Lab 2 - DMF, Body Mechanics, Bed Positions

Nursing process (definition)

A systematic approach to care using critical thinking, client-centred approaches to treatment, goal-oriented tasks, evidence-based practice recommendations, and nursing intuition (Toney-Butler and Thayer, 2023).

Nursing process: the 5 steps

Assessment, Diagnosis, Planning, Implementation, Evaluation.

Nursing process: Assessment

Focus on the whole person (holistic); social determinants of health (SDOH).

Nursing process: Diagnosis

Nursing diagnosis using clinical judgement to understand what is happening.

Nursing process: Planning

Collaborate with the client, families etc. to prioritize and come up with a realistic plan.

Nursing process: Implementation

Nursing interventions.

Nursing process: Evaluation

Reassessment of the client after the intervention.

Why the nursing process matters (significance)

• Gives structure and direction to care

• promotes critical thinking and scientific, evidence-based practice

• ensures holistic, individualized, patient-centred car

• cornerstone of professional nursing practice globally.

Client-centred care

• An approach in which clients are viewed as whole persons

• not merely delivering services where the client is located

• Involves advocacy, empowerment, and respecting the client's autonomy, voice, self-determination and participation in decision-making (RNAO, 2006).

Client-centred caring: 3 things it does

1) Ensures the client keeps control over their own choices

2) Helps them make informed decisions

3) Supports a partnership between individuals, families and health care providers.

Client's story

• The person's perception of their experience of health and the things that influence their health

• their own personal case study

• lived experience

• seeing the client as a real person, not just pain, physical experience or the reason they came to hospital.

Why learn the client's story?

• It lets students learn nursing, think critically, and attend to emotion as a source of self-knowledge and impetus for inquiry

• makes learning personalized, relevant and meaningful.

DMF = Decision-Making Framework

• Framework that guides nursing decisions with clients.

• The 5 steps in ORDER: Coming to Know, Salience, Pattern Recognition, Healing Initiatives, Reflection.

DMF steps in order

1) Coming to Know

2) Salience

3) Pattern Recognition

4) Healing Initiatives

5) Reflection

DMF Step 1: Coming to Know belongs to which phase?

Recognize Cues.

DMF Step 2: Salience belongs to which phase?

Recognize Cues.

DMF Step 3: Pattern Recognition belongs to which phase?

Recognize Cues.

DMF Step 4: Healing Initiatives belongs to which phase?

Generate Solutions.

DMF Step 5: Reflection belongs to which phase?

Evaluate Outcomes.

DMF: Coming to Know

• Within a culturally safe environment, the student comes to know the client and family's story by learning about the client's lived experience of health and healing through culturally safe and caring interactions.

What is included in Coming to Know?

• The physical assessment

• Gordon's Functional Health Patterns

• Social Determinants of Health

DMF: Salience

• The deliberative process of identifying what is important in a situation

  • what stands out, what is most critical to attend to, and what has the most relevance for the client.

How do students find what is salient?

• Using different ways of knowing (empirical, personal, ethical, aesthetic) with critical dialogue, reflection and questioning to uncover, with clients, what is salient.

DMF: Pattern Recognition

• Builds on salience by uncovering patterns of health issues identified by the client, family and student.

• Achieved by analyzing cues and critically analyzing knowledge gained in the previous phases.

DMF: Healing Initiatives

• Arise from the student assisting the client to recognize and understand their potential for health and healing and specific health issues of concern.

• Includes implementing specific therapeutic, preventive and health promotion strategies.

Healing Initiatives: what do the strategies involve?

• Interdisciplinary collaboration, multiple resources and services, a harm reduction approach and a trauma-informed approach to reduce client vulnerability.

Why are healing initiatives 'non-static'?

• The process is ever-evolving

• initiatives change in response to the health and healing of the client.

Most important outcome of Healing Initiatives

• Empowering clients to gain control, expertise and autonomy in decisions that influence their health and healing, as essential and central members of the health care team.

How is the plan of care developed in Healing Initiatives?

• The student, together with the client, family, interprofessional (IP) team and educator, develops a prioritized and individualized plan of care.

DMF: Reflection

• Critical reflection by the student is central to decision-making for nursing practice.

• In a culturally safe framework the client is also given the opportunity to reflect and evaluate whether their health goals were achieved.

Match: a student identifies that the client's fear of falling is the most critical thing to address

Salience.

Match: a student notices that the client's falls, dizziness and new medications form a pattern

Pattern Recognition.

Match: a student learns the client's story and does the physical assessment and Gordon's patterns

Coming to Know.

Match: a student works with the client, IP team and educator to make a prioritized individualized plan

Healing Initiatives.

Match: the student and client reflect on whether the client's health goals were achieved

Reflection.

Body mechanics

• Coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture and body alignment during lifting, bending, moving and activities of daily living.

STABLE: what does it stand for?

• Spine, Trunk, Arms, Base, Legs, Evaluate.

• Basic principles to prevent MSIs (musculoskeletal injuries).

STABLE: S = Spine

• Keep the spine neutral.

• mid range of motion keeps you stable

• beyond it, the back is not stable and muscles/joints risk strain and injury.

• Maintain neutral spine and effective body mechanics.

STABLE: T = Trunk

• Avoid trunk twisting by stepping with your feet in the direction of the move.

• Pulling twists the trunk, pushing is safer than pulling.

• Use body momentum, gravity and leg muscles

• keep a pelvic tilt (tighten abdominal and buttock muscles) to keep the spine neutral and trunk stable.

STABLE: A = Arms

• Keep your arms (elbows) close to your body

• use a palms-up grasp when possible for better leverage and control.

• Bring the load as close to your body as possible (or your body close to the load) while keeping a neutral spine.

• Avoid over-reaching.

STABLE: B = Base

• Maintain a wide base of support.

• Use a stride stance, feet shoulder-width apart, which maintains centre of gravity and a stable base.

• Do not pivot (reduces base).

• Step in the direction of the move or shift weight from one leg to the other.

STABLE: L = Legs

• Use your legs, thigh muscles are stronger than arms and trunk.

• Bend your knees, not your back.

• Keep a wide base and stride stance;

• shift weight leg to leg using leg-muscle momentum.

STABLE: E = Evaluate

• Evaluate the load, the environment, the resident's abilities and limitations, and your own ability and stability.

• Where are you coming from and going to?

• Many factors influence your abilities at any time, recognize them.

Centre of gravity

• The point at which the weight of the body is centred (the balance point of the body).

• A stride stance maintains it.

Base of support

• The area on which an object or the body rests

• the area between the feet. A wider base of support gives greater stability.

Centre of gravity and base of support: how to increase stability

• Widen the base (stride stance, feet shoulder-width apart)

• lower the centre of gravity by bending the knees

• keep the load close to the body.

Stride (lunge) stance

• One foot forward and one back (or feet staggered)

• shoulder-width apart

• knees bent

• widens the base of support in the direction of the move so you shift weight from leg to leg.

Why use a stride stance?

• Maintains the centre of gravity over a stable, wide base of support, and lets you shift your weight in the direction of the move without twisting.

Effective body mechanics reduce which injury?

• Musculoskeletal injuries (MSIs).

• Overexertion/patient handling is a leading cause of nurse injuries.

Bed height for a nurse working at the bedside

• Raise the bed to a height that makes 90 degrees with your arm

• adjust to shorter person's safety if working with two people

Fowler's position

• Head of bed raised to 45 degrees or more

• semi-sitting position

• foot of bed may also be raised at the knee

Fowler's: uses

• Preferred while the patient eats

• used during nasogastric tube insertion and nasotracheal suction
  promotes lung expansion.

Semi-Fowler's position

• Head of bed raised approximately 30 degree

• inclination less than Fowler's

• foot of bed may be raised at the knee.

Semi-Fowler's: uses

• Promotes lung expansion

• used when patients receive gastric feedings (reduces regurgitation and risk of aspiration).

Trendelenburg position

Entire bed frame tilted with the head of the bed DOWN.

Trendelenburg: uses

• Postural drainage

• facilitates venous return in patients with poor peripheral perfusion.

Reverse Trendelenburg position

Entire bed frame tilted with the foot of the bed DOWN.

Reverse Trendelenburg: uses

• Used infrequently

• promotes gastric emptying

• prevents oesophageal reflux.

Flat position

• Entire bed frame horizontally parallel with the floor.

• Flat = the client is in the supine position.

Flat: uses

• Patients with vertebral injuries and in cervical traction

• patients who are hypotensive

• generally preferred by patients for sleeping.

high Fowler's position

• Bed fully up around 90 degrees

After making a bed or leaving a patient: bed position

• Return to the lowest horizontal position to prevent falls if the patient gets in/out alone

• keep call light in reach

• use side rails to aid positioning and turning.

Stethoscope diaphragm

• Best for high-pitched sounds

  • breath, bowel, normal heart sounds.

• Hold firmly against the skin (firm enough to leave a slight ring afterward).

• Most commonly used.

Stethoscope bell

• Best for soft, low-pitched sounds such as extra heart sounds or murmurs.

• Hold lightly (just enough for a perfect seal)

• pressing harder makes the skin act as a diaphragm and obliterates low-pitched sounds.

Stethoscope: environment and conditions

• Quiet, well-lit, warm room with privacy.

• Place the stethoscope directly on skin (not over clothing) to avoid distortion and friction noise.

• Patient can be supine, sitting or left lateral recumbent (sounds may differ by position).

Stethoscope: cleaning

• Inspect for damage.

• Clean earpieces and chest piece before and after every use with 70% isopropyl alcohol.

• Clean tubing with 70% isopropyl alcohol or mild soapy water (do not submerge).

• Avoid solvents, oils, extreme heat or cold.

Stethoscope tips: the 7 steps

1) Clean the stethoscope

2) Tighten loose parts

3) Align the ear tubes

4) Adjust the tension

5) Rotate the chest piece to the correct side

6) Clean the diaphragm/bell before touching the client

7) Check the seal of the diaphragm/bell against the skin

Stethoscope: ear tubes

• Align the ear tubes so the earpieces angle forward toward your nose (toward the ear canal).

Stethoscope: why warm the diaphragm?

• Hold it in your palm 5 to 10 seconds to avoid startling the patient and promote comfort.

Stethoscope always goes where?

• Flat against the skin, not over clothing.