Foundations Comprehensive Final

Medical Asepsis (Clean Technique)

• hand hygiene

• PPE as indicated

• No items on the client’s floor

• Do not shake linens

• Cleans least soiled area first

• Place moist items in plastic bags

• Educate caregivers

Surgical Asepsis (Sterile technique)

• Avoid coughing, sneezing, and talking directly over field

• Only dry, sterile items touch the field (1 inch border is nonsterile)

• Keep all items above the waist within vision (do not turn back to sterile field)

• Wash hands and don sterile gloves, perform procedure

Chain of infection

Causative agent —> reservoir —> portal of exit —> mode of transmission —> portal of entry —> susceptible host

Standard Precautions

• Hand washing with appropriate product (soap/water and alcohol-based waterless)

• PPE as needed

Airborne precautions (agents less then 5 mcg)

• Measles, varicella, pulmonary, or laryngeal TB

• Negative pressure room

• Keep door closed

• N95 respirator

• Surgical mask to patient if leaves room

Droplet precautions (Agents > 5 mcg)

• streptococcal, pharyngitis, pneumonia, rubella, pertussis, meningococcal pneumonia

• PPE- mask, other as indicated

Contact Precautions

• spread by direct and indirect contact with body fluids

• Private room preferred, may be in room with patient with same infection

• Gloves and gowns worn by caregivers and visitors

• Infectious dressing material into nonporous bag

• Dedicated equipment for client and disinfect after use

• Leave room for essential reasons only

PPE Don order

• gown

• mask

• goggles/face shield

• gloves

PPE Doff order

• Gloves

• goggles/ face shield

• gown

• mask

Falls risk factors

• Older age

• History of falls

• Impaired mobility

• Cognitive and/or sensory impairment

• Bowel and bladder dysfunction

• Adverse effects of medications

Fall risk interventions

• Clutter free room

• Answer call lights promptly

• Nonskid footwear

• adequate lightening

• Bed in Low, Position, Wheels locked

• Chair or bed sensors

Restraints

• Reduce need/least restrictive

• Physical or chemical

• Remove physical restraints every 2 hours and assess neurovascular/neurosensory

• 2 fingers and tie to non-movable part of bed

• Provider notified immediately/ order renewed every 24 hours

Seizure precautions: pre-seizure

• Assess history

• Administer medications

• Rescue equipment: oxygen, oral airway, suction equipment

What to do during seizure

• Position for safety, remain with client

• If standing, ease to floor-protect head

• Do not put anything in pt. mouth

• Loosen restrictive clothing

• Administer medications as prescribed

Post-seizure requirements

• Protect airway

• Turn pt. to side

• Stay with pt.

• Notify PCP

• Document

What to do in case of fire

• (R) Rescue, protect, and evacuate pt. in immediate danger

• (A) Alarm: activate the alarm and report the fire

• (C) Contain: close doors and windows

• (E) Extinguish: Use correct extinguisher

Equipment safe usage

• Electrical equipment should be grounded

• No use of extension cords

• Inspect equipment for frayed cords

• Chemical agents and Radiation: nurses must know guidelines, signs - radioactive

Lift and transfers

• Assess mobility/strength

• Use assistance- mechanical lift and assistive devices

• Avoid twisting, use lower body

Positioning

• Transfer pt. bed to chair

• Reposition pt. in bed

Semi-fowlers position

30 degrees

Fowlers

45-60 degrees

High-fowlers

90 degrees

supine

laying on back

Prone

laying on stomach

Lateral side lying

lying on one side

Sims position

• semi-prone with pt. lying on left side

• Right knee and hip flexed

• Left knee and hip slightly extended

Lithotomy position

• Supine with legs separated

• legs flexed and raised in stirrups

Trendelenburg

Elevating the feet and legs of the patient above the level of the heart in the supine position

How to walk up stairs with crutches

• Up with unaffected leg

• Crutches move with affected leg

Walking downstairs with crutches

• Down with affected leg

• Crutches move with affected leg

How to use cane

• Unaffected side

• Move cane 6-10 inches, then move weaker leg, then stronger leg past cane

How to use walker

• Advance walker 12 inches

• Advance with affected lower extremity

• Contraindicated in pt. with Parkinsons

Stage 1 Pressure Wound

• Intact skin

• Non-blanchable redness

• usually over bony prominences

• Darkly pigmented skin have variance from surrounding tissue

Stage 2 Pressure wound

• Partial thickness loss of dermis

• Shallow, open ulcer with red-pink wound bed

• No slough

• May be intact or open/ruptured serum-filled blister

Stage 3 Pressure wound

• Full thickness

• Subcutaneous fat may be visible (NOT bone, tendon or muscle)

• Slough may be present

• May have undermining and tunneling

Stage 4 pressure wound

• Full thickness

• Exposed bone, tendon, or muscle

• Slough or Eschar

• Undermining and tunneling

Unstageable Pressure Wound

• Full thickness

• Bed of wound covered by slough or eschar

Deep Tissue Pressure Injury

• Dark maroon or purple

• May appear as blood filled blister

• Due often to shearing force

Intentional Wound

Surgical, controlled, sterile

Unintentional Wound

• Not purposeful wound

• Commonly caused by falls, crashes, fires, aspiration, burns, etc.

Acute wound

• Such as surgical incisions, usually heal within days to weeks

• Wound edges well-approximated

• Low risk of infection

• Usually progress through normal sequence of repair

Chronic wound

• Do not progress though the normal sequence of repair

• Healing process is impeded

• Wound edges are not approximated

• Risk of infection increased

• Normal healing is delayed (>30 days)

Open Wound

• Skin surface is broken providing a portal of entry for microbes

• Bleeding, tissue damage, increased risk for infection

• Delayed healing

• ex: incisions and abrasions

Closed wound

• Results from a blow, force, or strain caused by trauma such as a fall, assault, or crash

• Skin surface not broken

• Soft tissue damage

• Ex: ecchymosis and hematoma

Superficial Wound

• Ex: abrasion

• Skin and visceral linings of the body

Partial-Thickness Wound

• All or a portion of the dermis is intact

Full thickness Wound

• Entire dermis, sweat glands, and hair follicles are severed, which can expose muscle, tendon, or bone

Braden Scale Use

• Used to predict pressure injury risk

Braden Scale categories

• Sensory perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and shear

Skin integrity breakdown risk factors

• Age

• Nutrition

• Moisture

• Friction

• Sensation

Skin integrity breakdown Prevention

• Position

• Nutrition

• Moisture

• Dressings/treatment

Serous Drainage

• Composed primarily of the clear, serous portion of the blood and from serous membranes

• Clear and watery

Sanguineous Drainage

Consists of large numbers of RBC and looks like blood

Serosanguineous Drainage

A mixture of serum and red blood cells

Purulent Drainage

Made up of WBC, liquefied dead tissue debris, and both dead and alive bacteria

Sensory deprivation causes

• Environmental

• Inability to receive stimuli

• Inability to process stimuli

Sensory Deprivation Assessment

• Ability to concentrate

• Mood

Sensory Overload Cause

• Increased internal stimuli (pain, tubes, worry, decisions)

• Increased external stimuli (lights, noises, strangers, intrusive procedures)

Sensory Overload Assessment

• Agitation, confusion, hallucinations

• Crying, irritability, panic, depression, apathy

Encephalopathy

Term for any diffuse disease of the brain that alters mental function

Encephalopathy common causes

• Infections

• Kidney Failure

• Diabetic ketoacidosis

• autoimmune disorders

• brain tumor

Delirium

• Acute state of confusion

• Sundown syndrome

Sundown Sydrome

A state of confusion occurring in late afternoon and into the night

Delirium Causes

• Advanced Cancer

• Alcohol or drugs

• Dehydration or electrolyte imbalances

• Hospitalization

• Medicines

Dementia

Cognitive decline

Alzheimer’s disease

• Plaques and tangles forming in the brain

• A type of dementia (most common form)

• Destroys memory and other mental functions

Vascular dementia

• Damage to blood vessels in the brain

• Experience physical symptoms early on. Reasoning/judgement in earlier stages, memory loss in later

• Caused by multiple strokes

Preoperative phase

• Informed consent (nurse witness only)

• Assess allergies/verify NPO status

• Diagnostic Tests

• Client education

• Medications: hold anticoagulants for 7-10 days prior to surgery

• Incentive spirometry

• Turn, cough, deep breath

• Early ambulation, including leg exercises

Intraoperative Phases

• Universal protocol

• Conduct a pre-procedure verification process

• Mark procedure site

• Perform a “time-out” before starting procedure

• Safe environment

• Strict asepsis

Postoperative phase

• immediate recovery period

• Respiratory: verify airway/gag reflex, assess breath sounds, encourage cough and deep breathing

• Circulatory: vitals, assess tissue perfusion

• Neurological: Level of consciousness, assess reflexes and movement

• GU: Monitor I&O, assess urinary output

• GI: assess bowel sounds, asses for abnormal distention

• Integument: assess color, wound, drainage insertion sites

Allopathic Medicine

Traditional medical care

Complementary health approaches (CHA)

interventions that can be used with conventional medical interventions and thus complement them

Medication administration RN

• Assess allergies

• Current medication regimen

• 6 rights of medication administration ( pt., medication, dosage, time, route, documentation)

Drug monitoring

• Side effects

• ADR

• Therapeutic drug levels

• Peak levels: Oral 1-2 hours, IM 1 hour, IV 30 minutes

• Trough level: lowest concentration, 15 minutes prior to next scheduled dose

• Culture and sensitivity

Pain descriptors

• Timing

• Severity

• Duration

• Quality

• Location

• Associated factors

Pain Scales

• FLACC (children)

• FACES

• comfort

• numeric

Nursing process

• Recognize cues

• Analyze cues

• Prioritize hypotheses

• Generate solutions

• Take action

• Evaluate outcome

Function of Kidney

• Regulates acid-base balance

• Regulates fluid and electrolyte balance

• Excretes waste and regulates BP

• Minimum urine output 0.5 ml/kg/hr

Polyuria

Production of abnormally large volumes of dilute urine

Proteinuria

Elevated protein in urine

Anuria

No urine

Dysuria

Difficulty urinating

Nocturia

Increased need to urinate at night

Oliguria

Abnormally small amounts of urine (<300 mL)

Urine urgency

• Sudden, intense need to pass urine

• Cannot delay

Urine frequency

The need to urinate more often

Glycosuria

Sugars in urine

Routine Urine Specimen

• Pt. void into a bedpan or collection device on the toilet

• Don’t place tissue into urine

Clean-catch urine collection

• Pt. wipes with antiseptic and cleans meatus

• Pt. voids small amount into toilet

• Pt. voids into cup

• Cup should not touch skin

Sterile urine collection

• Catheterization of pt. bladder

• Taking specimen from already existing indwelling catheter

Urinary diagnostic tests

• UA: clean catch, sterile, culture

• Function test: BUN, creatinine, 24 hour creatinine clearance test

Stress incontinence

• Involuntary leakage of urine with sudden movement, coughing, sneezing, laughing

• Increased intra-abdominal pressure

Functional Incontinence

Inability to reach toilet

Total incontinence

Continuous and unpredictable loss of urine

what percent TBW adults

50%-60%

What percent of TBW infants

75-80%

How much of body fluids is intracellular

2/3

How much of body fluids is extracellular

1/3

2.2 pounds of body weight is how many L of fluid

1 L

Causes of fluid volume deficit

• Excess GI/renal loss

• Diaphoresis

• Fever

• Long term NPO

• Hemorrhage

• Aging