Nursing Foundations week 1

Measuring temperature steps

Make sure equipment is in the room

• GREET PATIENT

• HAND HYGIENE

• IDENTIFY PATIENT (name and DOB)

• Make sure patient has no contraindications to getting temperature checked through oral route

  • important to have probe in posterior sublingual pocket (close to blood vessels)

• take temperature

Measuring pulse steps

• 30 seconds on wrist and multiply by 2

  • finger flat against patient skin

  • if pulse unusual check apical pulse for full minute

Measuring respiratory rate steps

• dont let them know your counting, they might change way of breathing

  • 30 seconds counted x2

  • check respirations are usual, if not count for full minute

Measuring BP steps (alot)

Make sure patient has rested 5mins and hasnt had caffiene or nicotine in last half hour before taking BP
Dont use arm with IV or cast, or side where there has been breast surgery or surgery in axillary area, or side with IV shunt or a diseased limb
Avoid extremity with anything messing with blood flow
elevate forearm to same level as heart and uncross legs so systolic pressure isnt falsely elevated
Find brachial artery (palpate location)
Line up artery marking on cuff with brachial artery and make sure needle is in zero mark
estimate sytolic pressure (puff up and look for where pulse dissapears then add 30 wait one minute and then take bp inflate to that number)
Make sure patients BP matchesd baseline. if abnormal wait one minute after cuff is released and measure again
make sure patient comfortable and dip

Putting on PPE steps

gown, mask, shield, gloves (extend gloves to cover cuff of gown)

Taking off PPE steps normal

gloves, shield, gown, mask (take off before leaving room, except if wearing respirator in which case take off outside)

Taking off soiled PPE steps

* Pull gown until ties in the back break with gloves on

* ball into bundle and pull gloves off same time

Putting on sterile gloves steps

ask if patient allergic to latex always good to double check

• check package make sure no expousres and not expired

• peel outside wrapper and take out inner package and place down with cuff end side closest to you

• open top flap first (away) then bottom and sides without touching inner surface

• put glove on dominant hand first

• grab inside at cuff with opposite and put hand in above waistline with fingers pointing down keep thumb pointing out and cuff unfolded

• Lift up from inside cuff with gloved hand to waistline and put other hand into glove

• Extend cuffs

• 
  

AC meaning

Before meals

PC meaning

after meals

IVPB and IVP

IV piggy back and IV push

hs meaning (DNU)

before bed

Stages of infection

Incubation stage, prodromal stage, acute illness, priod of decline, convalescense

Products with a minimum of 60% alcohol are effective against what

gram-positive and gram-negative bacteria, many viruses, and fungi .

Infection control bundles

Guidelines for practice that are bundled together to help prevent HAIs such as CAUTIs, CLABSIs, VAPs, and SSIs

What precautions is someone with MDRO on?

contact

Closed glove technique

Used to don sterile gloves using surgical asepsis after the individual has performed a surgical hand scrub and donned a sterile gown; hands are kept inside the sterile gown until gloves are donned.

Open glove technique

Used to don sterile gloves using surgical asepsis; gloves are touched directly with the hands.

Incubation stage

the client may not feel ill or have visible manifestations, but changes in pathology occur that might be detectable through laboratory or diagnostic tests. Incubation lasts from the time the client is exposed to the infectious agent until the first symptom appears. The incubation period is different for each infectious agent, and can last for seconds, minutes, hours, days, or weeks

prodromal stage

MOST INFECTIOUS the client begins having initial manifestations as the infectious agent replicates. These symptoms are nonspecific, such as fever, aches, poor appetite, and malaise

acute illness stage

that manifestations of a specific infectious disease process become obvious. This is also the stage where the infection is considered severe.

period of convalescense

the client returns to the previous or a new, balanced state of health. Some infectious diseases are severe enough that the client does not regain all previous functions and is left with lasting effects

Local infections vs Systemic

 Local infections are confined to one area of the body. These infections can be treated with topical antibiotics and oral antibiotics. Systemic infections start as local infections and then move into the bloodstream, from which they infect the entire body. Intravenous antibiotics and careful monitoring are both needed to treat systemic infections

Nuetrophils expected range and function

55-75% First responder to injury

• Eat bacteria (phagocytosis)

Lymphocytes expected range and function

20-40% Fight chronic bacterial infections

• Fight acute viruses

Monocyte expected range and function

2-8% Phagocytes that clean up tissue damage from injury or infection

• Produce interferon

• Enhance the immune response

Eosinophils expected range and function

1-4% Active in allergic reactions and parasitic infections

• Can perform phagocytosis

• Fight inflammation and infection

Basophil expected range and function

0.5-1% Release histamine, serotonin, and heparin

• Can perform phagocytosis

Nurse responsibilities regarding medications

Nurse is responsible for having up to date knowledge about medications and their purpose, route of action, route of administration, safe dosage range, side effects, adverse effects, toxic responses, percautions, and contraindications for each medication administered

Nurse responsibilities regarding medication administration

Understanding clients medical condition and medication history is key before administration
What medications are they currently taking
Do any of these interact with the medication you are preparing?
Does the client have any allergies
What physical assessments are needed before you can safely administer medication
* For example don't give beta blocker if HR is low

Rights of administration

Right patient
* two identifiers and readable ID band

• Right medication

  • compare to record and ask does it make sense, make sure its not expired and consult colleagues to learn essential facts about it

  • Never administer a medication another nurse prepared always assume its incorrect

• Right time

  • Medication before or after meals within 30mins of meals

  • Time critical meds like insulin or antibiotics need to be within 30 minutes of schedules time

  • Parameters of when it can safely be administered such as within 1 hour of scheduled time

• Right route

• Right education

• Right evaluation

• Right documentation

  • Don't document if refused and give reason as why it wasn't given

• Right to refuse

Types of Prescriptions

• Routine

  • prescribed for a specific time and frequency

• Standing

  • protocol based with list of directives for certain situations, like if someone has this you can give them this med stat

• Single

• Stat

  • One time immediately in a emergency, make sure to give within 30mins of prescribed time

• PRN (as needed)

• Urgent or ASAP

  • like stat

Common medication errors

Administering the wrong medication

• Administering the wrong medication strength

• Infusing the wrong IV fluid

• Diluting the medication with the wrong solution

• Calculating the dose or infusion rate incorrectly

• Administering the medication to the wrong client

• Administering a medication by the wrong route

• Administering medication at the wrong time

• Administering a medication when the medical record indicates the client is allergic to it

• Omitting a dose

• Administering a medication beyond its expiration date

• Erroneously discontinuing a medication or an IV fluid infusion

Just culture

Shifting from blame and punishment so people report errors more freely

Tools for Safe medication practice

• Drug name suffixes

• Tall Man letters

• High-alert medications

• Look-alike and sound-alike medications

• Error-prone abbreviations​​​​​​​

• ZEROS

  • Always use leading zero, never a trailing

  • Be familiar with ER abbreviations and common look alike and sound alike medication names

Medication reconciliation

• Document an accurate and comprehensive list (name, dose, route, frequency, and purpose) of home medications upon admission, which includes prescriptions, over-the-counter medications, and supplements.

• Compare the list of home medications to newly prescribed medications during the current hospitalization and reconcile any discrepancies.

• Update the medication list and repeat the comparison and reconciliation process at any transition of care during the client’s hospitalization and discharge.

• Communicate the reconciled medication list to the next care provider.

• Educate the client and caregivers upon discharge and provide the client with written information about their medication.

Medical asepsis general facts

* Clean technique

* hand hygiene

* wearing gloves

* PPE

* cleansing from least soiled areas to most soiled

* not putting soiled linens on floor

* holding soiled linen away from you

* making sure to dispose soiled linen in correct area

Surgical asepsis general facts

* sterile technique

* OR, labor and delivery and some nurse-led bedside procedures

* only sterile touches sterile

* open packages away from you

* hold sterile objects above the waist

* no talking, coughing, sneezing, reaching over, or turning away

* consider outer 1 inch of sterile field contaminated

*

COME BACK AND DO PRECAUTIONS AND WHAT DISEASES PER

Components of the infection cycle

* Infectious agent

* Reservoir

* Portal of exit

* Means of Transmission

* Portal of entry

* Susceptible Host

Common portals of exit

• Sneezing, Bleeding, Emesis (vomitting) Gastrointestional,

Different kinds of transmission

* Direct (with the person, touching, kissing, intercourse)

* Indirect (touching vector (alive) or fomite (not alive))

Endemic vs Pandemic

Inflammatory response

Helps the body neutralize, control, or eliminate offending agent
* can be acute or chronic

Factors affecting host susceptibility (if they dont have this its bad)

* intact skin and mucous membranes

* Normal ph membranes in GI/GU tract

* Body's white blood cell count is sufficient

* Age

* Immunization

* Fatigue, nutritional and general health status

* Stress level

* Use of invasive or indwelling medical devices (catheters, trachs, vents)

Lab data indicating infection

* normal WBC is 5-10k

* Increase in specific types of red blood cells

* Elevated erythrocyte sedimentation rate (ESR)

* Presence of pathogen in Urine, blood, sputum, or draining cultures

Doctors vs Nurses role

Doctors treat diagnosis, Nurse treats what it does to the body