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Clara Barton
est. American Red Cross in 1882
cared for/fed Union soldiers during CW
Dorthea Dix
supt. of female nursing corps of Army (CW)
reform of treatment for mentally ill pts
Florence Nightingale
founder of modern nursing
differentiated nursing from medicine→art & science
Harriet Tubman
nurse & abolitionist on Underground RR
later joined Union Army
Nurse Practice Acts
define legal scope
rules & regulations
est. education standards
Goals of Nursing
promote health
prevent illness & restore health
facilitate coping w/ disability and death
**goals of nursing match goals of pt**
What does QSEN stand for?
Quality and Safety Education in Nursing
QSEN
est. by Institute of Medicine (2003)
targets for knowledge, skills, and attitude
6 competencies
patient centered care
teamwork and collaboration
quality improvement
safety
informatics
evidence based practice (research)
The Nursing Process
A- assess/analyze
D- diagnose
P- plan
I- intervention
E- evaluate
Clinical Judgement Model
recognize cues
analyze cues
prioritize hypothesis
generate solutions
take action
evaluate outcomes
Effective delegation
nursing process & nursing tasks are not the same
nursing tasks can usually be delegated
oversee UAP
know pts needs and what they’re at risk for
**only the RN can TEACH, EVALUATE, & ASSESS**
Infectious Cycle
infectious agent→ reservoir→ portal of exit→ means of transmission→ portal of entry→ host
Types of bacteria
transient: attached loosely to skin
resident: found in creases of skin
spherical (cocci)
rod shaped (bacilli)
corkscrew shaped (spirochetes)
Stages of Infection
incubation: growing and multiplying
prodromal: most infectious, non specific symptoms
full stage: specific symptoms
convalescent: recovery
Times for hand hygiene
before touching a pt
before a clean/aseptic procedure
after body fluid exposure
after touching a pt
after touching pts surroundings
Main categories of HAIs
UTIs
surgical site infections
bloodstream infections
pneumonia
standard precautions
gloves and mask (if needed)
all hospital pts regardless of diagnosis and infection status
transmission based precautions
used in addition to standard precautions
contact
hand hygiene, gloves, gown
droplet
hh, mask, goggles/face shield
airborne
N95
donning/doffing PPE
gown→ mask→ gloves
gloves→ gown→ mask
use of sterile field
operating room
labor & delivery
bedside: urinary catheter, sterile dressing change, preparing & injecting meds
sources of pain
nociceptive: actual/threatened damage→ peripheral tissue
cutaneous: skin/subq tissue
somatic: og. in tendons, ligaments, bones, bv, nerves
visceral: poorly localized; og. in body organs
neuropathic: lesion/disease of central nerves
origins of pain
physical: cause can be identified
psychogenic: cause cannot be identified
referred: perceived in a different area
responses to pain
physiologic→ increased BP, stronger pulse
behavioral→ crying
affective→ anxiety, exaggeration
pain assessment
P- provocation
Q- quantity/quality
R- region/radiation
S- severity
T- time
pharmacologic pain relief measures
analgesics
nonopioid analgesics
opioids/narcotics
adjuvant drugs (anxiety)
pt controlled analgesics
epidural
local
normal vital ranges for adults
oral temperature: 96.4-99.5 deg. F
pulse rate: 60-100 bpm
respirations: 12-20 breaths/min
blood pressure: 120/80
types of fever
intermittent: temp returns→ normal at least once every 24 hours
remittent: temp does not return→ normal; fluctuations
sustained/continuous: above normal; no variation
relapsing/recurring: returns→ normal for days, then back up for days
pulse physiology
regulated by ANS
PNS→ decreases HR
SNS→ increases HR
pulse rate: # of contractions over peripheral artery
respiratory physiology
pulmonary ventilation: air in/out of lungs
diffusion: exchange btwn alveoli and blood
perfusion: exchange btwn blood and tissues
changes on response→ tissue demands
respiratory centers→ medulla and pons
activated by chemoreceptors
CO2 is the strongest resp. stimulus
physiology of blood pressure
elasticity of arterial walls
ventricular contraction→ systole
heart relaxation→ diastole
systole/diastole
developmental considerations of skin
infants: easily damaged and subject→ infection
children <2: skin is thinner and weaker
becomes increasingly resistant to injury & infection
elderly: prolonged maturation of epidermal cells
thin, easily damaged skin
circulation & collagen formation dec.→ dec. elasticity→ increased risk for pressure injuries
wound classification
R-red→ protect; granulation tissue
Y-yellow→ cleanse; prevent infection
B-black→ debride; dead
factors affecting pressure ulcer development
aging skin
chronic illness
immobility
malnutrition
fecal/urinary incontinence
altered LOC
spinal cord & brain injuries
neuromuscular disorders
stages of pressure ulcers
stage I: redness
stage II: partial thickness; blister
stage III: full thickness; SQ fat
stage IV: full thickness; muscle and bone exposed
wound drainage
serous: clear
sanguineous: bloody
serosanguineous: combination of clear and bloody
purulent: green/yellow; infected
functions of skin
protection
body temp regulation
psychosocial
sensation
vitamin D production
immunologic
absorption
elimination
stages of sleep
NREM (75-80%)
stages I & II: light sleep
stages III & IV: deep sleep
REM (20-25%)
wake→ NREM I→ N II→ N III→ N IV→ N III→ N II→ REM→ N II…
assessing sleep patterns
restlessness
sleep postures/activities
snoring
leg jerking
energy level
facial characteristics
behavioral characteristics
physical data
promoting proper breathing
deep breathing
using incentive spirometer
pursed lip breathing
diaphragmatic breathing
bed up, proper position, humidified air
SBAR
S- situation
describe circumstances
“I’m calling about…”
B- background
data about pt
ex.) mental status, vitals, skin, oxygen
A- assessment
interpretation
“I think that…”
R- recommendation
ask for or provide recommendation
therapeutic relationships
orientation phase
tone & guidelines
use names
classify roles
orientation to hc system
working phase
work together→ meet pts needs
provide any assistance
provide teaching/counseling
termination phase
examine goals
make suggestions
help pt est. a relationship with new nurse or agency
interviewing techniques
open
“tell me about…”
closed
yes or no
clarifying
reflective
sequencing
directing (redirect pt)
adaptive response to stress
mind-body interaction
anxiety (most common)
coping mechanisms
developmental stress: progression→ growth & development
situational stress: no predictable patterns
stress management
exercise
rest and sleep
nutrition
support systems
stress techniques
relaxation
meditation
anticipatory guidance
guided imagery
biofeedback
crisis intervention
crisis intervention
identify problem
list of alternatives
implement a plan
evaluate the outcome
SAFER-R model
SAFER-R
S- stabilization
A- acknowledgement
F- facilitation of understanding
E- encourage effective coping
R- recovery
R- referral