Funds Exam 3

Specimen Collection Steps

1. Verify the order (right patient, right test, ect.)

2. Patient identification and education

3. Hand hygiene

4. collect the sample

5. label AT THE BEDSIDE (avoid errors)

6. transport the sample to the lab

Imaging Study Steps

1. Verify the order

2. Patient identification and education

3. Prep as needed for the ordered test

4. Monitor the patient as needed post test

Type and Screen Blood Test

• Have two nurses during a “type and screen” blood test

• Verify the patient

• Verify where the blood is coming from

• BOTH NURSES SIGN the tube of blood

WBC Count (WBC) value

5,000-10,000 mm³

Hemoglobin (Hgb) value

12-18 g/dL

Hematocrit (Hct) value

40-50 %

RBC Count (RBC) value

4.2-5.9 million mm³

Platelet Count value

100,000-400,000 mm³

Complete Blood Count (CBC)

• WBC Count

• Hemoglobin (Hgb)

• Hematocrit (Hct)

• RBC Count (RBC)

• Platelet Count

Differential

• Extension that includes the WBC

• Neutrophils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• Band Forms

WBC

• low WBC means immunosuppression which is inability to fight infection

  • put patient on room precautions

  • Reverse Isolations = dawning PPE for the patient’s safety (not the nurses)

    • NEED an order to do

• high WBC means infection and your body’s actively fighting something

Platelet

• low platelet count means they can’t control their bleeding

  • not appropriate time to do difficult ADLs, soft toothbrush, no shaving, cutting toenails

Sodium value

135-145 mEq/L

Potassium value

3.5-5 mEq/L

Blood Urea Nitrogen (BUN) value

8-20 mg/dL

Creatinine value

0.7-1.4 mg/dL

Basic Metabolic Panel (BMP)

• Sodium

• Potassium

• Blood Urea Nitrogen (BUN)

• Creatinine

• 8 components

Complete Metabolic panel (CMP)

• 14 components

Critical Values

• require immediate action

• first: assess patient

• then: notify provider and give SBAR

• Read back results on a call and REPEAT the numerical values

• it is a nurse’s obligation to NOTIFY PROVIDER if you receive critical values

Coagulation Studies

• Prothrombin Time (PT)

• International Nurmalized Ration (INR)

• Partial Thromboplastin Time/ Activated Partial Thromboplastin Time (PTT/aPTT)

Prothrombin Time (PT)

• 10-13.1 seconds

International Nurmalized Ration (INR)

• 0.88-1.16 seconds

• 2.0-3.0 for anticoagulation therapy

• 2.5-3.5 for mechanical heart valves

What do anticoags meds do to International Normalized Ratio (INR) and Prothrombin Time (PT)

Anticoagulants increase IRN and PT

Partial Thromboplastin Time/ Activated Partial Thromboplastin Time (PTT/aPTT) (heparin drip)

• 27.5-37.4 seconds

• Heparin therapy monitoring ref range: 58-99 seconds

Blood Cultures

• Draw 1st

• 15 minutes apart

• on one extremity, 15 minutes later do it on another extremity

Blood Cultures

• First draw aerobic bottle

• Then go to anaerobic to not add any air into the bottle

• “AE before AN”

• Germs can grow with or without air so know the type of infection you’re dealing with

Blood Tubes

• Do blue first because it needs to be filled to the top

  • Coagulation tests NEED to be filled to the top

  • 3.2 Sodium citrate additive

  • prevents blood from clotting by binding calcium

• Lavender/Pink

  • Hematology and blood bank

  • Potassium EDTA additive

  • prevents clotting by binding calcium

Changes in potassium?

• think about heart and use telemetry monitoring

24-Hour Urine Collection

• Void in bedpan

• Avoid toilet paper

• DO NOT have bowel mvmt in the bedpan

• note start time because the next nurse needs to know when to end 24/h

Radiography Types

• X-rays

• CT scans

• MRIs

• Ultrasound

X-rays

• obstructions, strictures, fractures, ect.

• No contrast used

  • ask patients if they’re allergic to shellfish

• emits radiation

  • do not use during pregnancy

• normal = negative

• positive = problem

CT Scans

• Cross-sectional images of bone and tissue

• May use oral or IV contrast to illuminate images

  • may or may not use contrast

• Emits radiation

• Normal = negative

• order BUN and Creatinine because you want the patient to be able to excrete the contrast in their urine output

MRIs

• Detailed anatomic views

• No radiation emitted

• May use IV contrast to illuminate images

  • may use contrast

• Normal = negative

• NO METALS

  • implanted devices

  • pacemakers

  • piercings

  • no wheelchair

  • need oxygen? NO oxygen tank

Ultrasound

• visualizes organs, soft tissue, blood flow through vessels, etc.

  • KIDNEYS, Carotid arteries, legs for DVT

• No contrast used, no radiation

• Normal = negative

• If we have limitations regarding radiation or contrast, we wan’t to know out options so use an ultrasound

Activities of Daily Living (ADLs)

self-care activities such as bathing, dressing, toileting, transferring, continence, feeding

Contractures

• permanently contracted state of a muscle

Footdrop

• complication resulting from extended plantar flexion

Instrumental Activities of Daily Living (IADLs)

• the activities of daily living needed for independent living such as managing finances and meal preparation

Isokinetic exercise

• exercise involving muscle contractions with resistance varying at a constant rate (muscle contraction with resistance)

Isometric exercise

• exercise in which muscle tension occurs without a significant change in muscle length (muscle contraction without shortening)

Isotonic exercise

• movement in which muscles shorten (contract) and move (muscle shortening and active movement)

Range of Motion

• complete extent of movement of which a joint is normally capable

AM Care

• Before Breakfast

  • assist patient with toileting

  • wash face and hands

  • provide mouth care

  • cluster your activities = do skin assessment and wound care with AM CARE

• After Breakfast

  • 3Ps = pain, potty, positioning

  • toileting (every 2-4 hours after breakfast)

  • oral care

  • bathing (can delegate)

  • special skin measures

    • discourage the use of powders unless prescribed

  • hair care (shampoo and condition)

    • stay away from shaving patient’s face

  • dressing

  • positioning for comfort

  • refreshing or changing bed linens

  • tidying up bedside

  • lotions should be non-scented, ph-balanced, sensitive

    • can delegate to a PCT, but if patient has ointment that’s a med, CAN’T delegate

Encourage independence when possible?

Yes!

Don’t eat lying down

• elevate head of the bed if they have an NG tube to avoid aspiration after AM Care

• lock the bed

• lower the bed when you leave

• call bell within reach

• personal items close by

As Needed Care (PRN) & Hour of Sleep (HS) Care

PRN

• offer individual hygiene measures as needed

• change clothing and bed linens of diaphoretic patients (over sweating)

• provide oral care every 2 hours if indicated (ESPECIALLY if unconscious)

HS

• offer assistance with toileting, washing, and oral care

• offer a back massage

• change any soiled bed linens or clothing

• position patient comfortably

• ensure that call light and other objects patient requires are within reach

Regular Pans vs Fracture Pans

• Difference in hip height

• RAISE BED TO WAIST LEVEL

• patients with hip/spinal/neck fractures

Eye Care

• clean from inner to outer canthus with wet, warm cloth, cotton ball, or compress

• use artificial tear solution or normal saline q4H if blink reflex is absent (unconscious patients)

• care for eyeglasses or contact lens, if indicated

• for matted eyelashes, use warm compress

Ears & Nose Care

• wash external ear with washcloth-covered fingers

  • NO Q TIPS, just outer ear!

• perform hearing air teaching and care if indicated

  • do no lose, expensive

• remove crusted secretions around nose by applying warm, moist compress

  • DO NOT trim nose hairs, ask them to blow their nose to clean

Hair Care

• Note any history of hair/scalp problems

  • dandruff, hair loss, baldness, alopecia

• Shampoo and groom hair

Can nurses remove contacts?

Yes!

• raise upper and lower lids and squeeze down

Foot Care

• avoid soaking the feet (get’s rid of moisture and a fall precaution)

• dry feet thoroughly, including the area between the toes

• moisturize the feet if they are dry

• anti-fungal foot powder if necessary

• avoid using scissors or nail clippers

• consult a podiatrist

• wear appropriate footwear

• wear cotton socks

• avoid using heating pads

Effects of exercise on body systems

• Neurological

  • dec Anxiety/depression

  • dec Dementia

  • dec Risk of stroke

  • inc Cognitive function

• Endocrine

  • dec Weight

  • dec Diabetes

  • dec LDL

  • inc HDL

• Cardiovascular

  • dec mortality

  • dec coronary artery disease

  • dec blood pressure

  • cardiac rehab

• Oncological

  • dec prostate cancer

  • dec breast cancer

  • dec bowel cancer

• Musculoskeletal

  • dec osteoporosis

  • dec falls

  • dec disability

• Encourage exercise, whatever form they can!

• Helps with constipation

Types of Exercise

• Muscle Contraction

• Body Movement

Muscle Contraction

• Isotonic

  • muscle shortening and active movement

• Isometric

  • facilitated exercise, muscle contraction without shortening = yoga

  • sitting position is isometric

  • extended plantar flexion = foot drops forward, prevent by exercise even while in bed, ask them to dorsiflex and then do a plantar flexion

• Isokinetic

  • muscle contraction with resistance

  • rehab

Body Movement

• Aerobics

• Stretching

• Strengthening and endurance

• Movement and ADLs

  • housework, caring for a playful toddler, climbing stairs vs. elevator

General Ease of Movement

normal findings

• body movements are voluntarily controlled (purposeful)

• fluid

• coordinated

Gait and Posture

normal findings

• head erect, vertebrae are straight

• knees and feet point forward

• arms at side with elbows flexed

• arms swing freely in alteration with leg swings

• while one leg is in the stance phase, the other is in the wring phase

Alignment

normal findings

• independent maintenance of correct alignment

• in the standing and sitting position, a straight line can be drawn from the ear through the shoulder and hip

• in bed, the head, shoulders, and hips are alligned

Joint structure and function

normal findings

• absence of joint deformities

• full range of motion

Muscle mass, tone and strength

normal findings

• adequate muscle mass, tone and strength to accomplish movement and work

Endurance

normal findings

• ability to turn in bed, maintain correct alignment when sitting and standing, ambulate, and perform self-care activities

NANDA Nursing Diagnoses: Activity

• activity intolerance

• impaired transfer ability

• risk for activity intolerance

• risk for constipation

  • because they are not moving around

• risk for injury

  • footdrop can be an injury

Nursing Interventions: Activity

1. Ergonomics to prevent injury

2. Safe patient handling and movement

   • Safe transfer, equipment and assistive devices

   • gait belts, transfer devices, lifts

3. Positioning patient in bed

   • devices for correct alignment

     • foam wedges and pillows, trapeze, foot board or shoes (footdrop), hand roll, trochanter roll

     • can use special shoes for footdrop

     • offloading pressure, maintaining a specific position

   • protective positioning

     • repositioning q2H

trochanter roll

don’t have contracture of the hands, use a washcloth

Safe Handling of Patient with Dementia

• Communication problems and weakness

• Face the patient when speaking

• Use clear, short sentences,

• call patient by name

• use calm, reassuring tone of voice

• offer simple, step-by-step instructions

• phrase instructions positively

  • don’t use the word “DON’T”

• ask one question at a time, allow the patient to answer

• identify the patient’s established patterns of behavior

Nursing Interventions: Activity

• using graduated compression stockings (remove when bathing)

• move a patient up in bed

• moving a patient from bed to stretcher or chair

• assisting with active/passive ROM exercises

• assisting with ambulation

  • isometrics, dangling, 1-person assist, 2-person assist

  • walkers, canes, crutches, braces

    • MUST be prescribed by a provider

• dangling to prevent orthostatic hypotension

Evaluation: Activity

• general ease of movement and gait

• body alignment

• joint structure and function

• muscle mass, tone and strength

• endurance

Culture

sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group.

Culture conflict

situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values.

Culture shock

those feelings, usually negative, a person experiences when placed in a different culture.

Ethnocentrism

belief that one’s own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one’s cultural norms as the standard to evaluate others’ beliefs.

Cultural assimilation

process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different.

Cultural blindness

the process of ignoring differences in people and proceeding as though the differences do not exist.

Cultural competence

care delivered with an awareness of the aspects of the patient’s culture.

Cultural imposition

tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group.

Linguistic competence

ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter.

• getting a translator!

Stereotyping

assigning characteristics to a group of people without considering specific individuality.

Transcultural nursing

providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society.

Factors Inhibiting Sensitivity to Diversity Practice Problems

Cultural Influences on Health Care

• reactions to pain

  • pain is whatever the patient says it is

• biological sex roles

• language/communication

  • by law can receive interpreter services

• food and nutrition

  • can bring food on restricted diet because they can learn the new diet

• family support

• socioeconomic status

  • transfers are incredibly difficult to get to the hospital

Culturally Respectful Nursing Care

• Develop an awareness of one’s own existence, sensations, thoughts, and environment in relation to others

• Demonstrate knowledge and understanding of the patient’s culture, health-related needs, and culturally specific meanings of health and illness

• Accept responsibility for one’s own education in cultural competence

• Not assuming that the health care provider’s beliefs and values are the same as the patient’s

• Accept and respect cultural differences

• Be open to and comfortable with cultural encounters

• Resisting judgmental attitudes

• Ask patient about their religious affiliation

• Add cultural/spiritual healers

Culturally Competent Nursing Care - Patient in Pain

• recognize that each person holds various beliefs about pain and that pain is what the patient says it is

• respect the patient’s right to respond to pain in one’s own fashion

• never stereotype a patient’s responses to pain based on the patient’s culture

• be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area or avoiding activities that intensify the pain

• how to see nonverbal pain: wincing, guarding, clenching teeth, vital signs

Cultural Assessment:

Cultural Assessment/Areas Nurses need to understand

• beliefs, values, traditions and practices of a culture

• culturally defined, health-related needs of individuals, families and communities

• culturally based belief systems of the etiology of illness and disease and those related to health and healing

• attitudes toward seeking help from health care providers

Elements of Cultural Competence

• developing self-awareness

• demonstrating knowledge and understanding of a patient’s culture

• accepting and respecting cultural differences

• not assuming that the health care provider’s beliefs and values are the same as the client’s

• resisting judgmental attitudes such as “difference is not as good”

• being open to and comfortable with cultural encounters

• accepting responsibility for one’s own cultural competency

Guildelines for Providing Culturally Competent Nursing Care

• develop cultural self-awareness

• develop cultural knowledge

• accommodate cultural practices in health care

• respect culturally based family roles

• avoid mandating change

• seek cultural assistance

Factors Influencing Communication

• developmental level

• sociocultural differences

• roles and responsibilities

• space and territoriality

• physical, mental, and emotional state

• values

• environmental

• be eye level with child

Forms of Communication

• verbal (language)

• nonverbal (body language)

  • facial expressions, tough, eye contact

  • posture, gait, gestures

  • general physical appearence

  • mode of dress and grooming

  • sounds, silence (silence can mean respect)

  • electronic communication (make sure messages are encrypted)

  • hand gestures

  • bouncy happy walk doesn’t always mean happy (masking depression)

Levels of Communication

• Intrapersonal

  • self-talk, communication within a person

• Interpersonal

  • occurs between two or more people with a goal to exchange messages

• Group

  • small-group

  • organizational communication

  • group dynamics

  • mutual respect is important with group dynamics

Electronic Communication

• Social media

  • Both the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) have issued guidelines for RNs regarding use of social media.

• Email and test messages

  • The risk for violating patient privacy and confidentiality exists any time a message is sent electronically.

  • Health care agencies usually have security measures in place to safeguard e-mail and text communications

  • do not text on your personal phone EVER

Phases of the Helping Relationship

1. Orientation phase

   1. where you collect data from a patient… why are you hospitalized? How are you feeling?

2. Working phase

   1. providing direct patient care

3. Termination phase

   1. when patient is discharged, upgraded to a higher level of care, when nurse leaves and goes to another place of employment

Goals of the Orientation Phase

• the patient will call the nurse by name

• the patient will accurately describe the roles of the participants in the relationship

• the patient and nurse will establish an agreement about:

  • goals of the relationship (working towards what)

  • location, frequency, and length of the contacts

  • duration of the relationship

• the patient will actively participate in the relationship

  • patient WORKS ALONGSIDE nurse to meet goal

• the patient will cooperate in activities that work toward achieving mutually acceptable goals

• the patient will express feelings and concerns to the nurse

Goals of the Termination Phase

• The patient will participate in identifying the goals accomplished or the progress made toward goals

• The patient will verbalize feelings about the termination of the relationship

Factors that Promote Effective Communication

Dispositional Traits

• warmth and friendliness

• openness and respect

• empathy

• honestly, authenticity, trust

• caring

• competence

  • taking responsibility for your strengths and weaknesses

• No cliches!!

Rapport builders

• Specific objectives

• Comfortable environment

• Privacy (provide privacy!!! do not speak about potential loudly)

• Confidentiality

• Patient vs. task focus

• Utilization of nursing observations

• Optimal pacing

Assertive

stand up for yourself and other with open, honest, and direct communication; clear, concise I statements

Aggressive

asserting one’s own rights in negative manner that violates the rights of others; aggressive communication tries to assert superiority through destructive comments targeted at others (*note: cocky borders on this)

Non-assertive

failing to stand-up for oneself or to communicate in clear, confident manner; often non-assertive person will feet hurt or angry after the communication

Characteristics of the Assertive Nurse’s Self-Presentation

• Confident; open body posture

• Use of clear, concise “I” statements

• Ability to share effectively one’s thoughts, feelings, and emotions

• Working to capacity with or without supervision

• Remaining calm under supervision

• Asking for help when necessary

• Giving and accepting compliments

• Admitting mistakes and taking responsibility for them

The Helping Relationship

• Does not occur spontaneously

• Purposeful and time limited

• Characterized by an unequal sharing of information & unequal focus: patient-centered

  • build on the patient’s needs

  • the nurse is the helper, and the patient is the person being helped

    • nurse is professionally accountable for actions & outcomes

• Communication is the means used to establish rapport and helping-trust relationships

• Dynamic