NUR206: Fundamentals Unit 2
Case Study 5
A. Fulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35-year-old American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer, and weakness and fatigue resulting from the anemia. B. Fulmala develops Ms. Skyfall's plan of care, which addresses pain, weakness, fatigue, nutrition, and patient safety. -Why are anemia and peptic ulcer not part of the care plan?
Case Study 8
A. Fumala writes down several independent nursing interventions that she is developing for Ms. Skyfall. -What are some examples of independent (without a healthcare provider order) nursing interventions that Fulmala may develop for Ms. Skyfall? Get her something to eat, assist w/ mobility, & to not overtax her body
Critical Thinking in Assessment of Patients
A. Gather as much information as possible. B. Stages of assessment: -Collection of information/data from a primary source (a patient) and secondary sources -The interpretation/review and validation of data to determine whether more data are needed and if it is accurate -Apply critical thinking using intellectual standards so that you can correctly investigate your findings
Types of Data Collected from Patients
A. Subjective -Patients' verbal descriptions of their health problems -Includes patient feelings, perceptions, and self-reported symptoms -Apparent only to person affected -Verbal description of health problems -Verified or described by that person only -Opinion/feelings (pain, nausea, itching, worry, grief) -"Symptoms" or Covert data
INJECTIONS EQUIPMENT
A. Syringes: -Hypodermic -Insulin -Tuberculin -3,5, & 10 mL -Prefilled Unit-Dose -Carpuject or Tubex B. Needles: -Filter needles used with glass bubble vials -Gauge and length vary based on need/use C. Alcohol Preps D. Gloves E. Cotton Ball or 2x2 Gauze & Band-aid F. Sharps Container
Case Study (3 of 4)
A. Yolanda asks Ms. Thompkins a series of questions about her pain, including: -"Describe your pain to me." -"Is the pain worse in the morning or in the evening?" -"Place your hand over the area that is uncomfortable." -"Rate your pain on a scale of 0 to 10." B. Which of Yolanda's questions to Ms. Thompkins addresses the nature of Ms. Thompkins' pain? A Location? C Severity? D Precipitating factors? B C. This is a focused assessment, focused on the problem.
Case Study (2 of 4)
A. Yolanda is the student nurse who has been assigned to admit Ms. Thompkins. B. Yolanda enters Ms. Thompkins' room, introduces herself, and begins the admission health history and physical assessment. During the assessment, Ms. Thompkins complains of pain at the incision site. C. Pain is what kind of data? subjective
Case Study (4 of 4)
A. Yolanda knows that the best source of information regarding Ms. Thompkins' care is the surgeon. True or False? False. Rationale: The best source of information regarding the patient's care is typically the patient, as long as the patient is conscious, alert, and able to accurately answer questions.
Consulting with Health Care Professionals (this is a nursing intervention!)
A. You consult with members of the health care team when you face problems in providing nursing or collaborative care or in delivering dependent interventions. (ex. dieticians) B. When to consult C. How to consult (see next slide) D. Successful planning equals patient participation -Follow your facilities guidelines for consulting - at our facilities, the healthcare provider usually makes the consultations, but we can request them.
D.O.A.
dead on arrival
D & C
dilatation and curettage
Non-Therapeutic Communication
•This type of communication would be social communication, not for patient/healthcare interactions •It involves equal disclosure of personal information and intimacy (My aunt had this kind of cancer and died in a week") •Both parties enjoy equal opportunities for spontaneity •In social communication both parties seek to have needs met •They share feelings mutually
Common Tests
●CBC: complete blood count ●BMP(CMP): basic metabolic panel (or complete metabolic panel) ●Liver Enzymes ●AMI: acute myocardial infarction ●Coagulation Studies ("Coag") ●And more!
Promoting Therapeutic Communication With Children
●Look for non-verbal cues ●Use pictures ●Use "play" communication
Promoting Therapeutic Communication cont.
●Nurses demonstrate caring by being with, doing for, and enabling patient well-being ●Becoming sensitive and supportive to self and others. ●Being present and encouraging the expression of positive and negative feelings. ●Instilling faith and hope. ●Respecting and allowing for spiritual expression.
Health History: Observation of Patient Behavior
●Observe verbal and nonverbal behaviors ●Does the verbal match the nonverbal? ●Observe the patient's level of functioning: physical, developmental, psychological, and social aspects of everyday living -Why is it important to determine if the verbal matches the nonverbal? -How does this relate to pain assessment?
What are the nurse's responsibilities?
●Obtain consent if required ●Schedule test if required ●Client prep = ex. NPO ●Accurate collection ●Assess the client after the test ●Monitor and report results
BMP Normal Ranges (*memorize all lab values)
●Sodium: 135 - 145 mmol/L ●Potassium: 3.5 - 5.3 mEq/L ●Chloride: 95 - 105 mEq/L ●Calcium: 4.5 - 5.5 mEq/L ●Magnesium: 1.5 - 2.5 mEq/L ●Glucose: ○70 - 110 mg/dL ○Greater than 140 (fasting), diagnostic for diabetes ●BUN: 5 - 25 mg/dL ●Creatinine: 0.5 - 1.2 mg/dL Cholesterol: less than 200 mg/dL
ml
milliliter
m.
minim
a.m.
morning
MAEs
moves all extremities
MI
myocardial infarction
N & V
nausea and vomiting
neg.
negative
N/S
normal saline
NPO
nothing by mouth
OB
obstetrical
oz.
ounce
PT
physical therapy
lb.
pound
qs
quantity sufficient
RBC
red blood count
sp. gr.
specific gravity
spec
specimen
SQ or subq
subcutaneous
TPR
temperature, pulse, respirations
TLC
tender loving care
tinct
tincture
T & A
tonsillectomy and adenoidectomy
TPN
total parenteral nutrition
TCDB
turn, cough, deep breath
bid
twice a day
VD
venereal disease
wc or w/c
wheelchair
prn
whenever or as often as necessary
WBC
white blood count
c
with
s
without
Barriers to Communication
•Altered mental status or level of consciousness: help by avoiding frustrating the patient, do not use long, complicated questions or answers, watch non- verbal cues, do not argue • Impaired senses including speech, sight, hearing... ●For hearing impaired, face patient, do not cover face, speak clearly, do not yell, but a bit louder may help, quiet no distractions, allow time to answer •Not recognizing differences related to age, gender, culture, values ●Language barriers
Standard Nursing Interventions
A. Standard interventions (ready made for your facility in the EHR - electronic health record) -Allows nurses to act more quickly and appropriately -Helps capture patient care information that can be shared across disciplines and care settings
What are these Guidelines and Bundles based upon?
A. Standards of practice -Nurses use the ANA Standards of Professional Nursing Practice i. as evidence of the standard of care provided to patients B. Quality and safety education for nurses (QSEN) -Standard competencies in knowledge, skills, and attitudes for the preparation of future nurses
Tuberculin syringe
. Called 1 ml syringes • Most accurate way to measure less than 1 mL of medication • The long lines represent 0.1mL
Routes of Administration Review: Sublingual & Buccal
A. Advantages: -Same as for oral, plus drug can be administered for local effect -More potent than oral route because drug directly enters the blood and bypasses the liver B. Disadvantages: -If swallowed, drug may be inactivated by gastric juice -Drug must remain under tongue until dissolved and absorbed. -May cause stinging or irritation of the mucous membranes -Drug is rapidly absorbed into the bloodstream
ICNP 7 Axes With Definitions
. Focus: The area of attention that is relevant to nursing (e.g., pain, homelessness, elimination, life expectancy, knowledge). • Judgment: Clinical opinion or determination related to the focus of nursing practice (e.g., decreasing level, risk, enhanced, interrupted, abnormal). • Client: Subject to whom a diagnosis refers and who is the recipient of an intervention (e.g., newborn, caregiver, family, community). • Action: An intentional process applied to or performed by a client (e.g., educating, changing, administering, monitoring). • Means: A manner or method of accomplishing an intervention (e.g., bandage, bladder-training technique) • Location: Anatomical and spatial orientation of a diagnosis or intervention (e.g., posterior, abdomen, school, community health center). • Time: The point, period, instance, interval, or duration of an occurrence (e.g., admission, childbirth, chronic).
Tips for Making Phone Consultations
. Have the information you need (e.g., medical record notes, medication sheets, recent nurse summary) available BEFORE you make a call. • Assess the patient yourself before making the call. For example, when you consult with health care providers, they rely heavily on your assessment so that they can give appropriate advice. • Address both the clinical history and patient's perspective, including social and cultural context. • Give a diagnosis or interpretation of the patient's problem with an explanation or a summary. Use of the ISBAR approach in reporting is helpful. • Understand why you are calling for consultation and think through some possible solutions. Your experience in caring for the patient allows you to make useful suggestions.
Controlled Substances
. Must be locked in a secured location •A record is kept of all administrations, with the person's name, amount, drug, and the name of the nurse •Usually counts are performed at the end of each shift comparing with is in the cabinet with what the record says should be there •Discrepancies must be report to the supervisor •Any wasted narcotics must be witness and signed by two nurses on the narcotic record •Nurse are also responsible to observe, document, and intervene if drug abuse is suspected by a healthcare provider (HCP) or nurse
Physical Environmental Factors That Promote Patient Healing
. Standardization of patient rooms and equipment for making routine tasks simpler, thus decreasing errors. • Improving light illumination in areas where medications are dispensed. • Features of a patient room and bath that reduce falls: no slippery floors, appropriate door openings, correct placement of rails and accessories, correct toilet and furniture height, single-bed rooms, easy-to-clean surfaces, automated sinks, and smooth edges in rooms (for easier cleaning). • Self-supporting systems, such as control over the position of the bed, control over the temperature, control over the lights (including dimmers), control over the sound (music and television), and control over the natural light. • Privacy and single-patient rooms
Barriers to Communication cont.
. Using cliches' "You'll be fine", "Everything will work out" Examples each of these? • Prying • Leading questions "You're feeling better, aren't you?" • Giving advice = "I wouldn't take that pill." • Belittling • Changing the subject from the patient's interests • Hostility • Physical barriers ex. tracheostomy tube • Nonverbal cues different from verbal • Uncomfortable or distracting environment (noise, odors, distractions, no privacy) Pain, fear, stress (ex. just after surgery) • Level of education - do not assume educated persons know more about healthcare • Personal space, should be 18 inches to 4 feet, not closer or farther • Touching someone without permission • Failure to treat patient as human • Failure to listen or observe • Inappropriate or sexual behavior • Routine use of closed ended questions (yes/no) • Judgmental attitude • Inappropriate humor
Types of Communication
1) Intrapersonal: Occurs within an individual 2) Interpersonal: One-to-one interaction between two people 3) Public: Interaction with an audience 4) Transpersonal: Interaction within a person's spiritual domain, (cosmos, humankind) 5) Small Group: Interactions with a small number of people
Routes of Administration Review: Transdermal
A. Advantages: -Prolonged systemic effect -Few side effects -Avoids gastrointestinal absorption problems -Onset of drug action faster than oral B. Disadvantages: -None
Ten "Rights" of Medication Administration
1) right medication -the medication given was the medication ordered 2) right dose -the dose ordered is appropriate for the patient -give special attention if the calculation indicates multiple pills/tablets or a large quantity of a liquid medication. This can be a "cue" that the math calculation may be incorrect -double-check calculations that appear questionable -know the usual dosage range of the medication -question a dose outside of the usual dosage range 3) right time -give the medication at the right frequency and at the time ordered according to agency policy -medications given within 30 minutes before or after the scheduled time are considered to meet the right time standard 4) right route -give the medication by the ordered route -make certain that the route is safe and appropriate for the client 5) right client -medication is given to the intended client -check the client's identification band w/ each administration of a medication -know the agency's name alert procedure when clients w/ the same or similar last names are on the nursing unit 6) right client education -explain information about the medication to the client (e.g., why receiving, what to expect, any precautions) 7) right documentation -document medication administration after giving it, not before -if time of administration differs from prescribed time, note the time on the MAR and explain reason and follow-through activities (e.g., pharmacy states medication will be available in 2 hours) in nursing notes -if a medication is not given, follow the agency's policy for documenting the reason why 8) right to refuse -adult clients have the right to refuse any medication -the nurse's role is to ensure that the client is fully informed of the potential consequences of refusal and to communicate the client's refusal to the health care provider 9) right assessment -some medications require specific assessments prior to administration (e.g., apical pulse, blood pressure, lab results) -medication orders may include special parameters for administration (e.g., do not give if pulse less than 60 or systolic blood pressure less than 100) 10) right evaluation -conduct appropriate follow-up (e.g., was the desired effect achieved or not? Did the client experience any side effects or adverse reactions?)
Communication in healthcare cont.
1. Communicate empathy = The ability to identify and understand another person's feelings and perspective from an objective stance 2. This will convey both verbally and non-verbally care, compassion, and concern for the patient, but does not mean that the nurse experiences the feelings or feels sorry for the patient (sympathy) 3. The nurse must be genuine and sincere to gain patient trust 4. Promoting Therapeutic Communication • Comfortable environment • Privacy, confidentiality • Patient-focused/centered • Look for non-verbal cues • Optimal pace and tone of voice ● Clarity & brevity(to the point) how many words do you use? ● Timing & relevance: when do you communicate?
Special circumstances: Insulin
1. Concentration - -100 units/mL (U-100) -500 units/mL (U-500) -Only use insulin unit-based syringes to draw up i. Ex. U-100 syringe for U-100 insulin 2. Mixing insulins -Only short-acting insulin can be mixed in a syringe with NPH -No other mixing is appropriate -Short-acting insulin drawn always drawn up first into the syringe to avoid contamination of the short-acting with long acting (inject air in the cloudy/NPH, then air in the clear/short-acting- then draw short-acting first)
Formulating the Diagnosis Statement: Three parts of PROBLEM FOCUSED dx:
1. Diagnostic labels- ex. impaired mobility, acute pain, ineffective grieving 2. Related factors - conditions that caused or influenced the response to the disease -Etiologies(causes)/the pathophysiology, circumstances, facts, influences i. From your nursing assessment -NOT diseases, medical diagnoses, not treatments or diagnostic studies -Ex. inflammation of the joints, right knee tissue trauma associated with surgical repair, deficient calorie intake, nausea, injury to heart muscle, loss of employment, death of spouse i. It is okay to list more than one 3. Major detailed characteristics/major assessment findings - the assessment findings that lead to your diagnosis -Ex. unstable gait, grimacing and guarding left knee, pain of 7 on a 1-10 scale, unintentional 20 pound weight loss over the last month, decreased urination, states, "I am so sad that I cannot get out of bed anymore." -Impaired mobility r/t inflammation of the right knee as evidence by unsteady gait and left knee pain
Essential Safety Measures
1. First check -Read MAR and remove the medication(s) from the the client's drawer. Verify that the client's name and room number match the MAR. -Compare the label of the medication against the MAR. -If the dosage does not match the MAR, determine if you need to do a math calculation. -Check the expiration date of the medication. 2. Second check -While preparing the medication (e.g., pouring, drawing up, or placing unopened package in a medication cup), look at the medication label and check against the MAR. 3. Third check -Recheck the label on the container (e.g., vial, bottle, or unused unit-dose medications) before returning to its storage place OR Check the label on the medication against the MAR before opening the package at the bedside
Purpose of Communication cont.
1. In patient care, only the patient can ultimately clarify and validate the meaning of their messages Example: Only a patient can determine if a lack of eye contact is due to low self-esteem or a cultural trait (ex. eye contact with a stranger is rude in some cultures).
What is the purpose of lab data?
1. Lab data is a tool used to provide information about the patient. 2. It can be used as a wellness check, to confirm diagnosis, monitor for illness, or to check the patient response to treatment. 3. Nurses need to know about lab data for best practice of patient care.
Nursing Responsibilities
1. Make a professional judgment that the order is complete, appropriate and acceptable considering: -¡the type of drug, therapeutic intent, usual dose, and mathematical and physical preparation 2. Note route compared to physical condition, patients ability to tolerate dose form 3. Note allergies or past problems taking the drug. 4. If there is any uncertainty, confusion, vagueness to an order, IT MUST BE CLARIFIED WITH THE HCP WHO WROTE THE ORDER 5. The nurse is ultimately responsible for any medication they give, even if the HCP or pharmacist or transcriber made an error
Safe Administration
1. Minimum of 3 Medication Checks ALWAYS!!!!!!! -¡Removing Medication from the Drawer / Dispenser i. Check Expiration Dates, too -¡Checking Against Order/MAR -¡In patient's room as you prepare to open the package 2. Calculate Doses Accurately - good idea to have someone double check you 3. Note the Patient Status Before Administration for comparison and to make sure it is safe to give = assessment, vital signs, pre-med assessment
Safe Administration cont.
1. Precautions for clients unable to swallow/Crushing medications •Liquid forms should be given when possible •Pills are often crushed to powder form or capsules emptied and mixed in applesauce, ice cream, or liquid •Pills are crushed with a pill crusher •Do NOT open capsules or crush pills if they are enteric coated, sustained release, sublingual or buccal medications • This would interfere with absorption, metabolism, and effectiveness; may irritate the upper GI tract or, will make them get all the medication at once that they should receive over time •Crushed pills must be used ASAP to prevent deterioration or confusion 2. Administering Medications via NG/Feeding Tubes •Patients often have these tubes in place to rest and pump the stomach by suction or for tube feedings •Often there are orders to give medications in these tubes •Liquid medications are best to prevent clumping and blockage •Pills must be crushed, capsules must be opened unless not safe for that drug (sustained release, enteric coated) •Mix each pill separately with a small amount of water before giving (usually 20-30mL), one at a time •Do not mix drugs with formula
7 Rights of Administration
1. Right Drug -¡Check order -¡Know Classification, Mechanism of Action, Side Effects, Special Considerations 2. Right Dose -¡Check Order -¡Verify Dose is Within the Normal Range -¡Check Therapeutic Lab Values if app. 3. Right Time -¡Check Order -¡Verify Rx is Within Correct Time Allowance -¡Know the Last Administered Time 4. Right Route -¡Check order -¡Verify Rx is appropriate route 5. Right Patient -¡Check Order -¡Do bedside verbal and armband check with patient -¡Use 2 Identifiers (name, DOB) verbal and armband 6. Right Reason -¡Confirm rationale for the ordered med -¡Revisit reasons for long-term use 7. Right Documentation -¡Document administration AFTER giving med -¡Chart time, route, and other specific information 8. CHECK FOR ALLERGIES -¡Check Order, MAR, Verbal with Patient -¡Know Potential Cross-Reactions
Purposes of Nursing Interventions Classification (NIC)
1. Standardize the language nurses use to describe sets of actions in delivering patient care. 2. Expand nursing knowledge about connections among nursing diagnoses, treatments, and outcomes. 3. Develop a nursing language for software of health care information systems. 4. Provide a standard set of interventions for effectiveness research, productivity measurement, and competency evaluation. 5. Link with the classification systems of other health care providers.
Communication in Healthcare
1. Therapeutic Communication -Interpersonal communication that promotes an environment that facilitates positive change, growth, and health -There is an explicit time-frame, a goal-directed approach, and a high expectation of confidentiality -The nurse establishes, directs, and takes responsibility for the interaction, and the patient's needs take priority over the nurse's needs -Focuses on the patient, helping them -Planned and directed by the nurse -Relies on the patients' disclosure -The nurse must remain objective and non-judgmental -Therapeutic/Active listening is an important component of nursing care. i. This allows the nurse to get to know the patient and his/her concerns and feelings -The nurse must be sensitive to the cues given by the patient and learn to prioritize the needs -Openness-remain open to as many aspects of patient's, their problems, and potential solutions as possible. -Avoid being "swept away" by their problems
Nursing Responsibilities cont.
1. Transcription •The nurse is responsible for the verification of the HCP's order and the transcription of the order to the MAR •Sometimes unit clerks enter the orders, but the nurse still must check for accurate transcription and sign that the order was transcribed correctly - "signing off" •The order is sent to the pharmacy in electronic form, but sometimes paper, after signing off. 2. Situations that require consideration before medication administration •Problems associated with the drug (dizziness, nausea) •Patient statements that the drug was "already given" "looks different" or "thought the doctor said this drug was stopped" - ALWAYS LISTEN!!! •Change in patient condition, especially vital signs, new symptoms, may need to contact HCP
Two Main Types of Communication
1. Verbal: can also include written -Unfortunately, people often do not think before they speak and may be unaware of what they are communicating to others -A frequent error is made when the speaker is communicating verbally what they do not mean (ex?) -The message may be misunderstood and cause interpersonal relationship issues (ex.? ) 2. Non-Verbal: Includes use of the senses -visual, auditory, kinesthetic (touch); Also, facial expressions, eye contact, touch, physical grooming (neatness), physical appearance, sounds, silence -Some authorities believe that non-verbal communication is the most accurate form of communication -It is defined as communication by behavior, body posture, gait, gestures -Ex. Depressed persons may walk slumped over with their heads down and look gloomy; someone in pain my grimace
Setting up the Equation
1.Determine desired unit(s). 2.Write this on the right side of the page. 3.Determine what is ordered. 4.Make sure desired units are started on top of the equation. 5.Determine what is available. 6.Include any/all needed conversions.
Setting up the Equation cont.
1.Make sure matching units are written diagonal from one another. 2.Cancel out diagonal units that match in 2s. 3.Double check to see that the desired unit is the same as the remaining unit once everything is cancelled. 4.Multiply all numbers straight across 5.Divide the top number by the bottom number. 6.Ask yourself is this is a reasonable answer?
Critical Thinking
A. Critical thinking involves asking: -Why does the patient have this condition? -Are the signs and symptoms what I would expect to see in this condition? -What do I know about the patient's situation? -What ways can I collect data to help me understand the problem? -What options do I have?
tid
3 times a day
Cultural Considerations
A. Cultural competency -Involves self-awareness, reflective practice, and knowledge of a patient's core cultural background B. Cultural humility -Requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives C. Show your patients respect and understand their individual needs and differences; do not impose your own attitudes, biases, and beliefs.
qid
4 times a day
The Assessment Process
A. Data Collection (a continuous process) B. Data Interpretation -Critically interpret assessment data to determine whether abnormal findings are present. -Analyze Cues (using your senses)and inferences (interpreting cues) i. (see next slide) -Clarify collected data, ID health problems C. Data Validation -Comparison of data with another source to determine data accuracy (ex. does what they say match the lab data, physician's health and physical report)
Which of the following factors does a nurse consider for a patient with the nursing diagnosis of "Disturbed sleep pattern r/t noisy home environment" in choosing interventions for enhancing the patient's sleep? Select all that apply. A. The intervention should be directed at reducing noise. B. The intervention should be one shown to be effective in promoting sleep on the basis of research. C. The intervention should be one commonly used by the patient's sleep partner. D. The intervention should be one acceptable to the patient.
A,B,D
Setting priorities for a patient with a nursing diagnosis is an important step in the plan. Which of the following statements describes elements to consider in planning care? (select all that apply) A. Priority setting establishes the preferential order for nursing interventions B. In most cases, wellness problems take priority over problem-focused diagnoses C. Recognition of symptom/assessment patterns helps in understanding plan interventions D. Long-term chronic needs take priority over short- term problems
A, C
Routes of Administration Review: Vaginal
A. Advantages: -Provides a local effect B. Disadvantages: -May be messy and may soil clothes
Routes of Administration Review: Intravenous
A. Advantages: -Rapid effect B. Disadvantages: -Limited to highly soluble drugs -Drug distribution inhibited by poor circulation
Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? SELECT ALL THAT APPLY A. Recognizing normal changes associated with aging B. Avoid direct eye contact C. Allow for pauses as the patient tells his story D. Use the list of questions from the clinic assessment form to complete all data
A,C
Which of these nursing diagnoses are written correctly? Select all that apply. A. Impaired skin integrity r/t immobility B Fatigue r/t heart disease C. Pain r/t leg pain D. Risk for infection r/t surgery E. Excess fluid volume r/t impaired urination
A,D,E
Handoff Communications
A. "A hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication." B. Joint Commission (shift report) C. Should be face-to-face D. Should include critical patient data (see side right of slide) E. I-PASS -Illness severity -Patient summary -Action list -Situation awareness and contingency plans -Synthesis by receiver -Can also use I-SBAR (previous slide) F. Also, -Allergy list -Code status -Medication list -Current laboratory tests -Current vital signs
Data Clustering
A. A data cluster = organizing and classifying patient data (signs and symptoms) into meaningful and usable chunks B. Finding a data cluster helps you think less about individual data points and instead focus on pattern recognition. C. Then, a nurse can compare the patient's data patterns with to see if they are consistent with normal, healthy patterns
Expected Outcomes
A. A goal is the ultimate, highest possible outcome. Expected Outcomes are measurable changes to aim to that goal
Collaborative Problems
A. A problem that requires both medicine and nursing interventions to treat B. All physiological complications are not collaborative problems. -If a nurse can prevent the onset of a complication or provide the primary treatment for it, then the diagnosis is a nursing diagnosis. C. Collaboration will better manage the multiple factors that influence the health
Data Documentation
A. Accurate, complete, factual, without judgement B. Record any subjective information by using quotation marks. -Ex. "My chest feels like an elephant is sitting on it." C. Documented data helps to: -identify a patient's health problems -to plan and implement care -to evaluate a patient's response to interventions
Routes of Administration Review: Rectal
A. Advantages -Can be used when drug has objectionable taste or odor -Drug released at slow, steady rate -Provides a local, therapeutic effect B. Disadvantages -Dose absorbed is unpredictable -May be perceived as unpleasant by the client -Limited use
Routes of Administration Review: Intradermal
A. Advantages: -Absorption is slow (this is an advantage in testing for allergies) B. Disadvantages: -Amount of drug administered must be small -Breaks skin barrier
Routes of Administration Review: Subcutaneous
A. Advantages: -Absorption is slower (an advantage for insulin and heparin administration) B. Disadvantages: -Must involve sterile technique because breaks skin barrier -More expensive than oral -Can administer only small volume -Some drugs can irritate tissues and cause pain -Can produce anxiety -Breaks skin barrier
Routes of Administration Review: Intramuscular
A. Advantages: -Can administer larger volume than subcutaneous -Drug is rapidly absorbed B. Disadvantages: -Can produce anxiety -Breaks skin barrier
Routes of Administration Review: Topical
A. Advantages: -Few side effects B. Disadvantages: -Drugs can enter body through abrasions and cause systemic effects -Leaves residue on the skin that may soil clothes
Routes of Administration Review: Inhalation
A. Advantages: -Introduces drug throughout respiratory tract -Rapid localized relief -Drug can be administered to unconscious client B. Disadvantages: -Drug intended for localized effect can have systemic effect -Of use only for the respiratory system
Routes of Administration Review: Oral
A. Advantages: -Most convenient -Usually least expensive -Safe, does not break skin barrier -Administration usually does not cause stress -Some oral medications are designed to rapidly dissolve on the tongue, allowing for faster absorption and action B. Disadvantages: -Inappropriate for clients w/ nausea or vomiting -Drugs may have unpleasant taste or odor -Inappropriate when gastrointestinal tract has reduced motility -Inappropriate if client cannot swallow or is unconscious -Cannot be used before certain diagnostic tests or surgical procedures -Drug may discolor teeth, harm tooth enamel -Drug may irritate gastric mucosa -Drug can be aspirated by seriously ill clients
Comparison of Interventions for Nursing Diagnoses With Different Related Factors
A. Anxiety: Uncertainty over surgery. Patient asks, "What type of pain will I have?" Restless and unable to sleep. Provide detailed instruction about surgery, recovery process, expected postoperative care. Plan formal time for patient to ask questions. B. Impaired Mobility: Acute pain. Pain rated a 7 on scale of 1 to 10 Limits movement of right leg. Administer analgesic 30 minutes before planned exercise. Instruct patient on how to splint painful site during activity. C. Anxiety: Loss of Job. Fired from position 1 month ago. Primary source of family income. Consult with social worker to arrange for job counseling. Encourage health promotion activities (e.g., exercise, routine social activities). D. Impaired Mobility: Musculoskeletal injury. Weakness in right leg. Reduced extension in right leg. Perform active range-of-motion exercises to right leg every 2 hours. Instruct patient on use of 3-point crutch gait.
Non-Verbal Communication
A. Behavior indicates the state of mind •Behavior shows a great deal about your feelings •Verbal and non-verbal messages may not match .Why do people misrepresent their feelings/needs in healthcare? .Might their non-verbal communication reveal the truth? B. All people have said things they do not mean •Nurses must learn to interpret the non-verbal cues to get the real picture of what the patient means .Nurses must also watch our own non-verbal cues that we are sending out!
Components of the Nursing Health History
A. Biographical information -Demographic i. Age, gender.... B. Chief concern or reason for seeking care -Chief concern for the day or reason for seeking help in quotes - "What is your biggest concern today? -"What brought you to the ER today" C. Patient expectations -What do they hope will happen? i. Ex. Fully informed about care, pain control,
Protection systems
A. Blunt needles when not puncturing the skin B. Self-sheathing IV or Syringes C. Needle free access systems for IV with male and female adapters D. Use a sharp's container for all sharp instruments E. No recapping of needles
When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of which of the following inappropriate communication techniques. A. Cliché B. Giving advice C. Being judgmental D. Changing the subject
A. Cliché
Standard Nursing Interventions cont.
A. Clinical practice guidelines and protocols -A systematically developed set of statements about appropriate health care -for specific health care problems or clinical situations (patients with pneumonia, ear surgery...) B. Care bundle -Group of interventions related to a disease process or condition C. Standing orders -Preprinted document containing medical orders -Directs patient care in a specific clinical setting
Implementation Skills
A. Cognitive skills -critical thinking, decision making B. Interpersonal skills -caring, communication, developing trust C. Psychomotor skills -a mixture of cognitive and motor skills - giving an injection
Compare Achieved Effect with Goals and Outcomes
A. Compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. B. Evaluate whether the results of care match the expected outcomes and goals set for a patient.
Introduction to Critical Thinking Using the Nursing Process
A. Critical thinking -Sorting pt. information into patterns to: i. Clarify patient problems/needs ii. recognize issues and changes in patient status iii. analyzing patient information/assessment data, evaluating information, and drawing conclusions iv. make appropriate care decisions, often under pressure, based on evidence-based knowledge
Choosing Nursing Interventions
A. Desired Patient Outcomes • Outcomes serve as the criteria against which to judge efficacy of interventions. • Nursing Outcomes Classification (NOC) outcomes are linked to NANDA Nursing Diagnoses and ICNP diagnoses with the same label. • NOC outcomes are also linked to Nursing Interventions Classification (NIC) interventions (Moorhead et al., 2018). Use these resources to develop care plans. B. Characteristics of the Nursing Diagnosis • Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. Example: Acute Pain related to trauma of surgical incision—choose interventions for Mr. Lawson that relieve swelling and strain on the incision site (positioning and turning measures) and that lower pain reception (analgesic). • When an etiological factor cannot change, direct the interventions toward treating the signs and symptoms (e.g., assessment findings for a diagnosis). Example: Lack of Knowledge regarding postoperative care related to inexperience with surgery and impending discharge with self-care needs—choose interventions that provide information that answers Mr. and Mrs. Lawson's questions about recovery procedures and wound care, and that prepares them to monitor Mr. Lawson's progress at home. • For risk diagnoses, direct interventions at altering or eliminating the risk factors for the diagnosis. Example: Risk for Infection requires interventions for keeping Mr. Lawson's incisional area clean and free from further trauma, and for maintaining good nutrition. C. Research Base • Be familiar with the research evidence for an intervention, and use it for the appropriate patient group and/or setting (see Chapter 5). • Research evidence in support of a nursing intervention will indicate the effectiveness of using the intervention with certain types of patients. • When research is unavailable, use scientific principles (e.g., infection control, learning) or consult a clinical expert about your patient. D. Feasibility • A specific intervention has the potential to interact with other interventions provided by the nurse and other health professionals. • Know and be involved in a patient's total plan of care. • Consider cost of an intervention and the amount of time required for implementation (in consideration of patient's condition). Example: If you plan to get a patient up into a chair three times a day, will there be staff to assist with the transfer? Is the patient becoming weaker? E. Acceptability to the Patient • When possible, offer a patient a choice of interventions to assist in reaching outcomes. • Promote informed choice; give patients information about each intervention and how they are expected to participate. • Consider a patient's values, beliefs, and culture for a patient-centered approach to selecting interventions. F. Capability of the Nurse • Have knowledge of the scientific rationale for the intervention. • Have the necessary psychosocial and psychomotor skills to complete the intervention. • Be able to function within the specific setting to effectively use health care resources.
Nursing Diagnosis Application to Care Planning
A. Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients. B. The care plan is a road map for delivering nursing care and demonstrates your accountability for patient care
Examples of Goal Setting with Expected Outcomes for Mr. Lawson
A. Diagnosis: Acute Pain related to trauma of surgical incision. Goal: Mr. Lawson will achieve pain relief by day of discharge. Expected Outcome: Mr. Lawson reports pain at a level of 3 or below by discharge. Mr. Lawson walks to chair with no increase in pain in 24 hours. Mr. Lawson's incisional area shows signs of wound healing by discharge. B. Diagnosis: Lack of Knowledge regarding postoperative care related to inexperience with surgery. Goal: Mr. Lawson will express understanding of how to minimize postoperative risks by discharge. Expected Outcome: Mr. Lawson describes activity restrictions to follow by discharge in 48 hours. Mr. Lawson demonstrates how to cleanse surgical wound by discharge day. Mr. Lawson describes three risks for infection in 24 hours. C. Diagnosis: Risk for Infection. Goal: Mr. Lawson will remain infection free by discharge. Expected Outcome: Mr. Lawson remains afebrile by discharge. Mr. Lawson's wound shows no purulent drainage by discharge. Mr. Lawson's wound closes at site of incision separation by discharge
Formulating the Diagnosis Statement: Two parts of HEALTH PROMOTION dx:
A. Diagnostic label with risk factors B. Major detailed characteristics/major assessment findings - the assessment findings that lead to your diagnosis C. As previously discussed -Ex. Readiness for enhanced self-care related to maintaining personal relationships and managing stress
Formulating the Diagnosis Statement: Two parts of RISK dx:
A. Diagnostic label with risk factors - ex. Risk for Infection, Risk for Falls B. Risk factors - the assessment findings that put them at risk -Surgical incision right knee -Decreased WBCs, <1000/mcL -Unsteady gait -Confusion -Lack of knowledge about appropriate walker use i. Ex. Risk for infection as evidenced by (aeb) surgical incision with sutures midline abdomen (no Related To on this one)
Revising the Care Plan
A. Discontinuing a care plan B. Modifying a care plan -Redefining diagnoses -Revising goals and expected outcomes -Revising interventions
Sources of Diagnostic Error cont.
A. Errors in creating nursing diagnosis: -Diagnostic statement - i. Using medical diagnosis or treatments as the etiology ii. Make sure your related, risk factors are treatable by a nurse iii. Using nursing care as the etiology ex. pain related to poor IV insertion iv. Making judgmental statements about the patient v. Making legally unadvisable statements, like blame, implying negligence vi. Circular statements - impaired breathing related to shallow breathing vii. Only include one problem/diagnosis in your diagnostic statement, ex. only pain, not pain and anxiety
Sources of Diagnostic Error
A. Errors in creating nursing diagnosis: -Errors in Data collection - validate your findings -Analysis and interpretation of data - basing dx of a single symptom, review carefully
Selection of Interventions
A. Factors to consider when selecting nursing interventions. -Desired patient outcomes -Characteristics of the nursing diagnosis i. (ex. what does ineffective airway clearance mean/stand for, what is the problem related to for your patient) ii. Specific application to YOUR patient - why are they in pain, what puts them at risk for infection -Research base knowledge for the intervention -Feasibility for doing the intervention -Acceptability to the patient -Your own competency
Evaluation
A. Fifth step in nursing process B. Determines whether a patient's condition or well-being improve after nursing interventions were delivered C. Did we achieve our desired outcomes for the patient (made with the patient)? -Yes - you can discontinue the plan of care -No - What should we change? Outcomes? Interventions? Was our goal/outcome not realistic? Did were are interventions ineffective or not well executed? i. You must use critical thinking to figure out how best to help the patient by adjusting the plan of care.
The Nurse-Patient Relationship in Assessment
A. Foundation for creating nurse-patient relationships -Trust building -Presence - the patient knows you are there for them, available -Rounding (making rounds to check on the patient throughout the shift)
Case Study 6
A. Fulmala develops Ms. Skyfall's plan of care, including writing the goals and expected outcomes. B. Fulmala knows that the guidelines for writing expected outcomes include that they be specific, measurable, and reasonable. -What two parts are missing for writing goals and expected outcomes?
Critical Thinking in Setting Goals and Expected Outcomes
A. Goal -A broad statement that describes the desired change in a patient's condition, perceptions, or behavior, with time limit—goal must be realistic! i. (ex. reduce pain today, increased stamina by discharge, Safe self-administration of insulin demonstrated today, remain infection free today) ii. Short-term - usually less than a week iii. Long-term usually over weeks or months -Often based on standards of care or clinical guidelines established for minimal safe practice.
Examples of Objective Evaluation of Goal Achievement
A. Goal: Patient will change surgical dressing correctly by 12/18. -Outcome: Patient demonstrates correct hand hygiene by 12/16. Patient describes material to use in dressing change by 12/17.Patient demonstrates dressing change by 12/18. -Patient Response: Patient used antiseptic hand rub correctly to wash hands. Patient applied clean gauze correctly and taped securely in place over incision. -Evaluation Finding: Patient shows progression toward outcomes and achieved desired behavior. B. Goal: Patient's lungs will be free of secretions by 11/30. -Outcome: Coughing is nonproductive by 11/29. Lungs are clear to auscultation by 11/30. Respirations are 20/min by 11/30. -Patient Response: Patient coughed frequently and productively on 11/29 following nebulization. Lungs were clear to auscultation on 11/30. Respirations were 18/min on 11/29. -Evaluation Finding: Patient will require continued nebulizer therapy. Condition is improving.
Organizing Data According to Gordon's 11 Functional Health Patterns
A. Health Perception/Health Management: Client's perceived pattern of health and well-being and how health is managed. Ex. Compliance with medication regimen, use of health-promotion activities such as regular exercise, annual check-ups. B. Nutritional-Metabolic: Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply. Ex. Condition of skin, teeth, hair, nails, mucous membranes; height and weight. C. Elimination: Patterns of excretory function (bowel, bladder, and skin). Includes client's perception of normal" function. Ex. Frequency of bowel movements, voiding pattern, pain on urination, appearance of urine and stool. D. Activity - Exercise: Patterns of exercise, activity, leisure, and recreation. Ex. Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living. E. Cognitive-Perceptual: Sensory-perceptual and cognitive patterns. Ex. Vision, hearing, taste, touch, smell, pain perception and management; cognitive functions such as language, memory, and decision making. F. Sleep-Rest: Patterns of sleep, rest, and relaxation. Ex. Client's perception of quality and quantity of sleep and energy, sleep aids, routines client uses. G. Self-Perception/Self Concept: Client's self-concept pattern and perceptions of self. Ex. Body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone. H. Role-Relationship: Client's pattern of role engagements and relationships. Ex. Perception of current major roles sand responsibilities (e.g., father, husband, salesman); satisfaction with family, work, or social relationships. I. Sexuality-Reproductive: Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern. Ex. Number and histories of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship. J. Coping / Stress Tolerance: General coping pattern and effective of the pattern in terms of stress tolerance. Ex. Client's usual manner of handling stress, available support systems, perceived ability to control or manage situations. K. Value - Belief: Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions. Ex. Religious affiliation, what client perceives as important in life, value-belief conflicts related to health, special religious practices.
Systems for Planning Nursing Care
A. Health care agency care plans -Nursing care plans are often standardized in the EHR (electronic chart/electronic healthcare record) -Sometimes there are inter-professional care plans B. Care plans for community-based settings -For home or community setting
Consulting with Health Care Professionals
A. How to consult? -Have the healthcare record ready, information needed in front of you -Make sure you assess the patient, just before calling -Include a brief summary of relevant history and patient perspective -Give diagnosis and major assessment findings -Explain what you are suggesting or think the patient might need from the consultation
Oral Medications cont.
A. If Drugs are ever omitted (intentionally or on purpose) the omission and reason must be documented in the chart. Reasons drugs may be omitted: 1.Must be NPO for a test or surgery or other, often the drug is caught up after the test 2.The problem for which the medication was ordered no longer exists, example laxative for a patient with diarrhea 3.Suspected or known allergy to the drug, you must report this B. Principles -Do not touch the pills or capsules -Pour or open the package directly into the cup Measure liquids at eye level on a flat surface
Examples of Nursing Diagnoses and Suggested Nurses Outcome Classification (NOC) Linkages
A. Impaired Oral Mucous Membrane -Oral Health (NOC) i. Knowledge of infection management ii. Self-care oral hygiene -Tissue Integrity (NOC) i. Hydration ii. Infection severity B. Activity Intolerance -Activity Tolerance (NOC) i. Oxygen saturation with activity ii. Pulse rate with activity iii. Respiratory rate with activity -Self-Care Status (NOC) i. Bathes self ii. Dresses self iii. Prepares food and fluid for eating
Implementing Nursing Care
A. Implementation begins after you develop a patient's plan of care (Step 4) B. A nursing intervention (also called a nursing order) is: -any treatment based on clinical judgement or knowledge that a nurse performs to enhance patient outcomes. C. Direct care interventions -Treatments nurses provide through direct interactions with patients or a group of patients (ex, insert FC/turn patient/meds.) D. Indirect care interventions -Treatments performed away from a patient but on behalf of the patient or group of patients i. Ex. Consult social services, room preparation to prevent infection, planning care E. ALL intervention should be evidence-based F. ALL should be within a nurses Scope of Practice based on the state's Nurse Practice Act
Good Communication skills: why are they important
A. Important for the person to receive the correct message B. As a student communication can make the difference between success and failure C. In patient care, your communication is just as important as the medications and treatments that are prescribed. -Builds trust, keeps patient informed, increased feelings of control and comfort for the patient, safety Examples?
Ex. Emergency Assessment Guide
A. In an emergency, this assessment acronym is often used: -Airways - patent? -Breathing - how well, patterns, difficulty? -Circulation - heart issues, blood loss, BP issues -Disability - current conditions putting them at risk (stroke, heart attack, hemorrhage, asthma attack) -Exposure - hypothermia, burns, major skin issues
Insulin syringe
A. Insulin syringes are measured in units, most common size is U-100 which means 100 units per mL B. 50 unit syringes have a calibration of 1 unit per small line and 5 units per large line C. 100 unit syringes have a calibration of 2 units per small line and 10 units per large line
Critical Thinking and Clinical Judgment Skills
A. Interpretation: Be orderly in collecting data about patients. Apply reasoning while looking for patterns to emerge. Categorize the data (e.g., nursing diagnoses [see Chapter 17]). Gather additional data and clarify any data about which you are uncertain. B. Analysis: Be open-minded as you look at information about a patient. Do not make careless assumptions. Does the data reveal a problem or trend that you believe is true, or are there other options? C. Inference: Look at the meaning and significance of findings. Are there relationships among findings? Do data about the patient help you see that a problem exists? D. Evaluation; Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior. E. Explanation: Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. F. Self-regulation: Reflect on your experiences. Be responsible for connecting your actions with outcomes. Identify the ways you can improve your own performance. What will make you believe that you have been successful?
The Patient-Centered Interview
A. Interview preparation - be prepared B. Communication skills -Courtesy - preferred name, confidentiality -Comfort- pain, nausea controlled; privacy -Connection - eye contact, listen, let them talk -Confirmation- nodding, summarize information to verify understanding
Creating a Nursing Diagnosis
A. Involves placing a label on a patient's response to health problems. -(ex. A pt. with a fractured leg and cast has an unsteady gait, grimaces when bearing weight left leg. Possible Nursing Dx = Impaired Mobility) B. Remember: Each patient is unique and requires and individualized nursing care approach, culturally appropriate
Document Outcomes
A. It is crucial to share information about a patient's progress and current status. B. Accurate information needs to be present in a patient's medical record
Nursing Health History
A. Key component of a comprehensive assessment B. Covers all health dimensions -Can use Gordon's Functional Patterns (next slide), or Pender's Health Model to guide your health history collection
Physical Assessment
A. Make sure you do a thorough head-to-toe physical assessment of patients -Upon admission -At least once per shift B. Focused Assessments -Assessments that focus on particular problems that occur during throughout a shift i. Ex. pain, respiratory problems, altered vital signs
Critical Pathways
A. Many hospitals are using critical pathways and enhanced recovery after surgery (ERAS) protocols (premade plans) to: -Reduce variations in clinical practice -Standardize evidence-based care -Reduce patient length of stay -Improve patient outcomes B. But, still must individualize patient care
Types of Nursing Diagnoses
A. Medical diagnosis - ID a disease condition, not what we do! B. Nursing diagnosis - a clinical judgement to describe a patient's response or vulnerability to a health condition. -Pathophysiological - responses to disease or condition -Treatment-related - response to medications, treatments -Personal - psychosocial issues, dying, loss, grief -Environmental - ex. overcrowding, exposure to toxins -Maturational - related to developmental issues, ex. parenting
Case Study 9
A. Miranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52-year-old Asian gentleman who was admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels. B. Mr. Bagley's current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagley's plan of care to determine which interventions are to be implemented first.
Case Study 10
A. Mr. Bagley's plan of care calls for oxygen therapy to improve his respiratory status. -Fill in the Blank: A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a standing order.
Case Study (1 of 4)
A. Ms. Carla Thompkins, a 52-year-old schoolteacher, is being admitted to the medical-surgical unit as a postop patient recovering from a below-the-knee amputation (BKA) secondary to complications of type 2 diabetes. B. Ms. Thompkins is admitted to the unit not only so her recovery from the BKA may be monitored, but also because she is going to receive preliminary occupational and physical therapy to help her adapt to the amputation. C. What would you expect to find during a postop assessment of Ms. Thompkins?
Recognize Errors or Unmet Outcomes (why didn't this work?)
A. Must have an open mind, actively pursue truth, be patient and confident, and engage in self-reflection B. Apply observational skills, critical thinking intellectual standards, knowledge, and reflection to recognize the actual results of care C. Self-reflection D. Systematic use of evaluation E. Correction of errors
Terminologies for Nursing Diagnoses
A. NANDA International (NANDA-I) B. Nursing Intervention Classification (NIC) C. Nursing Outcome Classification (NOC) D. Omaha System E. SNOMED CT for clinical terminology F. International Classification for Nursing Practice (ICNP®)
Example of Problem-Focused Patient Assessment: Pain
A. Nature of pain: Describe your pain. Tell me how the pain is affecting your daily life. Observe for nonverbal cues (e.g., facial grimacing, crying). B. Precipitating factors causing pain: What causes your pain to worsen during the day? Is your pain associated with movement? Anything else? Observe if patient demonstrates nonverbal signs of pain during movement (e.g., positioning, swallowing, walking). C. Severity of pain: Rate your pain on a scale of 0 to 10.Inspect area of discomfort. Palpate area for tenderness.
The Nursing Process: Step Three: Planning Nursing Care
A. Planning nursing care involves: -Setting priorities based on patient diagnoses and collaborative problems -Identifying patient-centered goals and expected outcomes -Prescribing nursing interventions appropriate for each diagnosis B. Planning requires critical thinking applied through deliberate decision making and problem solving.
Implementation Process cont.
A. Preparing for implementation -Time management -Equipment -Personnel -Environment -Patient
Intramuscular (IM) injection
A. Needle gauge: 18-25 B. Needle length: 5/8-1.5 inch C. Needle injection angle: 90 degrees . Preferred route for irritating medications • Use of large muscles lowers pain • Z track method can be used for irritating or straining medications (demo) • EMLA cream can provide local anesthetic if applied 1-2 hours before injection up to 0.5mm deep, most often used in children • Common sites are deltoid, ventrogluteal, vastus lateralis • Deltoid is usually only used for clear nonirritating solutions, less than 1mL only, up to 3 mL in the ventrogluteal and vastus lateralis for adults, but less is preferred • Rotate sites if frequent injections to enhance absorption, preserve tissue integrity, minimize discomfort • Do not give 2 different medications in the same site, unless a syringe compatible mix •For the average size to larger adults, 1- 1½ inch needle length is used, but adjustments may be needed for size.
Subcutaneous (SC) injection
A. Needle gauge: 23-30 B. Needle length: 3/8-5/8 inch C. Needle injection angle: 45-90 degrees . Must inject in areas with abundant SC fat, like middle lateral arm, either side of umbilicus, buttocks, middle and outer thigh, • May be from 45-90 degree angle • Usually a 45 degree angle except with insulin and heparin • Heparin is usually given 2 inches around the umbilicus only with a 5/8 to ½ inch needle at a 90 degree angle, do not massage heparin (a blood "thinner"), can cause bruise or hematoma • Insulin is also given at a 90 degree angle with a 5/8 to ½ inch needle to reduce tissue trauma from long term injections • If obese, select a 5/8 needle at 90 degree or 7/8 at 45 degree •Do not administer volumes greater than 2 mL at a single injection site. For infants and children, the volume injected should not exceed 0.5 mL.
Intradermal (ID) injection
A. Needle gauge: 25-27 B. Needle length: 3/8-5/8 inch C. Needle injection angle: 5-15 degrees -Occasionally used, most common in TB skin test (or other diagnostic antigens) or allergic skin tests -Usually in the central forearm or other thin keratinized areas, hairless -The angle is 10-15 degrees barely under the skin, the needle bevel is still visible, bevel up, insert about 3mm -Creates a wheal or bleb which looks like a mosquito bite -Do not massage or disrupt the wheal
Re-Capping Needles
A. Never! Recap a used needle after injection unless it has a safety tip or is spring loaded or automatic B. You can and should use the safety guard
Legal Responsibilities
A. Nurse Practice Act -¡What a nurse can legally do in your state, including related to medications, it varies Kentucky General Scope of Practice/Nurse Practice Act B. Valid Order (will discuss in a few slides)
Clinical Judgment in Nursing Practice
A. Nurses must make accurate and appropriate clinical decisions/judgments. B. Clinical judgment is (Tanner, 2006) C. Drawing a conclusion about a patient's needs or health problems -Influenced by a nurse's experience and knowledge -Partly relies on knowing the patient -Influenced by the context of clinical situations (is this expected?)
Types of Data Collected from Patients cont.
A. Objective -Findings resulting from direct observation -Can be detected by observer -Can be measured, verified, or tested -Seen, heard, felt, smelled (blood pressure, crying, rash) -Obtained by observation or physical exam -"Signs" overt data
Data Collection from Older Persons
A. Older persons -Sometimes have sensory problems i. Hearing, vision... -May tire more easily -Take your time -May shorten questions, simplify if hard of hearing ---speak clearly, not necessarily louder, good eye contact, give non-verbal encouragement, like nodding -Be attentive, engaged, caring, listen
Ongoing evaluation is needed
A. Ongoing process that includes a before-and-after comparison -or an after comparison with an established standard -ex. patients are usually able to walk with a walker by day three after this knee surgery, but the patient will not get out of bed B. Continuously examine results by gathering subjective and objective data from a patient, family, and health care team members
Concept Mapping
A. Organize assessment data B. Placing all of the cues together into the clusters that form patterns leads you to the next step of the nursing process, nursing diagnosis
Phases of the Interview Using therapeutic communication
A. Orientation and setting an agenda -Introductions -Set goals/plan for interview B. Working phase collecting data Techniques -Observation i. body language, posture, eye contact -Open-ended questions i. "Describe your pain" -Direct closed-ended questions - to get more information "Is it sharp or dull?" -Leading questions i. Risky "This is bothering you, isn't it?" -Back channeling i. Confirming you are listening "go on" "alright" -Probing i. "Is there anything else that happens when you arm starts getting numb?" -Interpret i. Repeat back "So, your arm gets numb when you look at your cell phone for more than an hour at a time, right? " C. Termination phase -Summarize your findings, then let them know the interview is about to end. "Two more questions...."
Role of Patients and Health Care Team in Goal Setting
A. Patient collaboration is needed to: -Better prioritize goals of care -Develop a realistic, clear, and relevant plan of care -So patient will participate, see the value B. Interprofessional team collaboration is increasing as a result of -More complex needs associated with chronic diseases -Increasing complexity of skills required to deliver care -Knowledge required to provide comprehensive care to patients -Increasing specialization within health professions
Problems with Data Collection
A. Patient reliability issues :confusion, lack of knowledge about their health, distraction, uncooperative, disinterested..... -Ex. "I take a pink pill twice a day" -Ex. "I am hurting too much to think about it." B. No family or caregiver available C. Gaps in data available in the record
Collaborate and Evaluate Effectiveness of Interventions
A. Patient-centered care is achieved only when a patient and family are actively involved in the evaluation process. B. Successful collaboration involves interactions in which professionals work together cooperatively C. with shared responsibility and interdependence toward achieving patient outcomes.
Assessment Data Sources cont.
A. Patient/Client - best source** B. Family caregivers and significant others C. Health care team - shift report/handoffs D. Very important to be thorough/share relevant data E. Medical records- but know who you can share this with (can you share with UAP? - usually only on a need to know basis) F. Other records military, employment...... (not used as often) G. Scientific Literature - evidence-based practice H. Nurse's experience
Components of the Nursing Health History cont.
A. Present illness or health concerns -Essential and relevant data about illness - timing, symptoms, severity, things that aggravate.... B. Past health history -surgeries, illnesses, all types of medications, all types of allergies C. Family history -hereditary issues like female cancers, heart disease D. Psychosocial history -Support systems, coping strategies, E. Spiritual health -Rituals, faith needs F. Review of systems (ROS) -Head to toe review of health issues by body system G. Observation of patient behavior H. Diagnostic and laboratory data evaluation
Anticipating and Preventing Complications
A. Preventing complications -Identify risks to the patient -Adjust interventions to the situation -Evaluate the relative benefit of a treatment vs. the risk -Initiate risk-prevention measures B. Identifying areas of assistance -Seek information about a procedure -Collect all necessary equipment -Consider consequences of performing the procedure -Request another nurse's assistance and guidance
Assessment Data Sources
A. Primary—direct source -Patient/Client provides this data -Usually the best source of data B. Secondary—indirect source C. Family members, friends, and caregivers provide this data -May be the main source of data if the client is too ill, young, confused, mentally ill, or has developmental issues -but, may need to get permission from pt., if the patient is not too ill, a child, or in a situation where they cannot answer. -Also, client records (lab results, diagnostics), health care professionals, and literature
Methods for Prioritizing (use critical thinking!)
A. Prioritizing by importance, what is an immediate need versus others -High Priority (ex. ineffective breathing patterns, acute pain) i. Nursing diagnoses that, if untreated, result in harm to a patient or other ii. Maslow's hierarchy of needs, ABCs -Intermediate (ex. risk for infection) i. Nonemergent and not life-threatening -Low (ex. lack of knowledge, anxiety) i. Not always directly related to a specific illness or prognosis but affect a patient's future well-being (health promotion/wellness) B. Review priorities each time you see the patient, they can change! Keep assessing - it a continuous process!
Establishing Priorities
A. Priority setting -Order nursing diagnoses chronologically, then number by prioritization, helps to prioritize care -Problem-focused diagnoses and problems take priority over risk for and health promotion problems i. Short-term usually takes priority over long term B. Helps you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems C. Establish priorities in relation to their ongoing clinical importance
Types of Nursing Diagnostic Statements
A. Problem-focused (an actual problem, ex. acute pain) -Identify an undesirable human response to existing problems or concerns of a patient B. Risk diagnosis (a potential problem, ex. risk for infection) -Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication C. Health promotion (ex. Readiness for Enhanced knowledge) -Identify the desire or motivation to improve health status through a positive behavioral change
Implementation Process
A. Reassessing a patient -Continuous process each time you interact with the patient B. Reviewing and revising the existing nursing care plan is a continuous process -Revise assessment data to reflect current status. -Revise nursing diagnosis, goals, and outcomes. -Select or revise specific interventions. -Choose methods of evaluation to determine whether outcomes were met.
Data Documentation cont.
A. Record the results of the nursing health history and physical examination in the chart/computer database -in a clear, concise manner -using appropriate medical terminology -"If you did not chart it, it was not done." B. Record all observations succinctly (to the point, not flowery)
Developing Critical Thinking Skills
A. Reflective journaling -Purposefully reviewing clinical experiences in your own words (part of our care plan) to recognize ways to improve B. Meeting with colleagues -Discuss and examine work experiences and validate decisions (pre/post conference in our clinicals) C. Concept mapping -Visual representation of patient problems and interventions that shows their relationships to one another Sample Concept Mapping
Nursing Diagnosis
A. Reflects a nurse's clinical judgment about the patient's: -Response to health conditions, or life events, or vulnerabilities for that response i. Ex. We not diagnosing diabetes, we are identifying the patient's response to diabetes - poor vision, poor blood flow to feet, lack of understanding of diet... -Can be focused on individual, families, or communities -Should be responses the nurse is licensed and competent to treat
Introduction to Nursing Diagnosis
A. Review: Nurses continuously collect assessment data. -The nurse constantly observes, interacts and applies physical examination techniques to gather information about a patient's condition. -A nursing diagnosis is made when a nurse identifies a health-related problem or the potential to develop a problem based on patient data and assessment.
Nursing Interventions /orders should be:
A. SPECIFIC, TIMED, MEASURABLE, AND REALISTIC -Ex. Reposition the patient every 1-2 hours while on bedrest -Ex. Provide oral care for the patient using a pediatric toothbrush every 4 hours daily B. REASONABLE FOR YOUR PATIENT. C. "THE NURSE WILL---"
Critical Thinking in Planning Nursing Care
A. Select interventions designed to help patients at their present level of health described in the goal and measured by the expected outcomes. B. Types of interventions -Nurse-initiated - individual nursing actions, ex. turn patient every 1-2 hours (based on scientific rationale) -Health care provider-initiated (dependent) directed nursing actions, must have a HCP order (ex. insert IV, administer pain medication as ordered) -Other Provider Initiated - ex. Dietician, Physical Therapy..... i. Reminder - The nurse can only perform interventions that they are trained and competent to perform and legally allowed to perform under the state Nurse Practice Act.
Dimensional Analysis
A. Simply multiply straight across first (on both sides of the horizontal line if applicable) and then divide. B. There is no cross multiplication or algebra involved in this method of problem solving. C. Note: This approach to drug calculations can be used with every type of problem. This is not true of other methods.
Oral Medications
A. Tablets -Most poplar, easiest to administer -Many are scored so it can be halved B. Capsules -A drug contained in a soft or hard soluble shell, usually gelatin C. Troches -Lozenges, dissolve slowly in the mouth D. Timed or sustained release -Allow slow or sustained release of the drug over time -Some are have wax that slowly dissolves in the stomach acid releasing small amounts of drug at a time -Some have a polymer coating that dissolves slowly over time E. Syrups = sweetened to mask the taste with sugar-free versions for diabetics F. Elixirs = solutions containing water and alcohol and other components (usually the drug cannot dissolve in water alone) G. Suspensions -Liquids with suspended solid particles -Must shake thoroughly just before administering to mix evenly
ROUNDING RULES
A. Tabs - nearest half or whole number. B. Capsules - nearest whole number. C. Double labels - nearest whole number. D. All other measurements round to the NEAREST TENTH.
Communication
A. The exchange of information ●Can be one-way, two-way, or multidirectional ●Involves a sender, message, and receiver 1.One-way: ex. news broadcast 2.Two-way: sender of the message and the receiver can both send and receive messages 3.Multidirectional-Involves more than two people. Several people send and receive messages
Anatomy of needles
A. The gauge represents the diameter of the hole through the needle B. Usually based on the thickness of the solution C. Thick or viscous solutions need a larger diameter
Patient Safety
A. The nurse must check against the six/seven "rights" before giving a medications/drugs • Right drug • Right dose • Right patient • Right time • Right route • Right documentation (note the date, time, name of medication, dosage, route after administering on the record, initials and signature of nurse) (also the site and response to treatment may be placed on the medication record) Right reason • Also, Right to refuse by the client (must document in the medication record, the date, time, reason for refusal) • Other client rights: know the name and purpose of the medication/its therapeutic effects, also potential side effects and adverse reactions
Promoting Therapeutic Communication
A. The nurse should be: • Knowledgeable • Honest • Caring • Empathetic • Show respect • Flexible • Clear, concise • Avoid words with many meanings (Ex. writing SOB) interpretations/slang • Relaxed, but alert, observant • Sit without arms crossed . Summarize, restate, clarify (Active listening) ●Provide feedback to let the patient know you are listening (nodding, "Go on"...) ●Think before answering ●Do not pretend to listen ●Non-judgmental ●Open-minded ●Warm, friendly ●Use proper physical distance ●Humor is okay when appropriate- be careful! ●Aware of cultural differences about touch, eye contact, speech ●Develop trust
3cc syringe
A. This 3mL syringe has a calibration of 0.1mL with each small line, the larger lines represent a half mL B. Most have a scale in minums (this scale is rarely or never used) and mL
Color Guide for Needles
A. This color Guide may be helpful, Especially with IV sizes that are already in a patient, but always go by label, not color -Olive: 14 gauge; outer diameter = .072 in (1.83 mm) -Amber: 15 gauge; outer diameter = .066 in (1.66 mm) -Gray: 16 gauge; outer diameter = .064 in (1.63 mm) -Green: 18 gauge; outer diameter = .050 in (1.27 mm) -Pink: 20 gauge; outer diameter = .036 in (.91 mm) -Purple: 21 gauge; outer diameter = .033 in (.83 mm) -Blue: 22 gauge; outer diameter = .027 in (.70 mm) -Orange: 23 gauge; outer diameter = .025 in (.63 mm) -Red: 25 gauge; outer diameter = .020 in (.53 mm) -White: 27 gauge; outer diameter = .016 in (.42 mm)
Professionalism in History Taking
A. To display professionalism and a caring approach during an interview: -Look at the patient and not the computer screen. B. Computer programs alone should not guide your assessment
Purpose of Communication
A. To send a message •All communication is filtered through the person's Knowledge, experience, and biases. •It is important to have a broad knowledge of cultures different from your own when caring for patients so that you can interpret accurately and respond appropriately to patient communications.
Concepts for a Critical Thinker
A. Truth seeking: Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions. B. Open-mindedness: Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions. C. Analyticity: Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge. D. Systematicity: Be organized, focused; work hard in any inquiry. E. Self-confidence: Trust in your own reasoning processes. F. Inquisitiveness: Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning's sake. G. Maturity: Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity.
RE-Assess and Document after Administration of the medication
A. What are we assessing for? B. What do we document? -Evaluation • Assess effectiveness of medications • Assess for adverse effects • Assess for ability to self-administer drug, if that is going to happen • Assess client's understanding of treatment, drug therapy, compliance with drug therapy
Critical Thinking in Implementation
A. When making decisions: -Review the set of all possible nursing interventions for a patient's problem. -Review all possible consequences associated with each possible nursing action. -Determine the probability of all possible consequences. -Judge the value of the consequence to the patient.
Interpreting and Summarizing Findings
A. When you evaluate the effect of interventions, you interpret or learn to recognize relevant evidence about a patient's condition B. Early detection is first line of defense C. Compare actual and expected findings D. Objectively evaluate the degree of success in achieving outcomes of care
Glass Ampule
A. Wrap tip with alcohol prep pad and open away from face/body B. Always use filter needle to draw medication from glass Ampule!
Expected Outcomes cont.
A. Writing expected outcomes (SMART acronym) -Specific - hint: only one behavior or response -Measurable -Attainable - patient agreed upon, motivated -Realistic - able to do it and relevant to patient -Times i. (ex. The patient will maintain a pain level of less than 5 on a 1-10 scale over the next 24 hours, instead of - The patient will have reduced pain today)
RBCs
Also called erythrocytes ❏The count represents the number of circulating RBC's in 1 mL of venous blood ❏Increased RBC's can occur with polycythemia (?), dehydration ❏Decreased RBC's can occur with blood loss, lack of nutrition - like poor iron intake ❏Normal ranges (in millions/cu mm) *memorize lab values: -Men= 4.6 - 6 -Women= 4 - 5
amb
Ambulatory
For a student to avoid a data collection error, the student should: A. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. B. review his or her own comfort level and competency with assessment skills. C. ask another student to perform the assessment. D. consider whether the diagnosis should be actual, potential, or risk.
Answer: A. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. Rationale: Data collection is an art that the nurse gets better at with experience, so asking for assistance from a colleague to help with an unsure finding can ensure that the diagnostic statement is correct.
A patient is suffering from shortness of air/breath. The correct outcome statement would be written as: A. the patient will be comfortable by the morning. B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. the patient will not complain of breathing problems within the next 8 hours. D. the patient will have a respiratory rate of 14 to 18 breaths per minute.
B
A nurse enters a patient's room at the beginning of the shift to conduct an assessment following a blood transfusion. The nurse took care of the patient the day prior. The patient has a number of issues to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and notes signs or symptoms of transfusion reaction. The nurse notes a change in the patients behavior from yesterday, a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make a clinical decision about the patient? SELECT ALL THAT APPLY A.Working the same shift each day B.Spending time during the patient assessment C.Knowing the early mobility protocol guidelines D.Caring for the patient on consecutive days E.Knowing the pattern of the patient behavior about ambulation
B, D, E
Which of the following is an end result that translates into observable patient behaviors that are measurable and desirable? A. Unexpected outcome B. Expected outcome C. Sensitive outcome D. Accomplished outcome
B. Expected outcome
A. Mr. Bagley is placed on Isolation Precautions. -Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety
B. Indirect
Which of the following is an example of potential problems with communication? A. A nurse sits down across from the client to talk about their concerns, rather than standing at the door B. The nurse crosses his arms across his chest while asking the client to explain how they contracted a sexually transmitted disease C. The nurse frequently nods and makes eye contact while a client is describing his or her pain D. The nurse asks for permission before holding a patients hand during a painful procedure
B. The nurse crosses his arms across his chest while asking the client to explain how they contracted a sexually transmitted disease
The nurse enters a room of a patient with cancer. He is crying and states, "I feel so alone." Of the following statements, which is the MOST therapeutic? A. "I understand how you feel. My mother said the same thing when she was ill." B. The nurse places a hand on the patient's arm and states, "You feel alone." C. "Why do you feel alone? Your wife has been here every day." D. The nurse holds the patient's hand and asks, "What makes you feel so alone."
B. The nurse places a hand on the patient's arm and states, "You feel alone."
Your patient has met the goals set for improvement of ambulatory status. You would now: A. modify the care plan. B. discontinue the care plan. C. create a new nursing diagnosis that states goals have been met. D. reassess the patient's response to care and evaluate the implementation step of the nursing process.
B. discontinue the care plan.
Which communication technique would be most appropriate when working with a mentally/cognitively impaired client? A.Turn on the television when communicating so the client will be comfortable B.Answer for the client if he or she responds too slowly C.Use simple, concrete communication questions D. Do not look the client in the eye
C. Use simple, concrete communication questions
A client reports that his chest hurts. The nurse asks where exactly it hurts. This is an example of what type of active-listening behavior? A. Summarizing B. Effective C. Restating D. Clarification
D. Clarification
Why is it important to know, at least generally, about the beliefs and norms of different cultural groups related to communication and health care? A. So that you do not have to ask patients any questions about their understand or beliefs related to the information B. In order to force patients to assimilate to American culture C. So that you can explain what is wrong with their beliefs and communication techniques D. So that you can better interpret their verbal and nonverbal cues and respond appropriately
D. So that you can better interpret their verbal and nonverbal cues and respond appropriately
Which of the following demonstrates appropriate therapeutic communication techniques? A. The nurse discusses the complications that her cousin had with a surgery similar to the clients B. The nurse keeps the conference room at a cooler than normal room temperature so that clients do not get drowsy during education conferences C. The nurse gets very close to clients physically so that he can be sure that he is not missing any nonverbal cues during education sessions D. The nurse expresses empathy rather than sympathy when working with seriously ill clients
D. The nurse expresses empathy rather than sympathy when working with seriously ill clients
Intramuscular injection deltoid
Deltoid muscle (upper arm muscle): Completely expose the upper arm. You will give the injection in the center of an upside down triangle. Feel for the bone that goes across the top of the upper arm. This bone is called the acromion process. The bottom of it will form the base of the triangle. The point of the triangle is directly below the middle of the base at about the level of the armpit. The correct area to give an injection is in the center of the triangle, 1 to 2 inches below the acromion process. This site should not be used if the person is very thin or the muscle is very small.
Dr.
Doctor
Developing Critical Thinking in clinicals cont.
Evaluation and Self-Reflection: (this is a sample from care plan) Includes: preparation for the day, skills accomplished, medication administration, organization, confidence, pt. teaching, ways to improve, what went well, what did you learn from this experience, anything you would do differently and why, etc. Also, discuss how you are balancing your clinical and personal lifestyle expectations.
F
Fahrenheit
Case Study 7
Fulmala knows that dependent interventions require an order from a physician or another health care professional.
Evaluation of Healthcare
Learning what is effective for individual patients builds your knowledge of evidence-based and improves of care.
Valid Order
The order must include: • Date • Time • Drug name • Dosage • Route • Frequency (how often) • Duration or length of administration (for how long) • Signature of prescriber (can be electronic)
Valid Order cont.
The order must include: • Order must always be written/computer entry, except in emergencies • In emergency a written order must be obtained ASAP • If verbal orders are given the nurse should encourage the prescriber to write the order •always repeat back all verbal or telephone orders, to verify correctness!! • If telephone order, a licensed nurse must take the order, preferably two licensed nurses • The prescriber must sign/electronic signature the telephone order on the physician's order sheet on the next visit (within 24 hours)
Types of Orders
Types •Stat = emergency orders, administer ASAP, single dose, one time only •Standing orders = Orders that that the HCP has written or agreed to as standard for patients with specific problems, sometime cancels after a few doses •Renewal orders = must be written and signed by the physician before the nurse can continue to administer •PRN orders = administer if/as needed, based on patient need and safety, you may give the medication no more often than the specified time period •Verbal orders = The person taking verbal or telephone orders is responsible for these (always repeat back what is ordered to ensure accuracy), usually must be signed by the doctor within 24 hours •Faxed orders = must have original signature with specific time
Im injection vastus lateralis & Rectus Femoris
Vastus Lateralis Muscle (Thigh): Look at thigh and divide it into 3 equal parts. The middle third is where the injection will go. The thigh is a good place to give an injection because it is easy to see. May be used in adults and children, THE site of injection for children younger than 3; few major vessels and nerves, well developed in children; Divide the anterior thigh in half and the lateral thigh in half inject anywhere between those areas SEE Pictures in book, must lie supine, insert 1 inch into adults lateral or slightly anterior to the thigh (blue jean line (no more than 1mL injected into children)
Landmarking im injection gluteus medius/Ventrogluteal
Ventrogluteal Muscle (Hip): Have the person getting the injection lie on his or her side. To find the correct location, place the heel of your hand on the upper, outer part of the thigh where it meets the buttocks. Point your thumb at the groin and your fingers toward the person's head. Form a V with your fingers by separating your first finger from the other 3 fingers. Point your index finger toward the anterior superior iliac spine and extend you middle finger along the iliac crest toward the buttock. You will feel the edge of a bone along the tips of your little and ring fingers. The place to give the injection is in the middle of the V. The hip is a good place for an injection for adults and children older than 7 months
White Blood Cells (WBCs)
What do WBCs do overall? ●Normal ranges for total WBC count (in cu mm): i. Adults= 4,500 - 10,000 ●Increase in WBCs: Infection_is present, especially bacterial ●Decrease in WBCs: Increases the chance of getting an infection (reduced immune response); Could indicate a viral infection
abd
abdominal
adm
admission
pc
after meals
amt.
amount
amp
ampule
et
and
A & P
anterior & posterior or auscultation & percussion
ad lib
as desired
stat
at once
ax.
axillary
BMR
basal metabolic rate
BRP
bathroom privileges
ac
before meals
B/P
blood pressure
BUN
blood urea nitrogen
BM
bowel movement
per
by
po
by mouth (os)
CA
cancer
cap
capsule
cath.
catheterized
CNS
central nervous system
CS
central supply
CVA
cerebrovascular accident
c/o
complains of
CBC
complete blood count
l
liter
mg.
milligram
gtt
drop (gtts=drops)
ECG or EKG
electrocardiogram
ER or ED
emergency room or department
q
every
q2h
every 2 hours
q3h
every 3 hours
q4h
every 4 hours
qh
every hour
FBS
fasting blood sugar
FUO
fever of unknown origin
fl. oz.
fluid ounce
GB
gallbladder
GI
gastrointestinal
GU
genitourinary
gr
grain
g
gram
hct.
hematocrit
hgb
hemoglobin
hr
hour
hs
hour of sleep, bedtime
I & O
intake and output
IM.
intramuscularly
IVP
intravenous pyelogram
IV
intravenously
Additional tests
★Amylase: ○Blood test used to detect pancreas abnormalities ○Normally secreted into the pancreatic duct and then into the duodenum, some is secreted in the mouth in saliva Increased with pancreatitis, ○ESR (Erythrocyte sedimentation rate/sed rate): nonspecific test used to detect disease processes (cont) ★ESR (cont): (inflammatory, infectious, neoplastic, and necrotic disease processes) ★HgbA1C (glycosylated hemoglobin): ○measurement of blood glucose that is bound to hgb ○Reflection of how well blood glucose levels have been controlled during the past 3-4 months; used to dx diabetes ○Increase: hyperglycemia in diabetics ★ABG's ○Blood samples from artery instead of vein; usually performed by respiratory therapist; indicators of O2 & CO2 in blood
Hemoglobin & Hematocrit (H&H)
★Hemoglobin (hbg): ○The total amount of hemoglobin present in the circulating blood ○Hgb is the transport agent of oxygen & carbon dioxide from the lungs to the tissues & back ○Normal ranges (g/dl): i. Men= 13.5 - 18 ii. Women= 12 - 15 ★Hemoglobin (continued): ○Increase could indicate: polycythemia, dehydration, ○Decrease could indicate: hemorrhage, anemia, cancer, kidney disease, fluid retention/overload in the blood
BMP/CMP
★These tests give a level on a variety of materials normally in the blood ★The substances tested for are necessary for the body's function ★Includes: electrolytes, "kidney function" tests, protein, glucose, and lipids (like, cholesterol) ★Electrolytes: ○Sodium: extracellular ion, indicative of hydration ○Potassium: if high/low, may cause cardiac disruption, common to lose with diuretics ○Calcium: in the bones, controls parathyroid function ○Magnesium: indicates cardiac function
Nurse-Health Care Team & SBAR
★Why is communication within the health care team important? ★How do we communicate with other health care team members? ★Nursing Workplace Incivility/lateral violence with other member of the healthcare team interferes ★I-SBAR is used when reporting patient problems to healthcare providers/consultations: ○Identification (name, room, DOB) ○Situation (What is happening) ○Background (Brief context) ○Assessment (Current status, ex. vitals...) ○Recommendation ("The opioid is not working. Anything else she could try?")
Additional Test Normal Ranges
❏Sed. Rate/ESR: i. Men= 0 - 15 mm/h ii. Women= 0 - 20 mm/h ❏HgbA1C: i. Below %6 is consider healthy
AMI tests (heart attack test)
❏Used to indicate AMI; also known as cardiac enzymes ❏Many times if MI is suspected, these labs will be run every four hours for 24 hours or every 8 hours to determine if patient has suffered an MI ❏Includes: CK (creatinine kinase), CKMB, myoglobin, & troponin ❏CK: indicator of heart function, skeletal muscles, & brain ❏CKMB: enzyme specific for heart ❏Myoglobin: oxygen-binding protein in skeletal & cardiac muscle ❏Troponin: specific for heart, elevates quickly in case of MI & remains elevated longer
WBCs (continued)
❖Neutrophils: ➢early responders to inflammation ➢Increase: stress, acute infection ➢Decrease: aplastic anemia, cancer, cancer treatments ❖Lymphocytes: ➢Body's specific immune response ➢Increase: chronic bacterial & viral infections ➢Decrease: leukemia ❖Monocytes: ➢Help fight chronic infections ➢Increase: inflammatory disorder, tuberculosis ➢Decrease: some medications ❖Eosinophils: ➢Disease-fighting WBC ➢Increase: allergic reactions, parasitic infections, leukemia ❖Basophils: ➢Not well understood ➢Increase: leukemia ➢Decrease: allergic reaction
What is included in a CBC test?
❖Red blood cells ❖Mean Corpuscular Volume (MCV) ❖Mean Corpuscular Hemoglobin (MCH) ❖Mean Corpuscular Hemoglobin Concentration (MCHC) ❖Hemoglobin ❖Hematocrit ❖White blood cells ❖Platelets
Liver Enzymes/Liver Function Tests
❖SGOT: found in cytoplasm of cells in heart, liver, skeletal muscle, kidneys, & pancreas; elevated with MI (myocardia infarction - heart attack) & alcoholism, liver damage ❖SGPT: elevated is highly indicative of liver damage ❖Bilirubin: what is left over after hgb breakdown, increased with liver damage or red blood cell destruction; high levels can cause jaundice ❖Additional tests include ALT & ALP -Elevated liver enzymes usually means trauma or damage to the liver with reduced function
The Importance of Good Therapeutic Communication
❖Why is it a key to patient safety? ❖How does it improve patient outcomes? ❖How does it increase patient satisfaction? ❖How do nurses improve their communication skills?
A Quick Overview of the Nursing Process; which helps nurses critically think
➔Assessment: to establish a client data base; collection and interpretation of information ➔Diagnosis: to identify client's health care needs--a clinical judgment about a human response ➔Outcome identification: to determine priorities of care and goals and expected outcomes ➔Planning: to select interventions and create a plan of care ➔Implementation: to enact the plan by performing interventions ➔Evaluation: to determine if patient outcomes were met
Means of RBC's
➔Mean Corpuscular Volume ➔80-100fL (MCV): the average size of a RBC ➔Mean Corpuscular Hemoglobin (MCH): the average amount of hemoglobin in a RBC ➔Mean Corpuscular Hemoglobin Concentration (MCHC): average concentration of hemoglobin per RBC
Coag Studies
➔What does coagulation mean? ➔PT (prothrombin time): used to evaluate the adequacy of clotting mechanism (extrinsic factor) or the time it takes a clot to form; increases with some diseases, coumadin ingestion, vitamin K deficiency ➔INR (international normalized ratio): used for coumadin monitoring; increase in INR means blood is "thinner" ➔PTT (partial thromboplasm time): used to assess intrinsic clotting mechanism, used to monitor heparin anticoagulation ➔Normal ranges: i. PT: 10 - 13 seconds ii. INR: normal is below 1; however, when on warfarin (Coumadin) the therapeutic range is typically between 2 and 3, higher means their clotting time is too slow, hold the dose & report to HCP iii. PTT: varies
Platelets
➔Work with blood clotting_(hemostasis), reflecting safety ➔Increase: polycythemia, iron deficiency anemia ➔Decrease: bleeding, leukemia, some types of anemia ➔Normal range (mL3): i. Adult= 150,000 - 400,000
BMP continued
➢Additional tests: ○Glucose: if blood glucose is high, the body is not producing enough insulin; most specific method for dx diabetes_ ○BUN: the kidneys normally eliminate urea & creatinine, urea is the end product of protein metabolism & is measured by the BUN, can be effected by protein intake = elevated in renal failure, dehydration ➢Additional tests continued: ○Creatinine: produced in relatively constant quantities by muscles & excreted by the kidneys; amount in blood relates to renal function (high can mean reduced kidney filtration), elevated in renal failure, dehydration ○Cholesterol (lipids): high can cause artery blockage ○Also: protein/ sometimes liver enzymes & CO2
Hemoglobin & Hematocrit (H&H) cont.
➢Hematocrit (hct): ○The percentage of RBC's in the total blood volume ○Usually about 3 times the hgb ○Increase can indicate: decrease in volume (from dehydration, burns), increased RBCs ○Decrease can indicate: overhydration, pregnancy ➢Hct continued: ○Normal ranges (in %): i. Men= 40 - 54 ii. Women= 36- 46
