Fundamentals

Multidrug-resistant organisms (MDRO):

bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria.

Can destroy tissues with lasting effects

Can adapt and no longer be effected by certain antibiotics

At least 2 million people become infected with MDRO and 23,000 people die as a direct result of these infections each year

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Agents that can cause infections

Bacteria, viruses, fungi, helminths, prions, protozoa

Healthcare-associated infections: (HAI)AKA Nosocomial infections

Often more resistant

The longer a patient is in a healthcare facility, the greater the risk of infection

Common examples:

Central Line-associated Bloodstream Infection (CLABSI)

Catheter-associated Urinary Tract Infections (CAUTI)

Surgical Site Infection (SSI)

Ventilator-associated Pneumonia (VAP)

Three risk factors that contribute to the development of HAI's

Environment: hospitals, outpatient clinics, extended care facilities, home, schools

Therapeutic regimen: multiple factors involved in therapies used to tx pts can also contribute to the increased risk of infection. Drugs, steroids, immunosuppressants, chemo, prolonged use of ABX'S, IV catheters, urinary catheters, feeding tubes, vent

Patient resistance: changes in the physical or psychological status of a patient can affect resistance to infection. Surgical sites, stress, fatigue, poor nutrition, poor hygiene, chronic illness, age, immunocompromised

Asepsis

Helps in the prevention of the transmission of disease-causing organisms

Make all surfaces free from disease-producing organisms

Medical asepsis:

aimed at controlling the number of microorganisms and is used for all clinical patient care activities.

Surgical asepsis

also known as "sterile technique" is aimed at removing all microorganisms and is used for all surgical/sterile procedures.

Sterile technique:

used when a body cavity is entered with an object

Aseptic technique

Starts and ends with handwashing, but includes the process of cleaning, disinfecting, and sterilization With handwashing, soap and warm water are preferred over the use of an alcohol-based product in instances when hands are visibility soiled, cases of clostridium difficile, before eating, and after using the restroom.

Use of personnel protective equipment

Equipment that is used to prevent the transfer of pathogens from one person to another is referred to as "barriers" or "PPE"

Aim is to contain pathogens by establishing aseptic barriers around the patient or personnel

Use of barriers to prevent the spread of MO include:

Gloves, masks, hair coverings, shoe coverings, gowns, patient isolation and private rooms

Standard precautions

For all patients to protect against blood and bloody fluid transmissions of potential infective organisms

This system protects against the transmission of both undiagnosed and identified infections

Don gloves whenever you are likely to encounter blood or body fluids, addition of a gown and/or mask if soiling or splashing is expected.

Transmission based precautions

Protect against the spread of highly transmissible or epidemiologically significant pathogens in patients with documented or suspected infection

Depending on the organism identified and its mode of transmission, airborne precautions (N95 mask) or contact precautions may be instituted

Airborne precautions

Used to protect against MO transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents

Patients are cared for in air: airborne infection isolation room Previously known as a negative air flow room

Healthcare providers should wear an N95 respirator mask when performing patient care and make sure that the patient is wearing a mask when transported out of the room

Examples: TB, measles, varicella

Droplet precautions

Used for MO transmitted by large particle droplets which disperse into air currents, sneezing, coughing, talking

Patients are in a private room, or with a patient infected with the same MO

A negative air room is NOT required

Use a mask and goggles when working within 3 feet of patient

Pt should wear a mask when outside of the room

Examples: Haemophiles influenza, Neisseria meningitides, diphtheria, rubella, mycoplasma pneumonia

Contact precautions

Used with serious organisms that can be easily transmitted by hand or skin-to-skin (direct contact)

Patients are in a private room or with a patient infected with the same MO

Always use gloves, and change gloves when exposed to potential infected material during care delivery, remove gloves before leaving patient room and wash hands immediately after removal of gloves

Examples: C-diff, shigella, impetigo

Surgical Asepsis

The purpose of the sterile technique is to prevent the introduction of MO from the environment to the patient

Surgical procedures

Used most extensively in the OR

Skin preparation, surgical handwashing, sterile field, sterile gloves

All procedures that invade the bloodstream

Procedures that cause a break in the skin or mucous membrane (SQ, IM, IV)

Selected dressing changes/wound care

Insertion of catheters or devices into sterile body cavities (foley)

High-risk groups (transplant recipients, burn patients, immunocompromised)

Identification

Self

Patient (2 forms)

Types of communication

Written

Verbal

Nonverbal

Metacommunication

Congruent communication

actions match words

Incongruent communication:

actions do not match words

Advocacy

Supports the patient's right to the information necessary to make his or her own decisions about treatment options and nursing care

Sharing information reduces anxiety and is an integral aspect of therapeutic communication

circle of confidentiality

Every patient has the right to privacy

However, depending on legal restrictions certain patient information must be shared with other professionals involved in the patient care

Clinically relevant information is shared with the team caring for the patient

This protects the nurse and the patient and clearly defines the limits of patient confidentiality

Any team member taking care of the patient are the only people that has access to the patient's chart

Any non-team member must get consent from the patient to speak about medical concerns

HIPPA

(Health Insurance Portability and Accountability Act): need consent to speak to anyone

The nurse-patient relationship

Built on interpersonal or person-to-person communication

This is a learned skill

The pt and his or her experiences, problems and issues are the main subject of communication

Therapeutic communication

: facilitates interactions focused on the patient and the patients concerns

Nurse- Patient relationship How does it work?

The nurse and patient work together to solve problems centered on the patient's healthcare needs

The patient feels cared for and understood

The family or significant others are included in the care

Health teaching is conducted

Health promotion and preventative care are delivered

It is a process for giving and receiving information, a form of interaction or transaction

A continuous human function

Therapeutic Communication Techniques

1) ACTIVE LISTENING - Shows clients that they have your undivided attention

2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand

3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history.

4) SUMMARIZING - Validates the accuracy of the story.

Open-ended questions

Cannot be answered by "yes" or "no"

They need to explain (ask "tell me about")

Therapeutic Communication Techniques extended

open- ended questions

Active listening

Restatement and reflection

Exploring

Focusing

Encouraging elaboration

Seeking clarification

Using silence

Summarizing

Nontherapeutic responses

Rescue feelings

False reassurance

Giving advice

Changing the subject

Being moralistic

Nonprofessional involvement

Routine self-care

The ability to bathe and perform normal grooming functions and to dress, feed, and toilet oneself

Skin:

the first line of defense against infection

Perspiration interaction with bacteria on the skin Causes...

body odor

Decreases patient comfort

Promotes bacterial growth

Increases likelihood of skin breakdown

Regular bathing removes..

excess oil, perspiration, and bacteria from the surface of the skin

Soap and water

Prepackaged and pre-moistened, rinse free, disposable washcloths

Research demonstrated daily bathing with chlorhexidine-impregnated washcloths.....

significantly reduces the risk of acquiring MDRO'S and hospital-acquired blood infections

Routine self-care examples

Feet and nail care

Hair care

Oral care

Eyes, ears, and nose care

Feeding

Toileting

Dressing and grooming

Factors that affect self-care

Environment

Motivation

Mental health

Cognitive abilities

Energy

Acute illness and surgery

Pain

Neuromuscular function

Sensory deficits

Toileting Interventions

Fracture bedpan

Bedpan

Commode

Condom catheter

Female urinal

Male urinal

Perineal care

Expose the perineal area only to clean

Perineal care For females

Wash from front to back

Use a clean washcloth for each stroke

Ask the patient to turn on her side

Wash, rinse, and dry buttocks and anal area

Cleanse anal area without contaminating perineal

Perineal care For males (uncircumcised)

Retract skin gently push skin towards the base of the penis

Hold penis by shaft

Wash in a circular motion from the tip down to the base

BE SURE TO REPLACE SKIN

Hair care

Moisten shampoo cap

Apply cap to patient's head

Massage cap on patient's head

Remove cap, rinse hair

THROW CAP AWAY

Shaving

Use soap to lather or shaving cream

Pull skin taught

Shave in the direction in which the hair grows to decrease irritation

Patients with bleeding disorders or on blood thinners - electric razor

Shaving underarm hair and leg hair is an important part of grooming for many women

Feeding

Raise the head of the bed

Assistive devices

Swallowing impairments -Dysphagia

quality and safety

The concepts of quality and safety are closely interrelated

Quality

refers to the excellence of something; viewed on a continuum from poor to high quality

Safety

is the avoidance or prevention of adverse outcomes for patients

Healthcare errors

are the third leading cause of death

Nearly 400,000 people die annually in the U.S from preventable healthcare errors

Quality and Safety Education for Nurses (QSEN)

project has been designed to provide a framework for the knowledge, skills, and attitude necessary for future nurses

IOM (institute of medicine) competencies

Patient-centered care

Teamwork and collaboration

Evidenced-based practice

Quality improvement

Safety

Informatics

Incident report:

an accident or an injury occurring in the hospital necessitates the filling of an incident report

The report remains confidential and is NOT part of the patient's medical record

Completely describes all aspects of the event that occurred

Accident description

Patient assessment

Interventions

Used as an internal review to improve the system to prevent similar error

NOT TO PENALIZE NURSE

Checklists (ex: universal protocol for surgical procedures)

Tools for quality and safety improvement

"Time out"

Two nurse check

Medication: successive checks

Communication

Tools for quality and safety improvement

Nonverbal communication

Written communication

Written notes

Nurse notes (head-to-toe evaluation)

Additional Measuring quality and safety outcomes

Care bundles

Measuring quality and safety outcomes

PASS for fire extinguishers

Pull the pin

Aim it

Swing

Sweep

RACE for fires

Rescue and remove any pt in immediate danger such as pt right next to fire.

MOVE pt's laterally from fire, one area to another

Activate the alarm, close all doors, and windows,turn off oxygen

Confine the fire

Extinguish

Admission or initial assessment:

name, DOB, past hx, social status, children, where they live, allergies, review of body systems

Focus assessment:

one specific region of the body

Time lapsed assessment:

looking at everything apart from the demographics, Medicare and Medicaid rules apply (62 days)

Emergency assessment:

always ask about allergies and medication

Observation:

uses all the senses to collect data. Begins immediately when the nurse meets the patient

Vision:

How does the patient look? In distress or discomfort or grimacing or scowling or frowning, guarding, holding a body part, nutritional status

Smell

body or breath odors

Hearing

active listening, clarifying the patient's statements

Touch:

nonverbal communication, preliminary appraisal of skin temperature and moisture

Subjective info:

comes from the patient, "I feel,"

Objective info:

how we write charts, can be measured

Chief complaint AKA reason for seeking care

never to be changed

ALWAY IN QUOTES & PT EXACT WORDS

Goals (Assessment of whole person)

To collect info about the patient's state of health

To develop a complete database

Health history: subjective (what the person states)

Physical exam: objective (what the examiner measures)

Used to make clinical judgments Nurse diagnosis

Health history:

subjective (what the person states)

Physical exam

objective (what the examiner measures)

Used to make clinical judgments Nurse diagnosis

Assessment Collect data:

Review of the clinical record interview

Health history

Physical exam

Functional assessment

Consultation

Review of the literature

Diagnosis

Interpret data: Identify clusters of clues Make inferences

Validate inferences

Compare clusters of clues with definition and defining characteristics

Identify health-related factors

Document diagnosis

Evaluation

Refers to established outcomes

Evaluated individual's condition and compare actual outcomes with expected outcomes

Summarize the results of the evaluation

Take corrective action to modify the plan of care as necessary document the evaluation of the person's achievement of outcomes and the modifications if any in the plan of care

Outcome identification

Identify expected outcomes

Individualize to the person

Realistic and measurable

Include a time frame

Implementation

Review the planned interventions

Schedule and coordinate the persons total health care

Collaborate with other team members

Supervise implementations of care plan by delegating appropriate responsibilities

Counsel the person and significant others

Involve the person in the healthcare

Refer individuals who required continuing care

Document the care provided

Planning

Establish priorities

Develop outcomes

Set time frames for outcomes

Identify interventions

Document plan of care

Developmental and cultural considerations

Consider life cycle and developmental stage when obtaining history and performing a physical examination

Cultural diversity is growing in the U.S. Be sensitive, respectful and non-judgmental

Interviewing

Is an essential skill that elicits subjective data from the paitent or family members

Factors affecting the quality of the interviewing are the nurses' skill and the patient's willingness to share information

dentifying who is providing info on the patient

History focuses on the patient's account of the actual or potential health problems and their impact on his or her health

Clarifies and verifies the patients perception of their health status (subjective data)

Compares the patient's present and past health status, behaviors, coping skills

Identifies actual and potential nursing diagnoses Ex. Actual = patient has diabetes, potential = patient is at risk for___

Develops the patient plan of care, identifies concerns about discharge planning implements nursing interventions to support the patient's adaptive responses

Charting is classified as

secondary information

Biographical data

Name:

Gender:

Marital status:

Address:

Phone:

DOB

Birthplace Important because different vaccines are given to people born in different countries

Age

Occupation important because of potential work exposure ex. exposure to chemicals, health hazards, mine workers, pharmaceutical researcher etc.

race/ ethnic origin

Language

Employer

Source and Reliability

Primary Source- patient

Secondary Source- someone besides the patient

Reliability- how reliable is the information given to me

ex. A patient with psychosis, a patient in a serious accident

Reasons for seeking care (chief complaint)** test question knowing reason for seeking care is the same as chief complaint

Write exactly what pt said " i feel like i have an elephant sitting on my chest"

Remains objective and anyone seeing that patient knows exactly what was going on at that moment.

Also protects the healthcare workers ex. "I have abdominal pain" ex. Psychotic episodes going in and out, split personality.

Eight critical characteristics:

Location: pain in the left side chest that radiates down the arm

Character or quality: pain is described as sharp

Quantity or severity: unable to catch breath pain is 8/10

Timing (onset): pain started an hour ago

Setting: running to catch the train

Aggravating, associated and relieving factors: The patient feels worse pain standing, sitting helps the pain

Associated factors: experiencing discomfort also in neck and jaw

Patients perception: pt thinks it is very serious and is very anxious "my father died of a heart attack as a young man"

General health (Past health)

Gaining more than 3lbs overnight with heart failure is indicative of congestive heart failure exasperation

Childhood illness (Past health)

ex. Rheumatic fever can affect the heart

ex. Chickenpox, leading to shingles

(Past health)

Accidents or injuries

Operations

Serious or chronic illnesses

ex. hypertension, autism, leukemia, etc

Hospitalizations

make sure to name the big ones if they say they have many

You could write "numerous" and then state the major ones

Obstetric history

Gravida- number of pregnancies

Term- pregnancies that went to term

Preterm- pregnancies that went preterm (before 40 weeks)

Ab/incomplete- abortions/miscarriages (surgical election, miscarriages, etc.)

Children living

Immunizations

keeps changing, so do not need to know the immunization schedule

can ask "Do you accept vaccines?" to make them not feel judged if yes ask, "Are you fully vaccinated?"

Last exam date

Ex. Breast exam

Allergies

Ask about medications & foods, pause, and then ask anything else

important to ask about the reaction to see how severe the rash is not an allergic response because there is no histamine response hives are an allergic reaction

ex. Shellfish is important because of IV contrast allergy

Current mediations

make sure you get all medications they take, even if not every day Often people forget to mention over-the-counter medications, vitamins, etc.

Family history

highlights particular diseases or conditions that your patient may be at risk of developing

examples Heart disease- could have a patient come in with mild chest pain, but a family history of heart attacks/death, and this could be a major medical disorder

Genogram

pictorial display of family relationships and medical history

Review of systems

HEENT (head, eyes, ears, nose, throat)