe with quick-release buckle; never a knot that is not a slip knot •Ensure restraint is not too tight •Assess for circulation, sensation, color of restrained body part. •Assess every 15 minutes for signs of injury •Release restraints at least every 2 hours and assess needs for toileting, food, fluids, mobility After 24 hours, before writing a new order, health care provider who is responsible for patient's care must see and reassess patient. A licensed independent health care provider responsible for the care of the patient evaluates the patient in person within 1 hour of the initiation of restraint used for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others
Nurse Practice Act of Alabama
•The law that regulates the practice of nursing (RN, LPN, APN) with the state. •Establishes the _____________ Board of Nursing (ABON) and gives the board authority over nursing practice •The ABON is authorized to give a license to a person to practice nursing...AND has the right to take it away!
State Nurse Practice Acts
•This IS the Law •State nurse Practice Acts define the Scope of Practice within each state •Protects the public! •NURSING LICENSURE....It's the Law! •To practice nursing in the United States, RN candidates must pass the NCLEX-RN exam •Same exam in every state •Regardless of educational preparation, the exam is the same •Tests minimum knowledge base
Standard Precautions (Tier 1)
•Used for all patients, regardless of risk or presumed infection status •Apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes •How does the nurse teach cough etiquette?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 non-patient 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 hand rub to perform hand hygiene. •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 (PPE) 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 agencies must make available needleless devices. Any needles should be disposed of uncapped, or a mechanical safety device must be 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 91.4 cm (3 feet) away from others if coughing
methods to maintain peristomal skin integrity
•With any ostomy requiring a pouching system, a secure seal to prevent leakage of the effluent and protect the skin around the stoma (peristomal skin) is vital to helping patients resume normal activities and accept the changes in their bodies as a result of surgery. •A reliable and effective pouching system is a very important factor in facilitating a patient's emotional adjustment to an ostomy. 1. Change ostomy pouches before they become full to avoid leakage. 2. Know the signs of a healthy stoma and surrounding skin. 3. Wear gloves during pouch and stoma care to reduce exposure to and transmission of infectious microorganisms.
seizure practice guidelines
•Within first 2 minutes establish and protect the airway when patient loses consciousness. •Provide noninvasive airway protection and gas exchange with head positioning, keeping the airway patent and administering oxygen. •Measure vital signs: oxygen saturation, blood pressure, and heart rate immediately and every 2 minutes. •Establish an intravenous (IV) route for emergency medications. •When seizure begins to subside, intubation (insertion of an artificial airway) should be attempted only if gas exchange is compromised or if patient is believed to have increased intracranial pressure.
Core measures
•are national standards of care and treatment processes for common conditions. •are proven to reduce complications and lead to better patient outcomes. •One common condition is acute myocardial infarction (AMI) -Based on research, treatments have been bundled that are proven to improve outcomes of patients having a heart attack -Examples: •An aspirin within 24 hours of arrival to the hospital •Aspirin, beta blocker, statin at discharge
patient fall risk factors
•patient's age (over 65), presence of co-morbidities, altered memory and cognition, incontinence or urinary frequency/urgency, reduced hearing and vision, orthostatic hypotension, arthritis, impaired gait, weak lower extremities, poor balance, fatigue, need for transfer assistance, and decreased peripheral sensation •Individual intrinsic factors such as co-morbidities, muscle weakness, and urinary incontinence increase the risk of falling in a hospital and community setting. Transient factors that can change over time such as postural hypotension, polypharmacy, and use of high-risk medications also are risks. •Extrinsic risks such as a health care agency's environment (e.g., poor lighting, slippery flooring, improper use of assist devices also contribute to them.
