N309 Foundation of Nursing Practice test 2 UMMC SON

Knowing How: Positioning the Bed-bound Client

Turn every 2 hours

Positioning devices: Maintain body alignment, prevent contractures and promote comfort.

- Beds

- Pillows: Foam wedge

- Siderails are designed to ensure patient safety. Serve as a reminder for the patient to call before getting out of bed.

- Universal fall precautions: 2 side rails raised

- Raising all 4 side rails is a restraint unless the patient is not physically able to get out of bed (Restraint restricts movement) if you cannot get out of bed, this does not restrict your movement.

Trapeze bar

Cradle boots: Prevent foot-drop & skin breakdown

Knowing Why: Safety

The Joint Commission

- National Patient Safety Goals

- Identify patients correctly

- Use medicine correctly

- Use alarms safely

- Prevent infection

- Identify patient safety risks (reduce risk for suicide)

- Prevent mistakes in surgery

Knowing Why: Safety (2)

To err is human

"Never events": Serious reportable events

- Hospital-acquired conditions (HACs)

- Costly errors that result in serious injury or death

- Falls, injuries from restraints

Root cause analysis: Focuses on the entire system rather than a single individual

Sentinel events: Patient harm resulting in unexpected death, permanent harm or severe temporary harm.

Knowing How: Safety (3)

Culture of safety

- ALL members of the healthcare team impact patient safety

- Team empowerment (every voice respected and valued for its contribution )

- Communication

- Transparency

- Accountability

Caring is creating a culture of safety

Safety is a basic need for all persons:

- Speaking up for safety; use CUS

- C-state your concern;

- U-say why you are uncomfortable;

- S-state "this is a safety issue", explain how and why;

- Stopping the line (calling for a preprocedural "time-out" when there is a concern);

- Escalating the safety issue when needed, communicating through the appropriate chain of command;

- Being open and transparent with patients/families/colleagues;

- Participating in safety huddles (quick conversation with a focus on safety);

- Opening all meetings with the topic of safety, allowing time for stories/concerns;

- Using SBAR (situation, background, assessment, recommendation) communication;

- Validating and verifying when unsure (have second nurse check);

- 200% accountability (calling other nurses or healthcare disciplines on handwashing or use of personal protective equipment);

- Reporting both actual and "near miss" medication errors, policy deviations, treatment and outcome variations and adverse events;

- Participating in your organization's Patient and Caregiver Safety Committee;

Knowing How: Pre-procedure Time-out

A time-out should be done before all invasive and surgical procedures.

Intentional pause for patient safety.

Verify: Correct patient, correct procedure, safety of equipment, correct consent

Knowing How: Equipment-Related Accidents

Equipment malfunction and/or improper use of equipment.

Prevent harm:

- Seek advice if you do not know how to operate the equipment

- Remove equipment that is not working properly from patient care

- Ensure equipment has been inspected for safety

- Observe for breaks or frays in electrical cords.

Knowing How: Alarm Safety

Alarm fatigue: Sensory overload when clinicians are exposed to an excessive number of alarms

National Patient Safety Goal: Use alarms safely

Knowing How: Fire Safety

RACE

- Rescue (anyone in immediate danger of fire);

- Alarm (activate the nearest fire alarm and call your fire response telephone number);

- Contain (fire by closing all doors in the fire area);

- Extinguish (small fires, if the fire can't be extinguished, leave the area and close the door);

PASS

- Pull (the pin, release a lock latch or press a puncture lever);

- Aim (the extinguisher at the base of the fire);

- Squeeze (the handle of the fire extinguisher);

- Sweep (from side-to-side) at the base of the flame

Knowing How: Fire Safety (2)

YOUR FIRST PRIORITY IS TO RESCUE THE PATIENT, NOT EXTINGUISH THE FIRE!

Knowing How: Fire Safety & Oxygen

Do not permit smoking near oxygen delivery systems

Allow no open flames near oxygen

Do not use petroleum products, aerosol products, or products containing acetone near oxygen

Secure oxygen tanks and portable cylinders

Knowing Why: Restraints

Restraint: A device or method used for the purpose of restricting a client's freedom of movement or access to their body, with or without their permission.

- Physical force (their own force)

- Mechanical device, material or equipment: Side rails, mitt restraints

- Chemical restraint: Sedatives (镇静剂)

Restraints are a safety hazard and increase the risk of injury!

Classification:

- Medical-surgical

- Behavior management

Knowing How: Restraints (2)

A restraint free environment is the standard of care.

Less restrictive alternatives:

- Consistency

- Provide relaxation and relieve anxiety

- One-on-one supervision

- Reduce environmental stimuli

- Anticipate unmet needs (4P's)

If restraints must be used, they must:

- Be medically prescribed by a healthcare provider (HCP)

- Only used after all less restrictive interventions have been tried first

Knowing How: Restraints (3)

Always follow agency policy

Use restraints only for safety of the patient or others

Restraints require a provider order

- NO standing orders or PRN orders ("as the situation demands," or simply, "as needed.") for restraints are allowed

The restraint order must be renewed every 24 hours

- More often for behavioral restraints

If possible, obtain consent from the patient and their family.

Knowing How: Restraints (4)

Assess restraints every 30 minutes

- More frequently for behavioral restraints

Remove restraints for assessment, feeding, hydration, toileting, ROM and skin care every 2 hours.

- More frequently for behavioral restraints

Always use a quick-release knot

Only attach to the bed frame, never the side rail

Restrained patients have a higher risk of falls

Remove the restraint ASAP

Restraint related death is a sentinel event

Knowing How: Restraints (5)

Types of restraints:

- Belt restraint: Used for a client in a chair or wheelchair

- Wrist restraint: Used to prevent agitated clients from pulling out tubes

- Mitt restraint: Used to prevent agitated clients from pulling out tubes, limit the use of the fingers

- Enclosed bed: Used to keep a patient from wandering or falling out of the bed

Skills videos: Promoting Safety

- Using restraints: Mitt restraint

- Using restraints: Wrist/ ankle restraints

Knowing How: Side Rails

Side rails can be viewed as a restraint

Full- length side rails are considered a restraint when they are used to restrict movement of the client to keep them from getting out of bed

Use of all 4 side rails is considered a restraint when they are used to restrict movement of the client to keep the client from getting out of bed

Knowing How: Hazards to Healthcare Workers

Back injury: Use proper body mechanics

Needlestick injury: Use sharps safely

Radiation injury

- Time: Limit the amount of time with the patient

- Distance: Perform care near the patient only when necessary

- Shielding: Wear appropriate protective gear (Lead apron)

Violence

- Typically begins as anxiety and escalates to verbal and physical aggression

- Your priority should be your own safety and the safety of others in the area

- Do not turn your back on an angry patient

- Keep the room door open; do not let the patient get between you and the door

- Do not engage verbally or physically

- Use a calm, reassuring approach

Knowing Why: Falls

Third leading cause of injury-related deaths, the leading cause for older adults

Older adults are at especially high risk

Falls are the most common incident reported in hospitals

Falls can lead to serious injury, disability, loss of independence and death

Falls: Recognizing Cues

All patients should be assessed for fall risk on admission

For clients at risk for falls, repeat the risk assessment every 8 hours

Identify medications that increase the risk for falls

Morse Fall Scale: 6 questions

- Higher the score = Higher the risk!

Falls: Taking Action

Prevention is key!

Universal fall precautions:

- Place call light within reach

- Provide a night-light

- Keep floors dry and free of clutter

- Keep the bed in a low, locked position

- Utilize non-slip footwear

- Hourly rounds: 4Ps

- Keep water, urinal, bedpan and tissues within reach

High-risk patients:

- Orient patient to their surroundings

- Place disoriented patients near the nurse’s station

- Use bed and chair monitoring devices when appropriate

- Place a warning sign on the door, utilize fall risk armbands

- Use a bedside safety mat

Falls: Taking Action (2)

Bed and chair alarms: Alarm when the patient exits the bed or chair or attempts to exit the bed or chair

Knowing How: Seizure Precautions

Seizure precautions are used to protect clients from injury during a seizure.

- Required for all patients with a history of seizures or condition placing them at an increased risk for seizure activity.

- Keep side rails raised

- Keep the bed in a low, locked position

- Pad side rails with commercial pads or blankets

- Emergency equipment should be readily available:

- Oral suction

- Alternative airway

- Oxygen

Knowing How: Seizure Precautions (2)

During the seizure: Think safety!

- STAY with the client

- Call for help

- Protect the airway:

- Turn the patient on their side

- Do NOT put anything in the client’s mouth

- If prolonged, administer oxygen

- Protect the client:

- Loosen restrictive clothing

- Move hard or sharp objects out of the way

- Do not try to restrain the client or control their movements

- Time the seizure

- Administer prescribed medications

Knowing How: Seizure Precautions (3)

After the seizure:

- Keep the patient on their side, suction and apply oxygen if needed

- Assess mental status, vital signs

- Explain what happened and provide comfort

- Keep NPO (nothing by mouth) until the client is fully alert and conscious

- Document seizure activity

- Notify HCP

What is documentation?

Documentation is the act of recording patient status and care.

What is the purpose of documenting?

Communication

Continuity of Care

Quality Improvement

Planning and Evaluation of Patient Outcomes

Legal Record

Professional Standards of Care

Reimbursement and Utilization Review

Education and Research

Standardized nursing language

Standardized terminology acceptable for electronic health record systems and paper documentation

On pg. 446 and 447 (terminology words)

Make note of the acceptable terms used for documentation purposes

The Joint Commission DO NOT USE list

Documentation system

Source-oriented

- Contains a variety of sections (admission, history and physical, diagnostic, media, nursing's notes, progress notes, labs, etc.)

Problem-oriented

- Organized by client problems and has four components (database, problem list, plan of care, and progress notes) UMC uses this system to chart.

Charting by exception

Only significant and new findings are documented

Preprinted flow sheets used

Documentation time is significantly reduced

Omissision (遗漏) of information and errors can occur

Electronic health records

Advantages

- Communication and collaboration

- Improved access to health information

- Time saving

- Improved quality of care

- For billing convenient

Disadvantages

- Expense (software expensive)

- Downtime for updates

- Learning new systems

- Lack of integration among other databases

Nursing notes: formatting

Narrative

PIE

SOAP/ SOAPIE/ SOAPIER

Focus

FACT

Electronic Entry

Narrative documentation

Able to use with both source- or problem- oriented documentation system

Creates a "story" of patient care

Can be lengthy and non-consistently charted because no one tells stories in the same way

PIE documentation

Problem

Interventions

Evaluations

Used only in problem-based charting

SOAP documentation

Subjective Data (typically they will have direct quotes because it comes from patients)

Objective Data (observed)

Assessment

Plan (short-term and long-term goals)

Page 445 - 448 (see examples)

Intervention

Evaluation

Revision (look at changes that have been made)

FOCUS documentation

Highlights the patients concerns, problems, and/or strengths into 3 columns

- Column 1: Time and Date

- Column 2: Focus or problem

- Column 3: Documentation formatted as (Data - subjective and objective, Action - planning and intervention, and Response - patient's response, evaluation of the process)

FACT documentation

Flow sheets individualized to specific services

Assessment with baseline data

Concise progress notes

Timely entries

Tip: This only includes the significant information about the patient!

Nursing admission assessment documentation (expectation)

Baseline data

Thorough

Help guides discharge planning

Make sure you assess every aspect of the patient.

Discharge planning documentation

Last record of patient care during admission

Details of departure time, method of transportation, any accompanying relatives, education completed, and patient condition

After Visit Summary with Follow-up instructions

Medication administration record

List of ALL medications prescribed

Provides information of medication alerts, such as allergies or contraindications

Able to document scheduled, PRN (as needed), STAT, or omitted doses

Patient care summary

Demographic data (人口数据)

Medical diagnoses

Allergies

Past medical history (pertinent)

Diet/activity

Safety Precautions

Prescribed treatments

Summary of medications

Special instructions for care team

Incident reports

Place to document any unusual occurrence that occurred during patient care

NOT a part of the patient's health record or permanent medical record

Used for quality improvement measures

UMMC uses I-Care software (can be viewed on intranet)

How to write: Briefly document in objective terms; use quote from the patient or anyone involved; avoid making conclusions

Handoff reports

Verbal

Walking/bedside

Audio-recorded (usually not used, not permit)

Handoff report: formatting

Use standardized formats:

- IPASS

- SBAR

- PACE

UMMC prefer IPASS (Illness severity, Patient summary, Action list, Situational awareness and Contingency plans, and Synthesis by receiver) and SBAR (Situation, Background, Assessment, Recommendation)

Handoff report

Keep it CUBAN:

- Confidential

- Uninterrupted

- Brief

- Accurate

- Named Nurse

Hand-off Report should include: patient demographics and diagnoses, relevant medical history, significant medical findings, treatments, upcoming test or procedures, any restrictions, plan of care, and any concerns

Verbal & telephone orders

Verbal orders

- Spoken to the nurse directly

- Often used during emergencies

Telephone orders

- Increased risk for errors

- Directly transcribe the order in the medical record:

- Date and time

- Transcription of conversation

- Include providers name and credentials

- Signature of nurse with credentials

- Provider must countersign (会签) within 24 hours

Questioning an order

Many reasons to question an order

Written illegible- contact provider

Uncomfortable following an order- follow the chain of command

If order does not make sense to contribute to the overall health and wellness of the patient

Additional guidelines for charting

Documenting patient care

Use required format by facility

Include all aspects of care

Be accurate, complete, and consistent

When paper charting

Maintain confidentiality

Use correct format

Ensure forms have correct patient identifier

Write legibly, neatly, and in an organized manner

Use black ink

Draw a line through incorrect documentation and initial it- NEVER use correction fluid or cover up written notes

Sign all paper documentation entries with your first and last name and professional credentials

Only use approved abbreviations

Page 445 -447

Review: Mobility & Physical Activity

Mobility: Body movement

Fitness: Ability to carry out ADL (ability of daily life) with vigor and alertness, without undue fatigue and with enough energy.

Physical activity: Bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a baseline level (exercise).

- Baseline activity: Activities of daily living (bathing, walking a dog, preparing for meal)

- Exercise: Planned, structured, and repetitive movement that is purposeful for maintaining a physical fitness, performance or health.

Knowing Why & Knowing How: Body Mechanics

Body mechanics: The way we move our bodies

- Body alignment: Keeps the center of gravity stable

- Balance

- Coordination

- Joint mobility

Before attempting to move a patient a client, perform a mobility assessment (first thing to do!) to determine the safest way to transfer.

- Bedside Mobility Assessment Tool (BMAT) UMMC uses this.

- Performed on admission and every shift

- Allows nurses to determine the appropriate patient handling and mobility equipment or device (nurse to determine how much your patient need!).

- Level 1: Dependent- Patient is unable to move or transfer self (totally dependent, need to turn every 2 hours).

- Level 2: Moderately dependent - Patient can come to a sitting position but cannot stand or transfer (can not bear their weight).

- Level 3: Minimal assist - Patient can bear weight and may require assistive devices (such as a walker).

- Level 4: Independent

Knowing How: Body Mechanics

Proper body mechanics reduce the risk of injury.

- Raise the height of the bed to waist level (protect your back)

- Get help when needed

- Use assistive devices

- Use a wide base of support

- Minimize bending and twisting

- Use your legs, not your back

- Keep objects close to your body

Self-care box p.1193: Tips to maintain proper posture

You should use mechanical equipment (lift, transfer board) or get assistance for lifting and transferring whenever possible. Do not rely on body mechanics alone to prevent injury.

Knowing Why: Factors Affecting Mobility & Activity

Developmental stage

Nutrition

Lifestyle

Attitude

Environmental factors

Physical abnormalities

Disease

Illness

MSK trauma

Knowing Why: Factors Affecting Mobility & Activity (2)

Developmental Stage: Older adults

- Least active age group

Nutrition

- Obesity

- Makes movement more difficult

- Increases the risk for joint & back injuries & osteoarthritis

- Malnourishment

- Associated with muscle wasting and fatigue

Knowing Why: Factors Affecting Mobility & Activity (3)

Lifestyle

Attitude

Environmental factors

- Weather

- Pollution

- Neighborhood conditions

- Finances

- Social support

Knowing Why: Factors Affecting Mobility & Activity (4)

Physical abnormalities

Acute illness & Chronic disease

- Musculoskeletal disease & Trauma (eg: a broken leg)

- CNS illness & Disease: Any disorder affecting the motor centers of the brain or the transmission of nerve impulses will affect mobility.

- Respiratory illness & Disease: Any disorder affecting ventilation will decrease activity tolerance (eg: COPD).

- Cardiovascular illness & Disease: Impaired circulation -> decreased 02 delivery -> decreased activity tolerance

Knowing Why & Knowing How: Prolonged Immobility

Mental health

- Benefits of regular physical activity

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Turn the lights on/off at appropriate times of day

- Orient the patient to the environment

- Encourage independence & activities as tolerated

- Get the patient out of bed as soon as it is safe to do so!

Knowing Why & Knowing How: Prolonged Immobility (2)

Cardiovascular Health

- Benefits of regular physical activity

- Complications of prolonged immobility

- Virchow's triad (intravascular vessel wall damage, stasis of flow, and a hypercoagulable state)

- Nursing interventions to prevent complications

- Orthostatic hypotension (dizzy)

- Increased risk for thrombosis 血栓生成 (Virchow's triad)

- Passive or active ROM exercises

- Sequential Compression Devices (SCD)

- Anti-embolism stockings

- Edema (be careful of the skin integrate, not only focus on bony part)

- Get the patient out of bed as soon as it is safe to do so!

Help to prevent blood clot!

Knowing How: SCD & Anti-embolism Stockings

Sequential compression device (have to take off before get off the bed)

- Safety

- Knee-high length

- Thigh-high length

- Monitor skin integrity

Anti-embolism stockings

- Knee-high

- Thigh-high

- Monitor for skin integrity

- Remove for 20-30 minutes every 8-12 hours

Davis's Nursing Skills Videos: Perioperative Care

Applying anti-embolism stockings

Applying sequential compression devices

Knowing Why & Knowing How: Prolonged Immobility (3)

Respiratory System

- Benefits of regular physical activity

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Turn, cough & deep breathe every 1-2 hours while awake (important for preventing pneumonia)

- Encourage use of incentive spirometer (key is to breath in - take a deep breath! Hold it for 3 seconds, and then exhale) Take around 10 times while they are awake; Goal for adult: 1200

- Elevate HOB (height of the bed; diaphragm goes down, better lung ventilation)

- Suction as needed

- Get the patient out of bed as soon as it is safe to do so!

Knowing Why & Knowing How: Prolonged Immobility (4)

Gastrointestinal System

- Benefits of regular physical activity

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Maintain hydration

- Give stool softeners, laxatives (泻药) or enemas (灌肠) as ordered

- Provide a fiber rich diet (vegetables, fruit)

- Get the patient out of bed as soon as it is safe to do so!

Knowing Why & Knowing How: Prolonged Immobility (5)

Musculoskeletal

- Benefits of regular physical activity

- Complications of prolonged immobility

- Nursing interventions to prevent complications (can lose 10% of muscle per week!)

- Turn Q2

- Use positioning devices to maintain proper body alignment

- Passive & Active ROM exercises

- ROM: Maximum movement possible by at a joint.

- Active: Performed by the individual without assistance

- Passive: Moving joints through ROM when the patient is unable to do so for themselves. (What is the most important movement for patients who can't move themseleves)

- Assist with ambulation as tolerated

- PT, OT (PT focuses on improving the patient's ability to move their body whereas an OT focuses on improving the patient's ability to perform activities of daily living)

- Get the patient out of bed as soon as it is safe to do so!

Contractures (common for stroke) - strongest muscles (flexors) pull the joints, leading to contractures, or joint ankylosis. Once a contracture occurred, it will be permanent!

Knowing Why & Knowing How: Prolonged Immobility (6)

Integumentary System

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Assess risk: Braden Scale (lower score with higher risk for skin breakdown!)

- Turn Q2 (turn every 2 hours)

- Use positioning devices

- Consider use of an air-mattress

- Keep skin clean & dry

- Get the patient out of bed as soon as it is safe to do so!

The biggest concern is skin breakdown!

Knowing Why & Knowing How: Prolonged Immobility (7)

Urinary System

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Maintain hydration

- Get the patient out of bed as soon as it is safe to do so!

Knowing Why & Knowing How: Prolonged Immobility (8)

Metabolism & Overall Health

- Benefits of regular physical activity

- Complications of prolonged immobility

- Nursing interventions to prevent complications

- Maintain hydration

- Provide high-protein diet, encourage proper food intake

- Get the patient out of bed as soon as it is safe to do so!

Knowing How: Positioning the Bed-bound Client (2)

Trochanter rolls: Prevent external rotation of the hips.

Splints

Hip abduction pillow

Different positions

Supine

- Lying flat on the back with arms and legs extended

- Assessment

Fowler

- Head of bed (HOB) elevated 45°-60°

- Promotes respiratory function by allowing greater chest expansion, reduces risk of aspiration

Semi-Fowler

- HOB elevated to 30°

- Promotes respiratory function by allowing greater chest expansion, reduces risk of aspiration

High-Fowler

- HOB elevated to 90°

- Promotes respiratory function by allowing greater chest expansion, reduces risk of aspiration

Orthopneic (AKA Tripod)

- HOB elevated to 90° with patient bent over table

- Promotes respiratory function by allowing greater chest expansion, reduces risk of aspiration

Lateral

- Side-lying

- Allows drainage of secretions

Prone

- Lying flat on the abdomen

- Allows full extension of the hips and knees, allows drainage of secretions

Sims

- Flexion of the hip and knees in a side-lying position

- Allows drainage of secretions, used to exam the rectal area, administer rectal medications & enemas

Knowing How: Moving Clients in Bed

Friction: Mechanical force when skin is dragged across a coarse surface

Shear: Mechanical force that acts internally on the skin tissue- Typically occurs when skin moves in an opposite direction from the body tissues

- Use a draw sheet, friction-reducing devices

Logrolling: Keeps the spine in alignment

- One person should be responsible for moving the head and neck as a unit

Davis's Nursing Skills Videos: Physical Activity & Immobility

Moving a patient up in bed

Turning a patient in bed

Logrolling a patient

Knowing How: Transferring Clients

Transfer board: Reduces the risk of injury and promotes a smooth transfer from a bed to stretcher, another bed, or chair

Mechanical lift: Uses a fabric sling to transfer patients

Transfer belt: Secure belt for transferring or to hold a patient when ambulating

- Placed around the abdomen

Davis's Nursing Skills Videos: Physical Activity & Immobility

Transferring a patient from bed to chair

Knowing How: Ambulating Clients

Prioritize safety

- Use appropriate equipment and assistance

- Scan the environment for safety

- Use non-slip footwear

- Use a transfer belt

Assess the client

- Physical conditioning

- Utilize a fall risk scale

Dangling the legs

Move slowly

- Observe for weakness, fatigue and dizziness

Davis's Nursing Skills Videos: Physical Activity & Immobility

Assisting with ambulation (1 nurse)

Knowing How: Cast Care

Casts (石膏) are used to maintain alignment. Often the joints above and below the site of injury are immobilized to prevent further injury.

Home Care box p. 1205: Teaching Care of a Cast at Home

- Keep the cast dry

- Call the HCP if you notice odor coming from the cast.

- Never put anything inside the cast.

- Crutches or other assistive devices will be needed to ambulate if the cast is on a lower extremity.

Knowing How: Ambulation Aids

Canes

- Single-ended: Provide minimal support

- Multi Prong: Provide a wide base of support

- Hold the cane on the stronger side

- Advance the cane and weaker leg simultaneously

Walkers

- Move the weaker leg forward as the walker moves

Braces

- Support joints and muscle, do not bear weight

- Assess the skin underneath the brace

Crutches: Limits or eliminates weight-bearing on the leg(s)

- Forearm support crutches

- Axillary support crutches

- The client should be able to comfortable grasp the bar while the elbow is slightly flexed

Table 29-4: Teaching Patients to use Walking Aids

Knowing Why: Application of Heat & Cold

Heat

- Increases blood flow

- Increases tissue metabolism

- Relaxes muscles

- Eases joint stiffness & pain

Cold

- Decreases inflammation

- Prevents swelling

- Reduces bleeding

- Reduces fever

- Diminishes muscle spasms

- Decreases pain

Knowing How: Application of Heat & Cold (2)

Safety first!

- Use caution in the very young and the very old

- Immobile clients are at an increased risk for injury

- Do not use in clients with impaired sensory (diabetes) perception, cold intolerance, vascular insufficiency, open wounds, Raynaud’s phenomenon

- Use for short intervals of time

Heat: Do not use over metal devices, do not use in the first 24 hours after a traumatic injury

Cold: Assess the site every 5-10 minutes

Pulmonary System

Airways and lungs

- Ventilation

- Movement of air into/out of the lungs

- Respiration

- Exchange of oxygen/carbon dioxide

- Alveolar capillary/capillary cell membrane

Factors Affect Pulmonary Function

Developmental Stage

- Infants, toddlers, adolescents, adults

Environment

- Stress, allergic reactions, air quality, altitude

Lifestyle

- Nutrition, obesity, exercise, substance abuse

Medication

- CNS depressants

Factors That Influence Pulmonary Function, Cont'd

Upper respiratory infections (URIs)

- Cold

- Rhinosinusitis

- Pharyngitis

- Influenza

Lower respiratory infections

- Respiratory syncytial virus (RSV)

- Acute bronchitis

- Tuberculosis

Alterations in Gas exchange

Hypoxemia

- low arterial blood oxygen levels

Hypoxia

- inadequate oxygenation of organs and tissues

Hypercarbia (hypercapnia)

- an excess of dissolved CO2 (acid) in the blood

Hypocarbia (hypocapnia)

- low level of dissolved CO2 in the blood

Physical Assessment

Respiratory assessment

- Bring forward from N302!!!

Pulse oximetry

Level of consciousness

Skin assessment

Cough: productive (color), non-productive, stress level

Respiratory Assessment

Rate/depth 12 - 20 (how quickly and deeply of breath)

Quality (labored/unlabored?)

Breath sounds

- Bilateral, clear?

Keep the client's patho in mind!

- Lung compliance (COPD, neuromuscular disease)

- Lung elasticity

- Airway resistance

What diseases do we know of that can cause decreased compliance/elasticity and increase resistance?

Greater than 15 seconds Page 1397

Pulse Oximetry

Measures the proportion of oxygenated hemoglobin in the arterial blood

aka Oxygen Saturation or O2 sats (please don't say "stats") or SpO2

95-100% considered normal

Level of Consciousness (LOC)

A measure of a person's arousability and responsiveness to stimuli from the environment

Oxygenation:

Experience inadequate oxygenation is very frightening. Anxiety, fear, and panic can set in very quickly.

Use a calm and confident approach when performing interventions to promote optimal respiratory function.

Provide emotional support

Sit down and look at the patient eye to eye.

Hold the person's hand, practice therapeutic touch, and sit with them while providing intervention.

Skin Assessment

Temperature

Color

Condition

Hypoxia

Early

- Restlessness and/or Confusion

- Dyspnea

- Increased HR

- Anxiety

- Increased BP

- Increased RR

Late

- Cyanosis

- Decreased LOC

- Bradycardia

- Decreased activity level

- Hypotension

- Metabolic acidosis

Chronic

- Clubbing of fingers/toes

- Peripheral edema

- Right-side HF

- Respiratory acidosis

- Oxygen saturation less than 87%

Analysis/Nursing Diagnosis

Airway Clearance Impairment

Breathing Pattern Impairment

Gas Exchange Impairment

Spontaneous Ventilation Impairment

Aspiration Risk

Nursing Interventions

Position (high fowler, semi-fowler) always the first thing to do

Ensure Patent Airway

Cough and Deep Breathing (ventilate gas exchange, clear airway)

Encourage Ambulation

Incentive Spirometry

Hydration

Suctioning - Pp. 1444-1447 (upper airway only)

Nursing Interventions (2)

Chest Physiotherapy (胸肺物理治疗)

- Moves secretions to large, central airways for expectoration (吐痰) or suction

- Involves postural drainage, chest percussion, chest vibration

- Drainage uses gravity to drain lungs, the affected area in the uppermost position

- Percussion is rhythmic clapping using cupped hands

- Vibration is the vibration of the chest wall with the palms of the hands

Procedure 33-3, CPT pg. 1423

Nursing Interventions (3)

Administering Respiratory Medication

- Bronchodilators

- Anti-inflammatory Agents

- Nasal decongestants (鼻减充血剂)

- Antihistamines (抗组胺药)

- Cough preparations (止咳药) not for kids age of 4

Chest Tubes

Used to remove air, fluid, or blood from the chest.

Fluctuation (tailing) of fluid level is appropriate.

Constant or intermittent bubbling in water-seal chamber or new vigorous bubbling indicates a leak!!

Accidently removed = cover opening to chest immediately (with a glove finger)!!

Setting up/caring for chest tube drainage system pp. 1451-1454

Peak Flow Monitoring

Measures the amount of air that can be exhaled with forcible effort.

Used mostly for patients with asthma to detect changes in their condition

Patients are usually taught how to use the meter at home

Color coded Green (80 -100% of best reading, follow regular medication plan), Yellow (50 -80% of best reading, caution your asthma might be worsening), Red (less than 50%, medical alert, get medical advice).

Indications for Oxygen Therapy

Hypoxia

Post-operative

Respiratory illness

Conditions that reduce circulation of blood through the lungs

Oxygen Therapy

Benefits

- Improves energy level

- Improves sleep

- Improves QOL (quality of life)

Hazards

- Combustible/fire

- Dangerous if not stored properly

- Pressure hazards

- Equipment malfunction

- O2 toxicity (non productive cough)

Initiation of Oxygen Therapy

Flow meter

Oxygen deliver device (NC, face mask, etc.)

Flow meter adapter

Extension tubing

Humidification ("water bottle") (If you are on a nasal cannula 4 liters or higher, you need it)

Oxygen Delivery Devices p. 1427

Nasal cannula (first step) (1 - 6 liters) non-critical patients

Simple face mask (6 - 10 liters) stable too; has holes on the sides so you can leave CO2;

Non-rebreather (6 - 15 liters); Remember the bag needs to be at least 1/3 to 1/2 full), more critical patients;

High flow NC

Face Tent

Oxygen Hood/Tent

Ambu bag (15 liters), Bag/Mask, or Resuscitation bag

Trach Mask (4 - 10 liters/min)

Collecting Specimens/Cultures

Nasal culture

Throat culture

Sputum collection/specimen

The best time to collect specimens is in the morning.

Patient Education

Maintain airway clearance and effective gas exchange

- No smoking

- Coughing techniques

- Sputum changes

- Fluid intake

Promote effective breathing

- Teach relaxation techniques

- Identify factors that effect breathing (i.e. stress, allergens, exposure to cold)

Home oxygen safety

Medications

Referrals

Prevent URIs - Immunizations/vaccines (pneumonia, influenza…)

Resources in the Community

Where medical equipment is purchased, rented, or obtained for free

Access to home oxygen equipment and services

Where to obtain supplies

American Lung Association and other organizations

Documentation of Oxygen Therapy

Assessment

Interventions

- Date/time started

- Delivery device/flow amount

- Patient's response

Adverse reactions

Patient education