NSG 212 FINAL

-reduced inflammatory and immune response (might have an advanced infection before identified)

-temp will not elevate like a younger person

-WBC may not elevate like a younger person

-agitation, confusion, or incontinence can be the only manifestations

older adults and infection

• Avoid coughing, sneezing, and talking directly over a sterile field.

• Advise clients to avoid sudden movements, refrain from touching supplies, drapes, or the nurse’s gloves and gown, and avoid coughing, sneezing, or talking over a sterile field.

• The outer wrappings and 1 inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1 inch border around the edges, is the sterile field to which other sterile items may be added.

• To position the field on the table surface, grasp the 1 inch border before donning sterile gloves. Discard any object that comes into contact with the 1 inch border.

• Touch sterile materials only with sterile gloves.

• Consider any object held below the waist or above the chest contaminated.

• Sterile materials may touch other sterile surfaces or materials; however, contact with non sterile materials at any time contaminates a sterile area, no matter how short the contact.

• Do not reach across or above a sterile field.

• Do not turn your back on a sterile field.

• Hold items to add to a sterile field at a minimum of 6 inches above the field.

• Keep all surfaces dry.

• Discard any sterile packages that are torn, punctured, or wet.

• Select a clean area above waist level in the client’s environment (a bedside stand) to set up the sterile field.

• Check that all sterile packages (additional dressings, sterile bowl, sterile gloves, and solution) are dry and intact and have a future expiration date.

• Make sure an appropriate waste receptacle is nearby

principles of surgical asepsis

• Remove the bottle cap.

• Place the bottle cap face up on a clean (nonsterile) surface.

• Hold the bottle with the label in the palm of the hand so that the solution does not run down the label.

• First pour a small amount (1 to 2 mL) of the solution into an available receptacle (LIP the solution).

• Pour the solution (without splashing) onto the dressing or site without touching the bottle to the site.

pouring sterile solutions

Assessment, Diagnosis, Planning, Implementation, Evaluation

nursing process

recognize cues, analyze cues, prioritize hypothesis, generate solutions, take actions, evaluate outcomes

clinical judgement model

assessment = recognize cues

diagnosis = analyze cues

diagnosis = prioritize hypothesis

planning = generate solutions

implementation = take actions

evaluation = evaluate outcomes

clinical judgement model vs. nursing process

• observe and assess pt (objective and subjective data)

• obtain pertinent info (health hx, labs, procedures, tests, meds)

• vital signs and head to toe assessment

• identify any subtle or apparent changes in pt’s condition

• what is most important/urgent

assessment/recognize cues

• identify client potential problems or complications

• what are the expected and unexpected findings in health

• what information is of immediate concern

diagnosis/analyze cues

• organize pt cues accordingly in order to determine any potential complications based on info obtained

• prioritize pt needs and problems based on analysis of information

• use standards of care and empirical frameworks for priority setting

prioritize hypothesis/diagnosis

• formulate pt outcomes and develop plan of care

• identify nursing actions and interventions to focus on managing the pt’s problem

• prioritize plan of care to achieve pt’s best outcome

• consider changing nursing actions based on pt’s condition

planning/generate solutions

• quickly and accurately perform nursing interventions based on pt’s prioritized diagnosis

• assess pt’s response to interventions performed

• coordinate care with other health care team members

• document pt care data and info

implementation/take actions

• determine if pt achieved expected outcome or goal

• change interventions based on pt’s response

evaluation/evaluate outcomes

• appropriate, uninterrupted care delivery

• smooth transition between settings

• establish a nurse-pt-family relationship upon admission is essential

• collaboration and teamwork are necessary to promote continuity of care and positive pt outcomes

• through admission, transfers, and discharge, it is a responsibility of the nurse to ensure information sharing and continuity of care

continuity of care

• name, address, DOB

• biological sex/gender identity

• marital status, occupation, employer, religious preference

• name of admitting serve, date and time of admission/admiting diagnosis

• name of nearest relative

• financial status

• identification number

• primary language, advance directive

• learning style, healthcare literacy

• vital signs, height, weight, allergies

• reason for seeking care, presenting illness

• PMH, family history, psychosocial history

• nutritional status, review of systems

• safety assessments, discharge info

admission info to collect

• basic info about pt (name, age, room)

• current dx

• significant assessment findings

• vitals signs and pain level

• evaluation of treatment

• abnormal findings

• preps, procedures

• ongoing need, new orders, updates to care plan

change of shift reports/transfer reports

• pt is legally free to leave

• choice carries risk for increase illness or complications

• pt must sign a release form and be informed of risks prior to signing form

• pt’s signature must be witnessed

• form becomes part of the medical record

leaving AMA

patient education

the process of influencing pt behavior to effect a change in knowledge, attitude, and skills with the goal of improved health (must be ongoing and interactive)

compliance/adherence

the extent to which behavior coincides with medical advice; the extent to which the pt’s choices about health behavior follow professional recommendations

-pt bill of rights states pt’s have a right to obtain complete info about their diagnosis, treatment, and prognosis in terms they can understand

-joint commissions require nurses/health care providers to educate pt’s

-pt’s must understand their condition to make informed decisions, implement self-care measures, and to cope with their health condition

why do pt education?

-high level wellness and related self-care practices

-disease prevention or early detection

-quick recovery with minimal or no complications

-enhanced ability to adjust to developmental life changes and illness

-pt and family acceptance of lifestyle nessicated by illness or disablity

teaching outcomes from pt education

cognitive

learning domain: storing and recalling of new knowledge in the brain (KNOWLEDGE)

-tell you what they learned

-lecture, panel, discovery, written materials, pamphlet

psychomotor

learning domain: learning a physical skill (SKILL)

-showing or demonstrating a skill

-role modeling, discussion, talking, audiovisual materials

affective

learning domain: changing attitudes, values, and feelings (ATTITUDE)

-change POV or perspective

-demonstration, discovery, printed materials

• fluids = varies by amount and type, caffeine and alcohol (increased urine output), high sodium (decreased urine output)

• lifestyle, activity, muscle tone

• psychological variables

• diseases

• incontinence (can create social isolation)

factors that affect urination

30 ml/hr (1200 cc/day)

-baseline, report if less especially in critically ill pt’s

minimal expected adult output

polyuria (diuresis)

abnormally large amounts of urine (2500 ml/day)

oliguria

scant amounts of urine (less than 500 ml/day) ABNORMAL ASSESSMENT

anuria

less than 100ml/day, very little or no urine; VERY ABNORMAL ASSESSMENT (must report to provider)

nocturia

frequency of voiding at night

urgency

immediate need to void

dysuria

painful/difficulty voiding

maturational enuresis

repeated involuntary urination in children less than 4-5

nocturnal enuresis

repeated involuntary urination in children less than 4-5 at night

urinary retention

accumulation of urine in bladder due to inability to fully empty; occurs when urine is produced normally but is not excreted completely from bladder

• must be done on every pt

• provides valuable info about pt’s fluid status (cues)

• output does not equal input

• output should be about 2400 ml/day

• need to use appropriate measuring devices and make sure pt knows how to use

• charting “occurrence” is better than nothing, but measuring in ml is best option

• do not need an order for I&O’s

• independent nursing intervention

• can weight adult briefs/diapers and tally incontinent occurrences

assessment of I&O for fluid balance

• most accurate assessment of fluid balance

• must take at same time daily

• weight gain or loss less than 1 pound/day is mostly fluid

• report gain or loss to provider

daily weight assessment for fluid balance

-indwelling catheter (foley) or straight catheter (I/O cath) are interventions for urinary retention

-if pt has an indwelling catheter, they CANNOT have urinary retention

-indwelling catheter stay in

-coude cath has a bend, used for men with enlarge prostates

indwelling catheter

lower sg = more dilute urine, overhydration, hold fluids

higher sg = more concentrated urine, dehydration, push fluids

what does lower specific gravity mean vs. higher specific gravity

BUN, CR, and estimated glomerular filtration rate (EGFR)

lab work for renal disease

5-20 mg/dL

normal BUN range

greater than or equal to 90 ml/min

-slight different for blacks, may need to multiply by 1.2 or 1.5

-may decrease with age

normal estimated glomerular filtration rate (EGFR)

0.9-1.3

normal CR range for men

0.6-1.1

normal CR range for women

0.3-1.0

normal CR range for children

CR and BUN = true renal dysfunction

BUN = dehydration

if both CR and BUN are elevated what does it usually indicate? if just BUN is elevate what does it indicate?

incontinence

decreased urinary control

stress incontinence

loss of small amounts of urine from abdominal pressure without bladder muscle contraction when laughing, sneezing, or lifting

-common in pregnancy or after childbirth

urge incontinence

inability to stop urine flow long enough to reach the bathroom

overflow incontinence

urinary retention from bladder overdistention and frequent loss of small amounts of urine

-bladder fills up, not getting normal urge)

reflex incontinence

involuntary loss of moderate amount of urine without warning

-often with spinal cord dysfunction

functional incontinence

loss of urine due to factors that interfere with need to urinate

-cognitive, mobility, environment, confusion

total incontinence

unpredictable, involuntary loss of urine that does not respond to treatment

-no control

women, elderly, and diabetics

UTI’s are most common in what groups

UTI’s

may result from catheterization

-can spread from bladder to kidneys (nephritits)

pain on urination, frequency, blood in urine

s/sx. of UTI

• encourage fluids/cranberry juice

• cotton underwear, avoid tight pants, shower, void before and after sex

• antibiotics

• tricyclic antidepressants (relieve urinary incontinence)

• urinary antispasmodics or anticholinergic agents (alleviate pain, treat spasms or manifestations, can turn urine orange)

treatment of UTI

subrapubic catheter

foley inserted above symphysis pubis into bladder (through abdomen to bladder), closed drainage system

• ostomy achieves stable size in 4-6 weeks (swollen first)

• keep skin around stoma clean and dry, observe site, use clean technique

• empty collection bag when 1/3-1/2 full, burp bag if needed, don’t throw away clamp

• teach pt about care, avoidance of gassy foods, and odor control

• green leafy veggies may cause gas, should be avoided

• yogurt, cranberry juice, and commercial odor products decrease odor

• provide emotional support, refer to ostomy RN, support groups

nursing care for ostomies

bowel diversion

an opening on abdominal wall for stool, can be temporary or permanent

dark pink/red (not pale or blue as that indicated decreased circulation) and not swollen

stoma should be

ileostomy

location of ostomy: liquid drainage, very acidic, minimal odor, frequent emptying

ascending colostomy

location of ostomy: liquid, acidic, some odor, frequent emptying

transverse colostomy

location of ostomy: odorous, mushy drainage without control

descending colostomy

location of ostomy: solid, can be regular, odor, normalish

end stoma

bowel diversion: result of cancer or bowel disease, permanent

loop colostomy

bowel diversion: in medical emergencies, temporary, a loop of bowel is supported on abdominal wall, proximal stoma drains tool, distal stoma drains mucus

double barrel colostomy

bowel diversion: 2 abdominal stomas, proximal drains stool, distal leads to inactive intestine, after injured intestine heals the two ends are reattached, temporary

• promote regular pattern (privacy, timing, nutrition/fluids, exercise, positioning, sitting upright on toilet or commode promotes pooping)

• digital removal of impaction (can cause injury or vagal response)

• medications = cathartics, suppositories (try mobility, fiber, fluids, privacy first), anti-diarrheals, enemas

• bowel training program

nursing interventions for alterations in elmination

primary

level of health promotion: directed toward promoting health and preventing the development of disease or injury

immunization clinics, health education in schools, nutrition/fitness activities or presentation, poison-control information, accident-prevention education (home fire safety, car seat training, stop drop roll)

examples of primary health promotion

secondary

level of health promotion: focus on screening for early detection of disease with prompt diagnosis and treatment of any found

assessing children for normal growth and development, encouraging regular medical/dental/vision exams, BP screenings, mammograms, early detection/screening for DM or colon cancer

examples of secondary health promotion

tertiary

level of health promotion: begins after an illness is diagnosed and treated, goal of reducing disability and helping rehab pt’s to a maximum level of functioning

ROM exercises on bedridden pt, teaching pt with diabetes to recognize and prevent complications, using PT to prevent contractures in pt that had a stroke or spinal cord injury, referring woman to support group after removal of breasts because of cancer, rehab services

examples of tertiary health promotion

c diffe, hsv, impetigo, MRSA, VRSA, covid, shigella

contact precaution diseases

flu, pertussis, mumps, rubella, plague, streptococcal pneumonia, meningococcal pneumonia, covid

droplet precaution diseases

measles, varicella, tuberculosis

airborne precaution diseases

-protect individuals providing aid

-OUTSIDE of paid position/NOT on the job

-Don’t prevent from being sued but reduce liability

-need to provide aid within training and scope of practice

-must not leave scene until medical assistance arrives or scene becomes dangerous or if you are leaving to get assistance

good samaritan laws

-safety is the first priority

-assess circulation and breathing and use BLS for unconscious pts; if traumatic assume spinal cord injury

-use PPE

-chest compressions, airway, breathing, defibrillation (CAB)

initial steps in first aid

-find source and apply direct pressure, and elevate area above heart

-remove wet clothing and cover with blanket

-nosebleed = pinch nose, tip head forward, if still bleeding a lot after 10 min go to ED

nsg interventions for external bleeding

if signs of shock, suspect internal bleeding, may see cyanosis/paleness

-call EMS, assist to comfortable position, mositor ABC’s/LOC

nsg interventions for internal bleeding

s/sx = first rapid pulse and cold clammy skin; then cyanosis, weakness, N/V, thready pulse; finally lost peripheral pulses, restlessness, yawning/gasping, unconsciousness

-lay down and raise legs (trendelenburg position), cover with blanket, ABC, stop bleeding, call EMS if unconscious, if anaphylaxis use epi pen

nsg interventions for shock

-do not remove large embedded objects, stabilize with gauze and get help

-stab or gunshot wounds = call ambulance and try to stop bleeding, if chest injury sit up to try to reduce blood loss and ease breathing

-amputations = get help, apply direct pressure, cover amputated part with moist dressing and put into clean plastic bag and then into ice water

nsg interventions for wounds

-thermal burn = cool with cold water (15-30 min) then cover with non-adhesive dressing, if large area or head/neck call EMS immediately

-don’t use ice directly on burn or use ointment or break blisters!!

-electrical burn = cover entry and exit wounds, monitor ABC

nsg interventions for burns

head exhaustion = loosen clothing, apply cool moist cloths, move to cool location, cool drinks, monitor

head stroke = emergency, call EMS, douse with cool water or cover with wet towels, ice packs to armpits/groin/neck, cool water to drink only only if no change LOC

nsg interventions for heat exhaustion/heat stroke

-call EMS

-loosen tight clothing and put in “W” position (lying back a bit with knees bent)

-if alert and not on anticoagulants, give 1 adult aspirin

-if have angina, give nitro; if unrelieved after 2 nitro, call EMS

-monitor ABC and VS

nsg interventions for MI or Angina

-call EMS

-help to comfortable position, observe ABC

-in unconscious place in recovery position on unaffected side

nsg interventions stroke/TIA

-protect from injury

-do not put anything in mouth during seizure

-after seizure, place in recovery position, monitor respirations

-try to monitor time in seizure

nsg interventions for seizures

-unbroken and healthy skin and mucous membranes defend against harmful agents

-resistance to injury is affected by age, number of underlying tissues, and illness

-adequately nourished and hydrated body cells are resistant to injury

-adequate circulation is necessary to maintain cell life

factors affecting the skin

-very thin and very obese people are more susceptible to skin injury (fluid loss during illness causes dehydration, skin appears loose and flabby)

-excessive perspiration during illness predisposes skin toe breakdown (skin integrity)

-jaundice causes yellowish, itchy skin

-diseases of the skin like eczema and psoriasis may cause lesions that require special care

causes of skin alteration

-intact skin is the first line of defense against microorganisms (portal of entry and exit)

-careful hand hygiene is used in caring for a wound

-surgical asepsis is preferable to be used in caring for a wound

-body will respond systemically (increased body temp, increases HR/RR, anorexia, NVD, hormonal changes)

-nutritional support

principles of wound healing

hemostasis, inflammatory, proliferation, maturation

phases of wound healing

immediately after injury

-blood clotting, platelets, exudate collecting causing swelling and pain

-head and redness are NORMAL in this stage

phases of wound healing: hemostasis

2-3 days

-WBC come to the site, leukocytes them macrophages (these are ESSENTIAL to the healing process), platelets for clotting, and nutrition to the wound via blood supply

-wound will present with pain, heat, swelling, and redness and may also see systemic response from the body

phases of wound healing: inflammatory

next 3-24 days

-involves replacing lost tissue with connective or granulation tissue, forms the foundation for a scar

-granulation tissue is beefy red, highly vascular, bleeds easily, and very fragile

-adequate oxygen and nutrition are needed to assist with healing, will have resurfacing of epithelial cells, the foundation for the scar begins here, collagen synthesis in this stage

phases of wound healing: proliferation

involves strengthening of the scar and resumption of a normal appearance

-can take more than 1 year to complete

-scar tissue is 80% as strong but less elastic than regular tissue

phases of wound healing: maturation

primary intention, secondary intention, tertiary intention

3 processes of wound healing/closure

little tissue loss, edges are approximate (close), heals rapidly with minimal scarring, low risk of infections, surgical wounds (sutures, staples, steri-strips)

-if a wound healing via primary intention becomes infected, it will need to heal via secondary intention

primary intention

wound involve tissue loss, edges are approximated, widely separated

-healing occurs from the inside out

-longer to heal, increase likelihood of scar, can see the wound

-if there is a chance of infection, they will do this (large wounds, burns, and trauma)

-ex. = infection, dog bite

secondary intention

widely separated wound is later brought together with some types of closure material

-may be closed at a later time, LONG healing time, deep and extensive damage

-high risk of infection and dehiscence

-ex. = abscess

tertiary intention