ATI Topic Descriptors Basic Care and Comfort (13) Plan A Hygiene Care: Evaluating Appropriate Use of Assistive Devices Cane instructions: Maintain two points of support on the ground at all times Keep the cane on the stronger side of the body Support body wt on both legs, move cane forward 6-10 inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg Dentures: Clients who have fragile oral mucosa require gentle brushing and flossing. Perform denture care for the client who is unable to do it himself Remove dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture. Place dentures in a denture cup or emesis basin Brush them with a soft brush and denture cleaner Rinse them with water Store the dentures, or assist the client with reinserting the dentures
Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for Pain Management Music decreases physiological pain, stress and anxiety by diverting the person"s attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music
Prostate Surgeries: Calculating a Client s Output When Receiving Continuous Bladder Irrigations !
purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or sediment can collect within tubing resulting in bladder sistention and buildup of stagnant urine) Med-Surg p. 1443 after prostate surgery, irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter. with CBI, irrigating soln is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. The inflow and outflow of irrigant must be continuously monitored. If outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If the outflow is blocked and patency cannot be reestablished by manual irrigation, the CBI is stopped and the physician notified. Record amount of urine output and character of urine every eight (8) hours or as per physician"s orders. (To obtain urine output, subtract amount of fluid instilled into bladder from total output.)
intermittent irrigation dorsal recumbent or supine position avoid cold solution bec may result in bladder spasm clamp cath just below soft injection port cleanse injection port with antiseptic swab (same port as specimen collection) insert needle through port at 30degree angle slowly inject fluid into cath and bladder withdraw syringe remove clamp and allow solution to drain into drainage bag if ordered by MD, keep clamped to allow solution to remain in bladder for short time (20-30min) Closed continuous irrigation Recording and Reporting
Record type and amt of irrigation soln used, amt returned as drainage and the character of drainage Record and report any findings such as complaints of bladder spasms, inability to instill fluid into bladder and/or presence of blood clots.
Urinary Elimination: Kegel Exercises for Urinary Incontinence sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( urine ( to learn the muscle) then practiced at nonvoiding times instruct client to contract muscle for a count of 3, hold and release for a count of 3, and repeat this 10x. Client should repeat these cycles for 25-30x 3x/day for 6 months. Client should do this 5x.day
Bowel Elimination Needs: Client Education Regarding Colostomy Care Stoma s/b pink. Dusky blue stoma---ischemia Brown-black stoma---necrosis mild to moderate swelling for 1st 2-3 weeks after surgery intact skin barriers with no evidence of leakage do not need to be changed daily and can remain in place for 3-5 days. skin should be washed with mild soap, warm water and dried thoroughly before barrier applied pouch must fit snugly to prevent leakage around stoma. The opening around the appliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks and does not reach usual size for 6-8 weeks empty pouch before it is 1/3 full to prevent leakage cleanse skin and use skin barriers and deodorizers to prevent skin breakdown and malodor
apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in; let dry 1-2 min apply non-allergic paper tape around the pectin skin barrier in a picture frame method. Burns: Non-pharmacologic Comfort Interventions for Dressing Changes Med/Surg p. 534-535 Distractions Relaxation tapes visualization guided imagery biofeedback meditation used as adjuncts to traditional pharmacologic txs of pain Visualization and guided imagery can be helpful to the nurse as well as the pt nurse ask the pt about a favorite hobby or recent vacation nurse can explore these areas further by asking questions that make the pt visualize and describe a favorite hobby or recent vacation by using this method, both the nurse and the pt must focus on things besides the task at hand. (ie dressing change) to keep the conversation flowing Relaxation tapes can be helpful when played at night to help the pt fall asleep. Application of Heat and Cold: Assess Need for Heat/Cold Applications Application of Cold: Ensure Safe Use of Cold Applications Potter/Perry p. 1253-1254 Cold and heat applications relieve pain and promote healing. selection varies with client"s conditions. moist heat can help relieve the pain from a tension HA cold heat can reduce the acute pain from inflamed joints avoid injury to skin by checking the temp and avoiding direct application of the cold or hot surface to the skin esp at risk: spinal cord or other neuro injury, older adults, confused clients
Ice massage or cold therapy are particularly effective for pain relief. Ice massage: apply the ice with firm pressure followed by slow steady, circular massage Cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located between the brain and the pain site. takes 5-10 minutes to apply cold each client responds differently to the site of the application that is the most effective application near the actual site of pain tends tends to work best a client feels feels cold, burning and aching sensations and numbness. When numbness occurs, the ice should be removed. cold is particularly effective for tooth or mouth pain when ice is place on the web of the hand between the thumb and index finger cold applications are also effective before invasive needle punctures Heat application don"t lay on heating element bec burning could occur Assessment for Temperature Tolerance Tolerance (P/P ( P/P p. 1549) before applying either, the nurse should assess the client"s physical condition for signs of potential intolerance to heat and cold first observe the area to be tx"d alterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleeding or localized areas of inflammation increase the client "s risk of injury. baseline skin assessment provides a guide for evaluating skin changes that might occur during therapy assessment includes id of conditions that contraindicate heat or cold therapy: an active area of bleeding should not be covered by a warm application bec bleeding will continue warm applications are contraindicated when client has an acute, localized inflammation such as appendicitis bec the heat could cause the appendix to rupture.
if client has CV problems, it is unwise to apply heat to large portions of the body bec the resulting massive vasodilation may disrupt blood supply to vital organs. cold is contraindicated if the site of injury is already edematous cold furth retards circulation to the area and prevents absorption of the interstitial fluid. if client has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area cold contraindicated in presence of neuropathy (client unable to perceive temp changes) cold contraindicated in shivering (intensifies shivering and dangerously increase body temp) If MD orders cold therapy to lower extremity, assess for cap refill, observing skin color and palpating skin temp, distal pulses and edematous areas if signs of circulatory inadequacy, question order if confused or unresponsive, make freq observations of skin integrity after therapy begins assess condition of equip used before applying heat and cold, understand normal body responses to local temp variations, assess the integrity of the body part, determine the client "s ability to sense temp variations and ensure proper operation of equipment. Crohn s Disease: Selecting a Low-Fiber, Low-Residue Diet !
No raw vegetables, vegs not strained, dried beans, peas, and legumes No raw fruits, fruits with skins, seeds No nuts, raisins, rich desserts no whole grain breads or cereals no fried, smoked, pickled or cured meats, no alcohol, fruit juices with pulp Dumping Syndrome: Client Education Regarding Dietary Interventions meal size must be reduced accordingly (6 small feedings) no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullness dry foods with low-carb content and moderate protein and fat content
proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullness short rest period after each meal
Cholecystitis: Dietary Restrictions Low in fat, and sometimes a wt reduction diet is also recommended (4-6 weeks take fat soluble vit supplements Palliative Care: Client/ Family Teaching caring interventions rather than curing interventions for any age, diagnosis, any time, and not just during the last few months of life preservation of dignity becomes the goal of palliative care allows client"s to make more informed choices, achieve better alleviation of sx and have more opportunity to work on issues of life closure establish a caring relationship with both client and family management of sx of disease and therapies Preparing the Dying Client"s Family (P/P 588) Objectives: family will be able to provide appropriate physical care for the dying client in home family will be able to provide appropriate psychological support to the dying client. Describe and demonstrate feeding techniques and selection of foods to facilitate ease of chewing and swallowing Demonstrate bathing, mouth care, and other hygiene measures and allow family to perform return demo show video on simple transfer techniques to prevent injury to themselves and client, help family to practice instruct family on need to enforce rest periods
teach family to recognize s/s to expect as the client "s condition worsens and provide info on who to call in an emergency discuss ways to support the dying person and listen to needs and fears solicit questions from family and provide info as needed. Evaluation: Have the family members demo physical care techniques ask family members to describe how they vary approaches to care when the client has sx such as pain or fatigue ask the family to discuss how they feel about their ability to support the client .
Cognitive Disorders: Promoting Independence in Hygiene for A Client with Alzheimer s Disease Stage S/S !
Stage 1, Forgetfulness
Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception
Stage 2, Confusion
Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities
Stage 3, Ambulatory dementia
loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn
Stage
Stage 4, End Stage
S/S
Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirror
Assess teaching needs for the client and especially for the family members when the client"s cognitive ability is progressively declining. Review the resources avail to the family as the client "s health declines. A wide variety of home care and community resources may be avail to the family in many areas of the country, and these resources may allow the client to remain at home rather than in an institution Perform self assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients with progressive dementia NCP Med/Surg 1592 Monitor pt"s ability for independent self-care to plan appropriate interventions specific to pt unique problems Use consistent repetition of daily health routines as a means of establishing them bec memory loss impairs pt"s ability to plan and complete specific sequential activities assist pt in accepting dependency to ensure that all needs are met. teach family to encourage independence and to intervene only when the pt is unable to perform to promote independence Bathing/Hygiene provide desired personal articles, such as bath soap and hairbrush, to enhance memory and provide care facilitate pt"s bathing self as appropriate to facilitate independence and provide appropriate help in hygiene Dressing/Grooming provide pt"s clothes in accessible area to facilitate dressing Be available for assistance in dressing as necessary to facilitate independence and provide appropriate help in dressing
Toileting Assist pt to toilet as specified intervals to promote regularity facilitate toilet hygiene after completion of elimination to prevent discomfort and skin breakdown.
Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203) If untreated lead to three problems insomnia abnormal movements or sensation during sleep or when awakening at night, or excessive daytime sleepiness. Four categories Dyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndrome
Parasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts
Nocturnal leg cramps REM Sleep disturbances nightmares REM Sleep behavior disorder sleep paralysis Other Parasomnias sleep bruxism (teeth grinding) sleep enuresis (bed-wetting) SIDS Sleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism Central degenerative disorders Other Med Disorders Nocturnal cardiac ischemia COPD PUD Proposed sleep Disorders Menstruation-associated sleep disorders Sleep choking syndrome Pregnancy associated sleep disorders Questions to Ask to Assess for Sleep Disorders Insomnia How easily do you fall asleep Do you fall asleep and have difficulty staying asleep? How many times do you awaken Do you awaken early from sleep What time do awaken for good? What causes you to awaken early? What do you do to prepare for sleep? To improve you sleep? What do you think about as you try to fall asleep
How often do you have trouble sleeping Sleep Apnea Do you snore loudly? Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate report this) Do you experience HAs after awakening Do you have difficulty staying awake during the day Does anyone else in your family snore loudly or stop breathing during sleep? Narcolepsy Are you tired during the day Do you fall asleep at inopportune times? Do you have episodes of losing muscle control or falling to the floor have you ever had the feeling of being unable to move or talk just before falling asleep Do you have vivid lifelike dreams when going to sleep or waking up?
Basic Care and Comfort (13) Plan B Mobility and Immobility: Recognizing Proper Use of Crutches
Crutch instructions Do not alter crutches after proper fit has been determined Follow crutch gait prescribed by physical therapy support body wt at hand grips with elbows flexed 30 degrees position crutches on unaffected side when sitting or rising from chair. Elkin---pg 135 Use of crutches may be a temporary aid for persons with strains, in a cast or following surgical treatments crutches may be routinely and continuously used for those with congenital or acquired MS abnormalities, neuromuscular weakness, or paralysis or they may be used after amputations. Crutch measurement includes three areas:
client"s height distance between crutch pad and axilla angle of elbow flexion [make sure shoes are on before measuring] Standing crutches 4-6 in in front of feet and side of feet Crutch pads two to three fingers between top of crutch and axilla Elbow should be flexed (30 degrees ATI) ATI) ***any tingling in torso means crutches are used incorrectly or wrong size if crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy) if crutch too short---bent over and uncomfortable low handgrips cause radial nerve damage high handgrips cause client"s elbow to be sharply flexed and strength and stability are decreased 4-point gait bearing on both legs requires wt requires wt bearing on often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients improves balance by providing wider base of support R crutch, L foot, L crutch, R foot 3 point gait bearing on 1 foot requires wt bearing on affected leg does not touch ground may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot 2-point gait requires partial wt bearing on bearing on each foot faster than 4-point gait requires more balance crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together. Swing to gait freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
easier of the two swing gaits requires ability to bear body wt partially on both legs Swing through gait requires client have ability to sustain partial wt bearing on both feet Stairs ( up) unaffected leg on step, both crutches come to step, repeat (down) move crutches to stair below, move affected leg forward, then unaffected leg Pain Management: Nonpharmacological Pain Management P/P---ch 42 P/P---pg 1250 Nonpharmacological interventions include cognitive-behavioral and physical approaches best if taught when not experiencing pain Goals of cognitive-behavioral interventions change client"s perceptions of pain alter pain behavior provide clients with greater sense of control Goals of physical approaches providing comfort correcting physical dysfunction altering physiological responses reducing fears associated with pain-related immobility Relaxation and Guided Imagery Relaxation mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel decrease in temp numbness of a body part use as feedback free of noise light sheet or blanket use with guided imagery or separate
progressive takes about 15 min pay attn to body noting areas of tension, tense areas replaced with warmth and relation some times better if eyes closed background music can help combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups. Guided Imagery client creates an image in the mind, concentrate on that image and gradually becomes less aware of pain Distraction RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input directs attention to something else and reduces awareness of pain even increases tolerance 1 disadvantage if works, may question the existence of pain works best for short, intense pain lasting a few minutes ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions singing praying describing photos or pictures aloud listening to music playing games may include ambulation, deep breathing, visitors, television, and music Music decreases physiological pain, stress and anxiety by diverting the person"s attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff
highly effective in reducing postop pain if pain acute, increase volume of music Biofeedback behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those responses used to produce deep relaxation and is effective for muscle tension and migraine HA Cutaneous stimulation stimulation of the skin to relieve pain massage warm bath ice bag for inflammation transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation) causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home reduce pain perception and help reduce muscle tension RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy Acupressure/Acupuncture vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points elevation of edematous extremities to promote venous return and decrease swelling Urinary Elimination Needs: Preventing Incontinence Use timed voidings to increase intervals between voidings/decrease voiding frequency perform pelvic floor (Kegel) exercises perform relaxation techniques offer undergarments while client is retraining teach client not to ignore urge to void provide positive reinforcement as client maintains continence
Urinary Elimination: Providing Catheter Care Prevent infection Maintain unobstructed flow of urine through the cath drainage system Perineal Hygiene perineal hygiene 2x/day or prn for client with retention cath soap and water are effective can be delegated to AP Catheter care assess urethral meatus and surrounding tissue for inflammation, swelling and discharge. Note amt, color, odor, and consistency of discharge. dischar ge. Ask client if any burning or discharge is felt with towel, soap and water, wipe in a circular motion along length of catheter for 4 inches apply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MD Mobility and Immobility: Evaluating for Complications of Immobility Complications of Immobility Integumentary-y--Maintain intact skin kin
turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr
Respiratory--maintain patent airway, airway, achieve optimal lung expansion and gas exchange and mobilize airway secretions
teach the client to turn, cough and deep breath q 1-2 hr yawn every hour use incentive spirometer CPT 2000ml fluid
Integumentary-y--Maintain intact skin kin
turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr
Cardiovascular---maintain CV fx, increase increase activity activity tolerance and prevent thrombus avoid valsalva maneuver formation stool softener ROM avoid pillows under knees use elastic stockings SCD give low dose heparin Metabolic---decrease injuries to skin and maintain metabolism within normal fxing
provide high calorie high protein diet with additional vits B and C monitor oral intake
Elimination--maintain or achieve normal urinary and bowel elimination patterns
maintain hydration (at least 2000 mL stool softener bladder and bowel training insert cath if bladder distended
Musculoskeletal--maintain or regain body alignment and stability decrease skin and MS system changes, achieve full or optimal ROM and prevent contractures
change position in bed q 2 hrs ROM nutritional intake CPM
Psychosocial--maintain normal sleep/wake coping skills patter, achieve socialization and achieve maintain orientation independent completion of self care develop schedule
Gastroenteral Feedings: Monitoring Tube Feedings Monitoring for tube placement initial placement is confirmed with xray monitor gastric contents for pH. A good indication of appropriate app ropriate placement is obtaining gastric contents with a pH between 0-4 Injecting air into the tube and listening over the abdomen is not an acceptable practice
Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual < 100mL return aspirated contents or follow protocol Flush tubing with 30-60 mL of H20 Acute Glomerulonephritis: Dietary Choice Acute Glomerulonephritis: insoluble immune complexes develop and become trapped in the glomerular tissue producing swelling and capillary cell death Maintain prescribed dietary restrictions Fluid restriction (24 hr output + 500 mL) Sodium restriction Protein restriction (if azotemia is present) Edema is treated by restricting sodium and fluid intake Dietary protein intake may be restricted if there is evidence of nitrogenous wastes. Varies with degree of proteinuria. Low protein, low sodium, fluid restricted diet
Rest and Sleep: Interventions to Promote Sleep for Hospitalized Clients Assist the client in establishing and following a bedtime routine Attempt to minimize the number of times the client is awakened during the night while hospitalized Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort Instruct the client to: Exercise regularly at least 2 hr before bed time Arrange the sleep environment to what is comfortable Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtime Apply CPAP devices as ordered by PCP for clients with sleep apnea
As a last resort, provide a pharmacological agent as prescribed.
ATI Topic Descriptors Plan A Health Promotion and Maintenance (13) Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736) Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates relaxed muscles allow rapid bleeding from the endometrial arterieries at the placental site bleeding continues until uterine muscle fibers contact to stop the flow of blood. retention of a large segment of the placenta does not allow the uterus to contract firmly and therefore can cause uterine atony Major signs of uterine atony include: fundus that is difficult to locate a soft or boggy feel when the fundus is located a uterus that becomes firm as it is massaged byt loses its tone when massage is stopped a fundus that is located above the expected levels which is at or near the umbilicus excessive lochia especially if it is bright red excessive clots expelled if a peripad is saturated in an hour, a lg amt of blood is considered to have been lost saturation in 15 min represents an excessive loss of blood in the early PP period a constant steady trickle is just as dangeiours if uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus one hand is placed just above the symphysis pubis o support the lower uterine segment while the other hand getnly but firmly massages the fundus in a cirucular motion clots are expressed by applying firm but gently pressure on the fundus in the direction of the vagina
critical that uterus is contracted firmly before clots are expressed pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage and rapid shock. ATI book p.304 uterine atony is hypotonic uterus that is not firm described as boggy. if untreated will result in postpartum hemorrhage and may result in uterine inversion Nursing assessments monitor for s/s of uterine atony which include a uterus that is larger than normal and boggy with possible lateral displacement on pelvic exam prolonged lochia discharge irregulaor or excessive bleeding Assessments for uterine atony include: fundal height, consistency and location lochia quantity, color, color, and consistency co nsistency
Normal Physiological Changes of Pregnancy: Calculating the client s delivery date !
ATI p. 34 Nagele"s rule: take the first day of the last menstrual period, subtract 3 months and add 7 days and 1 year. McDonald"s method measure uterine fundal height in centimeteres from the symphysis pubis to the top of the uterine fundus (between 18 to 30 weeks gestation age). The calculation is as follows the gestational age is estimated to be equal to fundal height.
Cesarean Birth: Appropriate Client Positioning ATI ATI p. 218
Positioning the client in a supine position with a wedge under one hip to laterally tilt her and keep her off her vena cava and descending aorta. This will help maintain optimal perfusion of oxygenated blood to the fetus during the procedure.
Antepartum Diagnostic Interventions: Interven tions: Monitoring during a Nonstress Test ATI ATI p. 85 Nonstress Test monitor the response of the FHR to fetal movement client pushes a button attached to the monitor whenever she feels a fetal movement that is noted on the paper tracing. beats/min for at least 15 sec and occurs 2 or NST Reactive : FHR accelerates to 15 beats/min for more times during a 20 min period placenta is adequately perfused and the fetus is well-oxygenated NST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetal movements occur in 40 min. if so, further assessment such as a contraction stress test or biophysical profile is indicated Disadvantages: high rate of false nonreactive results with the fetal movement response blunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturity client should be in a reclining chair or in a semi-fowlers " or left left lateral position position if there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen over the fetal head to awaken a sleeping fetus If still nonreactive, anticipate a CST or a BPP
Newborn Hypoglycemia: Identify Appropriate Interventions Inter ventions ATI ATI p. 424 Hypoglycemia : serum glucose level of less than 40mg/dL differs from preterm and term newborn
Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as a blood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as a blood glucose level of < 25 mg/dL Untreated hypoglycemia can result in mental retardation S/S poor feeding jitteriness. tremors hypothermia diaphoresis weak shrill cry lethargy flaccid muscle tone seizures/coma assessments: monitoring BG level closely monitoring IV if unable to orally feed monitoring for signs of hypoglycemia monitoring VS and temp Nursing interventions obtaining blood per heel stick for glucose monitoring freq oral and/or gavage feeding or continuous parenteral nutrition is provided early after birth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death)
Labor and Birth Processes: Assess for True Labor vs. False Labor ATI ATI p. 136 True Labor Contractions regular frequency stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measures Cervix progressive change in dilation and effacement moves to anterior portion bloody show
Fetus presenting part engages in pelvis False Labor Contractions painless, irregular freq, and intermittent decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop with comfort measures such as oral hydration Cervix (assessed by vaginal exam) no significant change in dilation or effacement often remains in posterior position no significant bloody show Fetus presenting part is not engaged in fetus
Bonding: Promoting Maternal Psychosocial Adaptation During the Taking-In Phase ATI p. 290 Taking In Phase--begins Phase--be gins immediately following birth lasting a few hours to a couple of days. Characteristics include passive-dependent behavior and relying on others to meet needs for comfort, rest, closeness, and nourishment. the client focuses on her own needs and is concerned about the overall health of her newborn. She is excited and talkative, repeatedly reviewing the labor and birth experience. Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soon after birth in an en face position Encourage the parents to bond with the infant through cuddling, feeding, diapering and inspecting the infant provide a quiet and private environment that enhances the family bonding process. provide frequent praise, support and reassurance to the mother during the taking-hold phase as she moves toward independence in care of the newborn and adjusts to the maternal role encourage the mother/parents to discuss their feelings, fears, and anxieties about caring for their newborn
Toddler: Recognizing Expected Body-Image Changes ATI the toddler appreciates the usefulness of various body parts toddlers develop gender identity by age 3 Wong"s Nursing Care of Children (p. 608) Growth slows considerably during toddlerhood. avg wt @ 2 years is 12 kg. head circumference slows and is usually equal to chest circumference by 1-2 years. Chest circumference continues to increase and exceeds head circumference during the toddler years. After the 2nd year the the chest circumference exceeds the abdominal measurement which in addition to the growth of the lower extremities, gives the child, a taller leaner appearance. However, the toddler retains a squat, “pot-bellied” appearance bec of less welldeveloped abdominal musculature and short legs. Legs retain a slightly bowed or curved appearance during the second year form the weight of the relatively large trunk.
Adolescent (12-20 years): Planning Age-Appropriate Health Promotion Education Substance abuse: Drug Abuse Resistance Education (DARE) and other similar programs provide assistance in preventing experimentation Sexual Experimentation:
Abstinence is highly recommended. if sexually activity is occurring the use of birth control is recommended Sexually Transmitted Diseases: Adolescents should undergo external genitalia exams, PAP smears, and cervical and urethral cultures (specific to gender). Rectal and oral cultures may also need to be taken The adolescent should be counseled about risk taking behaviors and their exposure to STDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDs Pregnancy identification of pregnant adolescents should be done to ensure that nutrition and support is offered to promote the health of the adolescent and the fetus. Following infant delivery, education should be given to prevent future pregnancies. Injury prevention encourage attendance at driver"s ed courses. Emphasize the need for compliance with seat belt use teach the dangers of combining substance abuse with driving (MADD) Insist on helmet use with bicycles, motorcycles, skateboards, roller blades and snowboards screen for substance abuse teach the adolescent not to swim alone teach proper use of sporting equipment Age-appropriate activities: nonviolent video games nonviolent music sports caring for a pet career training programs
reading social events
Contraception: Recognizing Correct Corre ct Use of Condoms ATI ATI p. 6 Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semen from entering the uterus Client Instruction man places condom on his erect penis, leaving an empty space at the tip for a sperm reservoir following ejaculation, the man withdraws his penis from the woman "s vagina while holding condom rim to prevent any semen spillage to vulva or vaginal area may be used in conjunction with spermicidal gel or cream to increase effectiveness. only water soluble lubricants should be used with latex condoms to avoid condom breakage. Immunizations: Recognizing Complications to Report Rep ort ATI ATI p. 279 anaphylaxis review sx with parents prodromal sx--uneasiness, impending doom, restlessness, irritability, irritability, severe anxiety, HA, dizziness, parethesia, disorientation cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia cutaneous manifestations are often followed by bronchiolar constriction-- narrowing of the airway, airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often lifethreatening laryngeal edema instruct parents to call 991 or other emergency number and to keep the child quiet until help arrives Encephalitis, seizures, and.or neuritis review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizure Thrombocytopenia usually associated with measles vaccination teach parents to observe for bleeding
instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs. Older Adult (0ver 65 years): Assessing Risk for Social Isolation Two forms of isolation may be a choice, the result of a desire not to interact with others may be a response to conditions that inhibit the ability or the opportunity to interact wiht others. vulnerable to its consequences vulnerability increased in the absence of the support of other adults as may occur with loss of the work role or relocation to unfamiliar surroundings. impaired hearing, diminished vision, and reduced mobility all contribute to reduced interaction with others and isolation the loss of the ability to drive may limit older adults " ability to live independently as well as contributing to isolation some withdraw bec of feelings of rejection older adults see themselves as unattractive and rejected bec of changes in their personal appearance due to normal aging nurse can assist lonely older adults to rebuild social networks and reverse patterns of isolation outreach programs meals on wheels socialization needs daily telephone call by volunteers need for activities such as outings Spinal Cord Injury: Promoting Independence In Self-Care Spinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control of elimination The level of cord involved dictates the consequences of spinal cord injury. For example, injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec of proximity of the phrenic nerve. Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremities Tetraplegia C1-C8 Paraplegia T1-L4
Level of Injury
Movement Remaining
Rehab Potential
C1-C3 Often fatal injury, vagus nerve domination of heart, respiration, blood vessels, and all organs below injury
movement in neck and above, loss of innervation to diaphragm, absence of independent respiratory fx
ability to drive electric wheelchair equipped with portable ventilator by using chin control or mouth stick, headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct others
C4 vagus nerve domination of heart, respirations and all vessels and organs below injury
sensation and movement in Same as C1-C3 neck and above; may be able to breathe without a ventilator
C5 vagus nerve domination of heart, respirations, and all vessels and organs below the injury
full neck, partial shoulder, back, biceps; gross elbow, inability to roll over or use hands; decreased respiratory reserve
Ability to drive electric wheelchair with mobile hand supports; indoor mobility in manual wheelchair; able to feed self with setup and adaptive equipment; attendant care 10 hrs per day
C6 vagus nerve domination of heart, respirations, and all vessels and organs below the injury
shoulder and upper back abduction and rotation at shoulder, full biceps to elbow flexion, wrist extension, weak grasp of thumb, decreased respiratory reserve
ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; attendant care 6 hrs per day
Level of Injury
Movement Remaining
Rehab Potential
C7-C8 vagus nerve domination of heart, respirations, and all vessels and organs below the injury
All triceps to elbow extension, finger extensors and flexors, good grasp with some decreased strength, decreased respiratory reserve
ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most selfcare; independent use of wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day
T1-T6 Sympathetic innervation to heart, vagus nerve domination of all vessels and organs below injury
full innervation of upper extremities, back essential intrinsic muscles of hand; full strength and dexterity of grasp; decreased trunk stability, stability, decreased decr eased respiratory reserve
full independence in selfcare and in wheelchair ability to drive car with hand controls (in most patients); independent standing in standing frame
T6-T12 Vagus nerve domination only of leg vessels, GI and genitourinary organs
Full stable thoracic muscle and upper back; functional intercostals, resulting in increased respiratory reserve
Full independent us of wheelchair; ability to stand erect with full leg brace, ambulate on crutches with swing (although gait difficult); inability to climb stairs
L1- L2 Vagus nerve domination of leg vessels
Varying control of legs and pelvis, instability of lower back
Good sitting balance; full use of wheelchair; ambulation with long leg braces
Level of Injury
Movement Remaining
L3-L4 Quadriceps and hip flexors, Partial vagus nerve absence of hamstring domination of leg vessels, function, flail ankles GI and genitourinary organs
Rehabilitation Potential Completely independent ambulation with short leg braces and canes; inability to stand for long periods
The success of rehabilitation depends on many variables, including the following:
• level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patient • family support It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The goal of SCI rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially.
Health Promotion and Maintenance Plan B Antepartum Diagnostic Interventions: Prenatal Fetal Heart Rate Monitoring
Nonstress Test Test (see below) Contraction Stress test (CST) an assessment performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contractions to determine how the fetus will tolerate the stress of labor. A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 sec each must be obtained to use for assessment data data Nipple stimulated CST consists of the woman lightly brushing her palm across the nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins The same process is repeated after a 5 min rest period Hyperstimulation of the uterus (uterine contraction longer than 90 sec or more freq than q 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of o f both nipples unless stimulation of one nipple is uncuccessful Oxytocin admin CST is used if nipple stimulation fails and consists of IV admin of oxytocin to induce uterine contractions Contractions started with oxytocin may be difficult to stop and can lead to preterm labor
A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterine contractions, there are no late decels of the FHR A positive CST (abnormal finding) is indicated with persistent and consistent late decels on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable decels may indicate cord compression and early decls may indicate fetal head compression. Nursing Management For a CST, CST, the nurse should Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document Complete an assessment without artificial stimulation if contractions are occurring spontaneously Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs. Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction pattern Complications Hyperstimulation of the uterus Preterm labor Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 min Biophysical Profile (BPP) uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. Five variables Reactive FHR: reactive nonstress test = 2, nonreactive = 0
Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or less than 30 sec duration = 0 Gross body movements: at least 3 body or limb extensions with return to flexion in 30 min = 2, less than 3 episodes = 0 Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension and flexion, lack of flexion, or absent of movement = 0 Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2 perpendicular planes = 2; pockets absent or less than 1 cm = 0 For BPP the nurse should follow the same management as ultrasound Complications of Pregnancy: Recognizing Abnormal Findings Bleeding during Pregnancy vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the cause Spontaneous Abortion when a pregnancy is terminated before 20 weeks gestation (the point of fetal viability) or fetal wt less than 500 g. Assessments vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy passage of tissue (products of conception) mild to severe uterine atony backache rupture of membranes dilation of the cervix fever abdominal tenderness s/s of hemorrhage such as hypotension
Ectopic Pregnancy
abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage. Assessments one or two missed menses unilateral stabbing pain and tenderness in the lower abdominal quadrant scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area). referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx) N/V freq after tube rupture sx of hemorrhage and shock
Gestational Trophoblastic Disease proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysis Assessments rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
Incompetent Cervix painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation. Assessments pink stained vaginal discharge or bleeding increase in pelvic pressure possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infection
Placenta Previa when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface Assessments painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position a palpable placenta VS that are usual and within normal limits Abruptio Placenta
the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death Assessments sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender a firm rigid uterus with contractions (uterine hypertonicity) fetal distress sx of hypovolemic shock Hyperemesis Gravidarum excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria.
Assessments excessive vomiting for prolonged periods dehydration with possible electrolyte imbalance wt loss decreased blood pressure increased pulse rate poor skin turgor
Gestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy pregnan cy,,
woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters. Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain. Eclampsia is severe preeclampsia sx along with the onset of seizure activity or coma. Assessments progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies rapid wt gain 2 kg per wk in the second and third trimester fetal distress Gestational Diabetes an impaired toleratnce to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level should fall between 60-120 mg/dL Assessments hunger and thirst freq urination blurred vision excess wt gain during pregnancy
TORCH infections group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic affects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus
infection
sign/symptom
T-toxoplasmosis
influenza sx or lymphadenopathy
O-other infection
dependent on infection
R-rubella (german measles)
rash, muscle aches, joint pain, mild lymphedema, fetal consequences including miscarriage, congenital anomalies and death
C-cytomegalovirus (member of Herpes virus family)
asymptomatic or mononucleosis-like sx
H-Herpes simples virus (HSV)
lesions initial outbreak
Circumcision: Evaluating Effectiveness of Discharge Teaching Postop parent teaching: Teach the parents to keep the area are a clean. Change the infant"s diaper at least every 4 hr and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. The diaper should be fan folded to prevent pressure on the circumcised area Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. A tub bath should not be given until the circumcision is completely healed. Until then, warm water should be gently trickled over the penis Notify the PCP if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the infant. Tell the parents a film of yellowish mucus may form over the glans by day 2 and it is important not to wash this off Teach the parents to avoid using premoistened towelettes to clean the penis bec they contain alcohol. Inform the parents that the newborn may be fussy or may sleep for several hrs after the circumcision
Inform the parents that the circumcision will heal completely within a couple of weeks.
Discharge Teaching: Evaluating Client s Understanding of Bulb Syringe Use !
Oral and Nasal Suctioning teach the parents to use a bulb syringe to suction any excess mucus from the nose and mouth parents should suction the mouth first and then the nose, one nostril at a time the bulb should be compressed before inserting it into the infant "s mouth or nose when suctioning the infant"s mouth, always insert the bulb on the sides of the infant "s mouth not in the middle and do not touch the back of the throat to avoid the gag reflex
Postpartum Physiological Changes and Nursing Care: Performing Fundal Assessment Document the fundal height, location and uterine consistency Determine the fundal ht by placing fingers on the abdomen and measuring how many fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the umbilical level Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full bladder) Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. Toddler: Provide Education on Age-Specific Growth and Development Stages of Development Theorist
Type of Development
Stage
Erickson
Psychosocial
Autonomy vs Shame
Freud
Psychosocial
Anal
Theorist Piaget
Type of Development Cognitive
Stage Sensorimotor Transitions to preoperational
Physical Development anterior fontanel close by 18 months of age Wt: At 30 months the toddler should weigh 4x his birth wt. Ht: the toddler grows by 7.5 cm (3 in) per year Developmental Skills development of steady gait climbing stairs jumping and standing on one foot for short periods stacking blocks in increasingly higher numbers drawing stick figures undressing and feeding self toilet training
Cognitive Development concept of object permanence is fully developed Toddlers demonstrate memory of events that relate to them language increase to about 400 words with the toddler speaking in 2-3 word phrases pre-operational thought does not allow for the toddler to understand other viewpoints, but it does allow toddlers to symbolize objects and people in order to imitate activities they have seen previously
Psychosocial Development
independence is paramount for the toddler who is attempting to do everything for himself separation anxiety continues to occur when a parent leaves the child Moral Development Moral development is closely associated with cognitive development Egocentric--toddlers are unable to see another"s perspective; they can only view thing from their point of view. the toddler"s punishment and obedience orientation begins with a sense of good behavior is rewarded and bad behavior is punished. Self Concept Development toddlers progressively see themselves as separate from their parents and increase their explorations away from them Age Appropriate Activities Solitary play evolves into parallel play where the toddler observes other children and then may engage in activities nearby filling and emptying containers playing with blocks reading books playing with toys that can be pushed and pulled tossing a ball Infant (Birth to 1 yr): Identifying Normal Physical Assessment Findings
Physical Development The infant"s posterior fontanel closes at 2-3 months of age The infant"s size is tracked by wt, ht, and head circumference
Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) per month the last 6 months. The infant triples birth wt by the end of the first year Ht: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in) per month the last 6 months. Head Circumference: The circumference of the infant"s head increases 1.25 cm (0.5 in) per month the first 6 months Following size, the infant develops gross motor skills Holds head up at 3 months Rolls over at 5-6 months Holds head steady when sitting at 6 months Gets to sitting position alone and can pull up to a standing position at 9 months Stand hold on at 12 months Stands alone at 12 months Fine motor development follows next in the sequence Brings hans together grasps rattle looks for items that are dropped from view transfers an object from one hand to the other (6 months) rakes finger food with hand ( 6 months) uses thumb-finger to grasp items (9 months) Bangs two toys together (9 months) Can nest one object inside another (12 months) Scoliosis: Recognizing Signs During Routine Screening School age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts.
Marked curvatures in posture are abnormal. A slight limp, a crooked hemline, or
# a
sore back are other s/s of scoliosis
inspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebral column is easily assessed in children bec of their propensity for constant motion durin exam ATI Topic Descriptors Management of Care (24) Plan A Advance Directives: Recognize Purpose (ATI) Advance directive are written instructions that allow a client to convey his wishes regarding medical tx for situations when those wishes can no longer be personally communicated. All clients admitted to a health care facility be asked if they have an advance directive. The client without an advance directive must be given written information that outlines his rights r/t health care decisions and how to formulate an advance directive. A health care representative should be available to help with this process Living wills allows the client to specify end of life decisions she does or does not sanction when unable to speak for herself. For example, the client can specify use or refusal of: CPR, if cardiac or respiratory arrest occurs Artificial nutrition through IV or tube feedings Prolonged maintenance on a respirator if unable to breathe adequately alone Living wills must be specific and be signed by two witnesses. They can minimize conflict and confusion regarding health care decisions that need to be made vary from state to state
A durable power of attorney for health care (health proxy) is an indiv designated to make health care decisions for a client who is unable based upon the client "s living will Based upon the client"s advance directives, the physician writes orders for lifesustaining tx. Examples include: DNR Medical interventions (eg comfort measures only, IV fluids but no intubation, full tx) Use of ABX Artificially administered nutrition through a tube. Nursing responsibilities regarding advance directives include: provide written information regarding advance directives document the clients advance directive status ensure that the advance directive is current and reflective of the client"s current decisions. inform all members of the health care team of the clients advance directive.
(P/P) Two basic advance directives living will written documents that direct tx in accordance with a client "s wishes in the event of a terminal illness or condition. may be difficult to interpret two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document if health care workers follow the directions of the living will, they are immune from liability durable power of attorney for health care
designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf. In order for living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment The determination of legal competency is made by a judge, and the determination of decisional capacity is usually us ually made by the physician and family. The implementation of the advance directive is done within the context of the health care team and the health care institution. When clients are legally incompetent and are unable to make health care decisions, the courts balance the state"s interest with what the client would have wanted.
Client Advocacy: Intervening on behalf of the Client As an advocate, nurses must ensure that clients are informed of their rights and have adequate information on which to base health care decisions Nurses must be careful to “assist” clients with health care decisions and not “direct” or “control” their decisions Situations in which the nurse may advocate for the client or assist the client to advocate for herself include: End of life decisions Access to health care Protection of client privacy Informed consent Substandard practice Essential Components of Advocacy
Skills risk taking vision self-confidence Articulate communication assertiveness Values caring autonomy respect empowerment The nurse protects the client"s human and legal rights and provides assistance in asserting those rights if the need arises keep in mind the client "s religion and culture
Discharge Planning: Interventions to Promote Timely Client Discharges The process begins at time of admission Plans are developed with client and family input, focusing on active participation by the client to facilitate facilitate a timely discharge Serves as a starting point for continuity of care for the client by the caregiver, home health nurse, or receiving facility. The need for additional client or family support is included with recommendations for support services such as home health, outpatient therapy and respite care. Discharge Summary includes: Step by step instructions for procedures to be done at home Precautions to take when performing procedures or administering meds S/s of complications that should be reported Names and numbers of health care providers and community services the client/family can contact. Plans for follow up care and therapies
Time of discharge, mode of transportation, and who accompanied the client. This should begin when the client is admitted to the facility unless the facility is to be the client"s permanent residence assess whether or not the client will be able to return to his previous residence determine whether or not the client will nee and/or have someone to assist him at home assess the residence to see if adaptations are required to accommodate the client prior to discharge make a referral to the social worker to arrange for community services required by the client at discharge communicate client health status and needs to community service providers. Clients Rights: Recognizing Client Rights Regarding Review of Records Only health care team members directly responsible for the client "s care should be allowed access to the client"s records. The client has the right to review his medical record and request information as necessary for understanding. Client"s rights To inspect and copy PHI To ask the health care agency to amend the PHI that is contained in a record if the PHI is inaccurate To request a list of disclosures made regarding the PHI as specified by HIPAA HIPAA To request to restrict the way the health care agency uses or discloses PHI regarding tx, payment or health care operations unless info is needed to provide emergency tx To request that the healthcare agency communicates with the client in a certain way or at a certain location ; the request must specify how or where the client "s wishes to be contacted. Collaboration with Interdisciplinary Team: Methods for Collaboration An interdisciplinary team is a group of health care professionals from different disciplines Collaboration is used by interdisciplinary teams to make health care decisions about clients with multiple problems. Collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. Key elements of collaboration include:
Effective communication skills Mutual respect and trust Shared decision making The nurse contributes Knowledge of nursing care and its management A holistic understanding of the client, her health care needs,and health care systems Nurse-primary care provider collaboration should be fostered to create a climate of mutual respect and collaborative practice Collaboration can occur among different levels of nurses and nurses with different areas of expertise. Nursing Interventions: Use effective communication skills Participate in client rounds and interdisciplinary team meetings Present info relevant to the client "s health status and tx regimen Attend interdisciplinary clinical conferences/case presentations.
COPD: Planning Strategies for Fatigue ATI---determine the client"s physical limitations and structure activity to include periods of rest promote adequate nutrition increased work of breathing increases caloric demands Med-Surg Energy Conservation Techniques Techniques pacing and pursing (pacing activity and using pursed lip breathing with activities
assuming the tripod position and a mirror placed on the table during use of an electric razor or hair dryer conserves more energy than when the pt stands in front of a mirror to shave or blow dry hair. use 02 during activities of hygiene bec these are energy consuming pt should be encouraged to make a schedule and plan daily and weekly activities so as to leave plenty of time for rest periods pt should also try to sit as much as possible when performing activities exhale when pushing, pulling or exerting effort during and activity and inhale during rest. walking is the best exercise for COPD coordinated walking with slow, pursed-lip breathing without breath holding. breathe in and out through now while taking one step then to breathe out through pursed lips while taking 2-4 steps walk 15-20 minutes a day with gradual increases use MDI 10 minutes before exercises Conflict Resolution: Identify Strategies Conflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an inevitable part of professional, social, and personal life and can result in constructive or destructive consequences Constructive Consequences
Destructive Consequences
stimulates growth and open and honest can produce divisiveness communication may foster rivalry and compeitition increases group cohesion and commitment misperceptions, distrust, and frustration to common goals can be created facilitates understanding and problem group dissatisfaction with the outcome may solving occur motivates group to change
Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout
The desired goal in resolving conflict in both parties is to reach a satisfactory resolution. This is a win-win situation
Conflict Resolution Strategies Strategy
Characteristics
Compromising
Each party gives up something To consider this a win-win solution, both parties must give up something equally valuable. If one party gives up more than the other it can become a win-lose situation
Competing
One party pursues a desired solution at the expense of others This is a win-lose solution Managers may use this when a quick or unpopular decision must be made The party who loses something may experience anger, frustration, and a desire for retribution
Cooperating/Accommodating
One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. this is a lose-win solution. The original problem may not actually be resolved. The solution may contribute to future conflict
Strategy
Characteristics
Smoothing
One party attempts to “smooth” other party, decreasing the emotional component of the conflict Often used to preserve or maintain a peaceful work environment The focus may be on what is agreed upon, leaving conflict largely unresolved This is usually a lose-lose solution
Avoiding
Both parties know there is a conflict, but they refuse to face it or attempt to resolve it. May be appropriate for minor conflicts or when one party holds more power than the other party or if the issue may work itself out over time Since the conflict remains, it may surface again at a later date and escalate over time this is usually a lose-lose solution
Conflict Resolution Technique Avoiding--ignoring the conflict
Advantages
Disadvantages
does not make a big deal conflict can become bigger out of nothing; conflict may than anticipated be minor in comparison to other priorities
Accommodating--one side is more concerned one side holds more power smoothing or cooperating. with the issue than the other and can force the other side One side gives in to the side to give in other side Competing---forcing; the two produces a winner; good or three sides are forced to when time is short and compete for the goal stakes are high
Produces a loser; leaves anger and resentment on losing sides
Conflict Resolution Technique
Advantages
Disadvantages
Compromising---each side gives up something and gains something
no one should win or lose but both should gain something; good for disagreements between indiv
Negotiating---high level discussion that seeks agreement but not necessarily consensus
stakes are high and solution agreements are permanent, is rather permanent; often even though each side has involves powerful groups gains and losses
Collaborating--both sides work together to develop optimal outcome
best solution for the conflict takes a lot of time; requires and encompasses all the commitment to success goals to each side
Confronting--immediate and does not allow conflict o obvious movement to stop take root; very powerful conflict at the very start
may cause a return to the conflict if what is given up becomes more important than the original goal
may leave impression that conflict is not tolerated
Genitalia and Rectum: Providing Privacy Preparation of the client (for Female pelvic exam) Client is asked to empty her bladder so that urine is not accidently expelled during the exam. Client is assisted in assuming the lithotomy position in bed or on an exam table for an external genitalia assessment and is assisted in stirrups if a speculum exam is to be performed. The nurse places a hand to the edge of the table and then instructs the client to move until touching the hand. The client"s arms should be at her side or folded across the chest to prevent tightening of abdominal muscles A square drape or sheet is given to the client. She holds one corner over the sternum, the adjacent corners fall over each knee, and the fourth corner covers the perineum. Close the door, or pull room curtains around the bathing area. While bathing the client, expose only the areas being bathed. During bowel elimination, the nurse should maintain the client "s privacy.
this is especially important for a client using a bedpan. The call light and a supply of toilet paper should be within easy reach. Respond Res pond immediately. immediately. Consultation: Referral in Response to a Client Concern A consultant is a professional who provides expert advice in a particular area. a rea. A consultation is requested to determine what tx/services the client requires. Consultations provide expertise to clients who require a particular type of knowledge or service (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist for a client whose risk for suicide needs to be assessed) Coordination of the consultant"s recommendations with other health care providers" recommendations is necessary to protect the client form conflicting and potentially dangerous orders. Consultation is a process in which a specialist is sought to identify methods of care or tx plans to meet the needs of a client. Consultation is needed when the nurse encounters a problem that cannot be solved using nursing knowledge, skills, and available resources Consultation also is needed when the exact problem remains unclear; a consultant can objectively and more clearly assess and identify the exact nature of the problem Referrals are made so that the client can access the care identified by the PCP or consultant The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg, hospice care, home health aide) Discharge referrals are based on client needs in r/t actual and potential problems and may enlist the aid of: social services specialized therapists thera pists (eg PT,OT PT,OT,, speech) speech ) care providers (home health nurses, hospice nurse) Knowledge of community resources i necessary to appropriately link the client with needed services Consultation (interventions) Initiate the necessary consults or notify the PCP of the client "s needs so the consult can be initiated. Provide the consultant with all pertinent info about the problem
Incorporate the consultant"s recommendations into the client"s plan of care Facilitate coordination of the consultant "s recommendations with other health care providers; recommendations to protect the client from conflicting and potentially dangerous orders. Referrals (Interventions) To ensure continuity of care by the use of referrals, the nurse should: Initiate the discharge plan upon the client "s admission. Evaluate client/family competencies in r/t home care prior to discharge. Involve the client and family in care planning Collaborate with other health care professionals to ensure all health care needs are met Complete referral forms to ensure proper reimbursement for services ordered. Client Education: Document Client Teaching Client teaching documentation Information presented, method of instruction (eg discussion, demonstration, videotape, booklet), client response, including questions and evidence of understanding such as return demo or change in behavior. Nursing documentation must be accurate to correctly record information regarding the client"s care. The purpose of reporting is to provide continuity of care for client when several nurses provide care. Reporting should be conducted in a confidential manner. Evaluation of Client Teaching Teaching Observe the client demonstrating the learned activity (best for eval of psychomotor learning) Ask questions. Listen to the client explain the info learned use written tools to measure accuracy of information
Request the client"s self-eval of progress Observe verbal and nonverbal communication Revise the care plan as needed.
Delegation: Use of the Five Rights of Delegation Right Task The right task is one that is delegable for a specific client, such as tasks that are repetitive, require little supervision and are relatively noninvasive. Identify what tasks are appropriate to delegate for each specific client. Delegate activities to appropriate levels of team members (eg LPN, AP) based on professional standards of practice, legal and facility guidelines, and available resources.
Ex: Right Task
Wrong Task
Delegate LPN to perform a dressing change on a client with cellulitis.
Delegate LPN to develop the care plan for a client with cellulitis.
Delegate AP to assist a client with pneumonia to use a bedpan
Delegate AP to administer a neb tx to a client with pneumonia.
Right Circumstances The appropriate client, available resources, and other relevant factors are considered. In an acute care setting, client "s conditions can change ch ange quickly. good clinical decision making is needed to determine what to delegate. If the circumstances have been assessed or are deemed too complicated, the nurse takes the responsibility and does not delegate to the AP. Ex:
Right Circumstance Delegate AP to take and record check-in VS of office clients.
Wrong Circumstance Delegate AP to take VS on a client receiving IV therapy for hypovolemic shock.
Delegate AP to assist in obtaining VS from a stable postop client. Delegate AP to assist in obtain VS from a postop client who required naloxone (Narcan) for depressed respirations.
Right person the right person is delegating the right tasks to the right person to be performed on the right person. Assess and verify the competency of the health care team member. the task must be within the team member "s scope of practice the team member must have the necessary competence/training Continually review the performance of the team member and determine care competency. Assess team member performance based on standards, and when necessary, take steps to remediate failure to meet standards. Ex: Right person
Wrong Person
Delegate an LPN to administer enteral feedings to a client with a head injury.
Delegate an AP to administer enteral feedings to a client with a head injury.
Delegate LPN to perform trach care on a client
Delegate an AP to perform trach care on a client.
Right Direction/ Communication
A clear, clear, concise, description of the task, including its objective, limits, and expectations is given. Communication must be ongoing between RN and AP during a shift of care. Communicate either in writing or orally: Data that need to be collected Method and timeline for reporting, including when to report concerns/assessment findings Specific task(s) to be performed; client specific instructions Expected results, timelines, and expectations for follow-up communication. Ex:
Right di direction/communication
Wrong di direction/communication
Delegate AP the task of assisting the client Delegate AP the task of assisting the client in room 312 with a shower, to be in room 312 with morning hygiene. completed by 0900. Delegate AP the task of obtaining a urine Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not catch urine specimen from the client in informing her of what type of urine room 423, bed 2 specimen, or which specific client in the room needs the specimen.
Right Supervision Appropriate monitoring, evaluation, intervention as needed and feedback are provided. AP should feel comfortable to ask questions and seek assistance. Ex:
Right Supervision An RN delegates to an LPN the task of administering enteral feedings to a client (after the RN performs a physical assessment to evaluate the client "s tolerance to feedings thus far). An RN delegates to an AP the task of ambulating a client after completing the admission assessment
Wrong Supervision An RN delegates to an LPN the task of providing client teaching to a client without a written care plan in place. An RN delegates an AP to ambulate a client prior to performing an admission assessment.
Care that cannot be delegated: Nursing process. Assessment Diagnosis Planning Evaluation Nursing judgment.
Delegation: Monitoring Outcomes of Delegated Tasks Another important step in delegation is evaluation of client "s outcomes. The RN must give constructive and appropriate feedback. The RN should always give specific feedback in regard to any mistakes that were made, explaining how the mistakes could have been avoiding. Giving feedback in private is the professional way and preserves the APs dignity. dignity. The RN may discover the need to review r eview a procedure with staff and offer demonstration or even recommend that additional training by scheduled with the education dept. Delegation: Assigning Tasks To To AP Based On Role parameters and Skill Required Assess the knowledge and skills of the delegate open ended questions Match tasks to the delegate "s skills know what skills are included in the training program of the facility Communicate clearly
alway provide unambiguous and clear directions by describing a task, the desired outcome, time period within which the task should be completed. never give task through another staff member Listen attentively Provide feedback. Roles/Tasks Roles/Tasks for AP/LPN Task
AP
LPN RN
Developing a teaching plan for a client newly dx "d with diabetes mellitus
x
Assessing a client admitted for surgery
x
Collecting VS q 30 min for a client who is 1 hr post cardiac cath
x
x
x
Calculating a client"s I/O
x
x
x
Administering blood to a client
x
Monitoring a client"s condition during blood transfusions and IV admin Providing oral and bathing hygiene to an immobilized client
x
x
x
x
x
Initiating client referrals
x
Dressing change of an uncomplicated wound
x
x
Routine nasotracheal suctioning
x
x
Receiving report from surgery nurse regarding a client to be admitted to a unit from the PACU
x
Initiating a continuous IV infusion of dopamine with dosage titration based on hemodynamic measurements
x
Administering subcutaneous insulin
x
x
Assessing and documenting a client"s decubitus ulcer
x
x
Evaluating a client"s advance directive status
x
Task
AP
Providing written information regarding advance directives
LPN RN x
Initial feeding of a client who had a stroke and is at risk for aspiration Assisting a client with toileting
x x
x
x
Developing a plan of care for a client
x x
Administering an oral med
x
x
x
x
Administering an IM pain med
x
x
Checking a client"s feeding tube placement and patency
x
x
x
x
Assisting a client with ambulation
Turning a client q 2 hr
x
x
Calculating and monitoring TPN flow rate
x
Disaster Planning and Emergency Management: Prioritizing Delivery of Client Care Triage is the process of separating casualties and allocating tx on the basis of the victims" potentials for survival. Highest priority is always given to victims who have life-threatening injuries but who have a high probability of survival once stabilized. Second priority is given to victims with injuries that have systemic complications that are not yet life threatening and could wait 45-60 min for tx Last priority is given to those victims with local injuries without immediate complications and who can wait several hours for medical attention, or those who have minimal probability of surviving.
Ethics and Values: Appropriate Response to Experiencing Negative Feelings about a Client
Countertransference refers to the feelings and thoughts that service providers have toward the client. The provider may harbor certain images of the client that result in “blind spots” which can be destructive or disruptive to the therapeutic process. This nontherapeutic event can be resolved with consultation, supervision, or both. Nurses must be aware of possible countertransference responses. Beneficence---the care give is in the best interest of the client.
Client Education: Assisting Clients to Access current Health Information Using Information Technology Client education assists individuals, families, and communities in achieving optimal health. Teaching in interactive, promotes pr omotes learning, and leads to a change in a behavior. Information technology can be used to enhance access to and delivery of knowledge
Client Education: Selecting Appropriate Information Infor mation Technology for Adolescent Client Education Adolescents are in transition between childhood and adulthood. Transition between concrete operations to formal operations in reasoning. Use logic and reasoning to grasp simultaneous influence of several variables to invent a systematic procedure for keeping track of results of experiments. Peer teaching is very effective. Teens Teens benefit from visiting others who are coping successfully with similar problems. Group instruction/discussion is a very powerful way to help teens belong to a group
Informed Consent: Ensure Informed Consent Informed Consent Once surgery has been discussed with the client or surrogate as tx, it is the responsibility of the PcP to obtain consent after discussing the risks and benefits of the procedure. The nurse is not to obtain consent for the PcP in any circumstance the nurse can clarify any information that remains unclear after the PCP "s explanation of the procedure The nurse"s role is to witness the client "s signing of the consent forma after the client acknowledges understanding of the procedure. Informed Consent Consent is required for all tx that is given to the client in a healthcare facility State laws prescribe who is able to give informed consent. Laws will vary regarding age limitations and emergencies. the nurse is responsible for knowing the laws in the state of practice People authorized to grant consent for another person include: parent of a minor legal guardian court specified representative by a court order spouse or closest avail relative who has durable power of attorney for health care The Provider: obtains informed consent The Client: gives informed consent The Nurse: witnesses informed consent ensuring that the provide gave the client the necessary information ensuring that the client understood the information and is competent to give informed consent Legal Responsibilities: Reporting Client Abuse Abuse and Neglect of Vulnerable Older Adults Description older adults may be the victims of emotional, physical and sexual abuse
the nurse must be alert to the signs of abuse and neglect possible from caregivers Signs of abuse include unexplained bruises or welts, multiple bruises; unexplained fractures, abrasions, and lacerations; multiple injuries; withdrawal or passivity or fear; depression and hopelessness Signs of neglect include dehydration; malnourishment; overmedication or undermedication; desertion or abandonment; inappropriate or soiled clothes; lack of glasses; dentures, or other aids if usually worn; and being left unattended Exploitation of the vulnerable older adult includes disappearance of possessions, forced to sell possessions or change a will, overcharged for home repairs, inadequate living environment, inability to afford social activities, being forced to sign over control of finances and no money for food or clothes The nurse must report abuse, neglect and exploitation to the proper authorities Intentional Torts Assault: any intentional threat to bring about harmful or offensive contact no contact is made the law protects clients who are afraid of harmful contact It is an assault for a nurse to threaten to give a client an injection or to threaten to restrain a client for an xray procedure when the client has refused consent Battery is any intentional touching without consent. Contact can be harmful
Performance Improvement: Utilize References to Improve Performance and Maintain Safe Practice Performance Improvement: includes measuring performance against a set of predetermined standards. In health care these standards may be set by the specific facility and take into consideration accrediting and professional standards. The Joint Commission (formerly JCAHO): sets standards in relation to policies, procedures, and the competency of health care team members Annually publishes the National Patient Safety Goals which specify the standard of care that clients should receive.
Requirements include: policies, procedures, and standards describe and guide how the nursing staff provides nursing care, tx, and services All nursing policies, procedures, and standards are defined, documented, and accessible in written or electronic format. Step 1 Standard is developed and approved by facility committee Step 2 Provide and document care according to the developed standard. An audit is performed to determine if the standard is being met. Retrospective audit: happens after the client receives care Concurrent audit: occurs while the client is receiving care Prospective audit: predicts how future client care will be affected by current level of services. Step 3 Educational or corrective action is provided when results indicate that a standard is not being met. The Nurse"s Role in Performance Improvement: Step 1 Serve as unit representative on committees developing policies and procedures Use reliable resources for information (CDC, professional journals, evidenced based research) Step 2 Enhance knowledge and understanding of the facility "s policies and procedures. Provide client care consistent with these policies and procedures Document client care thoroughly and according to facility guidelines Participate in the collection of info/data r/t staff "s adherence to selected policy or procedure Assist with analysis of the info/data
Compare results with the established standard Make a judgment about performance in regard tot eh findings Step 3 Assist with the provision of education of training necessary to improve the performance of staff Act as a role model by practicing in accordance with the established standard Assist with re-evaluation of staff performance by collection of info/data at a specified time.
Referrals: Assessing Need to Refer Clients for Assistance A referral is made so that the client can access the care identified by the primary care provider or the consultant The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg hospice care, home health aide) Clients being released from health care facilities and discharged to their home still require nursing care. Discharge referrals are based on client needs in relation to actual and potential problems and may enlist the aid of : social services specialized therapists (eg: PT, OT, OT, speech) care providers (eg home health nurses, hospice nurse Knowledge of community resources is necessary to appropriately link the client with needed services To ensure continuity of care by the use of referrals, the nurse should: Initiate the discharge upon the client "s admission Evaluate client/family competencies in relation to home care prior to discharge Involve the client and family in care planning Collaborate with with other health care professionals to ensure all health care needs are met
Complete referral forms to ensure proper reimbursement for services offered.
Staff Development: Selecting Staff Education Activities Based on Staff Learning Styles Domains of Learning Cognitive learning, which includes all intellectual activities. Ex: person is taught and then can list what is learned. Affective learning, which includes feelings, opinions, and values. Ex: person is attentive and willing to listen to instructor Psychomotor learning, which is learning to complete a physical activity. Ex: client practices a skill. Auditory learners---learn by listening Visual learners---learn by seeing Kinesthetic learners---learn by doing
Staff Development and Performance Improvement: Selecting Educational Activities to Ensure Staff Competencies Competence the ability to meet the requirement of a particular role Strategies to maintain competence include
use of checklists to provide a record of opportunities and the level of proficiency in relation to skills peer observation/evaluation, planned or incidental, to assess competence complete of electronic learning modules attendance at in-services to update skills attendance at training sessions to learn specialized skills (ACLS, PLS Supervising Client Care: Information Sources for Making Client Assignments Assignment Factors Client Factors complexity of care needed specific care needs (eg cardiac monitoring, mechanical ventilation) need for special precautions (eg private room with negative air pressure and anteroom, fall precautions, seizure precautions) Health care team factors Skills Experience Nurse to client ratio
Management of Care (24) Plan B Culturally Competent Care: Recognize Need for Use of Translator for Non-English Speaking Client Communication Improve the nurse/client relationship when the communication barrier is great enough to impact the exchange of info between the nurse and client
use interpreters when the communication barrier is great enough to impact the exchange of info between the nurse and the client cautiously use nonverbal communication as it may have very different meanings for the client and the nurse Peripheral Venous Disease: Modification of Care Plan in Response to DVT Development Interventions Deep Vein Thrombosis and Thrombophlebitis Encourage REST facilitate bedrest and elevation of extremity above the level of the heart (avoid using a knee gatch or pillow under knees) admin intermittent or continuous warm moist compresses (to prevent thrombus from dislodging and becoming an embolus, DO NOT massage the affected limb) provide thigh-high compression or antiembolism stockings to reduce venous stasis and to assist in venous return of blood to the heart. Admin meds as prescribed anticoags unfractionated heparin IV based IV based on body wt is given to prevent formation of other clots and to prevent enlargement of existing clot, followed by oral anticoag with warfarin. hospital admin is required for lab value monitoring and dose adjustment monitor aPTT to allow for adjustments of heparin dosage monitor platelet counts for heparin-induced thrombocytopenia ensure that protamine sulfate, the antidote for heparin is available if needed for excessive bleeding monitor the hazards and SE associated with anticoag therapy Low molecular wt Heparin (LMWH) is (LMWH) is given subq.
Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have consistent action and are approved for the prevent and tx of DVT may be managed at home by home care nurse must have stable DVT or PE, low risk for bleedign, adequate renal function and normal VS client must be willing to learn self injection the aPTT is not checked on an ongoing basis bec the doses of LMWH are not adjusted Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting Warfarin works factors takes 3-4 days before it has therapeutic anticoagulation heparin is continued until the warfarin effect is achieved then IV heparin may be d/c"d if client is on LMWH, warfarin is added after the first dose of LMWH. Therapeutic levels are measured by INR monitor for bleeding ensure that Vit K (the antidote for warfarin) is available in case of excessive bleeding Thrombolytic Therapy effective in dissolving thrombi quickly and completely must be initiated within 5 days after onset of sx to be most effective advantage is the prevention of valvular damage and consequential venous insufficiency or postphlebitis syndrome contraindicated during pregnancy and following surgery, childbirth, trauma, a CVA, CV A, or spinal injury tissue plasminogen activator (t-P (t-PA), A), a thrombolytic agent, and platelet inhibitors such as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may be effective in dissolving a clot or preventing new clots during the first 24 hr.
primary complication of therapy is serious bleeding Analgesics: Admin as ordered to reduce pain Venous Insufficiency Instruct client to elevate legs for at least 20 min four to five times/day above the level of the heart avoid prolonged sitting or standing, constrictive clothing or crossing legs when seated wear elastic or compression stockings during the day and evening put elastic stockings on before getting out of bed after sleep clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down replace worn out compression stockings as needed on using an intermittent sequential pneumatic compression system instruct the client to apply the system twice daily for 1 hour in am and evening advise the client with an open ulcer that the compression system is applied over a dressing Varicose Veins emphasize the importance of antiembolism stockings as prescribed instruct the client to elevate the legs as much as possible instruct the client to avoid constrictive clothing and pressure on the legs.
Consultation: Contacting Wound Care Consultant when Outcomes are Not Being Met A consultant is a professional who provides expert advice in a particular area. a rea. A consultation is requested to help determine what tx/services the client requires.
Consultants provide expertise to clients who require a particular type of knowledge or service (eg. a cardiologist for a client who had a myocardial infarction, a psychiatrist for a client whose risk for suicide needs to be assessed. Coordination of the consultant"s recommendations with other health care providers" recommendations is necessary to protect the client form conflicting and potentially dangerous orders. Interventions: Initiate the necessary consults or notify the PCP of the client "s needs so the consult can be initiated. Provide the consultant with all pertinent info about the problem (eg,, info from the client/ family, the client"s medical records). Incorporate the consultant"s recommendations into the client"s plan of care. Facilitate coordination of the consultant "s recommendations with other health care providers" recommendations to protect the client from conflicting and potentially dangerous orders. Question: A nurse is assigned to care for an older adult client who has been in the health care facility for 3 weeks due to a total hip replacement and subsequent pulmonary complications. During morning assessment, the nurse notes that the client is beginning to develop a decubitus ulcer on his coccyx. Which of the following actions by the nurse would be most appropriate in an effort to obtain a plan of care for this problem? a. Notify the unit manager manager that staff may may not be consistently or effectively carrying out the skin care protocol for high-risk clients. b. Call for a consult consult with the wound care nurse. nurse. c. Bring the problem problem to the attention attention of the surgeon surgeon during rounds d. Develop a nursing care plan for “impaired skin integrity: decubitus ulcer.” ulcer.” The nurse should call the wound care nurse for a consult with this client. since the wound care nurse is an expert in this area, she would be the most knowledgeable person to enlist in the development of a plan of care. While the surgeon should be notified of the decubitus ulcer, she may not be as knowledgeable about tx options. It is appropriate to notify the unit manager that a client on the unit has developed a decubitus ulcer and that this may indicate a staff education need. However, this action would not facilitate the development of a plan of care for this client. Development of a nursing care plan for “impaired skin integrity: decubitus ulcer: is indicated but should be done with the wound care nurse to enhance the quality of care prescribed.
Delegation: Making Appropriate Client Assignment for a Float Nurse Assignment Factors: Complexity of care needed Specific care needs (eg cardiac monitoring, mechanical ventilation) Need for special precautions (eg private room with negative air pressure and anteroom, fall precautions, seizure precautions) Health care team factors: Skills Experience Nurse-to-Client ratio Floating is an acceptable, legal practice used by hospitals to solve their understaffing problems Legally a nurse cannot refuse to float unless a union contract guarantess that nurses can work only in a specified area or the nurse can prove lack of knowledge for the performance of assigned tasks. Nurses in a floating situation must not assume responsibility beyond their level of experience or qualification Nurses who float should inform the supervisor of any lack of experience in caring for the type of clients on the new nursing unit The nurse should request and be given orientation to the new unit Delegation: Identification of Client Concerns to be Reported to Nurse by AP for Delegated Tasks Question: Toward the end of the shift, an LPN L PN reports to an RN that a recently hired AP has not totaled client"s I&O for the past 8 hr. Which of the following should the RN take? A. Confront the AP and instruct him to complete the I&O measurements B. Delegate this task to the LPN since the AP may not have been educated on this task C. Ask the AP if he needs assistance completing the I&O records. D. Notify the nurse manager to include this on the AP"s evaluation.
I&O measurements are routine AP tasks; however the AP is new and my need some assistance. Making assumptions and negative evaluation without direct evidence should be avoided.
Prioritizing Client Care: Recognizing Rec ognizing Assessment Priorities Among Multiple Clients Prioritizing is deciding which needs or problems require immediate action and which ones could be delayed until a later time bec they are not urgent.
Guidelines for Prioritizing The nurse and client mutually rank the client "s needs in order of importance based on the client"s physical and psychological needs, safety, and the client"s own needs and expectations; what the client sees as his or her priority needs may be different from what the nurse sees as the priority Priorities are classified as high, intermediate, or low. Client needs that are life threatening or that could result in harm to the client if they are left untreated are high priorities Nonemergency and non-life-threatening client needs are intermediate priorities Client needs that are not related directly to the client "s illness or prognosis are low priorities When providing care, the nurse needs to decide which ones could be delayed until a later time bec they are not urgent The nurse considers client problems that involve actual or life-threatening life-threatening concerns before potential health-threatening concerns When prioritizing care, the nurse must consider time constraints and availbalbe resources Problems identified as important by the client must be given high priority The nurse can use the ABCs---as a guide when determining priorities; client needs r/t maintaining a patent airway are always the priority
The nurse can use Maslow"s hierarchy of needs theory as a guide to determine priorities and identify the levels of physiological needs; safety, love and belonging, selfesteem; and self-actualization (basic needs are met before moving to other needs in the hierarchy) The nurse can use the steps of the nursing process as a guide to determine priorities; remember that assessment is the first step of the nursing process Ethical Practice: Recognizing Client s Rights !
The client"s rights document also called the patient "s bill of rights reflects acknowledgement of client"s right to participate in their health care with an emphasis on client autonomy The document provides a list of rights of the client and responsibilities that the hospital cannot violate. Right to considerate and respectful care Right to be informed about illness, possible txs, likely outcome, and to discuss this info with the MD Right to know the names and roles of the persons who are involved in care Right to consent or refuse a tx Right to have an advance directive Right to privacy Right to expect that medical records are confidential Right to review the medical record and to have info explained Right to expect that the hospital will provide necessary health services Right to know if the hospital has relationships with outside parties that may influence tx or care Right to consent or refuse to take part in research Right to be told or realistic car alternatives when hospital care is no longer appropriate Right to know about hospital rules that affect tx and about charges and payment methods
Legal Responsibilities: Reporting Suspected Staff Substance Abuse Nurses are required to report certain communicable diseases or criminal activities such as abuse, gunshot or stab wounds, assaults, homicides and suicides to the appropriate authorities The impaired nurse If a nurse suspects that a co-worker is abusing chemicals, the nurse must report the individual to nursing admin in a confidential manner. Nursing admin then notifies the board of nursing regarding the nurse"s behavior Resource Management: Identifying and Reporting Client Care Needs Resources (eg., supplies, equipment, personnel) are critical to accomplishing the goals and objectives in a health care facility Resource management includes budgeting and resource allocation Budgeting is usually the responsibility of the unit manager, but the staff nurse may be asked to provide input. Resource allocation is responsibility of the the unit manager as well as every practicing nurse. Providing cost-effective client care should be balanced with quality of care. Cost-effective resource allocation includes: providing necessary equipment and properly charging client. Returning uncontaminated unused equipment to the appropriate dept for credit. Using equipment properly to prevent wastage. Providing training to staff unfamiliar with equipment. Returning equipment (eg., IV, kangaroo pumps) to the proper dept (eg central service, central distribution) as soon as it is no longer needed. This action will prevent further cost to the client.
Performance Improvement: Recognizing Priority Data Needed to Plan Staffing
Referrals: Recognizing Client Need for Rehabilitation Services
Resource Management: Safe Cost-Effectiveness Nursing Interventions Cost-Effective resource allocation includes: Providing necessary equipment and properly charging the client Returning uncontaminated, unused equipment to the appropriate dept for credit. using equipment properly to prevent wastage Providing training to staff unfamiliar with equipment Returning equipment (eg IV, kangaroo pumps) to the proper dept (eg central service, central distribution) as soon as it is no longer needed. This action will prevent further cost to the client.
Staff Development: Evaluate Outcomes of Staff Education Activities
Staff Development: Orientation to the Workplace Orientation helps new graduates translate knowledge, principles, skills, and theories learned in nursing school into practice
is necessary for nurses new to health care facility or unit to learn the procedures and protocols
Topic Descriptors Descr iptors PHARMACOLOGICAL AND PARENTERAL THERAPIES (24) Form A Medications to Treat Depression: Recognizing Side Effects of Tricyclic Antidepressants Mohr--predominant SE of tricyclic antidepressants are: sedation dry mouth blurred vision urinary retention delayed micturition dizziness fainting Other SE confusion disturbed concentration weight gain constipation ATI---Select Prototype Med:
amytriptyline (Elavil)
Side/Adverse Effect Orthostatic Hypotension
Nursing Intervention/Client Education Instruct clients about the signs of postural hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down. Orthostatic hypotension can be minimized by getting up slowly
Anticholinergic effects (eg., dry mouth, Instruct the client on ways to minimize blurred vision, photophobia, acute urinary anticholinergic effects. retention, constipation, tachycardia) Advise the client to chew sugarless gum, eat foods high in fiber, and increase water intake to at lease 8-10 glasses/day Teach the client to monitor HR and report repor t noteworthy increases. Advise the client to notify the primary care provider if sx are intolerable. Cardiac toxicity usually only at excessive dosing
Obtain the client"s baseline ECG and monitor during tx
Sedation
Usually diminishes over time Advise clients to avoid hazardous activities such as driving if sedation is excessive. Advise the client to take med at bedtime to minimize daytime sleepiness and to promote sleep
Toxicity evidenced by dysrhythmias, mental confusion, and agitation, followed by seizures, and coma
Give Clients who are acutely ill only a 1week supply of med Monitor the client for signs of toxicity Notify the PCP if signs of toxicity occur.
Immunosuppressants: Recognizing Risk Factors for Infection Calcineurin inhibitors: cyclosporine (Sandimmune, Gengraf, Neoral) Glucocorticoids: Prednisone Cytotoxics: azathioprine (Imuran) tacrolimus (Prograf), methotrexate (Rheumatrex, trexall)
increases risk of infection such as fever an/or sore through advise the client if sx occur to notify the primary care provider immediately Glucocorticoids are contraindicated in recurring live virus vaccines (increases risk of infection) and systemic fungal infections. Cyclosporine is contraindicated in recent contact or active infection of chicken pox or herpes zoster
Estrogens: Recognizing Side Effects endometrial and ovarian CA--occur when prolonged estrogen is the only postmenopausal therapy give client progestins along with estrogen instruct client to report persistent vaginal bleeding advise client to have endometrial biopsy q 2 years potential risk for estrogen-dependent breast CA-rule out prior to starting therapy encourage regular self-breast exams and mammograms embolic events (ie: ( ie: MI, pulmonary embolism, DVT, DVT, CVA) discourage client from smoking monitor the client for pain, swelling, warmth or erythema in lower legs feminization (gynecomastia, testicular and penile atrophy),, impotence, and decreased libido in males avoid use of estrogen vaginal creams prior to sexual intercourse sx disappear when med is discontinued
Magnesium Sulfate Therapy: Appropriate Interventions to Counteract Toxicity for a client with Gestational Hypertension Gestational Hypertension begins after the 20th week of pregnancy
BP at 140/90 or greater systolic increase of 30 mmHg diastolic increase of 15 mmHg there is no proteinuria or edema client"s BP returns to baseline by 6 weeks postpartum Magnesium Sulfate Toxicity include absence of patellar DTRs UOP < 30 cc/hr Resp < 12/min decreased LOC If Mag toxicity is suspected immediately discontinue infusion administer calcium gluconate, (IV gluconate, (IV admin of 1 g (10ml of 10% soln) at 1 ml/min) Discontinue mag if RR < 12, a low pulse ox (<95%) persists or DTRs are absent Notify MD If UOP falls below 20ml/hr the MD is notified so that the drug "s admin can be adjusted to maintain a therapeutic range Calcium opposes the effects of mag at the neuromuscular junction Always have an injectable form of calcium gluconate avail when administering magnesium sulfate by IV
Succinylcholine: Recognizing and Responding to Malignant Hyperthermia Malignant hyperthermia is a rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death occurs in affected people exposed to certain anesthetic agents Succinylcholine (Anectine) especially in conjunction with volatile inhalation agents, appears to be the primary trigger of the disorder usually during general anesthesia but it may manifest in the recovery period as well.
fundamental defect: hypermetabolism resulting in altered control of intracellular calcium leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis and hemodynamic and cardiac alterations. hyperthermia not an early sign definitive treatment is Dantrolene (Dantrium) which slows metabolism along with symptomatic support to correct hemodynamic instability
Blood and Blood Products: Evaluating Client Response to Blood Transfusions NS ok No dexrose soln"s or lactated ringers. no other additives s/b given via the same tubing During 1st 15 min or 50ml the nurse should remain with the pt
rate s/b no more than 2ml per min usual rate after the 1st 15 min...1 unit over 2 hrs should not take more than 4 hrs to administer. Steps if acute blood reaction occurs. e. Stop the transfusion transfusion f. Maintain Maintain a patent patent IV IV line with saline saline soln g. notify the the blood bank and HCP immediat immediately ely h. recheck ID ID tags and numbers numbers i. mo moni nito torr VS VS and and UOP UOP j. tx sx per MD order k. save the blood bag and tubing tubing and send them to blood blood bank for exam l. complet complete e tranfusi tranfusion on reaction reaction reports reports m.collect required blood and urine specimens at intervals stipulated by hospital policy to evaluate for hemolysis n. document document on transfusion transfusion reaction. reaction.
Acute reactions: 15 min Delayed reactions: 2-14 days after administration
Acute hemolytic treat shock if present draw blood samples maintain BP with IV colloid soln give diuretics to maintain urine flow insert indwelling cath or measure amts of hourly UOP do not transfuse additional RBC Febrile give antipyretics as prescribed do not restart transfusion Mild allergic give antihistamine as directed if sx are mild and transient, transfusion may be restarted Anaphylactic and severe allergic initiate CPR if indicated have epi ready for injection 0.4 ml of 1:1000 soln SQ or 0.1 ml 1:1000 soln diluted to 10ml with saline for IV use Do not restart transfusion Circulatory overload place pt upright with feet in dependent position admin prescribed diuretics, 02, morphine phlebotomy may be indicated Sepsis obtain culture of pt "s blood and send bag with remaining blood and tubing to blood bank for further study treat septicemia as directed---abx, directed- --abx, IV, IV, fluids Vascular Access: Recognizing and Documenting Expected Finding for a Client with a central venous access device. PICC line
Insertion: basilic or cephalic vein at least 1 finger "s breadth below or above the anticubital fossa. tip is positioned in the lower 1/3 of the superior vena cava Indications: admin of blood long term admin of chemo abx tpn care: assess q 8 hr. note redness, swelling, drainage, tenderness and condition of dressing change tube and positive pressure cap per protocol (usually q 3 days) us 10ML or larger syringe to flush the line clean insertion port with alcohol for 3 sec, let dry perform flush for intermittent med admin usually 10 Ml of NS before, between and after meds. use transparent dressing usually change q 7 days and when indicated advise client to avoid excessive physical exercise on affected extremity Tunneled Caths (Hickman) Insertion: subq tunnel separating point where the cath enters the vein from where it enters the skin with a cuff indication: need for vascular access is long term (1 year or more) commonly for chemo
care: to access: apply local anesthetic, palpate to locate the port clean with alcohol for 3 sec access with noncoring needle flush after q use and at least once a month
Basic Pharmacological Principles: Expected Dosage Adjustments Based on Age of Client Pediatric dosages are based on body wt, body surface area and maturation of body organs. meds are based on age bec of greater risk for decreased skeletal growth, acute CV failure or hepatic toxicity.
Hematopoietic Growth Factors: Evaluating Client Outcomes Hematopoietic growth factors act on the bone marrow to increase production of red blood cells Epoetin used for anemia of CRF HIV infected clients taking Retrovir anemia induced by chemo anemia in clients scheduled for elective surgery SE: hypertension secondary to elevations in HCT increased risk for CV event Nursing Interventions: Monitor client"s iron levels RBC growth dependent on adequate quantities of iron, folic acid, and vit B12 monitor the client"s Hgb and Hct twice a week until target range is reached obtain baseline BP in CRF, CRF, control HTN before tx do not combine with other med Evaluation of med effectiveness : effectiveness : Hgb Hgb level of 10-12 and HCT of 40% increased reticulocyte count filgrastin (Neupogen), pegfilgrastin (Neulasta) stimulate the bone marrow to increase production of neutrophils decreases the risk of infection in clients with neutropenia SE: bone pain leukocytosis---decrease dose or stop tx if WBC > 50000 or platelets > 500000 contraindicated in clients sensitive to E. Coli should not be combined with other med
Evaluation of Medication Effectiveness absence of infection in chemo for CA tx, an absolute neutrophil count increase to greater than 10,000 after chemo induced nadir. sargramostim (leukine) acts on the bone marrow to increase production of WBC (neutrophils, monocytes, macrophages, eosinophils facilitates recovery of bone marrow after bone marrow transplant used in the tx of failed bone marrow transplant SE: diarrhea, weakness, rash, bone pain leukocytosis, thrombocytosis reduce tx if WBC> 50000, neutrophil > 20000 or platelets > 500000 contraindicated in clients allergic to yeast products use cautiously in clients with heart disease, hypoxia, peripheral edema, pleural and pericardial effusion Evaluation of Medication Effectiveness absence of infection WBC and differential within normal ranges
Proton Pump Inhibitors: Client Education omeprazole (Prilosec) reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (Zollinger-Ellison syndrome) Allow at least a 2 hr interval between this med and: Ampicillin Digoxin
Iron ketoconazole delayed absorption of these meds may occur if taken concurrently with omeprazole. Therapeutic Interventions and Client Education Do not crush, chew, or break sustained release capsules may sprinkle contents of the capsule over food to facilitate swallowing take once a day prior to eating avoid irritating meds (ibuprofen, ETOH) active ulcers should be tx"d for 4-6 weeks Protonix (pantoprazole) can be admin to client IV. Monitor IV site. may be low incidence of HA and diarrheat notify PCP for any sign of obvious or occult GI bleeding
Migraine Medications: Evaluating Appropriate Use of Sumatriptan (Imitrex) sumatriptan (Imitrex) serotonin receptor agonist prevent the inflammation and dilation of the incranial blood vessels thereby relieving migraine pain therapeutic uses to abort acute migraine attack prevent migraine attack Contraindicated in clients with ischemic heart disease, hx of MI, uncontrolled HTN and other heart diseases do not give with ergotamine (ergostat)---leads to spastic reaction of blood vessels. don not give triptans within 2 weeks of stopping MAOIs---can lead to MAO toxicity.
Cephalosporins: Evaluating Tx Effectiveness beta-lactam abx similar to PCNs that destroy bacterial cell walls causing destruction of microorganisms effective against gram neg organisms and anaerobes more able to reach CSF broad spectrum bactericidal meds with a high therapeutic index that treat UTIs, post op infections, pelvic infections, and meningitis. Evaluation of Medication Effectiveness improvement of infection sx: reduction of fever, pain, and inflammation, clear breath sounds, reduced UTI sx, negative urine CX Basic Principles of Med Admin: Client Education Regarding Age Related interventions Promoting Compliance in the older adults give clear and concise instructions, verbally and in writing ensure dosage form is appropriate. liquids should be admin to clients who have difficulty swallowing provide clearly marked containers that are easy to open assist the client to set up a daily calendar with the use of pill containers suggest that the client obtain assistance from a friend, neighbor, or relative. Medication Admin and Error Prevention: Disposing of Unused Controlled Schedule Medications If only one part of a premeasured dose of a controlled substance is given, a second nurse witnesses disposal of the unused portion and documents such on the record form Dosage Calculation: Calculating Hourly Infusion Rate for a Large Volume of Fluid A RN is to admin 500 mL of D5W over ov er 4 hr. The IV pump should be set to deliver how many mL per hour 125 mL/ hr
An IV med is to run over 20 min on the pump. The med is mixed in 50 ML of NS. The IV pump should be set to deliver how many mL/hr. 150mL/hr An IV med is to run over 45 min on the pump. The med is mixed in 100mL of NS. The IV pump should be set to deliver how many mL/ hr? 133 mL/hr. Intravenous Therapy: Priority Interventions with Initiation of Therapy Unexpected Outcomes and Related Interventions
Fluid volume deficit AMB decreased UOP, UOP, dry mucous membranes, membr anes, hypotension, tachycardia notify MD, may require adjustment of infusion rate Fluid Volume excess AMB crackles in lungs, shortness of breath, edema reduce IV flow rate if sx appear and notify MD Electrolyte imbalances AMB abnormal serum electrolyte levels, changes in mental status and alterations in neuromuscular function, changes in VS and other manifestations notify MD. additives in IV or type of IV fluid may be adjusted. Infiltration as indicated by swelling and possible pitting edema, pallor, coolness, pain at insertion site and possible decrease in flow rate stop infusion and d/c IV. IV. elevate affected extremity. restart new IV if continued therapy is necessary phlebitis as indicated by pain, increased skin temp, erythema along path of vein. stop infusion and d/c IV. IV. restart new IV if continued therapy is necessary. place moist warm compress over area of phlebitis Bleeding occurs at venipuncture site bleeding from vein is usually slow, continuous seepage. common in clients who have received heparin or have a bleeding disorder or if the IV site is over bend in arm/ hand if bleeding occurs around venipuncture site and catheter is within vein, gauze dressing may be applied over site. eventually IV may need to be discontinued blood on the dressing can result when the administration set becomes disconnected from the catheter"s hub. When blood appears on the dressing, verify that the system is intact and change the dressing
Intravenous Therapy: Documenting Discontinuation of IV Following Signs of Phlebitis Signs of Phlebitis Edema Throbbing, burning or pain at the site Warmth Erythema May be a red line up the arm with a palpable band at the vein site Slowed infusion Prevention: rotation of sites avoiding the lower extremities proper handwashing and surgical aseptic technique.
Promptly d/c infusion. Notify PCP elevation warm/moist compresses restarting with new tubing and fluid TED hose and/or anticoagulants culturing the site if drainage is present (P/P) Unexpected Outcomes and Related Interventions Phlebitis is present, as evidenced by erythema and tenderness along vein pathway. Stop IV infusion and d/c IV. Restart new IV in other extremity if continued therapy is necessary necess ary.. Record appearance of IV site, type of dressing, and status of IV fluid infusion. A special parenteral fluid flow sheet may be used for recording. Medications Affecting the Respiratory System: Recognizing Ineffectiveness of Beta2-Adrenergic Agonists. albuterol (Proventil, ventolin) act by selectively activating the beta2 receptors in the bronchial smooth muscle resulting in bronchodilation. As a result:
bronchodilation is relieved histamine release is inhibited ciliary motility is increased prevention of asthma tx for ongoing asthma attack long term control of asthma Effectiveness may be evidenced by long term control of asthma attacks prevention of exercise induced asthma attack resolution of asthma attack as evidenced by absence of SOB, clear breath sounds, absence of wheezing, return of RR to baseline. Oral Hypoglycemics: Client Teaching Regarding Use in Pregnancy Pregna ncy Avoid use in pregnancy and lactation (risk for fetal/infant hypoglycemia) Oral hypoglycemic medication contraindicated (causes birth defects). Medications Used to Treat TB: Recognizing Risk for Phenytoin Toxicity due to Med interactions. INH (isoniazid) highly specific for mycobacteria. Isoniazid inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall indicated for active and latent TB Latent INH only ---daily for 6 months Active: multiple med therapy including INH, rifampin, pyrazinamide, and/or pyridoxine daily for 6 months Med reaction: Phenytoin--INH interferes with the metabolism of phenytoin with accumulation of phenytoin, resulting in ataxia, and incoordination monitor levels of phenytoin. dosage of phenytoin may need to be adjusted based on phenytoin levels. Opioids: Monitoring Client for Interactions with Anesthesia
Opioids are used preoperatively for sedation and analgesia, intraoperatively for induction and maintenance of anesthesia and postop for pain management. Opioids alter the perception of pain and the response to painful stimuli. When admin before the end of a surgical procedure the residual analgesia often carries over into the PACU allowing the pt to awaken relatively pain free. depression. Respiratory depression may All opioids produce dose-related respiratory depression. be difficult to detect in the OR and therefore requires close observation and pulse oximetry monitoring. Respiratory depression is reversed with naloxone (Narcan). (Narcan). However its use is often associated with a reversal of the analgesic effects of the narcotics as well. Pain Management: Evaluating Effectiveness of Treatment Pain Management: The goals of teaching r/t pain management include that the pt and family member understand the following need to maintain a record of pain level and effectiveness of tx no need to wait until becomes severe to take drugs or use nondrug therapies for pain relief med will stop working after it is taken for a period of time, and dosages may need to be adjusted potential SE and complications associated with therapy. therapy. SE: N/V, constipation, itching, sedation and drowsiness, urinary retention, sweating need to report when pain is not relieved to tolerable levels.
client attained her pain relief goal most of the time client is performing ADLs, walking and ability to sleep if nurse assess that a client continues to have discomfort after an intervention, it may be necessary to try a different approach. If an analgesic provides only partial relief, the nurse may add relaxation exercises or guided imagery exercises. The nurse may also consult with the physician about increasing the dosage, decreasing the interval between doses, or trying different analgesics. nurse evaluates the client"s perceptions of the effectiveness of the interventions. The client may help decide the best times to attempt a tx. in essence, the client is the best judge of whether an intervention works. The nurse also evaluates tolerance to therapy and the overall relief obtained. a nurse admin an analgesic, SE from the med and the client"s reported pain relief must be assessed. client is the best resource for evaluating the effectiveness of pain relief measures. TPN: Recognizing Appropriate TPN Interventions
TPN: TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrients and electrolytes given through an indwelling or central IV catheter which may be inserted peripherally or percutaneously, implanted or tunneled. PN: is a form of specialized nutrition support in which nutrients are provided intravenously. Safe admin of the form of nutrition depends on appropriate assessment of nutrition needs, meticulous management of the CVC and careful monitoring to prevent or tx metabolic complications. Parenteral nutrition is admin in a variety of setting including the client"s home. Regardless of the setting, the nurse adheres to the same principle of asepsis and infusion management to ensure safe nutrition support. clients who are unable to digest or absorb enteral nutrition benefit from PN. goal to move toward the use of the GI tract is constant. lipid emulsions provide supplemental kilocalories and prevent essential fatty acid deficiencies. These emulsions can be admin through a separate peripheral line, through the central line by Y-connector tubing or as an admixture to the PN soln. The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is given over a 24 hr period. The mixture should not be used if oil droplets are observed or i an oil or creamy layer is observed on the surface of mixture. indicates that the emulsion has broken into large lipid droplets that can cause fat emboli if admin. Initiating PN: Clients with short-term nutritional needs often receive IV soln "s of less than 10% dextrose via a peripheral vein in combination with amino acids and lipids. Peripheral solns are not as caloricly dense as TPN solutions and therefore are usually temporary. Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into a high-flow central vein such as the superior vena cava by a MD under sterile conditions. After placement, the cath is flushed with saline or heparin until the position is radiographically confirmed Before beginning any parenteral nutrition infusion, verify MD "s order and inspect the soln for particulate matter or a break in the lipid emulsion. An infusion pump is always used. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased until the client"s complete nutrition needs are supplied. Preventing Complications include: mechanical complication from insertion of the CVC infection metabolic alterations
pneumothorax results from a puncture insult to the pulmonary system and results in the accumulation of air in the pleural cavity with subsequent collapse of the lung and impaired breathing. sudden sharp chest pain dyspnea coughing air embolus can occur during insertion of the catheter or when changing the tubing or cap have pt perform valsalva maneuver (hold breath and bear down) while assuming a left lateral decubitus position can prevent air embolus the increased venous pressure created by the maneuver prevents air from entering the bloodstream during cath insertion infection tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids. during dressing changes, sterile mask and gloves are always used and insertion sites should be assessed for s/s of infection
Vit K must be given as ordered throughout therapy. Vit K can be synthesized by microflora found in the jejunum and ileum with normal use of the GI tract however bec PN circumvents GI use, exogenous vit K must be administered. Admin of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (K+, Mg+ and Ph+) to move intracellularly. In malnourished or cachetic clients, the resulting low serum extracellular levels of electrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress, convulsions, coma, death. (Refeeding syndrome) Too rapid admin of hypertonic dextrose can result in an osmotic diuresis and dehydration. If an infusion falls behind scheule, the nurse should not increase the rate in an attempt to catch up. Sudden discontinuation of the soln can cause hypoglycemia. usually 5-10% dextrose is infused when PN soln is suddenly d/c "d. catheter occlusion
temporarily stop infusion and flush with NS or heparin. if effort to flush is unsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use of thrombolytic agent (urokinase) hypoglycemia to prevent: do not abruptly discontinue TPN but taper rate down to within 10% of infusion rate 1-2 hours before stopping. hyperglycemia monitor BG level daily until stable then as ordered or prn. TPN is initiated slowly and tapered up to maximal infusion rate. additional insulin may be required during therapy if problem persists.
Form B Aminoglycosides: Assessing for Nephrotoxicity Nephrotoxicity r/t high total cumulative dose resulting in acute tubular necrosis (proteinuria, casts in the urine, dilute urine, elevated BUN, creatinine levels Monitor I/O, BUN, creatinine levels Normal values: BUN 5-20 mg/dL Creatinine 0.5-1.3 mg/dL Instruct pt to report a significant decrease in UOP Glucocorticoids: Recognizing SE of Long Term Therapy Hypokalemia may develop Predisposition to peptic ulcer disease skeletal muscle atrophy and weakness mood and behavior changes fat from extremities is redistributed to trunk and face hypocalcemia r/t anti-vit D effect healing is delayed. at increased risk for wound dehiscence susceptibility to infection is increased. Infection develops more rapidly and spreads more widely suppression of pituitary ACTH synthesis occurs increased BP occurs
Protein depletion decreases bone formation, density and strength
Ceftriaxone (Rocephin): Clostridium Difficile Complication During Antimicrobial Therapy antibiotic associated pseudomembranous colitis observe the pt for diarrhea and notify the PCP d/c abx Abx can cause diarrhea by altering the normal bowel flora. Pts receiving abx are susceptible to Clostridium difficile infection. Health care workers who do not adhere to infection control precautions can transmit C. difficile from pt to pt. Some strains of C. difficile release a toxin that causes mucosal damage resulting in cramping, pain and diarrhea that may be bloody. C. Difficile infection can also result in pseudomembranous enterocolitis and intestinal perforation. Sx: watery diarrhea to severe abdominal pain; fever; leukocytosis; leukocytes in the stool Medications Affecting Blood: Appropriate Procedure for f or Transfusing Packed RBCs Admin of packed red blood cells increases the number of RBC Before starting a packed RBC transfusion, verify the PCP "s order, client"s blood typing, obtain consent for transfusion, and check client"s transfusion hx A second person is necessary to check id of donor blood and recipient, blood compatibility, compatibility, and expiration e xpiration order assess the client before, during and after admin
Upon initiation of the transfusion, obtain baseline VS and a nd assessment of UOP, UOP, document on client"s MR, record start and completion times of transfusion, total volume of transfusion and client"s response to transfusion, Assess infusion site for infection or infiltration assess patency of IV line do not admin blood along with any IV solution other than NS. IV solutions containing dextrose cause hemolysis of RBC
Admin blood using a gauge 19 or larger IV needle (to avoid breakage of cells and blockage of needle lumen), a blood filter (to remove particles and possible contaminants within old blood), and use a Y tubing connection (so that NS can be infused by piggyback) Observe universal precautions during handling and admin of blood products Do no admin blood products with any other meds Complete transfusion within 2-4 hr In the event of a blood transfusion reaction Stop transfusion immediately and notify the PcP do not turn on IV fluids that are connected to the Y tubing bec the remaining blood in the Y tubing will be infused and aggravate the client "s reaction. Admin a new IV soln of NS Stay with the client and monitor VS and UOP Notify the blood bank, recheck ID tag and numbers on the blood tag and send blood bag and IV tubing to blood bank for analysis Obtain urine specimen and send to lab to determine for RBC hemolysis Complete transfusion log sheet, which includes complete record of baseline VS, ongoing monitoring, and client"s response to transfusion.
Basic Dosage Calculation: Monitoring IV Heparin Infusion Monitor VS. In the case of heparin overdose, stop heparin, admin protamine sulfate and avoid ASA Monitor activated partial thromboplastin time (aPTT). Keep value at , 2 times the baseline. Dosages must be checked by another nurse before admin. For continuous IV admin, use an infusion pump. Rate of infusion must be monitored q 30-60 min. Monitor aPPT q 4-6 hr until appropriate dose is determined and then monitor daily Medication effectiveness:
aPTT levels of 60-80 sec No development or no further development of venous thrombi
Glucocorticoids for Rheumatoid Arthritis: Evaluating Client Education Regarding Long Term Effects Client Teaching Teaching for Corticosteroid Therapy E. Plan a diet high in protein, calcium (at least 1500 mg per day) and potassium but low in fat and concentrated concentra ted simple carbs such suc h as sugar, honey, syrups and candy. F. Identify measures to ensure adequate rest and sleep such as daily naps and avoidance of caffeine lat in the day G.develop and maintain an exercise program to help maintain bone integrity H.recognize edema and ways to restrict sodium intake to less than 2000mg per day if edema occurs I. monit monitor or glucose levels levels and recognize recognize sx and signs of hyperglycemia hyperglycemia (eg polydipsia polydipsia,, polyuria, blurred vision) and glycosuria (glucose in the urine). The pt should be instructed to report hyperglycemic sx or capillary glucose levels greater than 180 mg/ dL or urine positive for glucose J. notify HCP if experiencing postprandial heartburn or epigastric pain that is not relieved by antacids. K. See an eye specialist yearly to assess development of possible cataracts L. use safety measures such as getting up slowly from bed or a chair and use good lighting to avoid accidental injury M.maintain good hygiene practices and avoid contact with persons with colds or other contagious illnesses to avoid infection. Osteoporosis Advise the client to take Ca supplements, vit D, and/or biphosphonate Adrenal suppression advise client to observe for sx
Insulin: Monitoring Adequate Blood Glucose Control Medication effectiveness: Glucose levels of 90-130 mg/dL preprandial and < 180 mg/dL postprandial HgA1c < 7 % Normotensive (< 130/80 mmHg)
Cholesterol levels within normal range Insulin
Duration
For meal time dose, admin
Onset
Peak
Lispro insulin (Humalog)
Short, rapid 15 min ac acting (3-6.5 hr)
Rapid 15-30 min 1/2 - 2 1/2 hr
Aspart insulin (Novolog)
Short, rapid acting (3-5 hr)
Rapid 10-20 min 1-3 hr
Reg Insulin (Humulin R, Novolin R)
Short, slower 30 min ac 30 -60 min acting (6-10 hr) Bolus 30 min ac
1-5 hr
NPH insulin (Humulin-N, Novolin-N)
Intermediate (16-24 hr)
Admin 2x/day (same time)
1-2 hr
6-14 hr
Glargine insulin Long (24 hr) (Lantus)
Admin 1x/day (same time)
70 min
None
5-10 min ac
Cardiac Glycosides: Client Education to Reduce Risk Therapeutic Nursing Interventions and Client Education Advise clients to take med as prescribed and not to double the dose when a dose is not taken at the prescribed time Check pulse rate and rhythm before admin of digoxin and record, notify the PcP if HR is < 60 beats/min in an adult, <70 beats/min in children and < 90 beats/min in infants. Admin dig at same time daily. daily. Monitor dig levels periodically while on tx and maintain therapeutic levels between 0.5-2.0 ng/mL to prevent dig toxicity Avoid taking OTC meds to prevent adverse SE and med interactions Instruct clients to observe symptoms of hypokalemia such as muscle weakness, and to notify the PCP if sx occur. oc cur.
Instruct clients to observe sx of dig toxicity (eg anorexia, fatigue, weakness) and to notify PcP if sx occur Management of dig toxicity Dig and potassium sparing med should be stopped immediately Monitor K levels. For levels, < 3.5 mEq/L, potassium should be administered IV or by mouth. Do not give any further K+ level > 5.0 mEq/L Treat dysrhythmias with phenytoin or lidocaine treat bradycardia with atropine For excessive overdose, activated charcoal, cholestyramine, or Digibind can be used to bind Digoxin and prevent absorption Pharmacological Pain Management: Knowledge of Pudendal Blocks Pudendal blocks anesthetizes the lower vagina and part of the perineum to provide anesthesia for an episiotomy and vaginal birth using low forceps if needed A pudendal block does not block pain from uterine contractions and the mother feels pressure. The pudendal block is a highly localized type of regional block similar to a dental anesthetic that provides numbness for dental procedures The MD injects the pudendal nerves near each ischial spine with a local anesthetic. Perineum is infiltrated with local anesthetic bec the pudendal block does not fully anesthetize this area. As in local infiltration, a delay occurs between injection and onset of numbness. Possible maternal complications include a toxic reaction to the anesthetic, rectal puncture, hematoma, and sciatic nerve block. If maternal toxicity is avoided, the fetus is usually not affected Medications to Treat Psychoses: Recognizing Adverse Effects Antipsychotics: Conventional Thorazine, Haldol Extrapyramidal Symptoms
Early dystonia (severe spasms of tongue, neck, face and back) Parkinsonism (bradykinesia, rigidity rigidity,, shuffling gait, drooling) tremors Akathisia (inability to stand or sit , pacing) Late tardive dyskinesia (twisting or worm-like movement of the tongue and face, lip smacking) Neuroleptic Malignant Syndrome sudden high grade gra de fever, BP flucuations, dysrhythmias, muscle rigidity, change in LOC developing into coma Anticholinergic Effects dry mouth, visual disturbance, acute urinary retention, constipation, tachycardia Orthostatic Hypotension Sedation Neuroendocrine effects gynecomastia, galactorrhea, menstrual irregularities Sexual dysfunction Skin effects photosensitivity resulting in severe sunburn, contact dermatitis from handling meds Agranulocytosis Severe dysrhythmias Antipsychotics-Atypical Clozapine Risperidone olanzapine quetiapine aripiprazole Adverse Effects Agranulocytosis Seizures New onset of DM or loss of glucose control in clients with DM Wt gain Inflammation of hear muscle AEB dyspnea, increased RR, CP, CP, palpitations.
ACE Inhibitors: Intervening for Client Response ACE inhibitors produce their effects by blocking the production of angiotensin II This results in: vasodilation (mostly arteriole) excretion of Na and H20, and retention of K+ (through effects on kidney) possible prevention of angiotensin II and aldosterone-induced pathological changes in blood vessels and heart. Side/Adverse Eff Effects
Interventions/Client Edu Education
First First do dose se ortho orthosta static tic hypote hypotensi nsion on
if pt pt takin taking g diuret diuretic, ic, stop stop med med temporarily for 2-3 days prior to the start of an ACE inhibitor Start tx with a low dosage monitor the BP for 2 hr after initiation of tx instruct the client to change positions slowly and to lie down if feeling dizzy, lightheaded, or faint
Cough
inform client of dry cough notify PCP as med will most likely be d/c"d
HYPERKALEMIA
monitor K+ levels to maintain normal range of 3.0-5.0 mEq/L Only take K+ substitutes if instructed by PCP
Rash and and dysgeusia dysgeusia (altered (altered taste) taste) client should inform PCP Angioedema (manifested as swelling of the tongue and oral pharynx
treat severe effects with subcutaneous injection of epinephrine
Neutropenia--rare complication of Captopril
monitor the client"s WBC counts every 2 wks for 3 months, then periodically. inform the client to notify PCP at first signs of infection
Furosemide: Recognizing Interactions with Other Medications Furosemide (Lasix), a high ceiling loop diuretics work in the ascending limb of Loop of Henle to Block reabsorption of Na+ and Cl-, and prevent the reabsorption of H20 Cause extensive diuresis
SE: dehydration hypotension ototoxicity hypokalemia
Interactions with other Meds Medication Digoxin toxicity (can occur in the presence of hypokalemia
Nursing Intervention monitor pt"s cardiac status and K+ and dig levels K+ sparing diuretics are often used in conjunction with loop diuretics to reduce the risk of hypokalemia
Antihypertensives--concurrent use can monitor BP have additive hypotensive effect Lithiu Lithium-m--lev levels els can can rise due due to diuresi diuresis s
monito mon itorr Lithium Lithium level levels s
NSAIDS blunt diuretic effect
Watch for a decrease in effectiveness of diuretic such as a decrease in UOP
Medications to Treat Pain: Identifying Need for Additional Analgesia
Pain is whatever the person experiencing it says it is, and existing whenever the person says it does. The client"s report of pain is the most reliable diagnostic measure of pain. Self report using standardized pain scales are useful in clients over the age of & Pain assessment should be done and recorded freq, and may be considered the fifth VS Subjective: Location Quality Intensity Timing Setting Associated sx Behaviors complement self-report and assist in pain assessment of nonverbal clients facial expressions body movements moaning, crying decreased attention span Physiological measures of BP, BP, pulse, RR will be temporarily increased by acute pain. Follow a clinical approach ABCDE to pain assessment and management A---ask about pain p ain regularly, ASSESS pain systematically B---believe the client and family C---choose appropriate pain control options D---deliver interventions in a timely fashion E--empower the client and family Raking a proactive approach by giving analgesics before pain is severe (for PRN orders of pain med) Educating the client regarding misconceptions about pain Assisting the client to reduce fear and anxiety Creating a tx plan that includes both nonpharmacological and pharmacological pain relief measures. Total Parenteral Nutrition: Recognizing Desired Client Outcomes Based on Pathophysiology
TPN: TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrients and electrolytes given through an indwelling or central IV catheter which may be inserted peripherally or percutaneously, implanted or tunneled. PN: is a form of specialized nutrition support in which nutrients are provided intravenously. Safe admin of the form of nutrition depends on appropriate assessment of nutrition needs, meticulous management of the CVC and careful monitoring to prevent or tx metabolic complications. Parenteral nutrition is admin in a variety of setting including the client"s home. Regardless of the setting, the nurse adheres to the same principle of asepsis and infusion management to ensure safe nutrition support. clients who are unable to digest or absorb enteral nutrition benefit from PN. goal to move toward the use of the GI tract is constant. lipid emulsions provide supplemental kilocalories and prevent essential fatty acid deficiencies. These emulsions can be admin through a separate peripheral line, through the central line by Y-connector tubing or as an admixture to the PN soln. The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is given over a 24 hr period. The mixture should not be used if oil droplets are observed or i an oil or creamy layer is observed on the surface of mixture. indicates that the emulsion has broken into large lipid droplets that can cause fat emboli if admin. Initiating PN: Clients with short-term nutritional needs often receive IV soln "s of less than 10% dextrose via a peripheral vein in combination with amino acids and lipids. Peripheral solns are not as caloricly dense as TPN solutions and therefore are usually temporary. Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into a high-flow central vein such as the superior vena cava by a MD under sterile conditions. After placement, the cath is flushed with saline or heparin until the position is radiographically confirmed Before beginning any parenteral nutrition infusion, verify MD "s order and inspect the soln for particulate matter or a break in the lipid emulsion. An infusion pump is always used. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased until the client"s complete nutrition needs are supplied. Preventing Complications include: mechanical complication from insertion of the CVC infection metabolic alterations
pneumothorax results from a puncture insult to the pulmonary system and results in the accumulation of air in the pleural cavity with subsequent collapse of the lung and impaired breathing. sudden sharp chest pain dyspnea coughing air embolus can occur during insertion of the catheter or when changing the tubing or cap have pt perform valsalva maneuver (hold breath and bear down) while assuming a left lateral decubitus position can prevent air embolus the increased venous pressure created by the maneuver prevents air from entering the bloodstream during cath insertion infection tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids. during dressing changes, sterile mask and gloves are always used and insertion sites should be assessed for s/s of infection
Vit K must be given as ordered throughout therapy. Vit K can be synthesized by microflora found in the jejunum and ileum with normal use of the GI tract however bec PN circumvents GI use, exogenous vit K must be administered. Admin of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (K+, Mg+ and Ph+) to move intracellularly. In malnourished or cachetic clients, the resulting low serum extracellular levels of electrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress, convulsions, coma, death. (Refeeding syndrome) Too rapid admin of hypertonic dextrose can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up. Sudden discontinuation of the soln can cause hypoglycemia. usually 5-10% dextrose is infused when PN soln is suddenly d/c "d. catheter occlusion
temporarily stop infusion and flush with NS or heparin. if effort to flush is unsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use of thrombolytic agent (urokinase) hypoglycemia to prevent: do not abruptly discontinue TPN but taper rate down to within 10% of infusion rate 1-2 hours before stopping. hyperglycemia monitor BG level daily until stable then as ordered or prn. TPN is initiated slowly and tapered up to maximal infusion rate. additional insulin may be required during therapy if problem persists.
Topic Descriptors Descr iptors Physiological Adaption (21) Form A Prolapsed Umbilical Cord: Emergency Nursing Response Prolapsed Umbilical Cord occurs when the umbilical cord is displaced preceding the presenting part of the fetus or protruding through the cervix results in cord compression and compromised fetal circulation Assessment: client states she can feel something coming through the vagina visualization or palpation of the umbilical cord protruding from the introitus assessment that show FHR to have variable decelerations extreme increase in fetal activity that occurs and then ceases. This may be suggestive of severe fetal hypoxia. Nursing interventions include relieving the cord compression immediately and increasing fetal oxygenation call for assistance immediately notify the primary care provider of the prolapsed cord position the client"s hips higher than her head
reposition the client in a knee chest position. Trendelenberg or a side-lying position with a rolled towel under the client "s right or left hip to relieve pressure on the cord using a sterile gloved hand, insert two fingers into the vagina and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off the cord apply a sterile saline soaked towel to the cord to prevent drying and to maintain blood flow if it is protruding from the vaginal introitus. closely monitor the FHR with an electronic fetal monitor for variable decelerations indicative of fetal asphyxia and hypoxia from cord compression administer oxygen at 8-10 L via a face mask. This will improve fetal oxygenation Amnioinfusion of NS or LR solution as prescribed should be instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to alleviate cord compression if it is caused by oligohydramnios prepare the client for a C-section if other measures fail. Myocardial Infarction: Evaluating Effectiveness of Medication Interventions Nursing Interventions Administer 02 4-6 L as prescribed Obtain and maintain IV access Administer meds as prescribed Vasodilators oppose coronary artery vasospasm and reduce preload and afterload, decreasing myocardial oxygen demand NITROGlYCERIN Analgesics reduce pain, which decrease sympathetic stress leading to preload reduction MORPHINE Beta blockers have antidysrhythmic and antihypertensive properties and decrease the imbalance between myocardial oxygen supply and demand by reducing afterload in an acute MI, beta-blockers decrease infarct size and improve short and long term survival rates Thrombolytic agents can be effective in dissolving thrombi if admin within the first 6 hrs following an MI. Contraindications include recent surgery, recent head trauma, and any other situation that poses an additive risk for bleeding internally.
Antiplatelet agents inhibit cyclooxygenase, which produces thromboxane A2, a potent platelet activator ASPIRIN Anticoags (heparin, low molecular wt heparins) are used to prevent the recurrence of a clot after fibrinolysis Client education regarding response to chest pain stop activity and rest place nitro under tongue to dissolve (quick absorption) repeat every 5 min if the pain is not relieved. call 911 if pain is not relieved in 15 min.
Fractures: Discharge Teaching Regarding Cast Care Patient and Family Teaching Teaching Guide Do Not Get plaster cast wet Remove any padding Insert any foreign object inside cast Bear wt on new cast for 48 hr (not all casts are made for wt bearing; check with HCP when unsure Cover cast with plastic for prolonged periods Do Apply ice directly over fracture site for first 24 hr (avoid getting cast wet by keeping ice in plastic bag and protecting cast with cloth Check with HcP before getting fiberglass cast wet Dry cast thoroughly after exposure to water blot dry with towel use hair dryer on low setting until cast is thoroughly dry Elevate extremity above level of heart for 1st 48 hr Move joints above and below cast regularly Report signs of possible problems to HCP increasing pain
swelling associated with pain and discoloration of toes or fingers pain during movement burning or tingling under the cast sores or foul odor under the cast Keep appointment to have fracture and cast checked. Electrolyte Imbalances: Evaluating Effectiveness of Hypokalemia Interventions
Potassium normal levels (3.5-5.0 mEq/L)
most common causes: abnormal losses via the kidneys or GI tract, metabolic alkalosis, sometimes associated with tx of diabetic ketoacidosis bec of increased urinary K loss and shift of K into cells with admin of Insulin and correction of acidosis S/S Expected Findings serum K+ < 3.5 mEq/L metabolic alkalosis: pH> 7.45 EKG: PVCs, bradycardia, blocks, b locks, VTach, VTach, inverted T waves, ST depression depr ession
alters resting membrane potential potentially lethal ventricular arrhythmias flattening of T wave and eventual emergence of a U wave, increased P wave skeletal muscle weakness and paralysis (most observed in legs) respiratory muscles and those innervated by cranial nerves not involved muscle cramps and muscle cell breakdown (rhabdomyolysis) leads to myoglobin in the plasma and urine which can in tern, lead to renal failure. Nursing Implementation tx"d by giving potassium chloride supplements (PO or IV) and increasing dietary intake of potassium
Except in severe deficiencies, KCl is never given unless there is UOP of at lease 0.5 ml/ kg of body wt per hour. KCl supplements added to IV should never exceed 60mEq/L. Preferred level is 40 mEq/ L Rate should not exceed 10 to 20 mEq per hour to prevent hyperkalemia and cardiac arrest.
ATI Encourage foods high in potassium (avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas IV potassium never IV push (risk of cardiac arrest maximum recommended rate is 5-10 mEq/hr monitor for phlebitis monitor and maintain UOP monitor for shallow ineffective respirations and diminished breath sounds monitor the client"s cardiac rhythm and intervene promptly as needed monitor LOC and maintain client safety monitor bowel sounds and abdominal distention and intervene as needed. Fluid Imbalances: Appropriate Intervention in Response to Signs of Fluid Volume Excess hypervolemia: both water and sodium are retained abnormally high proportions overhydration: more water is gained than electrolytes Expected Findings HGB and HCT: Overhydration: decreased (hemodilution) Serum Osmolarity: Overhydration: decreased (hemodilution) osmolarity (<270mOsm/L) decreased protein and electrolytes Serum Sodium Overhydration: decreased (hemodilution) Electrolytes, BUN, creatinine
Hypervolemia: Increased electrolytes, BUN, and creatinine Nursing Interventions: Report abnormal findings to PCP Client Findings: VS: tachycardia, bounding pule, HTN, tachypnea, increased ICP Neuro: confusion MS: muscle weakness GI: wt gain, ascites Resp: dyspnea, orthopnea, crackles Other: edema, distended neck veins Nursing Interventions: Assess breath sounds Monitor ABGs for hypoxemia and respiratory alkalosis position the client in semi-Fowler "s position administer 02 as needed reduce IV flow rates Administer diuretics (osmotic, loop) as ordered. monitor daily I/O and Wt Limit fluid and sodium as ordered Monitor and document presence of edema (pretibial, sacral, periorbital) monitor and document circulation to the extremities Turn and position the client at least q 2 hr support arms and legs to decrease dependent edema as appropriate monitor for/treat skin breakdown Complications: Pulmonary Edema s/s include ascending crackles, dyspnea at rest, and confusion position in high Fowler"s admin IV morphine Admin IV diuretic prepare for possible intubation and mechanical ventilation
Electrolyte Imbalances: Recognizing Priority Interventions in Response to Hyponatremia
Na+ serum level 135-145 mEq/L hyponatremia is a net gain of water or loss of sodium rich fluids delays and slow the depolarization of membranes Expected Findings Serum sodium decreased <135 mEq/L Serum osmolarity decreased < 270 mOsm/L Expected Client findings depends on whether it is associated with a normal decreased or increased ECF volume VS: hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension Neur: HA, confusion, lethargy MS: muscle weakness to the point of possible respiratory compromise, fatigue, decreased DTRs GI: Increased motility, hyperactive bowel sounds, abdominal cramping Nursing interventions Report abnormal findings to PCP Fluid Overload: restrict water intake as ordered acute hyponatremia admin hypertonic oral and IV fluids as ordered encourage foods and fluids high in sodium (cheese, milk, condiments) restoration of normal ECF: administer isotonic IV therapy (0.9% NS, LR) monitor I/O and daily wt monitor VS and LOC--report abnormal findings. Complications: Seizures Congenital Heart Disease: Interventions for Decreased Cardiac Output Cardiac output (CO) depends on preload, afterload, and myocardial contractility, HR, and metabolic state of the individ.
overloaded heart resorts to compensatory mechanisms to try to maintain adequate CO. The main compensatory mechanisms include ventricular dilation, ventricular hypertrophy, increased SNS stimulation and neurohormonal responses. As CO falls, blood flow to kidneys decreases, Low CO causes a decrease in cerebral perfusion pressure. Interventions for CHF: If client is experiencing respiratory distress, place the client in high Fowler "s position and admin 02 as prescribed encourage bedrest until the client is stable encourage energy conservation by assisting with care and ADLs maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium intake) administer meds as prescribed diuretics: todecrease preload loop diuretics (furosemide (Lasix), bumetanine (Bumex) ) thiazide diuretics: HCTZ tech client taking loop or or thiazide diuretics to ingest foods and drinks that are high in K+ to counter hypokalemia effect. Potassium supplement may be required. Administer IV furosemide no fast than 20mg/min Afterload reducing agents ACE inhibitors (enalapril, captopril, monitor for initial dose hypotension beta blockers (Coreg, metoprolol) Angiotensin II blockers such as losartan Inotropic agents digoxin dopamine dobutamine milrinone to increase contractility and thereby improve CO Vasodilators nitrates to decrease preload and afterload
hBNP nesiritide (Natrecor) to tx acute HF by causing natriuresis (loss of sodium and vasodilation) Anticoagulants warfarin (Coumadin), heparin, clopidrogrel to prevent thrombus formation associated with congestion/stasis and associated afib. Shock: Recognizing S/S of Hypovolemia Hypovolemic shock occurs when there is a loss of intravascular fluid volume One of the first clinical signs of shock may be a fall in BP Decreased LOC Restlessness Anxiety Weakness Rapid, weak, thready pulses Arrhythmias Hypotension Narrowed pulse pressure cool clammy skin tachypnea, dyspnea, shallow irregular respirations decreased 02 saturation extreme thirst N/V chills feeling of impending doom pallor cyanosis obvious hemorrhage or injury temp dysregulation
Acute GI Disorders: Recognizing S/S to report Appendicitis mild or cramping, epigastric or periumbilical pain (initial) constant, intense RLQ pain (later) N/V
anorexia Rebound tenderness (pain after deep pressure is applied and released over McBurney"s point (located halfway between the umbilicus and anterior iliac spine) Pain that decrease with a decrease in right hip flexion or increases with coughing and movement may indicate perforation with peritonitis muscle rigidity, tense positioning, guarding may indicate perforation with peritonitis normal to low grade temp (higher suggests peritonitis) Acute Abdominal/GI Findings (Med-Surg) Diffuse, localized, dull, burning or sharp abdominal pain or tenderness rebound tenderness abdominal distention abdominal rigidity N/V/D hematemesis melena Abdominal Trauma Surface Findings abrasions or ecchymosis on abdominal wall, flank, or peritoneum open wounds, lacerations,eviscerations puncture wounds, gunshot wounds impaled object healed incisions or old scars Abdominal/GI Findings N/V Bloody urine abdominal distention abdominal rigidity abdominal pain with palpation rebound tenderness pain radiation to shoulder and back Herpes Zoster: Evaluating Client Teaching Interventions Use an air mattress or bed cradle for pain prevention/control isolate the client until the vesicles are crusted
maintain strict wound care precautions Herpes zoster is potentially transmissible and caution should be exercised around infants, pregnant women who have not had chickenpox, and immunocompromised clients. Administer meds as prescribed Analgesics (NSAIDS, narcotics) Antiviral agens such as acyclovir, valacyclovir, favicilovir (shorten the clinical course) moisten dressings with cool tap water or 5% aluminum acetate (Burow "s solution) and apply to the affected skin for 30-60 min 4-6x/day as prescribed Lotions (for example, Calamine) may help relieve discomfort. Cystic Fibrosis: Managing Illness at Home Care in the Home (ATI) (ATI) Ensure parents/caregivers have information regarding access to medical equipment Provide teaching about equipment prior to discharge Instruct parents/caregivers in ways to provide CPT and breathing exercises. For example, a child can “stand on her head” by using a large cushioned chair place against a wall. administer abx through a venous access port. Parents/caregivers need instruction in admin techniques, SE to observe for, and how to manage difficulties with the venous access port Promote regular PCP visits Ensure up-to-date immunizations with the addition of initial influenza vaccine at 6 months of age and then a yearly booster. Encourage regular physical activity Encourage participation in a support group and involvement in community resources. Question:
A child with cystic fibrosis and his parent are receiving discharge teaching by a nurse. Which of the following statements made by the parent indicates a need for further instruction o. My child should should not get an annual influenza influenza vaccine bec of increased increased risk p. I will have have my child stand stand on his head for for chest physiotherap physiotherapy y q. We will encourage encourage our child child to use the Flutter Flutter mucus clearance clearance device r. Our child child will use use a metered metered dose inhaler inhaler to to administer administer a bronchodil bronchodilator ator Cystic fibrosis is hereditary and is transmitted as an autosomal recessive trait, both parents must be carriers. Cystic fibrosis is a dysfunction of the exocrine glands, causing the glands to produce thick, tenacious mucus. Major organs affected are the lungs, pancreas and liver Initial sx may occur at varying ages during infancy, childhood, or adolescence Thick mucus obstructs the respiratory passages causing trapped air and overinflation of the lungs. Abnormally thick mucus leads to obstruction of the secretory ducts of the pancreas, liver and reproductive organs which alters the fx of those organs Sweat and salivary glands excrete excessive electrolytes specifically sodium and chloride The multisystem disease results in increased viscosity of secretions, causing obstruction of small pathways in various organs (eg bronchioles, pancreas, small intestine, bile ducts Chronic, recurrent respiratory infections are a classic sign of the disease process. Atelectasis and small lung abscess are common early complications. Bronchiectasis and emphysema may develop with pulmonary fibrosis Interventions Resp interventions Promptly tx resp infx with abx therapy provide pulmonary hygiene with CPT (eg breathing exercises to strengthen thoracic muscles) a minimum of twice a day (in the am and at bedtime) Have the child use the Flutter mucus clearing device to assist with mucus removal
Administer bronchodilators through MDIs or hand held neb to promote expectoration of excretions Administer dornase alfa (Pulmozyme) through a nebulizer to decrease viscosity of mucus. Promote physical activity that the child enjoys to improve mental well being, selfesteem, and mucus secretion. GI interventions Administer pancreatic enzymes with meals and snacks The amt of enzyme replacement will vary between children based on each child "s deficiency and response to the replacement instruct the child/family that the capsules can be swallowed whole or opened to sprinkle the contents on a small amt of food encourage the child to select meals and snacks if appropriate facilitate high caloric, high protein intake through meals and snacks multiple vits and water soluble forms of A, D, E, K are often prescribed. HIV/AIDS: Interventions to Prevent Spread of HIV HIV is transmitted through blood and body fluids (semen, vaginal secretions) HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes, cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate that these are unlikely sources of infections. Risk Factors unprotected sex (vaginal, anal, oral) multiple sex partners occupational exposure (healthcare worker) perinatal exposure blood transfusions (not a significant source of infection in the U.S.) IV drug use with contaminated needle
Med/Surg--Prevention techniques divided into safe activities (those that eliminate risk) and riskreducing activities (those that decrease risk but do not eliminate it). Decreasing risks r/t sexual intercourse safe sex eliminates the risk of exposure to HIV in semen and vaginal secretions abstaining is the most effective way to accomplish this but there are safe options for those who cannot or do not wish to abstain outercourse (limiting sexual behavior to activities in which the mouth, penis, vagina or rectum does not come into contact with a partner "s mouth, penis, vagina, or rectum) is safe bec there is not contact includes massage, masturbation, mutual masturbation, telephone sex insertive sex between partners who are not infected with HIV or not at risk of becoming infected with HIV is considered to be safe Risk reducing sexual activities decrease the risk of contact through the use of barriers. should be used when engaging in insertive sexual activity with a partner who is known to be HIV infected or with a partner whose HIV status is not known most common barrier device is male condom female condoms squares of latex plastic food wrap Decreasing risks r/t drug use major risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sex experiences while under the influence of drugs. basic rules do not use drugs if you do, don"t share equipment
do not have sex when under the influence of any drug (including alcohol) that impairs decision making ability use alternatives to injecting such as smoking, snorting, or ingesting the durg injecting equipment includes needles, syringes, cookers (spoons or bottle caps used to mix the drug) cotton, and rinse water another safe tactic is for the user to have access to sterile equipment (needle exchange programs) cleaning equipment before use is a risk-reducing activity Decreasing risks for perinatal transmission best way to prevent HIV in infants is to prevent HIV infection in women If HIV-infected pregnant women are tx "d with AZT, AZT, REtrovir, the rate of perinatal transmission is decreased. tx has minimal SE for the baby Combination ART as appropriate for the mother"s HIV infection can further decrease the risk of perinatal transmission to less than 2% Decreasing risks at work employers must protect workers from exposure to blood and other potentially infectious materials. precautions and safety devices decrease the risk of direct contact with blood and body fluids. should exposure to HIV infected fluids occur, postexposure prophylaxis with combination ART based on the type of exposure the volume of exposure and the status of the source pt decreases the risk of infections. Glomerular Disease: Recognizing Risk factors Risk Factors (ATI) (ATI) Immunological Reactions Primary infection with group A beta-hemolytic streptococcal infection (most common) Systemic Lupus Erythematosus
Vascular injury (HTN) Metabolic disease (DM) Nephrotoxic drugs Excessively high protein and high sodium diets Burns: Priority Interventions Chemical Burns Emergency Interventions Ensure patent airway assess airway, breathing, circulation before decontamination procedures Brush dry chemical from skin before irrigation flush chemical from wound and surrounding area with saline or water remove clothing, including shoes, watches, jewelry and contact lenses if face exposed establish IV access with large-bore catheter needle if greater than 15% TBSA burn begin fluid replacement blot skin dry with clean towels. Do not rub dry cover burned areas with dry, sterile dressing or clean, dry sheet anticipate intubation if significant inhalation injury present contact poison control center for assistance caregiver should protect self from potential exposure Ongoing monitoring monitor airway if airway exposed to chemicals Inhalation injury Emergency Management Ensure patent airway administer high flow 02 by non rebreather mask remove pt"s clothing establish IV access with large bore catheter needle begin fluid replacement place in high fowler"s position unless spinal cord injury suspected assess for facial/neck burns or other trauma obtain arterial blood gas carboxyhemoglobin levels and chest xray anticipate need for fiberoptic bronchoscopy or intubation
Ongoing Monitoring Monitor VS, LOC, 02 sat, respiratory status, cardiac rhythm Electrical Burns Emergency Management Removal of current source must be done by trained personnel with special equipment to prevent injury to rescuer Assess and tx pt after removal from source of current ensure patent airway stabilize cervical spine administer hi flow 02 by non rebreather mask establish IV access with large-bore catheter needle begin fluid replacement remove pt"s clothing check pulses distal to burns cover burn sites with dry dressing assess for any other injuries (fractures, head injury) Ongoing Monitoring monitor cardiac rhythm, VS, LOC, 02 sat, neurovascular status in injured limbs monitor UOP to ensure adequate volume replacement monitor urine for development of myoglobinuria secondary to muscle breakdown anticipate admin of mannitol and NaHCO3 for myoglobinuria and hemoglobinuria. Thermal Burns Emergency Management Ensure patent airway Stop the burning process inspect face and neck for singed nasal hair, hoarseness of voice, stridor, soot in the sputum administer high flow 02 by non rebreather mask anticipate intubation with significant inhalation injury establish IV access with large bore catheter begin fluid replacement remove clothing and jewelry identify and tx associated injuries (fractured ribs, pneumothorax) determine depth, extent, and severity of burn administer IV analgesia cover large burns with dry dressing apply cool compresses or immerse in cool water for minor injuries only (less than 10% TBSA burn)
insert urinary catheter for severe burns prevent loss of body heat transport asap to burn center do not debride burns or apply topical agents before transfer to a burn center administer tetanus prophylaxis as appropriate Ongoing monitoring monitor VS, LOC, 02 sat, cardiac rhythm, UOP monitor temp monitor pain and medicate as needed based on pt response. Mechanical Ventilation: Response to Ventilator Alarms and Respiratory Distress ATI Ventilators have alarms to signal that the client is not receiving correct ventilation If the nurse cannot determine the cause of a ventilator dysfx, the client is disconnected from the ventilator and manually ventilated with an Ambu bag Ventilator Ventilator alarms should never be turned turne d off There are three types of ventilator alarms: volume, pressure, and apnea alarms volume(low pressure) alarms indicate low exhaled volume due to disconnection, cuff leak and tube displacement pressure (high pressure) alarms indicate excess secretions, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and pneumothrorax. apnea alarms indicate that the ventilator does not detect spontaneous respiration in a present time period. Questions The high pressure alarm sounds on the ventilator. What should the nurse assess for? client biting of the tube breath sounds---indicating the need for suctioning kinks in the tube The low pressure alarm sounds on the ventilator. What should the nurse assess for? Tubing disconnections
air leak around the cuff. Pulmonary Embolism: Evaluation of Tx Effectiveness Objectives: prevent further growth or multiplication of thrombi in the lower extremities prevent embolization from the upper or lower extremities to the pulmonary vascular system provide cardiopulmonary support if indicated Evaluation The expected outcomes are that the pt who has pulmonary embolism will have adequate tissue perfusion and respiratory fx adequate CO increased level of comfort no recurrence of PE Treatment includes Conservative Therapy 02 by mask or cannula may be adequate 02 is given in a concentration determined ABG analysis endotrach intubation and mechanical vent may be needed to maintain adequate 02 turning, coughing and deep breathing to prevent or tx atelectasis for shock, vasopressor agents to support systemic circulation for heart failure, digitalis, diuretics pain with narcotics, usually morphine Drug Therapy anticoags Heparin and warfarin drugs of choice heparin should be started immediately and is continued while oral anticoags are initiated.
dosage adjusted according to PTT and warfarin dose is determined by INR may be indicated if the pt has blood dyscrasias, hepatic dysfunction, overt bleeding, a hx of hemorrhagic stroke or neurologic conditions Thrombolytic agents, such as tPA dissolve PE and the source of the thrombus in the pelvis or deep leg veins thereby decreasing the likelihood of recurrent pulmonary emboli Surgical Therapy if degree of pulmonary arterial obstruction is severe (greater than 50%) and the pt does not respond to conservative therapy, an immediate embolectomy may be indicated. COPD: Evaluating ABGs ABGs serial ABGs are monitored to evaluate respiratory status Increased paCO2 and decreased PaO2 Respiratory acidosis, metabolic alkalosis (compensation) Med-Surg ABGs Emphysema near normal ABGs, decreased PaO2, normal or decreased PaCO2 Chronic Bronchitis decreased Pa02, increased Pa02
Cancer: Preventing Complications of Radiation Treatments Stomatitis: Encourage pt to use artificial saliva teach pt to assess oral mucosa daily discourage use of irritant such as tobacco and alcohol apply topical anesthetics such as viscous Lidocaine N/V
teach to eat and drink when not nauseated admin antiemetics as needed use diversional activities Anorexia monitor wt provide small freq meals of high protein, high calorie foods gently encourage pt to eat but avoid nagging serve food in pleasant environment Diarrhea give antidiarrheal agents as needed Constipation provide stool softener as needed encourage to eat high fiber foods Hepatotoxicity monitor liver function tests Anemia Monitor Hgb and Hct levels Encourage intake of foods that promote RBC production Leukopenia monitor WBC count, especially neutrophils teach to report temp elevation and any other manifestations of infection teach to avoid large crowds and people with infections teach to use good hand washing techniques Thrombocytopenia observe for signs of bleeding monitor hgb and hct and platelet counts teach to use soft bristle toothbrush and use electric razor Alopecia discuss impact of hair loss on self image
suggest way t to cope with hair loss (hair pieces, wigs, scarves) cut long hair before therapy avoid excessive shampooing, brushing, and combing of hair avoid use of electric hair dryers curler and curling irons Skin reactions protect skin from trauma lubricate dry skin with nonirritating creams avoid the use of harsh soaps Cystitis monitor manifestations such as urgency, freq, and hematuria Reproductive dysfunction discuss these changes with patients Nephrotoxicity monitor BUN and serum creatinine levels Increased ICP may be controlled with steroids and pain meds Peripheral neuropathy monitor for these manifestations in pts on these drugs Pneumonitis monitor for dry, hacking cough, fever and exertional dyspnea Pericarditis and myocarditis monitor for clinical manifestations of these disorders cardiotoxicity monitor heart with ECG and cardiac ejection factions drug therapy may need to be modified Hyperuricemia
monitor uric acid levels allopurinol (zyloprim) may be given as a prophylactic measure encourage high fluid intake Fatigue tell pt that fatigue is an expected SE of therapy encourage pt to rest when fatigued to maintain usual lifestyle patterns as closely as possible and to pace activities in accordance with energy level Pain use an analgesic ladder to provide basis for pain med admin teach use of imagery, imagery, relaxation therapy
Pain Management: Recognizing and Responding to Complications of Opioid Use ATI Overdosing of opioid analgesics can lead to respiratory depression and even death sedation always precedes respiratory depression Oversedation and respiratory depression can be prevented by Identifying risks, titrating doses carefully and monitoring the client stopping the opioid and giving the antagonist naloxone if the client "s respirations are less than 8/min and shallow and the client is difficult to arouse. Naloxone must be diluted in NS (0.4mg/10mL) and given by IV slowly. slowly. After admin of naloxone, the client should be reassessed. Assessing the cause of sedation and monitoring the client "s level of arousal and respiratory rate and depth for one full minute using a sedation scale in addition to a pain rating scale to assess a client "s pain especially when administering opioids. Blood Transfusions: Interventions for Complications Transfusion Reactions Acute Hemolytic
Onset: Immediate chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, and hemoglobinuria Febrile Onset: 30min to 6 hr chills, fever, flushing, HA, anxiety admin: antipyretics Mild allergic Onset: During or up to 24 hr after transfusion itching, urticaria, flushing Admin antihistamines such as Benadryl Anaphylactic Immediate wheezing, dyspnea, chest tightness, cyanosis, hypotension Maintain airway, administer 02, IV fluids, antihistamines, corticosteroids, vasopressors vasopr essors Stop the transfusion immediately if a reaction is suspected Initiate a saline infusion. The saline infusion should be initiated with a separate line so as not to give more blood from the transfusion tubing Save the blood ag with the remaining blood and the blood tubing for testing Circulatory overload Sx include: dyspnea, chest tightness, tachycardia, tachypnea, HA, HTN, JVD, peripheral edema, orthopnea, sudden anxiety and crackles in the base of the lungs Admin 02, monitor VS, slow the infusion rate and admin diuretics as ordered Notify PCP immediately Sepsis and Septic Shock
sx include: fever, feve r, N/V, N/V, abdominal pain, chills, hypotension maintain patent airway and admin 02 admin abx therapy as ordered obtain samples for blood cultures admin vasopressors such as dopamine, to combat vasodilation in the late phase elevate the client"s feet If DIC occurs admin anticoags such as heparin in early phase admin clotting factors and blood products during the late phase (clotting factors are used up in the early stage administer activated protein C (xigris) to control inflammatory response. Oxygen Therapy: Assessing for S/S of Toxicity S/S include nonproductive cough substernal pain nasal stiffness N/V fatigue HA ST hypoventilation use the lowest level of 02 to maintain adequate Sa02 Monitor ABGs and notify PCP if Sa02 levels rise above expected parameters use of 02 mask with CPAP continuous positive airway pressure, bilevel positive airway pressure, or positive end-expiratory pressure while a client is on a mechanical ventilator may decrease the amt of need 02 the oxygen amt should be decreased as soon as the client conditions permits.
Form B Burns: Sequencing of Wound Care Interventions Wound care should be delayed until a patent airway, adequate circulation and adequate fluid replacement have been established. Full thickness wounds will be dry and waxy white to dark brown/black and will have little to no sensation bec nerve endings have been destroyed. Partial thickness burns are pink to cherry red and wet and shiny with serous exudate. These wounds may or may not have intact blisters and are painful when touched or exposed air. Cleansing and debridement can be done in a hydrotherapy tub, cart shower, shower, or bed. Debridement may need to be done in the operating room. During these procedures, loose, necrotic skin is removed. Care should be taken to accomplish this procedure as quickly and effectively as possible. Immersion in a tank for longer than 20-30 min can cause electrolyte loss from open burned areas Prolonged immersion can lead to chilling after the bath and cross-contamination of wounds from one area of the body to another Bec of these factors, some institutions do not submerge the pt. Instead the pt can be showered The water does not need to be sterile and tap water not exceeding 104 degrees is acceptable. Bec pathogenic organisms are present on the burn wound, a surgical detergent, disinfectant, or cleansing agent may be used. The pt may be bathed two time daily to limit the amt of bacterial growth. Degree of freq may be too painful for pt. A once daily bath or shower followed by a dressing change in the pt "s room is a popular alternative
Infection is the most serious threat to further tissue injury and further sepsis. Survival is directly r/t prevention of wound contamination. The source of infection in in burn wounds is the pt"s own flora, predominantly form the the skin, respiratory tract and TI tract. tract. Prevention of cross-contamination from one pt to another is a priority Two type of wound tx are used to control infection open method use of multiple dressing changes Open method burn is covered with a topical abx and has no dressing over the wound Multiple dressing changes sterile gauze dressings are impregnated with or laid over a topical abx. These dressings may be changed two to three times q 24 hr to once q 3 days. When pt"s wounds are exposed, the staff must wear disposable hats, masks, gowns and gloves. When removing dressing and washing the wound, the nurse should use nonsterile disposable gloves. Sterile gloves are used when applying ointments and strile dressings. Room must be kept warm (85%) All attire is changed before nurse treats another pt. Careful hand washing is also required to prevent cross-contamination. After the pt has bee tx "d in the tub, car shower, shower, or shower, shower, the equipment is is disinfected with a chemical prep. Coverage is the primary goal for burn wounds. Bec there is rarely enough unburned skin in the major burn pt for immediate skin grafting, other temp wound closure methods are used. Allograft or homograft skin (usually from cadavers) is commonly used. rejection eventually occurs bec the pt"s immune system reacts against foreign substance. Monitoring Intracranial Pressure: Preventing Complications Caring for a Client undergoing ICP monitoring
Before the insertion procedure, medication may be given to help the client relax. The head is shaved around the insertion site. The site is then scrubbed with an antibacterial soln. Local anesthetic is applied to numb the area. After the insertion procedure, the nurse observes ICP waveforms, noting the pattern of waveforms and monitoring for increased ICP (a sustained elevation of pressure above 15 mmHg). Normal ICP is 10-15 mmHg. Assess the client"s clinical status and monitor routine and neurologic VS q hour as needed. Calculate cerebral perfusion pressure (CPP) hourly. To To calculate CPP, CPP, subtract ICP from fro m mean arterial pressure (MAP) Keep the system closed at all times. There is a serious risk of infection. Inspect the insertion site at least q 24 hours for redness, swelling and drainage. Change the sterile dressing covering the access site per facility protocol. ICP monitoring equipment must be balanced and recalibrated as per facility protocols. Caring for clients with or at risk for increased ICP Monitoring and maintaining airway patency is the PRIORITY intervention for clients with increased IcP and deteriorating neurological status. When suctioning a client with increased ICP, ICP, hyperoxygenate with 100% prior to each ea ch suctioning attempt. Keep the PaCO2 around 35 mmHg and maintain a normal oxygen level by adjusting the rate of mechanical ventilation (for ex, hyperventilating to blow off CO2). Hypercarbia leads to cerebral vasodilation which increases ICP Maintain head at midline neutral position and keep the HOB at greater than 30 degrees to promote venous drainage. Prevent neck flexion or extension. Log roll client when turning. Avoid clustering nursing activities Avoid overstimulation of the client keep the client"s room dark and quiet discuss visiting limitations
speak softly and limit conversations to light and pleasant discussions. Complications Infection and Bleeding Follow strict surgical aseptic technique Perform sterile dressing changes Keep drainage systems closed Limit monitoring to 3-5 days Irrigate the system only as needed to maintain patency Occlusion of the Catheter--brain herniation Overdrainage and Collapse of the Ventricles Electrolyte Imbalances: Priority Interventions for Hyperkalemia Expected Client Findings VS: Slow, irregular pulse, hypotension Neuro: Restless, irritability irr itability,, parethesias MS: weakness to the point of ascending flaccid paralysis GI: N/V/D, increased motility, hyperactive bowel sounds Other signs: oliguria Nursing Interventions Decrease potassium intake Stop infusion of IV potassium Withhold oral potassium Provide potassium restricted diet (avoid foods high in potassium such as avocados, broccoli, dairy products, dried fruits, cantaloupe, bananas). Increase potassium excretion Administer loop diuretics, such as furosemide (Lasix), if renal fx is adequate Administer cation exchange resins such as sodium polystyrene sulfonate (Kayexalate)
Promote movement of potassium from ECF to ICF Admin IV fluids with dextrose (glucose) and Reg Insulin Administer sodium bicarbonate (reverse acidosis) Monitor the client"s cardiac rhythm and intervene promptly as needed.
Tonsillitis/T onsillitis/Tonsillectomy: onsillectomy: Assessing for Postoperative Pos toperative Complications Hemorrhage use a good light source and possibly a tongue depressor to directly observe the child"s throat assess the child for signs of bleeding (eg tachycardia, repeated swallowing, and clearing of throat, hemoptysis). Hypotension is a late sign of shock contact PCP immediately if there is any indication of bleeding Bleeding can occur either immediately or several days after the procedure. Discharge instructions must be carefully followed. Chronically infected tonsils may pose a potential threat to other parts of the body. some children who have freq bouts with severe tonsillitis may develop other diseases such as rheumatic fever and kidney disease Cleft Lip and Palate: Client Eduction Regarding Feeding Techniques Support mother"s decision to continue breastfeeding her infant. Assist her to be open to alternatives such as using breast milk placed in special feeding devices if necessary provide instruction to promote feeding. Teach Teach the parents to use an enlarged en larged nipple, which will stimulate the infant "s suck reflex and ensure that the infant swallow appropriately. After feeding, infant should be allowed to rest. Identify alternate feeding devices such as special nipple for a bottle Teach parents to feed the infant in an upright position Teach parent to burp the infant more mor e freq due to the amt of air swallowed. s wallowed. This will help prevent aspiration and abdominal distention.
Glaucoma: Planning Appropriate Postoperative Interventions IOP is checked 1-2 hr postoperatively by the surgeon postop eye is covered with a patch or protective shield client is instructed not to lie on the operative side and to report severe pain or nausea (possible hemorrhage) GERD: Recognizing Signs and Symptoms The chief sx of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relationship to eating or activities. Other sx include chronic cough, dysphagia, belching (eructation), flatulence (gas), atypical chest pain and asthma exacerbations
Infection Control: Preventing Prevent ing Transmission Communicable Diseases: Interventions to Prevent Transmission Transmission Precautions (Tier Two) Two) Airborne precautions are to protect against droplet infections smaller than 5 micrometers (eg measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require a: private room mask/respiratory protection device for caregivers and visitors negative pressure airflow exchange in the room of at least six exchanges an hour. Droplet precautions protect against droplets larger than than 5 micrometers (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia/sepsis or pneumonic plague) Droplet precautions require a: Private room or a room with other clients with the same infectious disease Mask for providers and visitors
Contact precautions protect the visitors and caregivers against direct client/ environmental contact infections (eg respiratory synctial virus, shigella, enteric diseases caused by micor-organisms, wound infections, herpes simplex, scabies, varicella zoster, and multidrug-resistant organisms). Contact precautions require private room or a room with other clients with the same infection gloves and gowns worn by the caregivers and visitors disposal of infectious dressing material in to a single nonporous bag without touching the outside of bag
Emergency Nursing Principles: Establish Patent Airway This is the most important step in performing the primary survey. If a patent airway is not established, subsequent steps of the primary survey are futile If the client is awake and responsive, the airway is open If the client"s ability to maintain an airway is lost, it is important to inspect for blood, broken teeth, vomitus, or other foreign materials in the airway that may cause an obstruction Unresponsive without suspicion of trauma the airway should be opened with a head tilt chin lift maneuver this is the most effective manual technique for opening a client "s airway It must NOT be performed on clients who have a potential cervical spine injury Technique: The nurse should assume a position at the head of the client, place one hand on the forehead, and the other on the chin. The head should be tilted while the chin is lifted superiorly. This lifts the tongue out of the laryngopharynx and provides for a patent airway. Unresponsive with suspicion of trauma The airway should be opened with modified jaw thrust maneuver Technique: The nurse should assume a position at the head of the client and place both hands on the side of the client "s head. Locate the connection between the maxilla and the mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine.
Once the airway is opened, it should be inspected for blood, broken teeth, vomitus and secretions. If present obstruction should be cleared with suction or a finger sweep method. The open airway can be maintained with airway adjustments, such as an oropharygeal or nasopharyngeal airway airway.. Bag-Valve-mask with a 100% 02 source is indicated for clients who need additional support during resuscitation Esophageal Varices: Response to Hemorrhage Hemorrhage and hypovolemic shock are serious complications of esophageal varices. observe the client carefully for sings of hemorrhage and shock Monitor VS, Hgb, and hematocrit Replace losses and employ therapeutic procedures such as gastric lavage, shunts and sclerotherapy to stop/control bleeding
HIV/AIDS: Evaluating Antiretroviral Treatment The use of potent combination ART to suppress HIV replication limits the potential for selection of antiretroviral resistant HIV variants, the major factor limiting the ability of antiretroviral drugs to inhibit virus replication and delay disease progression. Maximum achievable suppression of HIV replication should be the goal of therapy the most effective means to accomplish durable suppression of HIV replication is the simultaneous initiation of combinations of effective anti HIV drugs with which the pt has not been previously treated and that are not cross resistant with antiretroviral agents with which the pt has been previously treated. Antiretroviral drugs used in combo therapy regimens should always be used according to optimum schedules dosages. The available effective antiretroviral drugs are limited to number and mechanism of action and cross resistance between specific drugs has been documented. Therefore any change in ART can decrease future therapeutic options Women should receive optimal ART regardless of pregnancy status Acute primary HIV infections should be tx "d with combination ART to suppress virus replication to levels below the limit of detection
HIV infected persons even those with viral loads below detectable limits and those on effective ART should be considered infectious and should be counseled to avoid sexual and drug use behavior that are associated with transmission or acquisition of HIV and other infections pathogens Oncological Emergencies: Recognizing Sx of Radiation Therapy Complications Metabolic Emergencies are caused by the production of ectopic hormones directly from the tumor secondary to cancer tx. They include: Syndrome of inappropriate antidiuretic hormone (SIADH) from vincristine and cyclophosphamide (Cytoxan) which stimulate the release of ADH from the pituitary or tumor cells. Sx include: wt gain weakness anorexia N/V personality changes seizures coma Tx: fluid restriction in severe cases: IV admin of 3% sodium chloride solution Tumor Lysis syndrome (TLS) freq triggered by chemotherapy Results from rapid destruction of a large number of tumor cells which can cause fatal biochemical changes. often associated with tumors that have a high growth rates and are sensitive to the effects of chemo. TLS can result in acute renal failure The four hallmark signs of TLS are: hyperuricemia hyperphosphatemia hyperkalemia hypocalcemia
Usually occurs within the first 24-48 hrs after the initiation of chemo and may persist for approx 5-7 days. Primary goal of management is preventing renal failure and severe electrolyte imbalances Primary tx includes increasing urine production using hydration therapy and decreasing uric acid concentrations using allopurinol Spinal Cord Compression r/t metastases. Assess the client"s neurological status, including motor and/or sensory deficits. Administer corticosteroids as prescribed. Support the client during radiation therapy. Hypercalcemia A common complication of leukemia; breast lung, head and neck CA; lymphomas, multiple myelomas; and bony metastases of any cancer. Sx include: Anorexia N/V Shortened QT interval Kidney stones Bone pain Changes in mental status Administer isotonic saline, fusosemide (Lasix), pamidronate, and phosphates as prescribed Super vena cava syndrome Results from obstruction (for example, metastases from breast or lung CA) of venous return and engorgement of the vessels from the head and upper body. Sx include periorbital and facial edema, erythema of the upper body, dyspnea, and epistaxis. Initial lung expansion. High dose radiation therapy may be used for emergency temporary relief. Disseminated intravascular coagulation (DIC) A coagulation complication secondary to leukemia or adenocarcinomas. Observe the client for bleeding and apply pressure as needed. Avoid ASA and NSAIDS.
Pneumonia: Recognizing and Responding to Hypoxia
Hypoxia occurs when the PaO2 has fallen fallen sufficiently to cause s/s of inadequate oxygenation
Hypoxia is adequate tissue oxygenation at the cellular level S/S: apprehension restlessness inability to concentrate declining LOC dizziness behavioral changes Client is unable to lie down and appears fatigued and agitated. VS changes include an increased pulse rate and increased rate and depth of respiration During early stages, BP is elevated unless the condition is caused by shock As hypoxia worsens, the RR may decline as a result of respiratory muscle fatigue Hypoxemia can lead to hypoxia if not corrected. If hypoxia or hypoxemia is severe, the cells shift from aerobic to anaerobic metabolism . Anaerobic metabolism uses more fuel adn produces less energy and is less efficient. Waste produce is lactic acid.
monitor oxygenation levels and acid-base balance prepare for intubation and mechanical ventilation as indicated maintain adequate oxygenation and ventilation done by collaboration among the nursing, medical and respiratory care teams primary goal: correct hypoxemia Ineffective Breathing Pattern r/t inflammation and pain (amb rapid respirations, dyspnea, tachypnea, nasal flaring, altered chest excursion. Interventions
monitor respiratory and oxygenation status to provide baseline assessment auscultate breath sounds, noting areas of decreased or absent ventilation, and presence of adventitious sounds Position to minimize respiratory efforts to reduce oxygen needs monitor effects of position change on oxygenation (SpO2) to assess appropriate position initiate and maintain supplemental oxygen as prescribed to improve respiratory status admin drugs (eg bronchodilators) that promote airway patency and gas exchange Topic Descriptors Descr iptors Psychosocial Integrity (14) Form A Family and Community Violence: Evaluating Client Outcomes for the Client Who Has been Abused
Non-substance Related Dependencies: Providing Care and Support for Client Client with Gambling Dependency ATI provide emotional support and reassurance to the client and family Begin to educate the client about addition and the initial treatment goal of abstinence
Begin to develop motivation and commitment for abstinence and recovery (abstinence plus working a program of personal growth and self-discovery) Encourage self-responsibility help the client develop an emergency plan---a list of things the client would do and people he would contact if he felt like using or actually used. Individual psychotherapies CBT psychodynamic therapies relapse prevention therapy teaches the client to recognize s/s of relapse and factors that contribute to relapse and helps the client develop strategies such as meditating, exercising to create feelings of pleasure form activities other than using substances or from process addictions Group Therapy groups of clients with similar dx may meet in an outpt setting and within mental health residential facilities Family Therapy teaches families about abuse of substances educates the family regarding such issues as family coping, problem solving, relapse signs, and availability of support groups Self-help groups 12-step programs including AA, NA, Gambler"s anonymous teach that abstinence is necessary for recovery and use the belief in a higher power to assist in recovery. Crisis Management: Identifying Interventions Provide for client safety ensure that external controls such as hospitalization are applied for protection of the person in crisis if the indiv has suicidal or homicidal thoughts organize interventions so tangible threats are addressed first Use strategies to decrease anxiety develop a therapeutic nurse-client relationship
listen, observe and ask questions make eye contact ask questions r/t the client "s feelings ask questions r/t the event demonstrate genuineness and caring communicate clearly and, if needed, with clear directives avoid false reassurance and other nontherapeutic responses teach relaxation techniques such as medication use problem solving to anticipate the client "s needs (anticipatory guidance) identify and teach coping skills (eg assertiveness training, parenting skills, occupational training) assist the client with the development of an action plan short term no longer than 24-72 hrs focused on the crisis realistic and manageable identify and coordinate with support agencies and other resources plan and provide for follow up care Care of Those Who Are Dying: Providing Support to the Family Regarding Decision making End of life issues include decision making in a highly stressful time during which the nurse must consider the desires of the client and the family. Any decisions must be be shared with other HCP for smooth transition during this time of stress, grief, and bereavement. Advance directives are legal documents for medical treatment per the client "s wishes Durable power of attorney for health care---an agent appointed by the client or the courts to make medical decisions when the client is no longer able to do so. Mood disorders: Recognizing S/S of Relapse for Bipolar Disorder Use of substances (eg alcohol, drugs of abuse, caffeine) can lead to an episode of mania.
sleep disturbances may come before, be associated with, or brought on by an episode of mania. Cognitive Disorders: Recognizing S/S of Impaired Cognition Impairments in memory, judgment, ability to focus, and ability to calculate; impairments may fluctuate throughout the day (delirium) or not change throughout the day (dementia). LOC can be altered (delirium) or unchanged (dementia). Restless, agitation are common, sundowning (confusion during the night) may occur, behaviors may increase or decrease daily (delirium) or remain stable (dementia).
Amnestic disorder decreased awareness of surroundings inability to learn new info despite normal attention inability to recall previously learned info possible disorientation to place and time typically there is no personality change or impairment in abstract thinking. Psychopharmacological Therapies: Evaluating Client Teaching Teaching Regarding Lithium, Methlyphenidate, Disulfiram, and Fluoxetine Lithium Clients must maintain adequate sodium and fluid intake while taking lithium lithium takes the place of sodium in body advise the clients that effects of lithium begin within 5-7 days and that it may take 2-3 weeks to achieve full benefits advise the client to report signs of toxicity and to take the med as prescribed encourage the client to comply with lab appts needed to monitor lithium effectiveness and adverse effects encourage the client to comply with follow up appts to monitor thyroid and renal function Methylphenidate (Ritalin) Advising the client to swallow sustained release tablets whole and to avoid chewing or crushing tablets
Teaching the client the importance of administering the med on a regular schedule and taking the med exactly as prescribed Instructing the client to be alert for signs of mild overdose such as restlessness, insomnia and nervousness. Signs of severe overdose include panic, hallucinations, circulatory collapse and seizures. Suggesting to parents to initiate a periodic pill count if they doubt the client "s med compliance advising the client to avoid other CNS stimulants such as coffee, cola, tea, and chocolate instructing the client to avoid alcohol or OTC meds unless approved by the PcP. Many OTC meds contain CNS stimulant properties Educating the client about the SE of abruptly stopping the med (potential for abstinence syndrome) Instructing the client to take the morning (or daily) dose after breakfast and the last dose in the early afternoon to minimize wt loss and insomnia. the med should be taken at least 6 hr before bedtime advising the client that sucking hard candy, chewing gum and taking sips of water may help minimize dry mouth. Disulfiram (Antabuse) Inform the client of the potentials dangers of drinking any alcohol advise the client to avoid any products that contain alcohol (eg cough syrups, aftershave lotion) encourage the client to wear medic alert bracelet Fluoxetine (Prozac) Advise the client to take med with meals/food and to take the med on a daily basis to establish therapeutic plasma levels assist the client with med regimen compliance by informing hte client that therapeutic effects may not be experienced for 1-3 weeks and that it might take 2-3 months for full benefits to be achieved. instruct the client tot continue therapy after improvement in sx. sudden d/c of med can result in relapse
advise the client that therapy usually continues for 6 months after resolution of sx and may continue for 1 yr or longer older adults clients taking diuretics should be monitored for sodium levels. Obtain baseline sodium levels and an d monitor periodically. Spiritual Care: Evaluating If Needs Have Been Met
Interventions Identify the client"s perceptions for the existence of a higher power facilitate growth in the client "s abilities to connect with a higher power assist the client to feel connected or reconnected to a higher power by allowing time and/or resources fro the practice of religious rituals providing privacy for prayer, meditation, or the reading of religious materials facilitate development of a positive outcome in a particular situation provide stability for the person experiencing a dysfunctional spiritual mood. establish a caring presence in “being with” the client and family rather than merely performing tasks for them support all healing relationships holistic approach to care--seeing the large picture for the client using client-identified spiritual resources and needs identify and provide for the client "s support system family community pastoral religious artifacts and rituals be aware of diet therapies included in spiritual beliefs support religious rituals icons statues prayer rugs devotional reads music support restorative care
prayer meditation grief work Evaluation of care is ongoing and continuous with a need for flexibility as the client and family process the current crisis through their spiritual identity. Potter/Perry Evaluation Review the client"s self-perceptions regarding spiritual health Review the client"s view of his or her purpose in life Discuss with family and close associates the client "s connectedness ask if the client s needs are being met !
Example: if the nurse"s assessment finds the client losing hope, the follow-up evaluation will involve a discussion with the client to determine if the client has regained an attitude of something to live for family and friends with whom the client seeks to have fellowship can be a useful source of evaluative information successful outcomes should reveal the client developing an increased or restored sense of connectedness with family; maintaining, renewing, or reforming a sense of purpose in life and for some, a confidence and trust in a supreme being or power use established expected outcomes to evaluate the client "s response to care The nurse evaluates whether the client expectations were met. evaluating if the client"s spiritual practices were respected and if the nurse-client relationship was one of caring and support both client and family should be able to relate if opportunities were offered for religious rituals Sensoriperceptual Alterations: Planning Interventions for the Hearing Impaired Client Communication get the client"s attention before speaking Stand/sit facing the client in a well-lit, quiet room without distractions speak clearly and slowly to the client without shouting and without hands or other objects covering the mouth arrange for communication assistance (sign language interpreter, closed caption, phone amplifiers, TTY capabilities) as needed
Planning (P/P) select strategies to assist the client in remaining functional in the home adapt therapies depending on whether sensory deficit is hort or long term involve the family in helping the client adjust to limitations refer to appropriate HCP and/or community agency Clients who enter the health care setting and who have sensory alterations at the time are usually more informed about how to adapt interventions to their lifestyle. Stress Management: Evaluate Effectiveness of Teaching Regarding Stress Management Techniques Interventions Relaxation Techniques meditation includes formal meditation techniques as well as prayer for those who believe in a higher power guided imagery---a leader guides the client through a series of images to promote relaxation. Images vary depending on the indiv. for example, one client might imagine walking on a beach, while another might imagine himself in a position of success breathing exercises are used to slow rapid breathing and promote relaxation progressive muscle relation (PMR)--a person trained in this method can help a client attain complete relaxation within a few minutes of time physical exercise (eg yoga, walking, biking) causes release of endorphins that lower anxiety, promote relaxation, and have antidepressant antidepres sant effects
Journal Writing journaling has been shown to allow for therapeutic release of stress this activity can help the client identify stressors and plan for the future with more hope
Cognitive reframing the client is helped to look at irrational cognitions (thoughts) in a more realistic light and to restructure the thoughts in a more positive way
Priority restructuring the client learns to prioritize differently to reduce the number of stressors impacting her Biofeedback a nurse or other HCP trained in this method can assist the client to gain voluntary control of such autonomic functions a heart rate and blood pressure Assertiveness training the client learns to communicate in a more assertive manner in order to decrease psychological stressors (P/P) Goals and Outcomes Desirable outcomes for persons experiencing stress s. eff effect ective ive coping coping t. fa fami mily ly co copi ping ng u. caregiv caregiver er emotional emotional health health v. psychoso psychosocial cial adjustmen adjustment: t: life change change By evaluating goals expected outcomes, the nurse knows if the nursing interentions were effective and if the client is coping with stress. Family Dynamics: Interventions Involving Client Support Systems ATI Fundamentals Interventions Identify and adapt family strengths to perceived stressors Communication Adaptability Nurturing Crisis as a growth element parenting skills resiliency Set goals with the family that are realistic Provide information on support networks Child and adult day care caregiver support groups
Promote family unity Encourage conflict resolution when it exists minimize family process disruption effects remove barriers to health promotion increase family members abilities to participate perform interventions that the family cannot perform evaluate goals within the context of the family by checking back to ensure that the goals were realistic and achievable Effective Communication in Mental Health Nursing: Giving Broad Openings (Mohr) Giving broad openings Purpose: communicates a desire to begin a meaningful interaction Ex: What would like to discuss today? allows the client to define the problem or issue Ex: Tell Tell me about how you have been doing? Creating and Maintaining a Therapeutic and Safe Environment: Promote a Therapeutic Milieu for Group of Clients Management of the milieu means manipulating the total environment of the mental health unit in order to provide the least amount of stress while promoting the greatest benefit for all the clients Within this therapeutic milieu of the mental health facility the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of life The nurse, as manager of care, is responsible for structuring and/or implementing many aspects of the therapeutic milieu within the unit The structure of the therapeutic milieu often includes regular community meetings, which include both nursing staff and clients. Characteristics clean and orderly unit color scheme should be appropriate for the client"s age setting should include comfortable furniture for lounging and interacting with others solitary spaces for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping floors should be attractive, easy to clean, safe for walking
traffic flow considerations should be conducive to client and staff promote independence for self care and individual growth in clients allow choices for clients within the daily routine and within indiv tx plans tx client as indiv apply rules of fair tx for all clients model good social behavior for clients, such as respect for the rights of others work cooperatively as a team to provide care maintain boundaries with clients maintain professional appearance and demeanor promote safe and satisfying peer interactions among clients practice open communication techniques with HCP and clients promote feelings of self-worth and hope for the future clients should feel safe from harm (self-harm, as well as harm from disruptive behaviors of other clients) clients should feel cared about and accepted by the staff and others The therapeutic milieu includes safety for both the clients and the staff within the environment Physical Safety the nurse"s station and other areas should be set up for easy observation of clients by staff and access to staff by clients Set up the following provisions to prevent client self-harm or harm by others: no access to sharp or otherwise harmful objects restriction of client access to out of bounds or locked areas monitoring of visitors restriction of alcohol and illegal drug access or use restriction of sexual activity among clients deterrence for elopement from facility rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by trained staff Seclusion rooms and restraints should be set up for safety and used only after all less restrictive measures have been tried. When used, there should be procedures and policies to prevent any client harm Plan for safe access to recreational areas, occupational therapy and meeting rooms
Teach fire, evacuation, evacu ation, and other safety rules to all staff Have clear plans for keeping clients and staff safe in emergencies Maintain staff skills, such as CPR with in service training Considerations of room assignments on a 24 hr inpatient unit should include personalities of each roommate the likelihood of nighttime disruptions for a roommate if one client has difficulty sleeping medical diagnoses, such as how two clients with severe paranoia might interact with each other Nurses within a mental health unit must allow time for both structured and unstructured activity for clients and staff Structured activity may include time for Community meetings Group activities and indiv therapy sessions recreational activities psychoeducational classes such as learning about medication side effects Unstructured flexible time in which the nurse and other staff are able to observe clients and interact spontaneously within the milieu
Body Image: Interventions to Assist Client Adaptation ATI Fundamentals Interventions Establish a therapeutic relationship r elationship with the client. A caring and nonjudgmental manner puts the client at ease and fosters meaningful communication ensure privacy and confidentiality. many sensitive issues may be discussed, and hte client needs to know that these issues are safe to discuss. identify indiv who may be at risk for body image disturbances acknowledge anger, depression, and denial as normal feelings when adjusting to body changes
encourage the client to participate in the plan of care arrange for a visit form a volunteer who has experienced a similar body image change.
Form B Cognitive Disorders: Identifying Appropriate Interventions Environment Assign the client to a room close to the nurse "s station for close observation provide a room with a low level of visual and auditory stimuli provide compensatory memory aids such as clocks, calendars, photos, memorabilia, seasonal decorations and familiar objects windows may help time orientation and help decrease the “sundowning” effect Pharm Tx Admin meds as prescribed Meds that have been approved by the FDA that demonstrate positive effects on cognitive, behavioral and daily activity function include Tacrine (Cognex) Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Reminyl) Memantine (Namenda) Communication Reinforce orientation to time, place and person Establish eye contact and use short, simple sentences when speaking to the client Encourage reminiscence about happy times, talk about familiar things Break instructions and activities into short timeframes when instructing the client Safety Have the client wear an id bracelet; use monitors and bed alarm devices as needed
Ensure safety in the physical environment, such as lowered bed and removal of scatter rugs to prevent falls. Many aspects of the physical environment may need to be changed for the home bound client with dementia Provide eyeglasses and hearing assistive devices as needed Nursing care and Caregiver Education Monitor food and fluid intake, bowel and bladder fx, and sleep patterns Educate family/caregivers about illness, methods of care, and adaptation of the home environment provide support for caregivers; recommend local support groups for caregivers as well as respite care Establish a routine. Make sure all caregivers know/apply the routine. Attempt to have consistency in all caregivers.
Group Therapy: Appropriate Group Leader Communication Techniques Leadership Styles Democratic: this style supports group interaction and decision making to solve problems Laissez-faire: the group process progresses without any attempt by the leader to control the direction of the group Autocratic: The leader completely controls the direction and structure of the group without allowing group interaction or decision making to making to solve problems All therapy sessions should provide open and clear communication, guidelines for the therapy session and cohesiveness Be goal directed
Coping: Assessing Support Systems Identify the strengths and abilities of the client and family Discuss the client and family "s ability to deal with the current situation Identify available community resources and refer for counseling if needed Culturally Competent Care: Incorporate Religious Beliefs Respect the religious/spiritual practices of the client
Death rituals vary among cultures and the nurse must be prepared to facilitate such practices whenever possible End of Life: Assessing Client Coping Symptoms of Normal Grief feelings range from sadness to anxiety to yearning thoughts may be confused, hopeless and preoccupied with the decreased person difficulties sleeping, eating and crying are common behaviors fatigue, muscle tension or weakness and oversensitivity to stimuli are common physical sx Determine the state of grief the client and family are experiencing Understand the factors influencing the grieving process type of loss significance of loss past coping mechanisms that have been effective availability of support systems prior experiences with loss Understand the desires and expectations of the family for end of life care Family Dynamics: Interventions to promote Integration of Older Adults into family Structure
Death and Dying: Recognizing Preschool Responses to Death Egocentric thinking think magically, magically, which causes them to feel guiltily, shameful and to sense punishment
interpret separation from parents as punishment for bad behavior view dying as temporary, since they have no concept of time and the dead person may still have attribute of the living (sleeping, eating and breathing) Schizophrenia: Identifying Signs and Symptoms
characteristics
symptoms
positive sx
hallucinations delusions disorganized speech bizarre behavior, such as walking backward constantly
negative sx
blunted affect alogia (poverty of though or speech) avolition (lack of motivation in activities and hygiene) anhedonia anergia
cognitive sx
disordered thinking inability to make decisions poor problem solving ablilty difficulty concentrating to perform task memory deficits (long term)
depressive sx
hopelessness suicidal ideation
type paranoid
symptoms hallucinations and delusions
type
symptoms
disorganized
loose associations bizarre mannerisms incoherent speech hallucinations and delusions
catatonic
withdrawn stage (psychomotor retardation, waxy flexibility, self care needs) excited stage (constant movement, unusual posturing, incoherent speech, elf care needs, danger to self or others
residual
anergia, anhedonia, avolition withdrawal from social activities impaired role fx speech probs
undifferentiated
any positive or negative sx may be present
Developing and Maintaining a Therapeutic Nurse-Client Relationship: Intervene to Promote Trust In the orientation phase of relationship, build trust by establishing expectations and boundaries Topic Descriptors Descr iptors Reduction of Risk Potential (24) Form A Seizures: Client Education Regarding EEG EEG records electrical activity and identifies the origin of seizure activity. Client instruction includes:
No caffeine Wash hair before the procedure (no oils, sprays) and after the procedure (remove electrode glue) May be asked to take deep breaths and/or be exposed to flashes of a strobe light during the test Sleep may be withheld prior to test and possible induced during test
Rheumatic Fever: Recognizing Expected Lab Findings Antistreptolysin O titer Erythrocyte sedimentation rate C-reactive protein Throat culture WBC count Red blood cell parameters (HCT, Hgb, RBC)
> 250 IU/ml > 15 mm/hr in men, > 20 mm/hr in women Positive Positive for streptococci (usually negative) Elevated Mild to mod degress of normocytic, normochromic anemia
Diabetes Mellitus: Client Teaching Regarding Purpose of Self-Blood Glucose Monitoring
Attempt to maintain normal blood glucose levels to prevent development of complications Hypoglycemia Hyperglycemia Diabetic Ketoacidosis Acid-Base Imbalances: Identify Expected lab Data
pH
PaCO2
HCO3
Diagnosis
7.35-7.45
35-45
22-26
homeostasis
< 7.35
> 45
22-26
respiratory acidosis
pH
PaCO2
HCO3
Diagnosis
< 7.35
35-45
< 22
metabolic acidosis
> 7.45
< 35
22-26
respiratory alkalosis
> 7.45
35-45
> 26
metabolic alkalosis
Uncompensated: The pH will be abnormal and either the HCO3 or the PaCO2 will be abnormal Partially compensated: compensated: The pH, HCO3, and PaCO2 will be abnormal Fully Compensated: The Compensated: The pH will be normal, but the PaCO2 and HCO3 will both be abnormal Diabetic Ketoacidosis: Recognize Clinical Manifestations DKA is an acute, life-threatening condition characterized by hyperglycemia (> 300mg/ dL) resulting in breakdown of body fat for energy and an accumulation of ketones int eh blood and urine. The onset is rapid. Results in severe hyperglycemia from lack of sufficient insulin increased need for insulin DKA is more common in indiv with type 1 DM Signs/Symptoms polyuria, polydipsia, polyphagia (early signs) change in mental status signs of dehydration (dry mucous membranes, wt loss, sunken eyeballs, resulting from fluid loss such as polyuria Kussmaul respiration pattern, rapid and deep respirations, “fruity” breath N/V, abdominal pain
Fluid Imbalances: Interpret Lab Values for Dehydration Expected Findings Hgb and HCT = increased Normal Hgb = 13.5-18 g/dL (males) 12-16 g/dL (females) Normal HCT = 40-54% (males) 38-47% (females
Serum osmolarity = increased (hemoconcentration) osmolarity (> 300mOsm/L) increased protein, BUN, electrolytes and glucose Normal BUN = 10-30 mg/dL Potassium = 3.5-5.5 mEq/L
Urine Specific Gravity and osmolarity = increased (concentration) Normal Specific Gravity = 1.005-1.030 Serum Sodium = Increased (hemoconcentration) Normal 135-145 mEq/L Diabetes Insipidus: Recognizing Expected Lab Findings Urine chemistry: think DILUTE decreased urine specific gravity ( < 1.005) decreased urine osmolality (50-200 mOsm/kg) decreased urine pH decreased urine Na decreased urine K As urine volume increases, urine osmolality decreases Serum chemistry
increased serum osmolality ( > 295 mOsm/kg increased serum Na increased serum K+ As serum volume decreases, the serum osmolality increases
Heart Failure: Recognizing Expected Lab Findings BNP (Human B type Natriuretic Peptide) used to differentiate dyspnea r/t CHF vs respiratory problem and to monitor the need for and effectiveness of aggressive CHF intervention BNP levels < 100 pg/mL = no CHF BNP levels 100-300 pg/mL suggest CHF is present BNP levels >300 pg/mL = mild CHF BNP levels > 600 pg.mL = moderate CHF BNP levels > 900 pg/mL = severe CHF Hemodynamic Monitoring increased CVP (central venous pressure) increased right arterial pressure increased PCWP (pulmonary capillary wedge pressure) increased pulmonary artery pressure (PAP) decreased CO Conscious Sedation: Monitoring Client Physiologic Response Following Conscious Sedation Conscious Sedation is the admin of sedatives and/or hypnotics to the point where the client is relaxed enough that minor procedures can be performed without comfort, yet the client can respond to verbal stimuli, retains protective reflexes (gag reflex), is easily arousable and (most important) independently maintains a patent airway. Nursing Responsibilities After the Procedure The monitoring nurse continues to record VS and LOC until the client is fully awake and all assessment criteria return to pre-sedation levels. Typical discharge criteria: LOC as on admission VS stable for 30-90 min
Ability to cough and deep breathe ability to take oral fluids No N/V, N/V, SOB, or dizziness
Peripheral Venous Disease: Prevent Complications Complications Ulcer Formation: typically Formation: typically over malleolus, more often medially than laterally . May lead to amputation and/or death Pulmonary Embolism: Embolism: occurs when thrombus is dislodge, becomes emboli and lodges in the pulmonary vessels Interventions Deep Vein Thrombosis and Thrombophlebitis Encourage REST facilitate bedrest and elevation of extremity above the level of the heart (avoid using a knee gatch or pillow under knees) admin intermittent or continuous warm moist compresses (to prevent thrombus from dislodging and becoming an embolus, DO NOT massage the affected limb) provide thigh-high compression or antiembolism stockings to reduce venous stasis and to assist in venous return of blood to the heart. Admin meds as prescribed anticoags unfractionated heparin IV based IV based on body wt is given to prevent formation of other clots and to prevent enlargement of existing clot, followed by oral anticoag with warfarin. hospital admin is required for lab value monitoring and dose adjustment monitor aPTT to allow for adjustments of heparin dosage monitor platelet counts for heparin-induced thrombocytopenia
ensure that protamine sulfate, the antidote for heparin is available if needed for excessive bleeding monitor the hazards and SE associated with anticoag therapy Low molecular wt Heparin (LMWH) is (LMWH) is given subq. Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have consistent action and are approved for the prevent and tx of DVT may be managed at home by home care nurse must have stable DVT or PE, low risk for bleedign, adequate renal function and normal VS client must be willing to learn self injection the aPTT is not checked on an ongoing basis bec the doses of LMWH are not adjusted Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting Warfarin works factors takes 3-4 days before it has therapeutic anticoagulation heparin is continued until the warfarin effect is achieved then IV heparin may be d/c"d if client is on LMWH, warfarin is added after the first dose of LMWH. Therapeutic levels are measured by INR monitor for bleeding ensure that Vit K (the antidote for warfarin) is available in case of excessive bleeding Thrombolytic Therapy effective in dissolving thrombi quickly and completely must be initiated within 5 days after onset of sx to be most effective advantage is the prevention of valvular damage and consequential venous insufficiency or postphlebitis syndrome
contraindicated during pregnancy and following surgery, childbirth, trauma, a CVA, CV A, or spinal injury tissue plasminogen activator (t-P (t-PA), A), a thrombolytic agent, and platelet inhibitors such as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may be effective in dissolving a clot or preventing new clots during the first 24 hr. primary complication of therapy is serious bleeding Analgesics: Admin as ordered to reduce pain Venous Insufficiency Instruct client to elevate legs for at least 20 min four to five times/day above the level of the heart avoid prolonged sitting or standing, constrictive clothing or crossing legs when seated wear elastic or compression stockings during the day and evening put elastic stockings on before getting out of bed after sleep clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down replace worn out compression stockings as needed on using an intermittent sequential pneumatic compression system instruct the client to apply the system twice daily for 1 hour in am and evening advise the client with an open ulcer that the compression system is applied over a dressing Varicose Veins emphasize the importance of antiembolism stockings as prescribed instruct the client to elevate the legs as much as possible instruct the client to avoid constrictive clothing and pressure on the legs.
Sickle Cell Anemia: Preventing Sickle Cell Crisis Manifestations Vaso-occlusive (painful episode) usually lasting 4-6 days Acute severe pain, usually in bones, joints, and abdomen swollen joints, hands and feet anorexia, vomiting and fever hematuria obstructive jaundice visual disturbances Chronic increased risk of respiratory infections and/or osteomyelitis retinal detachment and blindness systolic murmurs renal failure and enuresis liver failure seizures deformities of the skeleton Sequestration excessive pooling of blood in the liver (hepatomegaly) and spleen (splenomegaly) tachycardia, dyspnea, weakness, pallor, and shock Aplastic extreme anemia as a result of decreased RBC production Hyperhemolytic increased rate of RBC destruction leading to anemia, jaundice, and/or reticulocytosis Avoiding Complications avoid high altitudes maintain adequate fluid intake treat infections promptly
pneumovax, influenza, and hepatitis immunizations should be admin treat chronic leg ulcers with bed rest, abx, warm saline soaks. take freq rest breaks during physical activities (minimize tissue deoxygenation) avoid contact sports if spleen is enlarged adequate nutrition, freq medical supervision, proper hand washing and isolation from known sources of infection Thyroidectomy: Assess for Complications
Complications Hemorrhage the surgical dressing and incision need to be assessed for excessive drainage or bleeding during the postop period. inspect the surgical dressing for bleeding especially at the back of the neck and change the dressing as directed avoid pressure on the suture line, encourage the client to avoid neck flexion or extension support the head and neck with pillows or sandbags. If client needs to be transferred from stretcher to bed, support the head and neck in good body alignment Thyroid Storm monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased BPs, anxiety) Airway Obstruction a trach tray should be kept near the client at all times during the immediate recovery period maintain the bed in high-fowler "s position to decrease edema and swelling of the neck
if the client reports the dressing feels tight, the surgeon needs to be alerted immediately Hypocalcemia and Tetany (due Tetany (due to damage to the parathyroid glands) monitor for s/s of hypocalcemia (tingling of the fingers and toes, carpopedal spasms and convulsions) have calcium gluconate available maintain seizure precautions Nerve damage nerve damage can lead to vocal cord paralysis and vocal disturbances teach the client that he/she will be able to speak only rarely and will need to rest the voice for several days and should expect to be hoarse after the procedure, monitor the client "s ability to speak with each measurement of VS assess the client"s voice tone and quality and compare it to the preop voice. CVA: CV A: Interventions to t o Prevent Aspiration Nursing Interventions Maintain a patent airway monitor for changes in client "s LOC (increased ICP sign) Elevate client"s head to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension, maintain head in midline neutral position and elevate to 30 degrees institute seizure precautions maintain a non-stimulating environment assist with communication skills if client "s speech is impaired.
assist with safe feeding assess swallowing reflexes: swallowing, gag, and cough before feeding
the client"s liquids may need to be thickened to avoid aspiration have client eat in an upright position and swallow with the head and neck flexed slightly forward place food in the back of the mouth on the unaffected side suction on standby maintain a distraction free environment during meals Aspiration Complication---suction as needed. preassess the client"s swallowing abilities. Postoperative Nursing: Preventing Circulatory Complications Prevent and Monitor for thromboembolism (esp following abdominal and pelvic surgeries) apply pneumatic compression stockings and/or elastic stockings reposition the client every 2 hr and ambulate early and regularly administer low-level anticoag as prescribed monitor extremities for calf pain, warmth, erythema, and edema Client positioning position the client supine with head flat (prevent hypotension) do not elevate the legs higher than placement on a pillow if the client has received spinal anesthesia do not put pillows under knees or use a knee gatch (decreases venous return) Angiography: Recognizing Complications Complications Cardiac Tamponade results from fluid accumulation in the pericardial sac signs include hypotension JVD muffled heart sound
paradoxical pulse (variation of 10 mmHg or more in systolic blood pressure between expiration and inspiration) hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressures) notify the PCP immediately admin IV fluids to combat hypotension as ordered obtain a chest xray or echocardiogram to confirm dx prepare the client for pericardiocentesis (informed consent, gather materials, admin meds as appropriate) monitor hemodynamic pressures as they normalize monitor heart rhythm; changes indicate improper positioning of the needle monitor for reoccurrence of signs after the procedure Hematoma Formation assess the groin at prescribed intervals and as needed hold pressure for uncontrolled oozing/bleeding monitor peripheral circulation notify PCP Restenosis (of treated vessel) assess ECG patterns and for occurrence of CP notify PCP immediately prepare the client for return to the cardiac cath lab Retroperitoneal Bleeding assess for flank pain and hypotension notify the PCP admin IV fluids and blood products as ordered.
Gastroenteral Feedings: Measures to prevent Aspiration Assess for gag reflex. Place tongue blade in client"s mouth, touching uvula to induce a gag response. identifies ability to swallow and determines if there is a risk for aspiration. Clients with impaired LOC may also have impaired gag reflex and their risk of aspiration is increased. Assist client to High Fowler "s position unless contraindicated reduces risk of aspiration and promotes effective effective swallowing
Complication Aspiration of stomach contents into the respiratory tract (immediate response) evidenced by coughing, dyspnea, cyanosis, auscultation of crackles and wheezes position client on side suction nasotracheally and oral tracheally consult PCP to order chest x-ray exam Aspiration of stomach contents into respiratory tract (delayed response) evidenced by dyspnea, fever, auscultation of crackles and wheezes consult PCP to obtain order for chest xray prepare for possible initiation of abx Head Injury: Assessing Neurological Status Assess/Monitor Respiratory Status---the priority assessment Changes in LOC--the EARLIEST indication of neurological deterioration LOC and length Cushing reflex (severe HTN with a widened pulse pressure and bradycardia)--late sign of ICP Posturing (decorticate, decerebrate, flaccid) Cranial Nerve function
Pupillary changes (PERRLA, pinpoint, fixed/nonresponsive, dilated) Signs of infection (nuchal rigidity with meningitis) CSF leakage from nose and ears (halo sign yellow stain surrounded by by blood, test positive for glucose)
GCS rating (15 normal; 3=deep coma)
Eye opening Response (E)
Verbal Response (V)
Motor Response (M)
4 = spontaneous
5 = normal conversation
6 = normal
3 = to voice
4 = disoriented conversation
5 = localizes to pain
2 = to pain
3 = words; but not coherent
4 = withdraws to pain
1 = none
2 = no words, only sounds
3 = decorticate posture
1 = none
2 = decerebrate posture 1 = none
E Score
V Sc o r e
M Score
Urinary Tract Infection: Recognizing Risk Factors Risk Factors/Causes of UTI
E+ V+ M = total score
Female Gender short urethra close proximity of the urethra to the rectum decreased estrogen in aging women promotes atrophy of the urethral opening toward the rectum. sexual intercourse freq use of feminine hygiene sprays, tampons, sanitary napkins, spermicidal jellies pregnancy women who are fitted poorly for diaphragms hormonal influences within the vaginal flora synthetic underwear and pantyhose wet bathing suits freq submersion into baths or hottubs Indwelling urinary catheters stool incontinence bladder distention urinary conditions (anomalies, stasis, calculi, and residual urine possible genetic links disease (DM) Joint Replacement: Client Teaching Regarding Postop Activity Limits Hip Replacement Surgery Early Ambulation Transfer out of bed from unaffected side Wt bearing status is determined by the orthopedic surgeon and by the choice of cemented (partial/full wt bearing as tolerated) vs non cemented prostheses (only partial wt bearing until after a few weeks of bone growth) use of assistive devices (for example, walker) Do
Don t !
use elevated seating/raised avoid flexion of hip > 90 toilet seat degrees use straight straight chairs with with arms avoid low chairs chairs
Do
Don t !
use and abduction between do not cross legs legs while in bed (and with turning) externally rotate toes
don not internally rotate toes
Client position: supine with head slightly elevated with affected leg n neutral position and a pillow or abduction device between legs to prevent abduction (movement toward midline) which could cause hip dislocation arrange for raised toilet seats, extended handle items (shoehorn, dressing sticks) Knee Replacement Surgery Positions of flexion of the knee are limited to avoid flexion contractures Avoid knee gatch and pillows placed behind the knee knee immobilizer may be used while in bed goal is to be able to straight leg raise kneeling and deep knee bends are limited indefinitely CPM is used to promote motion in the knee and prevent scar tissue formation . Preoperative Nursing: Recognizing Client Finding Indicative of Readiness for Surgical Intervention Preoperative Assessment Detailed hx (including med problems, allergies, med use, substance abuse, psychosocial probs, cultural considerations) anxiety level regarding the procedure lab results H-T assessment VS
Informed Consent Once surgery has been discussed with the client or surrogate as tx, it is the responsibility of the PcP to obtain consent after discussing the risks and benefits of the procedure. The nurse is not to obtain consent for the PcP in any circumstance the nurse can clarify any information that remains unclear after the PCP "s explanation of the procedure The nurse"s role is to witness the client "s signing of the consent forma after the client acknowledges understanding of the procedure. Postoperative Nursing: Maintain Function of Jackson-Pratt Drain Monitor incisions and drain sites for bleeding and/or infection monitor drainage (should progress from sanguineous to serosanguineous to serous) monitor the incision site (expected findings include pink wound edges, slight swelling, under sutures/staples, slight crusting of drainage). Report signs of infection, including redness, excessive tenderness and purulent drainage. monitor wound drains (with each VS assessment). Empty as often as needed to maintain compression. Report increases in drainage (possible hemorrhage) Change wound dressing as required using surgical aseptic technique use an abdominal binder for obese or debilitated clients encourage splinting with position changes administer prophylactic abx as prescribed The nurse looks for drainage flow through the tubing as well as around the tubing. A sudden decrease in drainage may indicate a blocked drain, and the PcP should be notified. When a drain is connected to suction, the nurse asses the system to be sure the pressure ordered is being exerted. Evacuator units such as Hemovac or JacksonPratt exert a constant low pressure as long as the suction device (bladder or bag) is fully compressed. These types of drainage devices are referred to as self-suction. When the evacuator device is unable to maintain a vacuum on its own, the nurse notifies the surgeon who can then order a secondary vacuum system (such as a wall suction) If fluid is allowed to accumulate in the tissues, wound healing will not progress at an optimum rate, and the risk of infection is increased.
Pain Management: Management of an Epidural Catheter Epidural analgesia is the infusion of pain-relieving medication through a catheter placed into the epidural space surrounding the spinal cord. the goal is delivery of med directly to opiate receptors in the spinal cord. The admin may be intermittent or constant and is monitored by the nurse. The overall effectiveness and the technique of admin result in constant circulating level and a total reduced dose of med. Intrathecal morphine can produce the same SE of nausea, mental clouding, and sedation bec it is absorbed via the CSF into the circulation of the epidural vascular plexus Nursing Implications catheter is connected to an epidural infusion pump, a port or reservoir or is capped off for bolus injections. to reduce the risk of accidental epidural injections of drugs intended for IV use, the catheter should be clearly labeled “epidural catheter” continuous infusions must be administered through electronic infusion devices for proper control. bec of catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection PcP notified immediately of any s/s of infections or pain at the insertion site thorough nursing care is needed during hygiene procedures to keep the catheter system clean and dray Prevent catheter displacement secure catheter (if not connected to implanted reservoir) carefully to outside skin Maintain catheter function check external dressing around catheter site for dampness or discharge (leak of CSF may develop) use transparent dressing to secure catheter and to aid inspection inspect catheter for breaks Prevent infection
use strict aseptic technique when caring for catheter do not routing change dressing over site change infusion tubing q 24 hrs Monitor for respiratory depression monitor VS esp respirations, per policy pulse oximetry and apnea monitoring may be used Prevent undesirable complications assess for pruritus (itching) and N/V administer antiemetics as ordered Maintain urinary and bowel function monitor I/O assess for bladder and bowel distention assess for discomfort, freq, and urgency Intraoperative Nursing: Circulating Nurse Role Priorities Circulating nurse must be an RN Responsibilities include: review of the preop assessment establishing and implementing the intraoperative plan of care evaluating the care providing for continuity of care postoperatively assists with procedures as needed such as endotrach intubation and blood admin monitors sterile technique and a safe operating room environment assists the surgeon and surgical team by operating nonsterile equipment, provides additional supplies verifies sponge and instrument counts and maintains accurate and complete written records. Blood Pressure: Recognizing and Responding to Factors Affecting Blood Pressure Key Factors Pulse pressure
the difference between the systolic and the diastolic pressure reading s Postural (orthostatic) hypotension a BP that falls when a client changes position from lying to sitting or standing and it may result from various causes (eg peripheral vasodilation, med SE, fluid depletion) Orthostatic changes are assessed by taking the client"s BP and HR in the supine position. next, have the client change to the sitting or standing position, wait 1-5 min, and reassess the BP and HR. the client is experiencing orthostatic hypotension if the SBP decreases more than 20 mmHg and/or the DBP decreases more than 10 mmHg with a 10-20% increase in the HR. Age infants have a low BP that gradually increases with age older children and adolescents will have varying BP based on body size. Large children will have higher BP older adult clients may have a slightly elevated SBP due to decreased elasticity of blood vessels Circadian Rhythms affect BP with BP usually being the lowest in the early morning hours and peaking during the later part of the afternoon or evening Stress associated with fear, emotional strain, and acute pain can increase BP Ethnicity African Americans have a higher incidence of HTN in general and at earlier ages Gender Adolescent to middle-age men have higher BPs than their female counterparts. Postmenopausal women have higher BPs than their male counterparts Medications opiates, antihypertensives, and cardiac meds can lower BP. BP. Some illicit drugs (cocaine), cold meds, oral contraceptives and antidepressants can increase BP Exercise can decrease BP for several hours afterwards.
Form B Angina: Recognize Appropriate Diagnostic Test Based on Client Findings Electrocardiograms (ECG): check for changes on serial ECGs Angina: ST depression and/or T wave inversion (ischemia) MI: T-wave inversion (ischemia), ST segment elevation (injury) and an abnormal Q wave (necrosis) Clients with non-ST elevation MIs have other indicators ST segment depression that resolves with relief of chest pain New Development of left BBB T-wave inversion in all chest lead Serial Cardiac Enzymes: Typical pattern of elevation and decrease back to baseline occurs with MI Cardiac Enzyme
Normal Levels
Elevated Levels 1st Expected Duration Detectable of Elevated Levels Following Myocardial Injury
Creatinine kinase MB 0% of total CK isoenzyme (CK-MB)- (30-170 units/L) more sensitive to myocardium
4-6 hr
3 da y s
Troponin T
< 0.2 ng/L
3-5 hr
14-21 days
Troponin I
< 0.03 ng/L
3 hr
7-10 days
Myoglobin
< 90 mcg/L
2 hr
24 h r
Myocardial Infarction: Recognizing Diagnostic findings and Planning Care in Response See above
Cervical CA: Recognizing Indications for Colposcopy and Biopsies Early cervical CA is generally asymptomatic. Sx do not develop until the cA has become invasive Pap tests are an effective screening tool for detecting the earliest changes associated with cervical CA. Cervical biopsy (definitive) is performed for cytologic studies when a cervical lesion is identified. Biopsy is usually performed during colposcopy as a follow up to an abnormal Pap smear. Unsatisfactory colposcopy findings or a positive biopsy necessitates removal of the lesion by conization, cryotherapy, laser ablation or loop electrosurgical excision procedure (LEEP) Clients with more extensive CA may require a total abdominal hysterectomy or a more extensive pelvic surgery called exenteration S/S painless vaginal bleeding watery blood tinged vaginal discharge leg pain (sciatic) or leg swelling Flank pain (hydronephrosis) unexplained wt loss pelvic pain Iron Deficiency Anemia: Identifying Expected lab Findings Hb/Hct---decreased McV---decreased MCH---decreased MCHC----decreased Reticulocytes------normal or decreased Serum iron-----decreased TIBC------increased Bilirubin------normal or decreased Platelets------normal or increased Conscious Sedation: Intervene for Complications Complications that may arise airway obstruction: insert airway airway,, suction
respiratory depression: admin 02 and reversal agents, such as naloxone (Narcan) and flumazenil (Romazicon) cardiac arrhythmias: set up 12 lead ECG, provide antidysrhythmics and fluids hypotension: provide fluids, vasopressors Anaphylaxis: Administer epinephrine
Osteoporosis: Measures to Prevent Injury Assess the home environment for safety (remove throw rugs, adequate lighting, clear walkways) Reinforce the use of safety equipment and assistive devices Instruct the client to avoid inclement weather (ice or slippery surfaces) Clearly mark thresholds, doorways and steps Prevention Teach the importance of o f regular, wt bearing exercise
Leukemia: Interventions to Reduce Infection Risks of Chemotherapy Prevent Infections freq thorough handwashing is a priority intervention place the client in a private room screen visitors carefully encourage good nutrition (low-bacteria diet, avoid salads, raw fruits, and vegs) and fluid intake Monitor WBC counts Encourage good personal hygiene Avoid crowds if possible
Immobilizing Interventions: Assessing for Altered Tissue Perfusion Neurovascular assessment is essential throughout immobilization. Assessments are done frequently following initial trauma to prevent neurovascular compromise r/t edema and/or immobilization device. Neurovascular assessment includes assessment of the following Pain Paresthesia Pallor Polar Paralysis Pulses Neurovascular Early or or La Late Si Sign Assessment Client Teaching/Sx Components Parameters to Report Pain
Early
Assess area involved increasign pain not using 0-10 rating relieved with scale; 0= no pain, 10 elevation or pain = worst pain med
Paresthesia
Early
assess for numbness or tingling, numbness/tingling; pins or needles pins or needles sensation sensation: should be absent
Pallor
Early
assess cap refill Brisk is < 3 sec
Polar
Late
assess skin temp by cool/cold fingers or touch: warm or cool toes
Paralysis
Late
assess mobility; unable to move moves fingers or fingers or toes toes able to plantar dorsiflex the ankle area not involved or restricted by cast
increased cap refill time > 3 sec , blue fingers or toes
Neurovascular Components Pulses
Early or or La Late Si Sign Late
Assessment Parameters
Client Teaching/Sx to Report
assess pulses distal weak palpable to injury; pulse is pulses, unable to palpable and strong palpate pulses, pulse detected only with Doppler
Angina: Assessing Risk Factors Risk factors: male gender hypertension smoking hx increased age hyperlipidemia metabolic disorders: DM, hyperthyroidism Methamphetamine or cocaine use Stress: Occupational, physical exercise, sexual activity Postoperative Nursing: Evaluating Postop Interventions to Prevent Complications Complications Airway Obstruction Monitor for choking, noisy irregular respirations, decreased 02 sat scores, and cyanosis and intervene accordingly accor dingly.. Keep emergency equipment at the bedside in the PACU Hypoxia Monitor oxygenation status and admin 02 as prescribed. Encourage the client to cough and deep breathe. Position the client to facilitate respiratory expansion Hypovolemic Shock Monitor for decreased BP and UOP, UOP, increased HR and slow cap refill. r efill. Admin fluids and vasopressors as indicated Paralytic ileus: Monitor bowel sounds, encourage ambulation, advance the diet as tolerated, and admin prokinetic agents, such as metoclopramide (Reglan) as prescribed Wound Dehiscence or Evisceration:
Monitor risk factors (obesity (obesity,, coughing, moving without splinting, sp linting, DM, day 5-10). If wound dehiscence or evisceration occurs, call for help, stay with the client, cover with sterile towel or dressing moistened with sterile saline, do not attempt to reinsert organs, monitor the client for shock and notify PCP immediately. Retinal Detachment: Evaluating Client Education Regarding Postop Care Restrict activity to prevent additional detachment cover the affected eye with an eye patch monitor for drainage Admin meds as prescribed mydriatics (dilating)--prevent pupil constriction and reduce accommodation antiemetics analgesics Instruct client to avoid activities that increase IOP bending over at the waist sneezing coughing straining vomiting head hyperflexion wearing restrictive clothing (for example tight shirt collars) DM: S/S of Hypoglycemia BS: < 50 mg/dL cool, clammy skin diaphoresis anxiety,, irritability, confusion, blurred vision anxiety hunger general weakness, seizures, (severe hypoglycemia)
Suctioning: Evaluation of Endotrach Suctioning Effectiveness
Endotrach Suctioning (ETS) is performed through a trach or endotrach tube Sterility must be maintained during endotracheal suctioning The outer diameter of the suction catheter should be less than 1/2 the internal diameter of the endotrach tube Hyperoxygenate the client utilizing a bag-valve-mask (BVM) or specialized ventilator function with 100% Fi02 immediately after the BVM ventilator is removed from the trach or endotrach tube, insert the catheter into the lumen of the airway. Advance until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the main stem bronchi). Intermittent suction is only applied during catheter withdrawal, lasting no longer than 10-15 sec at a time. Suction is performed by covering and releasing the suction port with the thumb while concurrently withdrawing the catheter, rotating it between the thumb and forefinger. Reattach the BVM or ventilator and supply the client with 100% inspired 02. Clear the catheter and tubing Allow time for client recovery between sessions. Repeat as necessary Many mechanical ventilators have in-line suction devices. This may eliminate the need for an assistant. Follow institution protocols for these systems. Always maintain surgical aseptic technique COPD: Interventions for Abnormal 02 Saturation Findings Pulse Oximetry monitor oxygen saturation levels Less than normal (normal = 94-98%) oxygen saturation levels Position the client to maximize ventilation (high Fowler "s) Encourage effective coughing, or suction to remove secretions Encourage deep breathing and use of incentive spirometer Administer breathing txs and meds as prescribed
Bronchodilators Short acting beta agonists, such as albuterol (Proventil, Ventolin) provide rapid relief Cholinergic antagonists (anticholinergic drugs, such as ipratropium (Atrovent), block the parasympathetic nervous system. This allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions Methylxanthines, such as theophylline (Theo-Dur), require close monitoring of serum med levels due to narrow therapeutic range. Anti-inflammatories decrease inflammation Corticosteroids such as fluticasone (Flovent) and prednisone. If given systemically,, monitor for serious SE (immunosuppression, fluid retention, systemically hyperglycemia, hypokalemia, poor wound healing) Leukotriene antagonists, such as montelukast (Singulair) Mast cell stabilizers, such as cromolyn sodium (Intal) Combination agents (bronchodilator and anti-inflammatory) Ipratropium and albuterol (Combivent) Fluticasone and salmeterol (Advair) If prescribed separately for inhalation admin at the same time, administer the bronchodilator first in order to increase the absorption of the anti-inflammatory agent. Admin heated and humidified oxygen therapy as prescribed. Monitor for skin breakdown from the 02 device. Instruct clients to practice breathing techniques to control dyspneic episodes Diaphragmatic or abdominal breathing Pursed lip breathing Provide oxygen therapy as prescribed to relieve hypoxemia
client with COPD may need 2-4 L/min per nasal cannula or up to 40% Venturi mask Clients with chronic hypercarbia usually require 1-2 L/min via nasal cannula. It is important to recognize that low arterial levels of oxygen serve as their primary drive for breathing Determine the client"s physical limitations and structure activity to include periods of rest Promote adequate nutrition increased work of breathing increases caloric demands proper nutrition aids in the prevention of secondary respiratory infections Provide support to the client and family Encourage verbalization of feelings Encourage smoking cessation if applicable. Smoking and other flame sources must be avoided by clients on supplemental oxygen (enhances (combustion) in the home Topic Descriptors Descr iptors Safety and Infection Control (17) Form A Newborn Discharge Teaching: Infant Safety Priorities Provide community resources to clients who may need additional and ongoing assessment and instruction on infant care (eg adolescent parents) Never leave the infant unattended with pets or other small children Keep small objects (coins) out of reach of infants (choking hazard) Never leave the infant alone on a bed, couch, or table. Infants move enough to reach the edge and fall off Never provide an infant a soft surface to sleep (eg pillows and waterbed). The infant "s mattress should be firm. Never put pillows, large floppy toys or loose plastic sheeting in a crib. The infant can suffocate.
Never place the infant on its stomach to sleep during the first few months of life. The back lying position is the position of choice when using an infant carrier, always be within arm"s reach when the carrier is on a high place such as a table. If possible, place the carrier on the floor near you. Do not tie anything around the infant "s neck. Check the infant "s crib for safety s afety.. Slats should be no more than 2.5 inches apart. The space between the mattress and sides should be less than 2 finger widths Keep a crib or playpen away form window blinds and drapery cords. Infants can become strangled in them. The bassinet or crib should be placed on an inner wall, not next to a window to prevent cold stress by radiation. Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if in contact with heat sources Smoke detectors should be on every floor of a home and should be checked monthly to assure they are working. Batteries should be changed yearly. (Change batteries when daylight saving occurs) Provide adequate ventilation. Control the temp and humidity of the infant "s environment. Avoid exposure to cigarette or cigar smoke in a home or elsewhere. Passive exposure increases the infant"s risk of developing respiratory sx and illnesses. Be gentle with the infant. Do not swing the infant by his arms or throw the infant up in the air All visitors should wash their hands before touching the newborn Any individual with an infection should be kept away from the newborn. Always use an approved car seat when traveling. Parent should be instructed about the proper installation of an approved car safety seat. The infant should always be in a rear-facing car seat from birth to 9.1 kg (20 lb) or 1 year of age, after which, a toddler seat should be used. The infant car seat should be secured in the rear seat of the car. The shoulder straps should be snug enough so they do not fall off the infant "s shoulders.
Disaster Planning: Identify Disaster Preparedness Activities Develop a disaster response plan based on the most probable disaster threats identifying community disaster warning system and communication center and learning how to use it identify the first responders in the community disaster plan making a list of agencies that are available for the varying levels of disaster both locally and nationally defining the nursing roles in first priority, second priority and third priority triage identifying specific roles of personnel involved in disaster response and the chain of command. locating all equipment and supplies needed for disaster management, including Level III suits, infectious control items, medical supplies, food, and potable water. Replenish these regularly. Checking equipment (including evacuation vehicles) regularly to ensure proper operation. evaluating the efficiency, response time, and safety of disaster drills, mass casualty drills and disaster plans. Emergency Management: Decontamination Following Exposure to Bioterrorism Anthrax: instruct clients to remove contaminated clothing and store in labeled plastic bags. Handle clothing minimally to avoid agitation. Instruct clients to shower throroughly with soap and water. Use standard precautions and wear appropriate protective barriers when handling contaminated clothing or other items. Recommended postexposure prophylaxis includes the admin of oral fluorquinolones (cipro, levofloxacin, and ofloxacin) Botulism: decontamination is not required Plague: Risk for reaerosolization form contaminated clothing of exposed persons is low. In the case of gross exposure, instruct clients to remove contaminated clothing and store in labeled plastic bags. Handle clothing minimally to avoid agitation. Instruct clients to shower thoroughly with soap and water. Use standard precautions and wear appropriate protective barriers when handling contaminated clothing or other items. Postexposure prophylaxis is recommended for clients and HCP. HCP. The antimicrobial agent of choice is doxycycline or cipro.
Smallpox: Client decontamination after exposure is not indicated. Ergonomic Principles: Prevention of Carpal Tunnel Syndrome Avoid repetitive movements of the hands, wrists, and shoulders. s houlders. Take Take a break q 15-20 min to flex and stretch joints and muscles. Adaptive devices such as wrist splints may be worn to hold the wrist in slight dorsiflexion to relieve pressure on the median nerve. Special keyboard pads that help prevent repetitive pressure on the median nerve Safe Medication Administration and Error Prevention: Selecting Appropriate Resources for Checking Prescription Accuracy Nursing drug handbooks Pharmacology textbooks Professional journals PDR Professional Websites.
Error Prevention: Ensuring Client Safety When Transcribing Orders Components of a medication order Name of client Date and time of order Name of med Dosage Route of Admin Time and Freq --exact times or number of times per day (dictated by facility/agency policy or specific qualities of the med) Signature of prescribing doctor
When the nurse receives a verbal or telephone order, he or she writes the complete order or enters it into a computer and then reads it back and receives confirmation from the prescriber to confirm accuracy. The nurse indicates the time and the name of the prescriber who gave the order and then signs the order. Common abbreviations may be used when writing orders. However, JCAHO now requires healthcare organizations to develop a “dangerous” abbreviation acronyms and symbols list. Handling Infectious Materials: Appropriate Disposal The CDC recommends a single bag for discarding items if the bag is impervious and sturdy and if the article can be placed in the bag without contaminating the outside of the bag. Soiled linen should be place in an impervious laundry bag in the client "s room the CDC recommends double bagging if it is impossible to prevent contamination of the bag"s outer surface. Double bagging is not otherwise recommended. Client Safety: Removing Fire Hazards Faulty equipment (eg frayed cords, disrepair) can start a fire or cause a shock and should be removed and reported immediately per the health care agency"s policy. Seizures: Appropriate Use of Seizure Precautions to Maintain Client Safety To develop a plan of care, assess the client with a hx of seizures for: freq type and date of last seizure meds triggers or trends of the seizures Ensure rescue equipment is at the bedside to include oxygen, an oral airway, and suction equipment. A saline lock may be put in for IV access if the client is at high risk for experiencing a generalized seizure Inspect the client"s environment for items that may cause injury in the event of a seizure and remove items that are not necessary for current tx Assist the client at risk for a seizure in ambulation and transfer to reduce the risk of injury Advise all caregivers and family not top put anything in the client "s mouth (except in status epilepticus, where an airway is needed) in the event of a seizure Advise all caregivers and family not to restrain the client in the event of a seizure, ensure the client"s safety by lowering him to the floor or bed, protect his head, remove
nearby furniture, provide privacy, put the client on his side, if possible and loosen clothing to prevent injury and promote dignity of the client After a seizure, explain what happened to the client, provide comfort and understanding and a quiet environment for the client to recover. Document the seizure in the client "s record with any precipitating behaviors and a description of the event (eg movements, any injuries, length of seizure, aura, postictal state) and report it to the PCP. PCP. Surgical Asepsis: Performing Perf orming Aseptic Technique Procedure: Wash hands Open plastic covering of package per manufacturer"s directions, slipping the package onto the center of the workspace with the top flap of wrapper opening away from the body. Reach around the package to open the top flap of the package, grasp the outside flap between the thumb and index finger and unfold the top flap away from body. Next open the side flaps, using the right hand for the right flap and the left hand for the left flap The last flap should be grasped and turned down toward body Additional sterile packages Open next to the sterile field by holding the bottom edge with one hand and pulling back on the top flap with the other hand. Place the packages that are to be used last furthest from the sterile field, and open these first. Add them directly to the sterile field. Lift the package from the dry surface holding it 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it onto the sterile field. Pour sterile solutions by Removing the bottle cap Placing the bottle cap face up on the surface Holding the bottle with the label in the palm of the hand so that the solution does not run down the label
First pouring a small amt (1 -2 ml) of the solution into an available receptacle. pouring the solution onto the dressing or site without touching the bottle to the site. Once the sterile field is set up, it is necessary to don sterile gloves. Sterile gloving includes opening the wrapper and handling only the outside of the wrapper. Don gloves by using the following steps. With the cuff side pointing toward the body, use the left hand and pick up the righ hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. wr apper. While picking up the edge of the cuff, pull the right glove on the hand. With the sterile right gloved hand, place the fingers of the right hand inside the cuff of the left glove, lifting it off the wrapper and put the left hand into it. When both hands are gloved, adjustments of the fingers in the gloves may be made if necessary nece ssary.. During that time, only the sterile gloved hand can touch the other sterile glvoed hand. At the close of the sterile procedure, or if the gloves tear, the gloves must be removed. Take Take off the gloves by grasping the outer part at the wrist, pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out and only the clean inside part is exposed. Discard into an appropriate receptacle. Infection Control: Identifying and Reporting Errors in Surgical Skin Preparation Surgical handwashing Turn on water using knee or foot controls and adjust to comfortable temp Wet hands and arms under running lukewarm water and lather with detergent to 5 cm (2 in) above the elbows. (Hands need to be above the elbows at all times Rinse hands and arms thoroughly under running water. Remember to keep hands above elbows. Under running water, clean under nails of both hands with nail pick. Discard after use
Wet clean sponge and apply antimicrobial detergent. Scrub nails of one hand with 15 strokes. Holding sponge perpendicular, scrub palm, each side of thumb and fingers and posterior side of hand with 10 strokes each. The arm is mentally divided into thirds and each third is scrubbed 10 times. Entire scrub should last 5-10 min. Rinse sponge and repeat sequence for other arm. A two-sponge method may be substituted. Discard sponge and rinse hands and arm thoroughly. Turn water off with foot and knee control and back into room entrance with hands elevated in front of and away from the body. Artificial Airway: Instructing Family on Safe Use of Equipment Provide trach care q 8 hrs to decrease the risk of infection and skin breakdown suction the trach tube, if necessary using sterile suctioning supplies remove old dressing and excess secretions apply the oxygen source loosely if the client desaturates during the procedure use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. Begin with H202 followed by normal saline. Clean in circular motion from stoma site outward. using surgical aseptic technique, remove and clean the inner cannula (use H202 to clean the cannula and sterile saline to rinse it. Use new inner cannula if it is disposable) Clean the stoma site and the trach plate with H202 followed by sterile saline. Place split 4x4 dressing around trach. Change trach ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a know is needed, tie a square know that is visible on the side of the neck. One or two finger should be able to be placed between the tie tape and the neck. document the type and amt of secretions, the general condition of the stoma and surrounding skin, the client"s response to the procedure, and any teaching that occurred.
Provide adequate humidification and hydration to thin secretions and decrease risk of mucus plugging
Do not suction routinely as this causes mucosal damage, bleeding and bronchospasm. Suction PRN when assessment findings indicate (eg audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia, presence of mucus in the airway.
Emergency Management: Order of Client Evacuation in Response to a Fire Clients who are close to the fire, regardless of its size, are at risk of injury and should be moved to another area. If a client is receiving oxygen but not life support, the nurse discontinues the oxygen, which is combustible and can fuel an existing fire. If the client is on life support, the nurse may need to maintain the client "s respiratory status manually with an Ambu-bag until the client is moved away from the fire. Abulatory clients can be directed to walk by themselves to a safe area and in some cases may be able to assist in moving clients in wheelchairs. Bedridden clients are generally moved form the scene of a fire by a stretcher, their bed or a wheelchair. If none of these methods, the client must be carried from the area. HIV/AIDS: Appropriate Environmental Precautions Direct contact (skin to skin or contact with mucous membrane discharges) HIV is transmitted through blood and body fluids (semen, vaginal secretions) HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes, cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate that these are unlikely sources of infections. Decreasing risks r/t sexual intercourse safe sex eliminates the risk of exposure to HIV in semen and vaginal secretions abstaining is the most effective way to accomplish this but there are safe options for those who cannot or do not wish to abstain outercourse (limiting sexual behavior to activities in which the mouth, penis, vagina or rectum does not come into contact with a partner "s mouth, penis, vagina, or rectum) is safe bec there is not contact
includes massage, masturbation, mutual masturbation, telephone sex insertive sex between partners who are not infected with HIV or not at risk of becoming infected with HIV is considered to be safe Risk reducing sexual activities decrease the risk of contact through the use of barriers. should be used when engaging in insertive sexual activity with a partner who is known to be HIV infected or with a partner whose HIV status is not known most common barrier device is male condom female condoms squares of latex plastic food wrap Decreasing risks r/t drug use major risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sex experiences while under the influence of drugs. basic rules do not use drugs if you do, don"t share equipment do not have sex when under the influence of any drug (including alcohol) that impairs decision making ability use alternatives to injecting such as smoking, snorting, or ingesting the drug injecting equipment includes needles, syringes, cookers (spoons or bottle caps used to mix the drug) cotton, and rinse water another safe tactic is for the user to have access to sterile equipment (needle exchange programs) cleaning equipment before use is a risk-reducing activity Decreasing risks for perinatal transmission best way to prevent HIV in infants is to prevent HIV infection in women
If HIV-infected pregnant women are tx "d with AZT, AZT, REtrovir, the rate of perinatal transmission is decreased. tx has minimal SE for the baby Combination ART as appropriate for the mother"s HIV infection can further decrease the risk of perinatal transmission to less than 2% Decreasing risks at work employers must protect workers from exposure to blood and other potentially infectious materials. precautions and safety devices decrease the risk of direct contact with blood and body fluids. should exposure to HIV infected fluids occur, postexposure prophylaxis with combination ART based on the type of exposure the volume of exposure and the status of the source pt decreases the risk of infections. Meningitis: Client Education Regarding Prophylactic Precautions Risk Factors Bacterial Infections (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae) such as upper respiratory infections (otitis media, pneumonia, sinusitis) Immunosuppression Invasive Procedures, skull fracture, or penetrating head wound (direct access to CSF) Overcrowded Living conditions prevention of respiratory infection through vaccination program for pneumococcal pneumonia and influenza should be supported In addition, early and vigorous tx of respiratory and ear infections is important. persons who have close contact with anyone who has bacterial meningitis should be given prophylactic antibiotics.
Client Safety: Evaluating Appropriate Selection of Restraints Based on Client Situation
Client Safety: Appropriate Use of Restraints Reasons for use of a physical restraint are to be clearly stated the use of restraints must be part of client "s medical tx all less restrictive interventions must be tried first, other disciplines must be consulted, and supporting documentation must be provided. if a nurse uses restraints in an emergent situation, such as when a client is a danger to self or others, a face-to-face assessment is to be done within 1 hr by a PCP a physician"s order is required based on a face-to-face assessment of the client. the order must state the type of restraint, location, and specific client behaviors for which restraints are to be used and must have a limited time frame. these orders should be renewed within a specific time frame according to the agency"s policy. Assessment must ongoing. Proper documentation including behaviors that necessitated the application of restraints, the procedure used in restraining and the condition of the body part restrained and the evaluation of the client response is essential. Use of restraints must meet the following objectives: reduce the risk of client injury from falls prevent interruption of therapy such as traction, IV infusions, NG tube feeding or Foley cath prevent the confuse or combative client from removing life support equipment reduce the risk of injury to others by the client Client Safety: Maintain Prescribed Restraints Remove or replace restraints frequently to ensure good ciruclation to the area and allow for full ROM to the limb that has been restricted. Pad bony prominences and do neurosensory checks (to include loosening or removing the restraint and testing temperature, mobility, and capillary refill) q 2 hr to identify any neurological or circulatory deficits.
Always tie the restraint to the bed frame (loose knots that are easily removed) where it will not tighten when the bed is raised or lowered. Leave the restraint loose enough for ROM and with enough room to fit two fingers between the device and the client to prevent injury. always explain the need for the restraint to the client and family so as to help them understand that these actions are for the safety of the client. Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring the client"s safety. Never leave the client unattended without the restraint. Restraints should: Never interfere with tx Restrict movement as little as is necessary to ensure safety Fit properly Be easily changed to decrease the chance of injury and to provide for the greatest level of dignity Documentation for the use of restraints is very specific and must include: the behavior that makes the restraint necessary nursing interventions used prior to the placement of restraints. client"s LOC type of restraint used and location education/explanations to the client and family exact time of application of removal client"s behavior while restrained.
Form B
Emergency Management: Appropriate Response to Fire The RACE mnemonic is a basic guideline for reacting to a fire within the health care facility. Rescue
Rescue everyone from the area
Alarm
Pull the fire alarm which will activate the EMS response Systems that could increase fire spread are automatically shut down with activation of alarm
Contain
Once the room or area has been cleared, the fire doors should be kept closed in order to contain the fire. Keep fire doors closed as much as possible when moving from section to section within the facility
Rescue
Rescue everyone from the area
Extinguish
Make an attempt to extinguish small fires using a single fire fi re extinguisher, smothering, or water (except with an electrical or grease fire). Evacuation should occur if the nurse cannot put the fire out with these methods. Attempts at extinguishing the fire should only be made when the employee has been properly trained in the safe and proper use of a fire extinguisher and when only one extinguisher is needed.
Clients who are close to the fire, regardless of its size, are at risk of injury and should be moved to another area. If a client is receiving oxygen but not life support, the nurse discontinues the oxygen, which is combustible and can fuel an existing fire. If the client is on life support, the nurse may need to maintain the client "s respiratory status manually with an Ambu-bag until the client is moved away from the fire. Abulatory clients can be directed to walk by themselves to a safe area and in some cases may be able to assist in moving clients in wheelchairs. Bedridden clients are generally moved form the scene of a fire by a stretcher, their bed or a wheelchair. If none of these methods, the client must be carried from the area.
Ergonomic Principles: using Body Mechanics to Prevent Injuries to the Nurse The center of gravity is the center of a mass. In the body, the center of gravity is the pelvis. When an individual moves, the center of gravity also shifts. The closer the line of gravity is to the center of the base of support, the more stable the individual is. To lower the center of gravity, bend the hips and knees. Avoid twisting the spine or bending at the waist (flexion) to minimize the risk for injury When lifting, use the major muscle groups to prevent back strain and tighten the abdominal muscles to increase support to the back muscles. Distribute the wt between the large muscles of the arms and legs to decrease the strain on any one muscle group
and avoid strain to smaller muscles. When lifting from the floor, flex the hips, knees and back. Get the object to thigh level keeping the knees bent and straightening the back. Hold the object as close as possible, bringing the load to the center of gravity to increase stability and decrease strain. Use assistive devices whenever possible, and find assistance whenever it is needed. When pushing or pulling a load, widen the base of support. if pushing, move the front foot forward and if pulling, move the rear leg back and promote stability. Face the direction of movement if moving a client. It is easier and safer to pull toward than to push away from the center of gravity. use body wt when pushing or pulling to decrease the strain on muscles which makes the movement easier. Sliding, rolling and pushing require less energy than lifting and have less risk for injury Guidelines to Prevent Injury Plan ahead for activities that require lifting, transfer or ambulation of a cliet and ask others to be ready to assist at the time planned. Rest between these heavy activities to decrease muscle fatigue Maintain good posture and exercise regularly to increase the strength of arm, leg, back and abdominal muscles so these activities require less energy Get help from others, use assistive devices and offer to help others in lifting clients to reduce the load for any one indiv indiv.. Use smooth movements when lifting and moving clients to prevent injury through sudden or jerky muscle movements When standing for long periods of time, flex the hip and knee through use of a foot rest. When sitting for long periods of time, keep the knees slightly higher than the hips The client who is debilitated does not move easily and has difficulty changing positions freq. it is the responsibility of the caregiver to reposition the client regularly while maintaining good body alignment for the client, and using good body mechanics for the provider"s safety. Avoid repetitive movements of the hand, wrists and shoulders. Take Take a break every 15-20 min to flex and stretch joints and muscles. Maintain good posture (head and neck in straight line with the pelvic) to avoid neck flexion and hunched shoulders which can cause impingement of nerves in the neck.
Error prevention: Questioning Prescriptions
A nurse is obligated to carry out a physician"s order except when the nurse believes an order to be inappropriate or inaccurate A nurse carrying out an inaccurate order may be legally responsible for any harm suffered by the client The nurse should clarify with the physician an unclear or inappropriate order or an order in question If no resolution occurs regarding he order in questions, the nurse should contact the nurse manager or supervisor
Hazardous Materials: Appropriate Handling of Chemotherapy Disposal of Cytoxic Drug 1. All material contaminated with cytotoxic drugs must be placed in yellow plastic sharps/chemotherapy disposal containers. 2. All needles and syringes must be placed as a single unit into the yellow sharps/chemotherapy disposal containers.
Client Safety: Interventions to Prevent Falls Assess the client"s risk for falling Assign the client at risk for falling to a room near the nurse "s station Alert all personnel to the client "s risk for falling Orient the client to physical surrounding s Instruct the client to seek assistance when getting up Explain use of the call bell system Keep the bed in the low position with side rails up if required Lock all beds, wheelchairs, and stretcher Keep personal items within reach Eliminate clutter and obstacles in the client "s room Provide adequate lighting Reduce bathroom hazards maintain the client"s toileting schedule throughout the day
Incidents: Priority Responses
Incident reports are used as a means of identifying risk situations and improving client care. Follow specific documentation guidelines fill out the report repor t completely, completely, accurately and factually The report form should not be copied or placed in the client "s record Make no reference to the incident report form in the client "s record. The report is not a substitute for a complete entry in the client "s record regarding the incident. Examples of incidents: Accidental omission of ordered therapies Circumstances that led to injury or a risk for client injury Client falls Medication admin error Needlestick injuries Procedure related or equipment related accidents A visitor having symptoms of an illness
Security Plans: Appropriate Interventions to Maintain Security on Obstetrical Unit Teach parents how to recognize picture identification badges worn by birth facility personnel Parents should also be aware of other identifying measures such as color coded badges or uniforms for maternity staff Written and verbal information, including a picture of special identification badges worn by staff should be given to parents Parents must be cautioned never to give their infant to anyone who does not have proper identification Question anyone carrying a newborn near an exit or in an unusual part of the facility
Be suspicious of anyone who does not seem to be visiting a specific mother, asks detailed questions about the nursery or discharge routines, asks to hold infants or behaves in an unusual manner Be suspicious of unknown people carrying large bags or packages that could contain an infant respond immediately when an alarm signals that a remote exit has been opened or an infant has been taken into an unauthorized area Never leave infants unattended. Teach Teach parents that infant must be observed observe d at all times. Suggest that mothers have the nursing staff take over care of the infant if the mother feels unwell or is napping and no family members are available to watch the infant Take infants to mothers one at at time. never leave an infant in a crib in the hall while the nurse is in a room with another mother. Never leave an infant unsupervised. When infants are left in mother "s room, position the crib away from the doorways, preferably on the side of the mother "s bed opposite the door If entrances to the maternity unit or nurseries are equipped with locks that open to codes or card keys, protect them from others When a parent or family member comes to the nursery to take an infant, always match the infant and adult identification bracelet numbers. never give an infant to anyone who does not have the correct identification bracelet or other proper id Alert hospital security immediately when any suspicious activity occurs Suggest that parents do no place announcements in the paper or signs in their yard that might alert an abductor that a new baby is in the home
