Foundations
factors affecting vital signs
age, gender, genetics, weight, circadian rhythms, state of health, environmental temp, stress, meds, disease states, fever
BP: emotional state & body position
sites for assessing temp
oral
tympanic
temporal
rectal
axillary
sites for assessing pulse
temporal
carotid
apical
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis
sites for assessing BP
brachial artery most common
popliteal
forearm
ankle
assessing temp
thermometers
which one & where depends on age, cooperation, accessibility of location
assessing pulse
count beats per 30 sec x2 bpm
assessing respirations
1 resp = 1 full inhalation + 1 full exhalation
count # resp in 30 sec x2 rpm
assessing BP
palpate brachial artery
apply cuff
palpate radial artery & pump cuff until no longer felt
position stethoscope over location of brachial artery & release cuff at rate of 2-3 lines/sec
1st korotkoff sound = systolic
loss of sound = diastolic
quickly release cuff & record
normal temp values
96.4-99.5
35.8-37.5
normal pulse values
60-100
80 avg
normal respiration values
12-20
normal BP values
120/80 or less than
pulse deficit & what it indicates
difference between apical & radial pulse rates
apical (felt at heart)
radial (felt at wrist)
if unequal, listen to each for 1 min & measure difference (apical – radial)
deficit > 10 needs further investigation, call physician
major classification of hypertension
increased BP
“silent killer”
can lead to hemorrhagic stroke, embolism, heart attacks
Primary/Essential: increase in both BP #s w/out known cause
Secondary: increase in both BP #s w/ known cause
factors affecting hygiene practices
culture
socioeconomic status
spiritual practices
developmental levels
health status
personal preferences
disease/illness status
bed baths
complete: all areas covered
partial: genital, perineum, hands, face
therapeutic: long-term care
shower
tub
bath in bag
oral care
2x/day or 1x/shift
pt lying on side if performing on unconscious pt
nail & foot care
typically done by podiatrist depending on facility
cut nails across & file sides
always dry thoroughly
don’t soak if pt has diabetes or neuropathy
perineal care
decreases risk for infection especially in pt’s w/ catheters, given birth, had rectal surgery, or uncircumcised males
hair & scalp care
wash & comb
shower cap if needed
shaving
get pt input what they’d like done
use warm towel 1st to soften area
be careful w/ pts on anticoagulants, blood thinners, etc.
considerations when assisting pts w/ hygiene
whether or not pt is diabetic
whether or not pt uses dentures
whether or not pt can assist w/ hygiene care
assessments done while assisting pts w/ hygiene
odors
lesions
heart sounds
skin integrity
tolerance
any other abnormal findings
nursing interventions associated with assisting pts w/ hygiene
when documenting, nurse should include what’s done, pt’s level of involvement, findings, pt’s response to care, & any education provided
aims of nursing
promote health
prevent illness
restore health
facilitate coping w/ disability/death
roles of a nurse
caregiver
communicator
teacher & educator
leader
counselor
researcher
advocate
collaborator
professionalism in nursing
standards of ethics
culturally congruent practice
communication
collaboration
leadership
education
EPB
research
practice quality
professionalism evaluation
resource utilization
4 concepts common to all nursing theories
describes, explains, predicts, controls desired outcomes of nursing care practices
4 metaparadigms
4 metaparadigms
person/pt
environment
health
nursing (relationship between pt & nurse)
quantitative research
involves concepts of basic & applied research
#s based
what rather than why
measurable & countable
tells us how much, how often, how many
data is objective (factual)
qualitative research
conducted to gain insight by discovering means
why rather than what
focus on change over time
seek in depth understanding of social phenomenon
basic research
designed to generate & refine theory
findings aren’t often directly useful in practice
basic purpose is to acquire infromation
advance knowledge w/out any immediate goal in mind or use of practice in mind
applied research
designed to directly improve/influence clinical practice
seen in nursing
look at pain managements
influences of nurses as far as length of pt’s hospital stay
evidence-based practice in nursing care
provides problem-solving approach to making clinical decisions using best evidence available collected from reputable sources
steps (form clinical question, gather best evidence, analyze evidence, apply evidence to clinical practice, assess results)
elements (integration of best practices to guide current practices, viewing clinical expertise as component in care efficacy, & considering pt’s preferences/values/engagement in decision making)
EBP
evidence-based practice
HAI
hospital-acquired infection
homeostasis in wound healing
activation of coagulation cascade
inflammation in wound healing
may experience low-grade fever
proliferation in wound healing
repair phase
granulation begins to appear
adequate nutrition important
maturation in wound healing
starts about 3 wks post-surgery
collagen production forms scar
classification of wounds
intentional vs unintentional
open vs closed
acute vs chronic
factors affecting skin health & wound healing
age (skin thins w/ age leading to tears, less collagen production, decreased peripheral circulation, slower tissue regeneration)
state of health (obese are more susceptible to skin injury, dehydration, excessive perspiration, jaundice, eczema/psoriasis, smoking, chronic disease, meds)
pts at risk for pressure ulcer development
immobile
elderly
suffer from malnutrition
incontinent
altered level of consciousness
spinal cord/brain injuries
neuromuscular disorders
stages of pressure ulcers
nonblanchable
partial-thickness
full-thickness
full-thickness w/ extensive destruction
unstageable
nonblanchable
stage I
redness to area, stays red when press on it
partial thickness skin loss
stage II
blister, shallow-crater appearance, involves epidermis
full thickness skin loss
stage III
damage to epidermis & dermis
full thickness skin loss w/ extensive destruction
stage IV
involves destruction through all skin layers & some part of tendon, muscle, or bone
unstageable
base of ulcer covered by slough &/or eschar
assessing wounds
inspect: sight & smell
palpate: swelling
exudates: serous, sanguineous, serosanguineous, purulent
sutures/drains/tubes: S&S of infection
measurement: length x width x depth
serous exudate
clear, watery
sanguineous exudate
bloody
serosanguineous exudate
light pink, watery
purulent exudate
yellow/green, thick
pus
nursing interventions preventing pressure ulcer
mobility: turn q 2 hrs
nutritional status: safe swallow, pre-surgery, eating well
moisture & incontinence: always change pt quickly, be sure to dry well after bath
appearance of PU if already existing: monitor & change dressings
assess pain
proper wound management
clean wound every dressing change, use careful motions to minimize trauma, use 0.9% normal saline solution, document/report drainage or necrotic tissue
dressings, bandages, binders
dressings
telfa
gauze
transparent
bandages
typically roller bandages
circular turn, spiral turn, figure-8 turn, recurrent stump
binders
straight
t-binder
sling
straight binder
abdomen/chest
usually to support surgical incision
t-binder
rectum, perineum, groin
usually to secure dressings
sling
support arms
infection cycle & how hand hygiene can break it
infectious agent, reservoir, portal of exit (blood/GI/genitourinary/nasal/drainage/breaks in skin), means of transmission, portal of entry, susceptible host
hand hygiene can eliminate transmission of infectious agents from 1 pt to another or to staff
stages of infection
incubation period
prodromal stage
full stage
convalescent period
incubation period
from pathogen entry to S&S
prodromal stage
non-specific symptoms
most infectious
full stage
specific S&S of disease
convalescent period
starting to feel better but typically categorized by fatigue
factors increasing risk for infection
breaks in skin
abnormal pH levels
low WBC count
age, gender, race, genetics
immunization (natural or acquired)
nutrition
general health status
stress
indwelling/invasive medical devices
healthcare-associated infections & how healthcare providers can prevent
infections acquired in healthcare facility
CAUTI, SSI, pneumonia, bloodstream infections, MRSA, VRE, C diff
prevent by using standard & surgical aseptic/sterile techniques, wash hands between pts, frequent pt monitoring especially of indwelling medical devices
standard precautions
used in all hospital settings & will at pts
regardless of diagnosis
apply to blood, body fluids, secretions/excretions, respiratory etiquette
transmission-based precautions
used in addition to standard when infectious pathogen suspected whose transmission is airborne, droplet, or contact
PPE required, pt-specific tools (stethoscope)
surgical asepsis
requires sterilization of equipment & environment
assessments, hx, & physical findings increasing pt’s risk for safety issues
questions & visual inspection (stairs at home, pt limping, feel safe at home)
pt hx (previous falls/accidents, drug/alcohol use, assistive devices for ambulation, knowledge of family support/home environment)
physical exam (mobility status, ability to communicate, level of awareness, sensory perception, potential safety hazards)
finding suggestive of violence, neglect, or abuse
fall prevention nursing interventions
inspect gait
ask/notice impaired vision/balance
notice any postural hypotension (take BP)
notice slowed reaction time, confusion, or disorientation
violent-behavior restraints
used for aggression when pt is harm to themselves/others
4 point locking
DR order good for 3 hrs (must see pt w/in 1 hr)
documentation required every 15 min (vitals/fluid intake/cognition/skin integrity)
requires enhanced pt monitor/sitter
no orders needed to remove if staff feels no longer necessary
non-violent behavior restraints
behavior threatens pt safety (ex: pt pulls out IVs/ tubes/med devices needed for care)
DR order good for 24 hrs (must see pt w/in 24 hrs)
documentation required every 15 min (vitals/fluid intake/cognition/skin integrity)
enhanced pt monitor not needed
no orders needed to remove if staff feels no longer necessary
chemical restraints
drugs keep pt in calmer state
mitt restraints
not considered restraint but noteworthy
no order needed
velcro always facing outward
interventions keeping pts safe during nursing care
5 R’s of med admin
correct transferring procedures
aseptic wound dressing changes
minimizing wrong-site surgeries & burns by always checking on pt’s w/ heating pad
variables influencing body alignment & mobility
developmental factors (age, cognitive abilities)
physical health (COPD)
mental health (stress, fatigue)
lifestyle (fitness level, job)
external factors (environment, neighborhood)
effects of exercise & immobility on major body systems
decreased circulatory ability
decreased bone density
decreased muscle strength
increased fat
decreased BMR
blood in leg stasis
impaired balance
assessing body alignment, mobility, & activity tolerance
use visual cues - kyphosis, scoliosis, gait, movement patterns, assistive devices or lack thereof but needed
can pt do ADLs on own
gait belts
around waist or chest
depending on abdominal wounds
2 fingers between belt & pt
canes
limits pressure of weight-baring joints
hold in hand OPPOSITE affected limb
moves same time as affected limb
crutches
adjust based on height
should be 2-3 finger space between armpit & top
2, 3, or 4 point gaits
walker
adjust based on height
handles line up w/ wrists
arms 15˚ when in use
2 types: Wheels (2 or 4) & No-Wheel (4-prong)
don’t use on stairs
wheelchair
decreases workload on heart & O2 demands
lead from strong side when transferring
always lock when not in use
lifts
2 kinds: sit to stand (must be able to load-bear at least somewhat) & standing lift (no weight-bearing at all)
nursing interventions preventing complications of immobility
gait belt
safe transferring practices
skin assessment &/or repositioning q 2 h
bed alarms
correct Foley positioning
case management/social work follow-up
key components of nursing process
ADPIE
Assess
Diagnose
Plan
Implement
Evaluate
assess
identify needs & additional required data
objective & subjective
diagnose
identify patterns/trends
compare data w/ expected values
judge significance of data
arrive at conclusions to guide care
plan
create comprehensive poc
modify as assessments come back
discharge planning
SMART
client-centered goals
nurse-initiated vs physician-initiated interventions
implement
use problem solving & clinical judgement skills to select & apply appropriate therapeutic interventions
evaluate
outcomes vs planned goals
continue what’s working & change/discontinue what’s not
problem-focused nursing diagnosis
clinical judgement concerning undesirable human response to health condition or life process existing in individual, family, group or community
risk nursing diagnosis
clinical judgement concerning vulnerability of individual, family, group, or community for developing undesirable human response to conditions or life processes
health promotion nursing diagnosis
clinical judgement concerning motivation & desire to increase well-being & to actualize human health potential
responses expressed by readiness to enhance specific health behaviors & can be used in any health state
responses may exist in individual, family, group, or community
purpose & benefits of nursing process
prioritized, complete, systematic, factual & accurate, relevant, & recorded in timely manner
pt safety, positive therapeutic interventions, holistic pt care