clinical #1
congruence: agreement or conformity
effectiveness of caregiver communication:
1) read back: reading back information to the patient can be beneifical ti make sure the patient understands what is going on and the nurse can make sure she is following the procedure correctly
2) develop a list of accronyms or other abreviations that should n longer be used because they illicit confusion
3) report critical test results immediately
4) handoff communication: the information you hand off to a nurse that is now taking over the patient. this involves crucial information that is impirtant to the patients well being
What is a technique you can use for handoff communication: the SBAR technique: this tech. covers situation, background, assessment and recommencdations for the patient that is being handed off
S-situation: identify yourself and the patient and the primary concerns
B-background-provide the medical background of the client as well as any important background information that might be beneficial for the next nurse to know
A-assessment: give the essential assessment parameters of the clients current state: vital signs
R-recommendation-make suggestions for continued care
Communication techniques:
when clients had an opportunity to respond and ask questions they felt more at ease in the emrgency department
Formal handoff approach in the ER: IPASBATON
I - Introduction: Introduce yourself and your role to the receiving team.
P - Patient: Provide a brief summary of the patient’s background and presenting problem.
A - Assessment: Share the current status and critical findings.
S - Situation: Discuss the current situation and any immediate concerns.
B - Background: Review the relevant medical history and pertinent details.
A - Actions: Outline the interventions that have been performed and their results.
T - Timing: Indicate any important timelines or deadlines that need consideration.
O - Ownership: Ensure clarity regarding who is responsible for the patient's care moving forward.
N - Next steps: Suggest recommendations for ongoing care and follow-up
achknowledgement is importsnt to make sure the patient feels heard and you arent inserting your own beleifs or biases
clarification is importnt in making sure you understand what the patient is saying before making your own assumptions, take extra steps to clarify
dont use false reassurence cliches like “its all going to be alrigt” because it is not really comforting at all
Skill 4.1.1 Introducing yourself to a client
the procedure is as follows, obtain the client assignment, read the cart, check the care plan and clarify if any questions present, perform hand hygeine, once in the room check client ID with 2 forms of idenitficaiton such as address and DOB, introduce yourself, and youre done
4.1.2 beginning a client interaction
after introducing yourself, relate the purpose of the interaction, explain what services you will be conducting, ask if the client understands and promopt them if they have any questions regarding their care, encourage patient to describe how they are currently feeling and in regardd to pain you can use a scale or soemthing or compare it to soemthing, encourage participation, assess verbal and nonverbal communication by mking sure you are always observing, ask client for feedback, complete communication by telling patient when you will return, and then follow through
4.2.1 Initiating a nurse-client relationship
read clients chart and be familar with things like medications taking, fmaily history, and status, identify client with 2 forms of ID, perform hand hygeine, introduce yourself, assess the problems if any or the situation at hand, establish a beginning relationship, establish mutual goals, be consistent by doing what yu say you will do and being completely honest, encourage participation, be warm towards the patient
4.2.2 facilitating a nurse-client relationship
in every interqction assume the role of the facilitator, accept client as a worthy individual regardless of who they are, keep cponverdastions reality oriented in the here and now, focus on how, what, when and where rather then why, asking why can make people defensive and close off, help client identify express and cope wiht feelings, and develop alternative coping mechanisms if necessary
7.1.1 preventing client falls
equpiment
-side rails and hand rails
-alarm system
-restraints
-locks for moveable equipment such as beds, wheelchairs, etc.
procedure: perform hand hygiene, identify patient with 2 forms of ID, introduce yourself and explain the procedure, assess all clients for risk factors for falls
Risk factors:
Intrinisc risk factors:
-decreased vision and other senses
-weakness and alterations in mobility/gait (what is gait)
-urinary incontinecne or the loss of bladder control
-chroninc illness and confusion
- polypharmacy which is the use of 5 or more medicaitons
-alcohol consumption
-chronic pain
-orthostatic hypotension
-length of time at the hospital
-fear of falling and a history of falls
extrinsic risk factors:
-lack of grab bars
-poor condition of floor surfaces
-inadequate use of assitive devices
-reaching for articles out of the way
Risk assessment
1) cdc fall checklist
2) falls efficacy scale-measurement of how confident the indicidual is when performing ADLs
3) morse fall scale assessment
what to do to avoid the potential of client falls: complete a comprehensive interview to detemrine the potential for falls evalutating intrinsic risk factors, detemrine psychosocail status, orient new clients to their surroundings, instruct clients on using the bathroom showers and emergency protocal equipment, determine the clients ability to safely use fall prevention aids, place bed in low and locked postion when you are not providing care, determine the appropriate use of siderails, keep half side rails up fpr disoriented or older indicuals, etc.
8.1.1 folding a mitered corner
keepsbed linens tight and wrinkle free
8.1.2 changing a pillowcase
8.1.3 making an unoccupied/surgical bed
8.1.4 changing an occupied bed
Chapter 12: unknown terms
ambulate: walking or the ability to walk
atrophy-decrease in size of organ or tissue
fowlers position-head of bed is at a 45 degree angle, clients knees may or may not be flexed
high fowlers position-head of bed is at a 60 degree angle-often used to achieve max chest compression
hoyer lift-a m,echanical device that enables one individual to safely transfer a client from bed to chair
orthosis-use of special equipment to stabalize or immobolize a body part protect against injury or assist with function
what are the primary parts of the musculoskeletal system-muscles, bones, and joints
joints-the places where bones meet and serve to provide motion and flexibility. most joints are composed of ligaments connecting bone to bone and cartilahe which covers and cushions the ends of our bones
12.1.2 applying body mechanics
procedure-determine the need for assitance in moivng or turning a client, this is where a lot of back pain can occur, place bed at the correct height (waist level when providing care, hip level when moving a client),
12.1.3 maintaing proper body alignment
procedure-begin with proper stance, evaluate working height
12.2.3 turning to lateral position
12.2.4 turning to a prone position
prone is the opposite of supine
12.2.5 moving client up in the bed
12.2.6 moving client with assitance
12.2.7 logrolling the client
logrolling essentially is moving the client while keeping them as straight as a log to avoid any duress this is typically done after brain or spinal cord surgery to avoid injurying vulnerable parts
14.1.1 Hand Hygeiene medical asepsis
under what 5 circumstances are nurses required to wash their hands: before tuching a client, before clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings
What is an aseptic procedure: An aseptic procedure is a medical practice that aims to prevent contamination by pathogens, ensuring a sterile environment during interventions such as surgery, catheter insertion, or wound care. In addition, aseptic techniques involve strict adherence to hygiene protocols, use of sterile instruments, and appropriate protective equipment to minimize the risk of infection.
14.1.3 donning and removing clean gloves
20.3.5 Calibrating a blood glucose meter
-this is a blood glucose monioring device, people use this to moniotr diabetes, it tells us how much sugar is in a single drop of blood
procedure-obtain glucose test strips and remove a calibration strip, compare lot numbers on calibration strip to lot number on side of glucose test strips bottle, place calibration strip in meter by opening door and inserting the top of the strip into slot on right side of meter, obtain blood specimen
20.3.6 obtaining blood specimen for glucose testing
25.1.2 donning sterile gloves
unknown terms on weekly outline
Hypoglycemia signs and symptoms: hypoglycemia is low blood sugar, usually below 70mg/dL. glyc means sugar or glucose and emia means some sort of blood condition; therefore, glycemia refers to the presence of glucose in the blood, which is crucial for diagnosing and managing conditions like hypoglycemia.
Sweating
Trembling
Rapid heartbeat
Dizziness
Confusion
Hunger
Irritability
Weakness
Hyperglycemia signs and symptoms: usually above 125 mg/dL while fasting
Increased thirst
Frequent urination
Fatigue
Blurred vision
Headaches
Difficulty concentrating
What is an accute check in nursing ? An acute check in nursing refers to a focused assessment performed when a patient presents with sudden or severe symptoms, such as those experienced in cases of blurred vision, headaches, or difficulty concentrating. This assessment aims to promptly identify potentially life-threatening conditions and initiate appropriate interventions. During an acute check, the nurse evaluates vital signs, neurological status, and conducts relevant tests to determine the underlying cause of the symptoms.