Normal Range
Temp
96.8° - 100.4°F
Normal Range
pulse
60/100 beat/min
Normal Range
RR
12-20 breaths/min
Normal Range
Pulse Ox
95%-100%
Normal Range
pain
scale from 0-10
Classifications of Pain
Cutaneous/Superficial
localized
short duration (needle stick)
Classifications of Pain
Deep Somatic/ Visceral
pain from internal organs
can diffuse/radiate
Classifications of Pain
Radiating
pain extending from 1-side to another
Classifications of Pain
Referred
pain is separate from the source
Classifications of Pain
Phantom
pain in a limb is NO longer there
Classifications of Pain
Psychogenic
brain causes pain when there is NO source
NONpharmacological interventions for pain
relaxation/guided imagery
music/humor
journaling
massages
cold/hot compress
Non-Opiod Analgesics
NSAIDS
Acetaminophen
Opioids
Narcotics
PCA pump
Adjuvant
antidepressants/anti-seizure
muscle relaxants
steroids
ABCDE
A-ask ab pain regularly
B- believe patient in their pain report
C- choose pain control options appropriate for patient
D- deliver interventions timely, logical fashion
E- empower patient and family
body’s reaction on UNRELIEVED pain
increased HR, BP and O2
increased cardiac workload
shallow breathing
depression/anxiety
When documenting pain, make sure you document…
pain assessment
pain management
patient response to pain & treatment
updated pain assessment
__A__DPIE
A
Assessment
gather information on patient’s condition
A__D__PIE
D
Diagnosis
what is the problem?
AD__P__IE
P
Plan
how do we fix the problem?
ADP__I__E
I
Implementation
put plan to action!
ADPI__E__
E
Evaluation
did the plan work?
PURPOSE of nursing diagnosis
classify health problems within the domain of nursing
What is a Nursing Diagnosis?
a statement of patient’s health status
NURSES can identify, prevent, and treat independently
Medical diagnosis
From a Doctor
defines a medical condition/disease/ or injury
TYPES OF NURSING DIAGNOSIS
Problem-Focused
based on response to existing problem
TYPES OF NURSING DIAGNOSIS
Risk diagnosis
increased potential for patient to develop a problem
TYPES OF NURSING DIAGNOSIS
Health Promotion
represents patient’s desire/motivation to improve their health
Formulating an ACTUAL DIAGNOSIS (3pts)
problem
related factors
defining characteristics
Formulating a RISK NURS. DIAGNOSIS (2pts)
problem
related factors
Classification of Priority
Emergent, Urgent, Non-urgent
ABC’s
Maslows Hierarchy
Chronic vs Acute
“SMART" acronym
for Goals
Specific
Measurable
Attainable
Realistic
Timely
Selection of Intervention
DARFCH acronym
__D__esired patient outcome
__A__cceptability to the patient (doing good by them)
__R__esearch-based knowledge (for intervention)
__F__easibility of intervention
__C__haracteristics of Nurs. Diagnosis
__N__urse competency
TYPES OF INTERVENTIONS
Nurse Initiated
independent
actions a Nurse initiates
TYPES OF INTERVENTIONS
Health- Care provider initiated
dependent
requires DR order
TYPES OF INTERVENTIONS
Collaborative
INTERdependent
required combined skill & knowledge
What is Direct Care?
treatments preformed through interaction WITH patient
What is Indirect Care?
treatments preformed away from the patient (but on behalf of the patient)
4 indicators for comprehensive evaluation
ECRU
__E__xamine results
__C__ompare achieved effects with goals
__R__ecognize errors
__U__nderstand patient situation
FACTORS INFLUENCING HYGIENE
social practices
ex: do you showering everyday?, wake up & brush teeth?, etc..
FACTORS INFLUENCING HYGIENE
socioeconomic status
can person afford hygiene products?
FACTORS INFLUENCING HYGIENE
developmental stage
look @ who the patient is
child/toddler
cognitive: is patient confused?
FACTORS INFLUENCING HYGIENE
physical condition
is patient physically able to clean themself?
partial bed bath
face, pits, ass, perineal area, feet, hands, etc..
CHG bath
antimicrobial bath
sitz bath
usually for women who just gave birth
or
patients with hemorrhoids
tub bath
usually only seen in long term care
What does patient need in order to be cleared for a shower
Need a physician’s orders
fall risk
what is infection
invasion of a susceptible host by a pathogen
Colonization
WITHIN HOST
NO tissue damage
NO active disease
Communical disease
able to MOVE from PERSON TO PERSON DIRECTLY
STAGES OF INFECTION
incubation
time it takes for infection to develop AFTER EXPOSURE
STAGES OF INFECTION
prodromal
AFTER INCUBATION → infection agents replicate/multiply
STAGES OF INFECTION
Illness
presence of specific signs/symptoms of disease
STAGES OF INFECTION
Convalescence
symptoms resolve, patient begins to return to normal function
TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS
exogenous
from OUTSIDE source (salmonella, tetanus, etc…)
TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS
endogenous
flora becomes ALTERED
OVERGROWTH occurs
caused by antibodies
TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS
Iatrogenic
due to invasive procedure
Physical/chemical barriers
skin, tears, mucus, cilia, stomach acid, urine, neutrophils
non-specific innate
barriers that keep harmful materials from entering your body
specific adaptive
antibodies that attack and destroy foreign invaders and are able to prevent disease in the future by remembering what those substances look like
CHAIN OF INFECTION
infection agent
pathogens
normal flora become infected
Virulence (ability to produce disease)
CHAIN OF INFECTION
reservior
Source of infection
location where that pathogens thrive (warm&dark)
anaerobic VS aerobic (requires O2 for growth)
CHAIN OF INFECTION
Portal of entry
how infection spread and exits
CHAIN OF INFECTION
Mode of transmission
contact
direct: touching, kissing, sex
indirect: doorknob (inanmiate object)
CHAIN OF INFECTION
Mode of transmission
droplet
water droplets inhaled/entered thru eyes
ex: cough, sneeze, inhaled sputum
CHAIN OF INFECTION
Mode of transmission
airborne
through particles in the air
ex: TB, COVID, measles
CHAIN OF INFECTION
Mode of transmission
vector
from a tick/mosquito bite
CHAIN OF INFECTION
Mode of transmission
Vehicle
from dirty instruments or needles & soiled linens
TRANSMISSION BASED PRECAUTIONS:
Contact precautions
private room
clean gown/gloves/face shield
double-bag linen
TRANSMISSION-BASED PRECAUTIONS:
Droplet precautions
same as contact precautions
clean gown/gloves/face shield/EYE PROTECTION/MASK
TRANSMISSION-BASED PRECAUTIONS:
Airborne precautions
same as contact
special room and mask
Protective Isolation
for ANY immunosuppressed patients
prevent spread of any microorganism to these patients
Protective Isolation precautions
room w/ air filters
avoid standing H2O (humidifier)
restrict visitors
How do you break the chain of infection
promote ASEPSIS
support Host defense
Medical Asepsis
state of being free from disease causing microorgansims
Surgical Asepsis
removing ALL microorganisms (used for sterile procedures)
cardiopulmonary structures
heart, blood vessels, trachea, lungs, and bronchi
cardiopulmonary functions
responsible for picking up & carrying O2 to cells
discarding CO2
Ventilation
movement of air IN and OUT the respiratory system
Perfusion
circulation of blood thru vessels or other natural channels
Exchange of Respiratory Gases
O2: bloodstream → lungs
CO2: lungs → blood
FACTORS THAT INFLUENCE OXYGENATION
physiological
cardiac disorder
respiratory alterations
decreased O2 carrying capacity
decreased inspired O2
increased metabolic rate
Hypovolemia
decrease in circulating blood volume results in hypoxia to body tissue
hyperventilation
ventilation in excess of that requires to eliminate CO2 produced by cellular metabolism
hypoventilation
alveolar ventilation inadequate to meet body’s O2 demand of to eliminate
Lifestyle factors
nutrition
lack of exercise
smoking
substance abuse
anxiety/stress
Environmental factors
air quality
urban VS rural
occupational hazards
developmental factors
premature infants (they ”forget to breathe”)
infants & toddlers (smaller shorter airways)
children & adolescents (2nd hand smoke, vaping, respiratory infection)
young/middle age adults (smoking?)
older adults (decreased muscle mass)
purpose of oxygen therapy
prevent/relieve hypoxia
Methods of O2 delivery
nasal cannula (NC)
oxygen mask
what is the % of O2 in room air
21%
Simple Mask
short term supply
6-12 L
35-50% O2
long term may cause skin breakdown
Venturi Mask
delivers precise concentration
4-12 L
24%-60% O2
Non-rebreather and Partial breather
for higher O2 concentration
10-15 L
60-90% O2
level of O2 will depend on PT’s overall health
reservoir bag should be filled with O2 @ all times
How do you liquefy secretions?
humidify O2 & offer fluids to patient
what does liquefying secretions do?
thins out secretions → this then allows patient to cough up secretions
Chest PT
helps loosen & move secretions so they can be coughed up
LUNG EXPANSION
Ambulation
change of position