NSG-119 Exam 1

Evidence-based practice

-gives the patient the safest and the best research care.
-uses patient preferences, research, and clinical experience
-Gives best practices + research
-Always based on the patient

Evidence-based practice steps

1. Ask a question.
2. Find information/evidence to answer the question.
3. Critically appraise the information/evidence.
4. Integrate appraised evidence with clinical expertise and patient preferences
5. Evaluate

Communication

-SBAR: situation background assessment recommendation
-TeamStepps: communication that is designed for safety and quality
-No medical slang
-Empathy
-Communicate everything you do with the patient
-Even they are not alert and oriented

Ethical and legal

-The code of ethics outline standards and expectations of professionals' behavior (ANA)
-Standards of care
HIPAA
ADA
PPACA

autonomy

independence

Beneficence

Doing good, best interest for pt

nonmalefcence

do no harm

fidelity

faithfulness; loyalty, no abandonment no matter the situation

veracity

truthfulness

social justice

fair treatment of all people in a society

4 basic principles of ANA code of ethics

-responsibility
-advocacy
-accountability
-confidentiality

Clinical judgment

demonstrated when a nurse develops the ability to analyze collected data via critical thinking, apply reasoning to that data (which reflects clinical reasoning), and make an appropriate decision basedon the context of the specific situatio

Clinical reasoning

using critical thinking to examine and analyze patient care issues. It involves understanding the medical and nursing implications of a patient's situation when making decisions regarding patient care.

Critical thinking

your ability to focus your thinking to get the results you need in various situations, has been described as knowing how to learn, be creative, generate ideas, make decisions, and solve problems.

NCSBN CJMM 6 step process:

1. Recognize cues (similar to assessment)
2. Analyze cues (similar to assessment)
3. Prioritize hypotheses (similar to Diagnosis)
4. Generate solutions (Similar to Planning)
5. Take action (similar to Interventions)
6. Evaluate outcome (similar to Evaluation)

Critical thinking - QSEN competencies:

-Patient-centered care
-Safety
-EBP
-Informatics
-Teamwork and collaboration
-Quality improvement

Safety and quality improvement

-Quality improvement (QI) programs involve systematic actions that monitor, assess, and improve health care quality.
-The joint commission - sentinel events
-Quality safety education: knowledge, skills, attitudes
-Models
-PDSA
-FOCUS-PDCA
-DMAIC
-Assessments
-ANA
-QSEN
-Joint commission
-To improve healthcare, condition of patients, and safety for nurses

What can you delegate

-Activities of daily living
-Hygiene
-Linen change
-Routine
-Documenting input/output
-Positioning
-Vitals on stable pt
-Safe ambulation
-always have to follow up

5 rights of Delegation

-Right task
-Right circumstance
-Right person
-Right communication
-Right supervision

Active immunity

You make your own antibodies to fight the pathogen
-long lasting

passive immunity

you get antibodies from a different organism, you don't make your own antibodies
-short lasting

natural passive immunity

immunity acquired from antibodies passed in breast milk or through placenta

artificial passive immunity

immunity gained through antibodies harvested from a person or animal

natural active immunity

immunity gained through illness and recovery

artificial active immunity

immunity acquired through a vaccine

Type I: anaphylaxis

-Most common type

-Cause: increased production of immunoglobulin E (IgE) antibody class

-Angioedemia

-anaphylaxis

-Swelling

-Sore throat

-Wheezing

-Normal but overreactive response

Type II: Cytotoxic Reactions

-Cause: Body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them
-Clinical examples
-Hemolytic anemias
-Immune thrombocytopenic purpura
-Hemolytic transfusion reactions
-Goodpasture's syndrome
-Drug-induced hemolytic anemia

Type III: Immune Complex Reactions

-Cause: Excess antigens cause immune complexes to form in blood ➡ Circulating complexes lodge in small blood vessels ➡ Deposited complexes trigger inflammation, resulting in tissue or vessel damage
-Sites: Kidneys, skin, joints
-Clinical examples
-Rheumatoid arthritis
-Systemic lupus erythematosus

Type IV: Delayed Hypersensitivity Reactions

-Local collection of lymphocytes and macrophages causes edema, induration, ischemia, tissue damage at site
-Clinical examples
-Positive purified protein derivative
-Contact dermatitis
-Poison ivy skin rashes
-Local response to insect stings
-Tissue transplant rejection
-Sarcoidosis

Nursing care for clients with altered immune response

-KEEP AIRWAY OPEN
-wear a bracelet
-LAB: IgE, CBC/diff, Basophils, lysophils
-ASK: "are you allergic to anything or have you been exposed"
-What they are taking
-Hand hygiene
-Masks
-Patient corhorting
-Precautions
-We can hurt them and they can hurt them but its mostly us hurting them

Pathophysiology of the excessive immune system response.

-B lymphocytes= bone marrow and produce antibodies
-T lymphocytes= thymus and is for immunity to viruses, tumors, fungi
-Immunoglobulins: igG most abundant,
-igE in anaphylaxis
-Releasing iGE and attaches to a mast cell
-Body starts to develop swelling and inflammation
-Inflammation: pain, redness, swelling, loss of function, warmth

Management of anaphylactic reaction

-remove exposure
-epinephrine
-IV steroids
-AIRWAY OPEN
-rapid fluid replacement
-call rapid response team

Pathophysiology of the reduced immune system response.

-CD4-T is the target cell for HIV
-normal WBC count = 5000 and 10,000 cells/mm3
-Normal levels of CD4 is 600-1500
-HIV caused a decrease in CD4 levels
-CD4+ count is below 200/mm3 = opportunistic infection

Nursing care for clients with HIV/AIDS

-coping (emotional)
-consistently taking medications as prescribed
-safe sex (condoms/absence)
-lower stigma (you can only get It through bodily fluid)
-collect a thorough history

Collaborative care for clients with HIV/AIDS

-dietitian (pt may lose weight)
-infectious disease
-pt
-family
-case/social worker
-Infectious disease control

Opportunistic diseases associated with AIDS

-CD4-T count less than 200 = opportunistic infection
-Kaposi's sarcoma
-Esophageal candidiasis (thrush)
-Meningitis
-toxoplasmosis
-Candidiasis
-Cervical cancer—invasive
-Cryptococcosis
-Cytomegalovirus
-Interstitial cryptosporidiosis—chronic
-Mycobacterium avium complex
-Non-Hodgkin lymphoma (certain types)
-Pneumocystis jirovecii pneumonia
-Tuberculosis

Complications associated with long-term treatment of HIV infection.

-Acute infection: flu-like symptoms, 2-3 weeks after infection
-Asymptomatic infection: symptoms are absent or vague
-Symptomatic infection: CD4-T cells are closer to 200
-AIDS after being left untreated
-Immunocompromised
-Can get new conditions
-Memory deficits (AIDs)

Assessment of functional health status of clients with altered immunity

-Ask them if they are able to do things
-Shortness of breath?
-Tiredness - "hard time falling asleep?"

Labs tests nurses should run for HIV/AIDS

-Lymphocyte counts

-CD4+ T-cell and CD8+ T-cell count

-Antibody tests

-ELISA

-Western blot

-Home tests (e.g., OraQuick In-Home HIV test)

-Viral load testing

-Blood chemistries,

-CBC with differential

-stool testing, biopsies

-Altered liver function (LST)

Chain of infection

-infectious agent (bacteria)
-reservoir (wound)
-portal of exit (coughing, blood)
-mode of transmission (hands)
-portal of entry
-susceptible host (immune compromised)

Preventing transmission of infection

-WASH HANDS
-Clean equipment
-Being sterile
-Standard precautions
-Infection prevention and control: patient safety
-Safe injection practices
-Handling specimens for culture
-Urinary catheters and drainage sets
-Wound cleaning
-Perineal care after toileting
-Handling Dirty Linen
-Central LIne Care
-Maintain skin integrity

What is a HAI?

an infection that a patient acquires from the hospital 24-74 hours after admission

Endogenous HAI

from patients flora

Exogenous HAI

from outside the patient (healthcare workers, tubes, implants)

Major sites for HAI infection:

-surgical (planned or emergency)
-traumatic wounds
-Urinary and respiratory tracts
-Blood stream

what are examples of HAI?

-UTI
-pneumonia
-catheter-associated urinary tract infection (CAUTI)

Lab/diagnostics for surgical infection

-WBC (5000-10,000)
-Culture (blood, urine)
-ESR

Population at risk

-pt with catheters
-very young/old
-Not always the age it depends on what is going on with them
-recent surgery
-immunocompromised
-malnourished (give proteins, vitamin A, C, zinc)
-Have drainage tubes or catheters, intravenous cannulas, or other invasive devices

Nursing care for clients with surgical wounds

-Using sterile technique (1 inch non sterile border)
-never shake always lay down
-never lay on a moist area
-always be ready to use the sterile field
-fluid flows in the direction a gravity

Collaboration to promote wound healing

monitor glucose (70-140)
monitor for signs of infection
-redness
-temp
-smell
-drainage
-Nutrition: protein
-Albumin level
-Medications we might need = provider
-The patient = teach them
-Look at the dressing
-Clean it
-Smells

Signs of infection

-Redness
-Swelling
-Distension
-purulent drainage
-Fever
-Altered vital signs
-lowered/elevated WBC = sepsis

Complications of wound healing

-infection
-dehicence- surgical site opens
-evisceration- intestines come out (medical emergency, never leave, call for help, keep moist and sterile)
hemorrhage
-hematoma
-geriatric have a higher risk of sepsis due to no signs and symptoms

Management of infected wound

-keep wound moist and clean
-never allow to dry
-debridement may be necessary
-granulation and re-epithelializion
-dressings: wet-dry, hydrocolloid
-topical antimicrobials used with caution

What do you get during Stage 3 of an HIV infection

AIDs

what is sanguineous?

blood and clear drainage

What is serous?

clear/watery drainage

what is purulent?

containing pus

Normal for the surgical site in 24 hours

-Redness
-Warmth
-Swelling

Develops safe care

-ANA
-Jayco
-hospital is following safety codes
QSEN
-Safety for pt and ourselves

Evidence based practice with cultures

-Dignity
-Social justice
-Understanding there culture and asking questions
-Be conscious of biases

Professionalism autonomy

-Independence
-Let pts know the plans

Not allowed to sgn off on advance directives or power of attorney

Next step: educate them, involve social workers

Type 1 anaphylaxis:

-Most life threatening
-Overactive immune response
-Call rapid response

How to find if someone has Allergies

-Ask them
-Medcal records
-Allergy bracelet
-Skin test
-Positive if swelling/itching at the site

Emergency Care of the Patient with Anaphylaxi

immediately assess respiratory status, airway, oxygen saturation
-call rapid response team
-ensure intubation and trach equipment is ready
-apply oxygen using a high-flow, nonrebreather mask at 90%-100%
-immediately discontinue IV drug or infusing solution but DO NOT take out the IV. Instead, change the IV tubing and hang normal saline.
-be prepared to administer epinephrine IM. Repeat drug as needed every 5-15 minutes until pt responds.
-keep head of bed elevated about 10 degrees if hypotension is present and 45 degrees it BP is normal to improve ventilation
-rase feet and legs
-stay w/ pt
-reassure pt that appropriate interventions are being instituted

Altered immune system we have to worry about

infections

what we have to do for pts with an altered immune system

-masks
-corhorting

Taking care of pts with surgical wounds

-Protein
-Sterile technique

If you Suspect infection

-Assess the wound first
-Clean it
-Cultures and sensitivities BEFORE antibiotics

What does the sensitivity do

What antibiotic works

Primary intention

edges brought together with skin lined up in correct anatomical position

secondary intention

requires gradual filling in of dead space with connective tissue

Tertiary intention

delayed closure; high risk for infection with resulting scar

local infection

An infection that affects only one body part or organ

systemic infection

affecting the entire body, rather than a single organ or body part

Inflammatory response because of infection

-Pneumonia
-Steroids and antibiotics
-Tuberculosis
-Arthritis
-COVID
-Meningitis
-Cancer patients

Cells that get activates in inflammatory response

-T cells
-B cells
-WBCs
-IgE

Have to turn NG tube off when giving meds

Pt will vomit if you dont and it will aspirate the pt

Reasons for NG tube

-Trying to decompress the stomach
-EX: bowel obstruction - blockage
-LIS = low intermittent suction
-monitor what the canister pulls up
-if you pull out too much = electrolyte imbalance and alkaline

Biggest thing we utilize to prevent infections for entering out bodies

-skin
-muscus membranes

populations we should be worried about for HAIs

-Post surgery
-Older people
-Uninsured people
-Immunocompromised
-Transplant pt
-Diabetic (heal slower + glucose spikes)
-Insulin (sliding scale)