Physical Assessment Techniques

      Supporting a Client’s Wishes As Advocates, nurses must ensure that clients are informed of their rights and have adequate information on which to base health care decisions. Nurses must be careful to assist clients with making health care decisions and not direct or control their decisions Nurses mediate on the client’s behalf when the actions of others are not in the client’s best interest or changes need to be made in the plan of care. Teaching about Advocacy Situations in which nurses might need to advocate for clients or assist them to advocate for themselves include end of life decisions, access to health care, protection of client privacy, informed consent, substandard practice. Nurses are accountable for their actions even if they are carrying out a provider’s prescription. It is the nurser’s responsibility to question a prescription if it could harm a client. Essentials Components of Advocacy are Risk-taking, Visionary, Conceptual thinker, Self Confidence, Articulate communication, Assertiveness. Educating Staff about Providing Cost- Effective Care Using all levels of personnel to their fullest when making assignments. Delegating effectively to members of the nursing care team. Providing necessary equipment and properly charging clients. Returning uncontaminated, unused equipment to the appropriate department for credit. Priority Action to Take if medications are unavailable Nurses have a responsibility to be advocates and to identify and report ethical situations. Some state nurse association offer protection for nurses who report substandard or unethical practice Doing so through the chain of command offers some protection against retribution. Referral for Care Following Discharge Evaluate client/family competencies in relation to home care prior to discharge. Involve the client and family in care planning Collaborate with other health care professionals to ensure all health care needs are met and necessary referrals are made. Recommending Clients for Discharge During a Disaster First, discharge or relocate ambulatory clients requiring minimal care. Plan for continuation of care for clients who require some assistance, which could be provided in the home or tertiary care facility.       Do not discharge or relocate clients who are unstable or require continuing nursing care and assessment unless they are in imminent dangers. Hazardous Material Incidents Hand hygiene using an alcohol-based waterless product is recommended after contact with the client when the hands are not visibly soiled or contaminated with blood or body fluids and after removal of gloves. Use soap and water for C. Difficile Properly clean all equipment for client care; dispose of one-time items according to facility policy. Transmission Prevention Airborne: Measle,varicella,tuberculosis Standard: Implemented for all clients Droplet:Haemophilus influenza type(Hib), pertussis, mumps, rubella, plaque, streptococcal pneumonia, meningococcal pneumonia, SARSCoV-2 Airborne Precautions Use airborne precautions to protect against droplet infections smaller than 5 mcg. Airborne precautions require, a private room, and use of mask and respiratory protection devices for caregivers and visitors. Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure. Responding to a Client About Constipation Nausea and Vomiting might occur due to hormonal changes and/or increase pressure within the abdominal cavity as the pregnant client’s stomach and intestines are displaced within the abdomen. Constipation might occur due to increased transit time of food through the gastrointestinal tract and, thus increased water absorption. Teaching about risk factors for Osteoporosis Lack of physical activity or prolonged immobility increases risk. Tobacco smoke exposure (active or passive) and high alcohol intake(three or more drinks per day) causes decreased bone formation and increase bone absorption. Excess Caffeine consumption causes excretion of calcium in the urine. Physical Assessment Techniques Requiring Intervention Subjective data is that information obtained from the patient perspective. Nurses should document subjective data as direct quotes, within quotation marks, or summarize and identify the information as the client’s statement. Objective data is that information the nurse obtains through assessment of the patient.