saftey + infection + med administration + teaching + documentation

foundations of nursing concepts (NURS 411)

short term goal

something you can be specific with and can evaluate by the end of your shift with the patient

long term goal

something you can evaluate by the end of the patient’s hospital stay

contact isolation

blood borne contaminants, e-coli, MRSA, VRE, lice, scabies, herpes

gloves, gown, mask

contact enteric isolation

c-diff

gloves, gown, mask, goggles

droplet isolation

pneumonia, influenza, mumps, rubella, covid

mask and gloves

airborne isolation

TB (room with negative air pressure)

N95 mask and gloves

surgical asepsis

operating room, must maintain sterile field

never turn back away from sterile field, do not reach over sterile field, and sterile gloves do not go below the waist

medical asepsis

bedside care, deliver non-sterile care as cleanly as possible

ex. IV placement, NGT insertion/removal, straight cath

reverse isolation

for immunosuppressed patients, protects pt from outside germs, positive air pressure room and strict hygiene

cerebral cortex, cerebellum, basal ganglia

parts of the brain that involve balance and coordination?

what does lack of exercise produce in the metabolic/endocrine system?

negative nitrogen and calcium balance, fluid retention, decreased metabolism

what does lack of exercise produce in the respiratory system?

secretion pooling, atelectasis, pneumonia. It is important to patients to cough and deep breath to open alveoli.

(collapsed alveoli can develop into pneumonia)

orthostatic vital signs

3 sets of vital signs checked when pt is laying down, sitting up, and standing up

safety outcomes

risks will be detected and adressed, restore baseline status, increase knowledge base

in-patient fall prevention

room orientation, wires/tubing/linens, clear pathways, dry floors, non-skid footwear, adequate lighting, reminder signage, alert and oreintatedness of pt

restraint orders

must be documented, must get a new order every 24 hrs, document and assess skin + restraints every 2 hrs

physical restraints

devices or methods that physically limit a pts movement (ex. 3 bedrails max)

chemical restraints

medications used to control behavior or restrict movement

restraints in emergency cases

if pts or staff are in immediate harm, restraints can be obtained without an order

leather restraints are only used in the ED

medical order components

medication name, dosage, route, time, purpose

(ex. Phenergan 25 mg IM q6h prn nausea)

safe medication administration

right patient, right medication, right dose, right route, right time, right documentation

before giving medication

name + DOB, ask ab any allergies, vital signs before if required, document once given

after giving medication

check vital signs, check response, document outcomes

telepohone orders

must write telephone orders down and read order back to provider to clarify, chart that it was a telephone order (TORB)

transdermals (patches)

must wear gloves, document placement, date/time marked on patch

pharmacokinetics

absorption → distribution → metabolism → excretion

intradermal

medication injected directly under the epidermis (ex. TB testing)

subcutaneous injection

medications injected into fat (arm or belly) at either a 45 or 90 degree angle

(ex. insulin shot)

intramuscular injection

medication injected into muscle (arms usually), must give straight down (90 degree angle) to get to muscle

(ex. flu shot)

IV push/bolus

manually pushing medication through the IV (vein) under a certain period of time (usually short period)

infiltration

IV pulls out of vein and fluids leak to surrounding tissues causing swelling to limb

extravasation

IV pulls out of vein and medication from IV begin to leak into tissues and eat away at tissues causing damage

this can cause skin blistering, pain, or burning at the site

phlebitis

IV is in the vein but vein becomes inflamed causing redness to the site

deep vein thrombosis (DVT)

blood clot in a deep vein (usually the leg) cauing swelling to the limb

cellulitis

bacterial infection of skin and subcutaneous tissue causing very bad pain, redness, tenderness, and warmth to the limb

(happens with excessive scratching with diabetes pts)

appropriate documentation

Document as soon as possible

Use approved medical abbreviations only

Chart what you see, hear, measure

Use quotes for patient statements (“Patient reports chest pain 8/10”

Chart objective data before subjective opinions such as “pt was rude and drug seeking”

Use correct date & time for every entry

ideal setting for patient readiness to learn

quiet, private, not rushed, accommodate for sensory issues, positive feedback and repetition

cognitive learning domain

focuses on knowledge, thinking, and comprehension

does the pt understand? can they make connections?

affective learning domain

focuses on attitudes, feelings, and emotions (facial expressions)

how doe sthe pt feel ab this? what emotions will this invoke?

psychomotor learning domain

focuses on skill demonstration and motor actions

does the pt have the ability to perform the skill?

health + wellness (primary prevention)

prevent illness + early diagnosis/catch early (secondary prevention)

restore optimal health (tertiary prevention)

what does health teaching promote?

teaching documentation components

persons present for teaching, content taught, resources offered, patient validation of comprehension, pt progress follow up

saftey

A → airways

B → breathing

C → circulation