295 Fundamentals

Tanners Clinical Judgement Model

Notice, Interpret, Respond, Reflect

Nursing Process

Assessment, Analysis, Planning, Implementing, Evaluation

Clinical Judgement Action Model

Recognize Cue

Analize Cues

Generate Hypothesis

Prioritize Solutions

Take Actions

Evaluate Outcomes

MASD

Moisture-Associated Skin Damage, look under skin, pannus, breast, clean gently, anti-fungal powder, smooth with gloves, wash patients hands

Maceration

MASD, soften and breaks down outer skin layer

Environmental cleaning

Side of bed (Wipe around edges), keyboard, doornobs, water bottle, cabinet, COW computer on wheels, light switches, phones, bedside table, side rails

Cleaner Purple: All purpose

Orange: Bleach C-Dff, gloves, let it dry

Have Hair Up!

Diabetic

To clean wound, don’t keep pouring hydrogen peroxide, kills healthy cells too

Therapeutic Relationships

Face to Face, get to know, take off armour, stethoscope, put them at ease, eye level, sitting down

Before showers your wounds should be

covered with adhesives, plastic wrap and tape

CHG bath Chlorhexidine Bath

Use no other soap or lotion, one cloth per body area, least to most contaminated, tubes, first 6 inches, air dry, it will feel sticky, but it’s the medicine doing its job

Oral care

Don’t use lemon Glycerin Swabs, don’t leave dentures in mouth overnight, put in solution and label container, with chemotherapy, rapidly dividing cells will die, hair, mucous, stomach, oral care

Diabetes, Peripheral neuropath, Vascular insufficiency

Reduction in blood flow to the extremities impairs healing and increases the risk of infection and loss of sensory, motor, and autonomic nerve function. Foot injuries in these patients can quickly turn into serious problems. Banging the toe or stepping on foreign objects. Foot ulcers can become infected quickly and lead to gangrene, increasing the risk for amputation. 

Ischemia

A medical Condition where a part of the body does not get enough blood flow and oxygen

Gangrene

Death of body tissue due to lack of blood flow or a serious bacterial infection

Xerostomia

Dry mouth/hyposalivation can cause fungal infection, risk of ulcerations and trauma, stomatitis (e.g., chemotherapy, radiation, dehydration, diabetes)

Abrasion

Clean & Prevent Infection

• Mild soap + water

• Dry gently

• Protect the area

• Monitor dressing for moisture

Dehydration or NPO status

Causes dryness and fragility of oral mucosa and increases the accumulation of secretions on the tongue and gums.

Nasogastric (NG) or oxygen tubes; mouth breathing

May cause medical device–related pressure injuries (MDRPI) from pressure or friction. Can also dry the oral mucosa and lips.

Chemotherapy

Damage rapidly dividing cells, including cells lining the oral cavity, which can cause oral ulcers and inflammation.

Radiation therapy to head and neck

Decreases salivary flow and lowers saliva pH, increasing risk for stomatitis and tooth decay.

Immunosuppression or altered blood clotting

Increases risk for inflammation and bleeding of the gums.

Diabetes mellitus

Increases risk for dry mouth, gingivitis, periodontal disease, and tooth loss.

Endotracheal intubation with mechanical ventilation

Increases risk for ventilator-associated pneumonia (VAP). Proper oral care reduces risk

Dialysis

Patients may experience oral pain, halitosis (Persistent bad breath), xerostomia (dry mouth), gingivitis, stomatitis, tooth decay, tooth loss, and jaw problems.

External medical devices such as casts, restraints, oxygen masks, and NG tubes

Pressure and friction —> medical device–related pressure injuries (MDRPI).

Medical adhesives used for ostomy appliances, dressings, and tubing

Repeated adhesive removal can cause medical adhesive–related skin injury (MARSI), including skin stripping, tears, maceration, dermatitis, inflammation, and tape burns.

Obesity

Skin breakdown and pressure injuries.

Reduced sensation from stroke, spinal cord injury, diabetes, or nerve damage

Patient may not feel excessive heat, cold, pressure, friction, or chemical irritants, increasing risk for unrecognized skin injury and pressure injuries.

Altered cognition from dementia, psychological disorders, or delirium

Patient may be unable to communicate skin-care needs or recognize prolonged pressure or exposure to urine, feces, or secretions. Requires frequent skin assessment.

Limited protein/calorie intake or reduced hydration

Impairs tissue synthesis and wound healing. Skin becomes thinner and less elastic, while dehydration decreases skin turgor.

Excessive secretions/excretions such as perspiration, urine, watery stool, or wound drainage

Causes maceration & Moisture-associated skin damage (MASD).

Vascular insufficiency

Inadequate arterial blood supply or impaired venous return decreases circulation and can cause tissue ischemia (medical condition where a part of the body does not get enough blood flow and oxygen), skin breakdown, and infection.

Oral hygiene in older adults

often overlooks, cognitive impairments or function risk of aspiration pneumonia

Corns

Cone-shaped, round and raised, refer to podiatrist, wear wider softer shoes

Athlete’s foot

Keep feet well ventilated, keep feet dry, between toes, foot powder, wear clean socks/stockings

Ingrown Nails

Swelling and pain, infection, avoid soaks with diabetes, proper nail-trimming techniques, refer to a podiatrist

Paronychia

Inflammation of tissue between the nail fold and nail plate, infection, warm compression, topical antibiotic, careful nail care/manicuring

Glossitis

Inflamed tongue

Cheilitits

Cracked Lips

Halitosis

Foul smelling breath

Edentulous

Without teeth, still assess gums and palate

Pediculoisis Capitis

Head lice, lice comb, medicated shampoo, 2 to three days, vacuum infest areas of home

Pediculosis Corporis

Body Lice, lay eggs on clothing and furniture, after bathe and shower thoroughly and skin is dried, apply recommended pediculicide lotion, after 12 to 24 hours take another bath or shower, bag infested clothing or linen until laundered in hot water, vacuum rooms thoroughly and throw away bags

Pediculosis Pubix

Crab lice Pubic hair lice, gray and white with red legs, shave, clean as body lice, if sexually transmitted notify partner

Alopecia

Hair Loss - Stop damaging hair (Teasing, picks, tight braids, excessive heat when blow drying)

CHG

Chlorhexidine gluconte (pink soap) feels sticky but declines the HAI health care-associated infection, it is becoming more of a standard practice across hospitals, safe to use on superficial wounds, abrasions, and rashes, and for perineal care. Not on deep wounds, only around. Can also be used in showers but don't rinse off

Use bath time for

Physically assessing the patient, range of motion exercises

Bathe older adults and infants

Only once or twice a week, prevent removal or protective skin oils

Cognitially impaired bathe refusal

Adapt bathing procedures and the environment to reduce triggers, example administer an order analgesic 30 minutes before a bath, be gentle with approach, keep patients body warm

Effleurage

(Back Rub) Reduced measured anxiety, heart rate, and respiratory rate, back massage 3 minutes and hand massages of 10 minutes significantly improve both psychological and psychology indicators of relaxation in older people

What to do for diabetics

Inspect feet daily, bottoms and tops, heels and toes, use a mirror or family member, wash feet in lukewarm water, dry thoroughly, between toes, avoid harsh chemicals or long soaks, do not soak the feet, well fitting shoes, clean dry socks at all times, no barefoot, apply lotion but no between toes, trim toes straight across and square file the edges smooth, improve blood flow by wiggling toes and moving ankles up and down for 5 minutes 2 to 3 times a day, do not cross legs for long periods of time and do not smoke, protect feet from hot and cold

Take care of those dogs

Peripheral Neuropathy

• Muscle wasting of lower extremities

• Foot deformities

• Soft tissue infection in lower extremities

• Abnormal gait

• Absent or decreased deep tendon reflexes

• Decreased response to vibratory, touch, or painful stimuli

Vascular Insufficiency

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• Decreased hair growth on legs and feet

• Absent or decreased pulses

• Infection of the foot

• Poor wound healing

• Thickened nails

• Shiny appearance of the skin

• Blanching of skin on elevation

Stomatitis

Inflammation of the oral mucosa, burning, pain, and change in food and fluid tolerance, brush gently, no commercial mouthwash, use normal saline once, 30 mL on awakening in the morning, after each meal, and bedtime help clean the oral cavity

Blood thinning medication shave

They have low platelet count need to use an electric razor

Never use CGH solution or clothes on

Eyes, ears, face & Deep Wounds

Eye care

If eyes dont close, eye patch, eye drops, unconscious patients need more eye care

Podiatrist or diabetic foot care specialist

Can recommend patient-specific foot care assessments and treatments for patients with PVD, diabetes mellitus, and foot ulcers. Your job is to make sure it’s clean

Clinical Judgement Measurement Model

Recognize cues 

Analyze cues

Prioritize hypothesis 

Generate solutions 

Take action 

Evaluate actions

How can you distinguish peripheral neuropathy from vascular insufficiency?

Neuropathy → sensation/reflexes/motor function

Vascular insufficiency → circulation/pulses/skin changes

How does acute illness affect hygiene care?

The patient may have temporary decreased strength, mobility, endurance, or cognition, requiring more assistance.

How does chronic illness affect hygiene care?

The patient may have long-term limitations requiring adaptations, education, and ongoing self-care strategies.

What is the Braden Scale used for?

Assessing a patient's risk for pressure injury/skin breakdown.

What is VAP?

Ventilator-associated pneumonia, a lung infection that can develop in patients receiving mechanical ventilation.

Why is oral care important for mechanically ventilated patients?

Oral care helps reduce oral bacteria and secretions, which can contribute to respiratory infection and VAP. Use CHG oral care

A patient slides down in bed. What type of skin injury force is involved?

Shear

What is the priority when providing hygiene to a patient with limited mobility?

Safety and prevention of injury/skin breakdown while maximizing independence.

What does hemiplegia mean?

Paralysis on one side of the body.

When should an assistive device be used for a transfer?

When the nurse would have to lift more than 35 lb (16 kg).

When is assistance especially important for transfers?

After prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma.

What is the correct walker elbow angle? Where should the top of a walker line up?

15–30°. With the crease of the inside of the wrist. Eyes ahead, stand tall, don’t lean forward, down and step in

How should a patient go UP stairs with crutches? going down?

Strong leg first. Down, lead with the bad, when sitting down weaker side have the more steady thing by

How far below the axilla should crutch pads be?

1½–2 inches or about 2–3 finger widths, wrist crease, 30-15 degrees, 6 inches around the crutches

When is a quad cane useful?

For patients with unilateral weakness, such as after a stroke. Wrist Crease, 15-30, Cane, Weak leg, Strong leg

What should you do if BP drops and the patient becomes dizzy when sitting up?

Have the patient sit for 2–3 minutes; if systolic BP drops 20 mmHg, return the patient to bed.

How do you calculate target heart rate?

60–90% of maximum heart rate, depending on provider recommendations. 220-age

Who must clear a patient before starting an exercise program?

The health care provider.

What should happen to BP after exercise?

It should increase and return within 1–5 minutes.

What are the 4 BMAT tasks?

Sit and Shake → Stretch → Stand → Step. it tests Strength, coordination, balance, tolerance, and ability to follow directions.

What is proprioception?

The body's ability to sense its position, movement, and location in space.

What is osteogenesis imperfecta?

An inherited disorder where bones become short, bowed, and deformed.

Hygiene’s Saves Lives

Ventilator Associated Pneumonia (VAP)

Catheter-Associated Urinary Tract Infection (CAUTI)

Central Line-Associated Bloodstream Infections (CLABSI)

Post-Op Wound Infections

Sepsis/Septic Shock

Certification

Training program, role, tasks (CNA, PCT, MA)

Are you trained to do this?

Licensure

Education, Degree, Passing National Example, Legal Accountability, Scope

Legally authorized and accountable

Unlicensed Assistive Personnel (UAP)

Untrained/Untested

What to consider before delegating

Legal, Routine, Judgement, Competence, Stability, Supervision

The RN delegates tasks but not

the nursing process

5 rights of delegation

1. Right task

2. Right Circumstances

3. Right person

4. Right supervision

5. Right direction and communication

It is not about trust; it is about legality, predictability, and accountability

High, Medium, Low Priority

ABC’s Airway, Breathing, Circulation

Emergency>Routine

Unstable>Stable

Acute>Chronic

Unexpected>Expected

Prioritizing Assessment First

Gather more information when assessment results would inform/change your next actions

Safety/Risk Reduction

Provide safe and effective care in the least restrictive manner possible

Different types of restraints

Physical - mittens, wrist

Environmental - tight sheets, bed rails (all 4)

Chemical Restraints - Sedation

Procedural/Situational Restraints - IV, Urinary catheters, Oxygen

Psychological/Socai Restraints (unethical) - no call light, ignoring

Preferences vs. Policy

Patients’ preferences > Policy

Patient-centered care, policy matters sometimes

Maslow’s Hierarchy

1. Physiological needs: air, water, food, shelter, sleep, clothing, reproduction

2. Safety needs: employment, security, resources, health, property

3. Love and belonging, friendship, intimacy, family, connection

4. Esteem, respect, self-esteem, status, recognition, strength, freedom

5. Self-actualization, desire to become the most that one can be

A patient expresses concern about recovery after a myocardial infarction (MI) followed by coronary artery stent placement what is the best response?

Encourage him to express his feelings ←-

Gait Belt

Belts with handles preferred, nurse walks on weaker side, not lift but leverage

Wheelchairs

Go backwards down a ramp, pressure relief