Nursing - Test 2 Notes

Bed bath temp 100-120 degrees Safety measures to consider when transferring patients -bed is in lowest position -wheels locked -patient in proper non-slip footwear -check for activity restrictions -make sure to check all equipment before transfer transferring patient to chair (safety measures) -assess patients ability -check for activity restrictions -determine patients weight -bed lowest position/locked -wheelchair/chair locked and secured -assess for dizziness, have patient sit with legs dangling for a few minutes -use gait belt -brace patients injured knee with your own steps for transferring patient from chair to bed · Make sure bed brakes are locked and put chair next to bed against a secure object · Stand shoulder length apart with one foot near head of the bed and slighty in front of the other foot · Assess for balance · If the pt is too heavy then lower back down onto the bed. · Can be delegated. · Gait belt · Get as close as you can to pt with your foot positioned on the outside of the pts foot. · Lift with gait belt and not back · Assess pts alignment moving patient up in bed (steps) · Assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure. Assess the patient's level of consciousness, ability to understand and follow directions, and ability to assist with moving. Assess the patient's weight and your strength to determine the number of caregivers required to assist with the activity. · The patient is at risk for injuries from shearing forces while being moved · During any patient handling task, if any caregiver is required to lift more than 35 lb of a patient's weight, consider the patient to be fully dependent and use assistive devices · Use a friction reducing sheet · Slight Trendelenburg position, remove all pillows · Lower side rails, have pt fold arms across chest and lift chin to chest · Pt can help by pushing with legs moving patient up in bed safety measures -use friction reducing sheet -have patient fold arms and bring chin to chest/ pillow should be at top of bed -make sure to raise side rails after transferring patient to stretcher safety measures -friction reducing sheet -make sure patient is covered (privacy) -arms folded and chin to chest patient to stretcher steps -implement safe patient algorithm for transfers -hand hygiene and make sure stretcher is properly cleaned -raise bed and lower hand rails -bed blanket on top, remove covers -friction reducing sheet is rolled under patient -have pt cross their arms and put their chin to chest -move her to the side closest to the transfer -roll pt away from stretcher and place under -one nurse pulls transfer board/one nurse pushes -remove transfer board and secure patient with handrails raised -cover pt with blanket and remove bath blanket -clean transfer board Neurological Assessment -awake, alert and oriented x 3 (Name, where, time) -forgetful? confused? agitated? lethargic? -pt respond to verbal/tactile stimuli? -assess patient speech (slurred, aphasia, dysphasia, tongue deviation, voice hoarseness, epistaxis) -facial droop? (ask pt to smile, indicator of stroke) -pt report headaches? lightheadedness/dizzy? -visual impairments (PERRLA) -hearing impairments (glasses, glaucoma, cataracts, hearing aids, hard of hearing, tinnitus) -pt report paresthesia in extremities -unequal strength? ability to push/ pull equal? (have pt pull arms, squeeze fingers, all bilaterally done) PERRLA pupils equal, round, reactive to light and accommodation parathesia numbness and tingling, may indicate neurological problem also electrolyte imbalance aphasia loss of speech, may indicate neurological problem dysphasia speech difficulty, may indicate neurological problem tongue deviation tongue points to one side when patient extends it, may indicate neurological problem epistaxis nosebleed, may indicate neurological problem contact precautions -Place the patient in a private room, if available. -Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. -Change gloves after having contact with infective material. -Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. -Limit movement of the patient out of the room. -Avoid sharing patient-care equipment. When are contact precautions used? Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO) example: MRSA, CDIFF When are airborne precautions used? Use these for patients who have infections that spread through the air examples: tuberculosis, varicella (chicken pox), and rubeola (measles) airborne precautions -Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside, or monitored filtration if air is recirculated. -Keep door closed and patient in room. -Wear a respirator when entering room of patient with known or suspected tuberculosis. -If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible. -Consult CDC guidelines for additional prevention strategies for tuberculosis. When are droplet precautions used? Use these for patients with an infection that is spread by large-particle droplets examples: rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. droplet precautions -Use a private room, if available. Door may remain open. -Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. -Transport patient out of room only when necessary and place a surgical mask on the patient if possible. -Keep visitors 3 ft from the infected person. standard precautions -Follow hand hygiene techniques. -Wear clean nonsterile gloves when touching blood, body fluids, excretions or secretions, contaminated items, mucous membranes, and nonintact skin. -Change gloves between tasks on the same patient as necessary and remove gloves promptly after use. -Wear personal protective equipment such as mask, eye protection, face shield, or fluid-repellent gown during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. --Use gown to protect skin and prevent soiling of clothing. -Follow respiratory hygiene/cough etiquette. Any patients, family members, and visitors with undiagnosed, transmissible respiratory infections require education to cover their mouth and nose with a tissue when coughing and promptly dispose of the tissue. -During periods of increased occurrence of respiratory infections, offer a surgical mask to coughing patients and other symptomatic people upon entry to the health care facility or office. -Encourage the coughing patient to maintain more than a 3ft separation from other people in the health care facility or office. -Avoid recapping used needles. If you must recap, never use two hands. Use a needle-recapping device or the onehanded scoop technique. Place needles, sharps, and scalpels in appropriate puncture-resistant containers after use. -Use safe injection practices including single-dose vials when possible; use disposable needles and syringes for each injection, and prevent contamination of injection equipment and medication. -Wear face mask if placing a catheter or injecting material into the spinal or epidural space. -Handle used patient care equipment that is soiled with blood or identified body fluids, secretions, and excretions carefully to prevent transfer of microorganisms. -Clean and reprocess items appropriately if used for another patient. -Use adequate environmental controls to ensure that routine care, cleaning, and disinfection procedures are followed. -Review room assignments carefully. Place patients who may contaminate the environment in private rooms (such as a patient who is incontinent). asepsis absence of pathogenic microorganisms, achieved through the use of gloves Why gloves with an infectious patient? -Block pathogens from patient and nurse -Use with oral care order in which you would see patients least infected to most infected first step to stop infections hand hygiene TB airborne precaution Mumps droplet precautions multidrug resistance (mrsa) contact precautions health-illness continuum -Conceptualizes a person's level of health -Views health as a constantly changing state with high-level wellness and death on opposite sides of a continuum -Illustrates the dynamic (ever-changing) state of health trust vs mistrust stage (INFANT) according to Erikson, the period during which infants develop a sense of trust or mistrust, largely depending on how well their needs are met by their caregivers autonomy vs shame and doubt stage (TODDLER) according to Erikson, toddlers develop either independence and autonomy if they are allowed the freedom to explore, or shame and doubt if they are restricted and overprotected. safety: no balloons, normal if they are shy initiative vs guilt stage (3-6) according to Erikson, the period during which children aged 3 to 6 years experience conflict between independence of action and the sometimes negative results of that action -safety.. seat belt, helmets, road crossing safety industry vs inferiority stage (6-12) according to Erikson, the period from age 6 to 12 characterized by a focus on efforts to attain competence in meeting the challenges presented by parents, peers, school, and the other complexities of the modern world -safety.. seat belts, helmets, stranger danger, hormones identity vs role confusion stage (TEENS) Erikson's stage during which teenagers and young adults search for and become their true selves -safety.. guns, driving, drugs intimacy vs isolation stage (YOUNG ADULT) according to Erikson, a period during early adulthood that focuses on developing close relationships generativity vs. stagnation stage (MIDLILFE) according to Erikson, the stage during middle adulthood in which people consider their contributions to family and society (fulfilled vs unfulfilled) -safety (start screenings) integrity vs despair stage (ELDERLY) according to Erikson, the process in late life by which people try to make sense of their lives -- they understand that dying is a part of life -safety (risk for injury) general physiological changes in elderly -Progressively decreasing efficiency of physiologic processes results in a fragile balance and hinders the body's ability to maintain homeostasis. -Physical or emotional stressors cause the older adult to be more vulnerable because of decreased physiologic reserves. -The older adult may continue to engage in all activities of middle age but intuitively adjusts to a modified pace and more frequent rest periods. integumentary changes in elderly Wrinkling and aging of skin, dryness and scaling, moles, more likely to bruise Musculoskeletal changes in elderly decrease in fat and weight, muscle mass and strength decrease, bones become brittle neurological changes in elderly response decreases, temperature regulation and pain/pressure perception decreases, may be loss of sensation, difficultly in balance/coordination/fine movements, sleep at night shortens thus catnaps become common sensory changes in elderly decreases visual acurity/depth perception, cataracts = difficulty reading fine print or difficulty driving at night, diminished hearing, wax builds up, senses of taste and smell are decreased TEETH Tooth decay and loss continue for most older adults. cardiopulmonary changes in elderly Blood vessels become less elastic and rigid, venous return becomes less efficient, lower edema may occur gastrointestinal changes in the elderly digestive juices diminish and nutrient absorption decreases, malnutrition and anemia become common, decreased peristalsis, constipation and indigestion are more common, dry mouth genitourinary changes in the elderly nephrons decrease to 50%, pee often, 75% of men get hypertrophy of the BPH, women's genital tract atrophies and becomes thin and decreased secretions pay attention to these details with older adults takes time for them to understand things and respond, decreased learning due to sensory changes functional ability the ability to perform ADLs such as eating, dressing, and walking health restoration restoring health, needs a trusting relationship depends on patients’ motivation, desire, aspirations and persistence primary prevention immunizations, talk about diet, etc. secondary prevention mammograms, yearly check-up, screenings tertiary prevention disease management, goals to reduce disability, return pt to optimal health health promotion process -enables individuals to increase control over their health -self management requires motivation, adherence, teaching -levels of prevention (primary, secondary, tertiary) someone who does not take their medicine are in a state of illness Therapeutic communication Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship. trusting relationship between nurse and patient open ended questions Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities teaching plans for older adults first identify any learning barriers such as sensory loss, limited physical mobility, or inability to comply with the recommended therapeutic regimen. Sensory deficits that can affect learning in older adults include the presence of cataracts that can cloud vision; a decrease in lens accommodation that necessitates adequate lighting; a decrease in peripheral vision that requires that teaching materials be kept immediately in front of the learner; or a hearing loss that make it imperative for the teacher to speak slowly and clearly Goal of a trusting relationship health promotion and well-being of patient fight/flight response an involuntary reaction resulting in a state of physiological readiness to deal with a sudden and immediate threat by either confronting it (fight) or running away to safety (flight) physiological changes in fight response Sympathetic response— Stimulates heart rate and force Dilates skeletal muscle blood vessels Dilates blood vessels to the brain Stimulates release of glycogen stores. physiological changes in the flight response Parasympathetic response - Regulates heart rate Stimulates secretion of digestive juices and digestive tract smooth muscle Stimulates insulin secretion. Local Adaptation Syndrome Body attempts to limit damage from trauma to one area, ie local inflammatory response, reflex pain response generalized adaptation syndrome describes the body's general response to stress three stages alarm, resistance, exhaustion alarm stage first stage of GAS is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. resistance stage second stage of GAS Vital signs, hormone levels, and energy production return to normal. exhaustion stage third stage of GAS This depletion of resources results in damage to the body in the form of wear and tear or systemic damage. Without defense against the stressor, the body may either rest and mobilize its defenses to return to normal or reach total exhaustion and die. Mind-Body Interaction The body's response to threats as if they are real; preparation for resistance or flight. example: Tomorrow, you are scheduled to take a final examination, and you must earn a passing score to pass the course and remain in the nursing program. After being awake most of the night, you cannot swallow any food at breakfast, you have a rapid heartbeat, you are filled with feelings of apprehension, and you have diarrhea. mild anxiety symptoms anxiety that is present in day-to-day living. It increases alertness and perceptual fields (e.g., vision and hearing) and motivates learning and growth. Although mild anxiety may interfere with sleep, it also facilitates problem solving. Mild anxiety is often manifested by restlessness and increased questioning. Moderate Anxiety Symptoms narrows a person's perceptual fields so that the focus is on immediate concerns, with inattention to other communications and details. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, a complaint of "butterflies in the stomach," and slight increases in respirations and pulse severe anxiety symptoms The person has impaired learning ability and is easily distracted. Severe anxiety is characterized by extreme fear of a danger that is not real, by emotional distress that interferes with everyday life, and by avoiding situations that cause anxiety. It is manifested by difficulty communicating verbally, increased motor activity, a fearful facial expression, headache, nausea, dizziness, tachycardia, and hyperventilation. Panic symptoms -Palpitations -Tachycardia -Feeling of suffocation/choking -Dilated pupils -Flushed face -Dizzy/faint -Feeling of impending doom/death Repression (defense mechanism) - Involuntary blocking of unpleasant feelings and experiences from ones awareness. EX: An accident victim can remember nothing about the accident displacement (defense mechanism) - The transfer of feelings from one target to another that is considered less threatening or that is neutral. EX: A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse. 5 stages of grief 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance denial stage of grief cannot accept that someone is dying/illness cannot accept news of person's death/illness anger stage of grief The person may feel powerless and unfairly deprived. These feelings are often experienced as anger. bargaining stage of grief -Client may bargain with God, the clinician, or others. -"I will do some extra credit to get my grade up." -"If I attend all of my therapy sessions, you will assume the responsibility for curing my disorder." depression stage of grief person realizes full impact of the loss; overwhelming sadness, hopelessness, and loneliness acceptance stage of grief person incorporates the loss into life; develops the capacity to have a breadth of emotions, even positive ones; finds ways to move forward culturally competent care the ability to bridge cultural gaps in caring, work with cultural differences, and enable clients and families to achieve meaningful and supportive caring.