Exam 2 Flashcards
Collaboration (3)
-development of partnerships to achieve the best possible outcomes that reflect the particular needs of the patient, family, or community
-requires an understanding of what others have to offer
- to labor together or to work with others in an intellectual endeavor.
4 Attributes of Collaboration
- Values and ethics (mutual respect and trust)
- Teams and teamwork
- Roles and Responsibilities (know yours and others)
- Communication (use common language, responsible and responsive)
Kim’s Theory of Collaboration
Collaborative decision making is assessed on a continuum:
-lowest level of collaboration is expressed as complete domination of decision making by the nurse
- highest level of collaboration is expressed as an equally influencing joint decision making (this is where we want to function)
How is Collaboration addressed as a professional standard?
-ANA includes it in the code of ethics
-Complexity of healthcare delivery system requires multidisciplinary approach
What is the economic impact of collaboration?
-positive impact at organizational level
-Cowan’s study found collaboration is linked to decreased length of stay for patients and increased economic benefits for health care organizations
How is Collaboration changing in research?
Health sciences research is moving away from the private investigator model to a collaborative model represented by interprofessional collaborators.
What does QSEN say has a positive impact on length of hospital stay and total charges?
Daily interprofessional rounds in inpatient, acute hospital settings
What are situations of Nurse-Nurse (Intraprofessional) Collaboration?(3)
-patient care handoff (bedside report)
-Mentoring
-Shared Governance
Patient Care Hand-Off (2)
*A transfer and acceptance of patient care responsibility using effective communication.
*High-quality hand-off is complex and structured. (a Joint Commission Standard)
8 Contributing factors to hand-off communication breakdowns
- Insufficient or misleading information
- Lack of safety culture
- Ineffective communication methods
- Lack of time
- Poor follow-up between sender and receiver
- Interruptions or distractions
- Lack of standardized discharge and transfer procedures
- Insufficient staffing
I in IPASStheBATON for Handoffs
Introduction (Introduce yourself and your role or job (include patient)); write name on whiteboard
P in IPASStheBATON
Patient (Name, identifiers, age, sex, location)
A(1st) in IPASStheBATON
Assessment (Present chief complaint, vital signs, symptoms, and diagnosis)-new nurse quickly assesses
S (1st) in IPASStheBATON
Situation (Current status or circumstances, including code status, level of (un)certainty, recent changes, and response to treatment)
S (2nd) in IPASStheBATON
SAFETY Concerns (Critical lab values or reports, SES factors, allergies, and alerts (falls, isolation))
What is SBAR? What does it improve? What does it stand for? (3)
- A common language and tool for communicating critical information to healthcare providers in a standardized, structured, and timely manner.
- Improves perception of communication and information about patients between health care professionals.
- Situation, Background, Assessment, and Recommendation
B in IPASStheBATON
Background ( Comorbidities, previous episodes, current medications, and family history)
A(2nd) in IPASStheBATON
Actions (What actions were taken or are required? Provide brief rationale)
T in IPASStheBATON
Timing (Level of urgency and explicit timing and prioritization of actions)
O in IPASStheBATON
Ownership (Who is responsible (person or team) including patient or family?)
N in IPASStheBATON
Next (What will happen next? Are there anticipated changes? What is the plan?
Are there contingency plans?)
Shared Governance (3)
-decentralized management style which creates an environment of empowerment via involving all staff in decision making
-Managers are facilitative versus controlling
-Increases collaborative effort, professional accomplishment, competence, and satisfaction
What are 4 situations of Interprofessional Collaboration?
-Patient rounding
-Rapid Response Team
-SBAR
-Interprofessional education
3 Challenges of IPC
-power and authority imbalances
-tension with boundaries
-confusion of roles and responsibilities
5 strategies to improve IPC
- Address colleague by name
- Be prepared with patient’s record
- Share expectations of what, when , and how to communicate
- Focus on patient problem
- Be professional and assertive (not aggressive or confrontational)
What is the interprofessional purpose of patient rounding? What is the Intraprofessional purpose of patient round?
- Interprofessional goal is to monitor progress and communicate clear goals and a plan of care for each patient.
- Intraprofessional goal is to check on patients on a predetermined timeframe assess the patient’s need such as pain level and assisting with basic needs.
What is the difference in team members between the Medical Response Team and Rapid Response Team?
Medical Response Team: respond to emergencies (includes nurses and physicians)
Rapid Response Team: Respond to emergencies, Follow up on patients discharged from ICU, Proactively evaluate high-risk patients, Educate and act as liaison to unit staff (critical care nurse, respiratory therapist, and physician)
S in ISBAR
Situation (concise statement of the problem)
B in ISBAR
Background
- Pertinent and brief information related to the situation.
- Diagnosis and co-morbidities
- Relevant background clinical information (i..e. medications, specialists, procedures)
A in ISBAR
Assessment
- Analysis and considerations of options
- What are your assessment findings?
- What do you think the problem is?
R in ISBAR
Recommendation
- Action requested/recommended
- What do you suggest needs to be done?
- What are you requesting?
- Is everyone clear about what needs to be done?
What is TeamSTEPPS in IPC? What are the 5 principles?
-evidence based team work (increases team awareness and communication; decreases barriers to patient safety)
-Principles: team structure, communication, leadership, situation monitoring, mutual support
CUS Tool in IPC
I am Concerned
I am Uncomfortable
This is a Safety Issue
SACCIA in IPC
- Sufficiency-enough detail
- Accuracy- include physical physiological, & behavioral facts
- Clarity - concise w/ essential info
- Contextualization & Interpersonal adaptation – adjust explanations to experience level of who you are talking to
4 ways to reduce Lateral Violence
- Zero tolerance policy
- Develop conflict management and assertive communication
- Mentors (can help and be personal support)
- Don’t retaliate , stay calm , report incidences
5 examples of Clinical Information Systems (CIS)
Examples include:
* Electronic health records
* Clinical data repositories
* Decision support programs
* Handheld devices
* Communication tools: electronic messaging systems and patient portals
5 links of Standardized Information Systems
- Efficiency
- Cost containment
- Codified terminology
- Taxonomies and nomenclature
- care communication
Meaningful use criteria (4)
requires that use of tech results in:
- improved quality, safety, and efficiency of health care
- increases coordination of health care delivery
- advances public health
- protects the privacy of personal health records
The application and utilization of technology in healthcare must demonstrate: (3) per HITECH
- Meaningful use criteria
- Certification standards
- Practices to reduce barriers for information exchange
Nurse Informaticians: (3)
*Use their knowledge of patient care combined with understanding of informatics concepts, methods, and tools to analyze, design, implement, and evaluate information and communication systems
*Advanced education and training
*Collaboration with other health care professionals and IT specialists
HIPPA Privacy vs Security rule
Privacy rule: requires disclosures of PHI be limited to specific info required for particular purpose
Security rule: specifies administrative, physical/ and technical safeguards for 18 elements of PHI in electronic form
What did Florence Nightingale say about health informatics?
To Err Is Human: Building a Better Health System: appropriate technologies can help to reduce errors and ensure patient safety
Translational bioinformatics
focuses on preventive measures as it relates to health information
Electronic Health Records (EHR)
- Documentation systems used to record the process and outcome of delivered patient care
- It is comprehensive of Multiple records from multiple providers
Documentation
- A written account of pertinent patient data, clinical decisions and interventions, and patient responses to care in a health record
- Available for all members of the health care team to revive, document, and receive data
6 Purposes of Health Care Record
- Auditing and Monitoring
- Reimbursement (via diagnosis-related groups)
- Interprofessional Communication
- Education
- Research (w/ de-identification of PHI)
- Legal documentation (confidential and permanent info related to patient care)
5 Documentation mistakes that can lead to malpractice
- failure to record pertinent health or med info
- failure to record nursing actions ( including medication admin)
- failure to record medication reactions or changes in patient condition
- failure to document discontinued medications
- incomplete or illegible records
11 legal Guidelines for Documentation
- No retaliatory comments or opinions about HCP or patient
- Correct all errors promptly
- Record facts
- Discuss communication you initiated for orders or clarification
- Document only for yourself
- Avoid generalized statements “status unchanged” or “tolerated well”
- Begin with date and time, end with signature and credentials
- Password protection
- Do not leave blank spaces or lines
- Do not erase or scratch out errors made while recording
- Record all written entries legibly using black ink and not felt tip pen or erasible ink
4 Guidelines for Quality Documentation
- Only include facts
- Write in short sentences
- Use simple, short words
- Avoid the use of jargon or abbreviations
6 standards for Quality Documentation
-Factual (avoid opinions and vague terms; only subjective data should be from patient
-Accurate (avoid irrelevant details)
-Appropriate Usage of Abbreviations
-Current (document right after things occur)
-Organized
-Complete (appropriate and essential info)
How Documentation is used for Research?
De-identified data can be used for statistical analysis of: Frequency of clinical conditions, Complications, Use of specific medical and nursing therapies, and Clinical outcomes
Analysis of the data contributes to evidence-based practice and quality care
5 Error-prone abbreviations
- U, u for unit
- QD or QOD for daily or every other day
- IU for international unit
- trailing and leading zeros
- MS , MSO4, MgSO4 for morphine sulfate and magnesium sulfate
5 Benefits of CPOE
- Reduces safety issues and medication errors related to illegible handwriting and transcription errors
- Increases the implementation time of ordered diagnostics test and treatments
- Improves reimbursement
- Increases productivity
- Cost effective
Point of Care Testing (POCT) and 4 examples
-quick lab tests near the patient which reduces time for clinical decision making
- glucose monitoring
- arterial blood gas (ABGs) monitoring
-pregnancy test
-rapid strep test
Flow Sheets (2)
-Documentation method used to document patient assessment data, routine care, repetitive care (hygiene, ambulation, safety checks)
- photos and graphics organized by body system so quick and easy
Narrative (What is it? What are the disadvantages? What are the advantages)
- Traditional, Story-like, Free text or menu selection documentation method
- Time consuming and Repetitious
- Enhances clinical communication and interdisciplinary understanding of patient care
SOAP
-Documentation Method to identify interprofessional problems
Subjective, Objective, Assessment, Plan
PIE
-Documentation Method with specific nursing focus
* Problem: Nursing problem or diagnosis
* Intervention: Interventions that will be used to address the problem
* Evaluation: Nursing evaluatione
Focused Charting
Documentation method used to report problems and address patient concerns
* Data: subjective and objective
* Action: nursing intervention
* Response: response of the patient
Problem-Oriented Medical Record Documentation method includes:(4)
- Database
- Problem list
- Progress notes
- Standardized care plans or clinical practice guidelines (CPGs)
Charting by Exception (4)
- Documentation Method which says Patient meets all standards unless otherwise documented
- Uses standards of care and EBP
- Usually there are drop-down menus with defined criteria to document “normal” i.e WDL or WNL
- When the patient’s status changes, or selections are not available, include a nurse’s note (narrative note)
Critical Pathways (2) in Case management model
- Interprofessional care plan that identifies patient problems, pertinent interventions, and expected outcomes within an identified time frame
- Variance may occur when the tasks on the critical pathway are not completed or patient does not meet outcomes as expected
6 Guidelines for Telephone and Verbal Orders
- Verbal order only in emergencies
- Only authorized staff receive and record telephone and verbal orders.
- Clearly identify the patient’s name, room number, and diagnoses.
- Document “TO” (telephone order) or “VO” (verbal order), including date and time, name of patient, the complete order; the name and credentials of the health care provider giving the order(s); and your name and credentials as the nurse taking the order.
- Read back all orders prescribed to the health care provider who gave them and document “TORB” (telephone order read back) when signing your name and credentials.
- Have another nurse listen, repeat details of prescription, obtain provider signature within 24 hrs
Acuity Rating Systems
Determines the hours of care and number of staff required for a given group of patients every shift or every 24 hours
-patient acuity level based on type and # of nursing interventions required in 24 hrs
What is the Rationale and Correct Action for the following documentation Guideline:
Do not document retaliatory or critical comments about a patient or care provided by another health care professional. Do not enter personal opinions.
Rationale: Statements can be used as evidence for nonprofessional behavior or poor quality of care.
Correct Action: Enter only objective and factual observations of a patient’s behavior or the actions of another health care professional. Quote all patient statements.
What is the Rationale and Correct Action for the following documentation Guideline:
Correct all errors promptly.
Rationale: Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence.
Correct Action: Avoid rushing to complete documentation; be sure that information is
What is the Rationale and Correct Action for the following documentation Guideline:
Record all facts.
Rationale: Record must be accurate, factual, and objective.
Correct Action: Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care.
What is the Rationale and Correct Action for the following documentation Guideline:
Document discussions with providers that you initiate to seek clarification regarding an order that is questioned.
Rationale: If you carry out an order that is written incorrectly, you are just as liable for prosecution as the health care provider.
Correct Action: Do not record “physician made error.” Instead document that “Dr. Smith was called to clarify order for analgesic.” Include the date and time of the phone call, with whom you spoke, and the outcome.
What is the Rationale and Correct Action for the following documentation Guideline:
Document only for yourself.
Rationale: You are accountable for information that you enter into a patient’s record.
Correct Action: Never enter documentation for someone else (exception: if professional has went home and forgot to document something)
What is the Rationale and Correct Action for the following documentation Guideline:
Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
Rationale: This type of documentation is subjective and does not reflect patient assessment.
Correct Action: Use complete, concise descriptions of assessments and care provided so that documentation is objective and factual.”
What is the Rationale and Correct Action for the following documentation Guideline:
Begin each entry with date and time and end with your signature and credentials.”
Rationale: Ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered.
Correct Action: Do not wait until the end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., M. Marcus, RN).
4 mechanisms of Disrupted Fluid Electrolyte balance
- Normal output but deficient intake or absorption—Children
- Increased output not balanced by increased intake—BP pills, hemorrhage, diarrhea
- Output less than excessive or too rapid intake-IV (crackles in lungs)
- Decreased output not balanced by decreased intake—Urinary retention/oliguria
4 forces of filtration
- Capillary Hydrostatic Pressure (strong, outward - force) → strongest @ arterial end and weakest @ venous end
- Blood colloid osmotic pressure (inward - force) - stronger @ venous end
- Interstitial fluid hydrostatic pressure (weak)
- Interstitial fluid osmotic pressure (very small)
What is the Rationale and Correct Action for the following documentation Guideline:
Do not erase or scratch out errors made while recording.
Rationale: Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record.
Correct Action: Draw single line through error, write word “error” above it, and sign your name or initials and date it. Then record note correctly.
What is the Rationale and Correct Action for the following documentation Guideline:
Do not leave blank spaces or lines in a written nurse’s progress note.
Rationale: Allows another person to add incorrect information in open space.
Correct Action: Chart consecutively, line by line; if space is left, draw a line horizontally through it and place your signature and credentials at the end.
What is the Rationale and Correct Action for the following documentation Guideline:
Record all written entries legibly using black ink. Do not use pencils, felt-tip pens, or erasable ink.
Rationale: Illegible entries are easily misinterpreted, causing errors and lawsuits; ink from felt-tip pen can smudge or run when wet and may destroy documentation; erasures are not permitted in clinical documentation; black ink is more legible when records are photocopied or scanned.
Correct Action: Write clearly and include appropriate abbreviations using black ink
Why are infants at greater risk of fluid imbalance? (4)
Ø High metabolic rate
Ø Immature kidneys
Ø More rapid respiratory rate
Ø Proportionately greater BSA compared to adults
Why are older adults at greater risk of fluid imbalance? (3)
Ø Thirst and taste sensation blunted
Ø Kidneys less able to respond to ADH
Ø Impaired ability to conserve water (low body weight)
What are some red flags of health history related to fluid imbalance?
Ø Vomiting, diarrhea, organ failure (kidney, heart, liver)
Ø Unexplained nausea, fatigue, dizziness, shortness of breath, muscle cramping, edema, sudden changes in weight
7 nursing interventions related to fluid balance
- Patient Teaching
- Daily weight (1st thing in morning with same amount of clothes; if increase or decrease for by ≥5 pounds then fluid loss or gain)
- Monitoring fluid intake and output (can delegate to UAP)
- Safety risk assessments (Fluid imbalance can cause orthostatic hypotension, dizziness)
- Comfort measures
- Oral hygiene
- Assess vitals
BUN and Creatinine normal range
BUN-6-24
Creatinine-0.6-1.2
When does BUN increase? What does it mean if BUN and creatinine are high?
BUN increases with dehydration and decreases with ECF excess. If BUN and Creatinine are high, there may be dehydration and kidney failure
Hematocrit and Hemoglobin normal range
Hematocrit (% of RBC in blood)-36-48
Hemoglobin (amount of protein in RBC)—12-16
Hematocrit to Hemoglobin ratios
Normal 3:1
Dehydration/Hypovolemia: >3:1
Fluid Overload: <3:1
Differentiate isotonic, hypotonic, hypertonic solutions
Isotonic solution has the same number of solutes as human intravascular fluid so the red blood cell stays the same.
Hypotonic solution: solutes in solution are dilute so the red blood cell in the intravascular space swells.
Hypertonic solution: solutes in solution concentrated so the red blood cell in the intravascular space shrinks.
When someone is dehydrated what does Gatorade, Water, and Pedialyte do?
Gatorade is hypertonic so is draws water from cells; good for prevention
Water is hypotonic so it pulls water from intravascular compartment; good for prevention
Pedialyte is isotonic and will increase circulating volume to nourish all cells; good for treatment
Purpose and 2 examples of Isotonic fluids
-increase ECV but do not enter cells; given for dehydrated, hypotensive, or hypovolemic shock
- Normal Saline (0.9%)
- Lactated Ringers-includes Na+, K+, Ca2+, Cl−, and lactate, which liver metabolizes to HCO3−
10 Signs of Hypovolemia
- sudden weight loss (overnight)
- decreased skin turgor (elasticity)/tenting
- postural hypotension
- no tears or sweat, dry mucus
- Tachycardia
- Rapid Thready pulse (comes and goes; difficulty finding)
- Flat neck veins
- Restlessness/decreased LOC
- Sunk eyes
- Oliguria (less than 30 mL/hr)
6 causes of hypovolemia
- Abnormal GI losses: vomiting, diarrhea, GI suction,
- Abnormal Skin losses: diaphoresis, prolonged fever, wound drainage
- Abnormal renal losses: diuretic therapy
- Third space shifting: peritonitis (inflammation of belly abdomen), ascites (fluid shift in abdomen), burns
- Hemorrhage: blood loss after surgery, GI bleed
- Enteral feeding without sufficient free water
9 signs of hypervolemia
- Sudden weight gain (overnight)
- Confusion
- Orthopnea (unable to breathe laying down)
- Hypertension
- Tachypnea (fast breathing
- Crackles in lower bases of longs
- Bounding pulse
- Distended neck veins
- Pulmonary edema
7 causes of Hypervolemia
- Congestive heart failure
- Liver cirrhosis
- Increased glucocorticoids
- Kidney failure
- Excess Sodium intake
- Water replacement with no electrolyte replacement
- Excess IV
Purpose and 5 Examples of Hypertonic fluids
§ Used to draw water from cells.
§ 3% or 5% NS
§ D10W (becomes hypotonic in body)
§ D5 ½ NS (becomes hypotonic after D5 absorbed)
§ D5 NS (becomes isotonic after D5 absorbed)
§ D5 LR (becomes isotonic after D5 absorbed)
Purpose and 2 Examples of Hypotonic fluids
§ Used to expand ECV and hydrate cells before surgery
§ 0.225% NS
§ 0.45% NS
When to use hypertonic solutions? (3)
§ Dextrose rapidly enters cells. D5 is isotonic for patient’s not eating
§ 3 or 5% NS if pulling fluid off of brain after stroke
§ D10 if insulin shock
3 Types of IV devices
- Central Venous Catheters (CVCs) – catheter tip in central circulatory system (used for high osmolality, irritating fluids, large volumes)—includes PICCs
- Peripheral IVs- catheter tip in vein of one of the extremities (used for low osmolality)
6 notes on Venipuncture Sites
- Inner arm=most common
- No hands on older adults or ambulatory individuals
- Feet only in children
- Avoid areas of flexion and compromised veins
- No sites on chest, breast, abdomen, or trunk
- No sites of infection, infiltration or thrombosis
Infiltration and Extravasation Assessment Findings (3)
- Skin around catheter site taut, blanched, cool to touch, pitting edema;
- may be painful as infiltration or extravasation increases
- infusion may slow or stop
Infiltration and Extravasation Nursing Intervention (5)
§ Stop infusion (discontinue if not vesicant; if vesicant disconnect and aspirate) and call HCP
§ Remove the IV site
§ Prop the arm
§ Do not apply heat or cold unless ordered, (can react with substance)
§ Do not apply pressure (can cause more contact with skin)
Phlebitis (vein inflammation) Assessment Finding
hard, red, painful, hot lump where IV site is ; may or may not have red streak or palpable cord along vein
Phlebitis Nursing Interventions (5)
§ Take out IV and call doctor.
§ Elevate affected extremity
§ Do not apply heat or cold without order.
§ May need IV antibiotics.
§ Start new IV line proximal or in other extremity
Infection of IV site Assessment Finding
Redness, burning ,swelling, weeping or discharge; not hard
Infection of IV site Nursing Intervention (4)
§ Remove catheter and contact HCP
§ Need antibiotics to prevent sepsis
§ Clean skin with alcohol and culture drainage if ordered
§ Initiate appropriate wound care
4 Types of circulatory overload of IV Solution Assessment Findings
- Na+-containing isotonic fluid (crackles in parts of lungs, shortness of breath, edema)
- Hyponatremia with hypotonic fluid (confusion, seizures)
- Hypernatremia with hypertonic fluid (confusion, seizures)
- Hyperkalemia from K+ fluid (cardiac dysrhythmias, muscle weakness, abdominal distention)
Circulatory overload of IV solution Nursing Interventions (3)
§ Reduce IV flow rate and notify HCP
§ With ECV excess, raise head of bed; administer oxygen and diuretics if ordered.
§ Monitor vital signs and laboratory reports of serum levels.
Air embolism Assessment Finding (7)
Sudden onset of dyspnea, coughing, chest pain, hypotension, tachycardia, decreased level of consciousness, possible signs of stroke
Air embolism Nursing Interventions (3)
- Prevent further air from entering the system by clamping or covering the leak.
- Place patient on left side, preferably with head of bed raised, to trap air in the lower portion of the left ventricle.
- Call emergency support team and notify HCP
Bleeding at venipuncture site Assessment Finding
Oozing or slow, continuous seepage of blood; sometimes pooling under extremity
Bleeding at venipuncture site Nursing Interventions (3)
- Assess whether IV system is intact.
- If catheter is within vein, apply pressure dressing over site or change dressing.
- Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged, IV is disconnected, or bleeding from site does not stop
Barriers to establishing therapeutics relationships and interpersonal connections with patient: (5)
- Institutional Demands
- Time constraints
- Reliance on technology and cost-effective health care strategies
- Efforts to standardize and refine work
- Nurses torn b/w human caring model and the task-oriented biomedical model
Caring relationships require (4):
- Sincerity (respect and accepting)
- Presence
- Availability
- Engagement (listening)
Benner’s Caring is Primary (2)
Caring is the essence of excellent nursing practice and means that people, events, projects, and things matter to people
Caring is specific and relational for each nurse-patient interaction
Benner’s Caring is Primary says Caring improves the nurse’s ability to: (3)
- Know a patient (listen to them and their stories)
- Recognize a patient’s problems
- Develop and implement individualized (patient-specific) plans of care
When nurses implement caring towards patients, the following occurs according to Benner: (3)
- Helps patients to recover during illness
- Give meaning to their illness
- Maintain or reestablish connection
What is compassion fatigue?
Secondary traumatic stress combined with burnout
Family Care (3)
- The family is an important resource.
- Caring for an individual means caring for their family as well.
- Start a relationship by learning who is included in the patient’s family and their roles in the patient’s life.
Relieving Symptoms and Suffering (4) and caring
It is more than giving medications or implementing interventions, caring gives a person:
* Comfort
* Dignity
* Respect
* Peace
Spiritual Caring (4)
Nurse and patient move toward a healing relationship via:
- Mobilizing hope
- Finding an understanding or interpretation of the illness
- Assisting the patient in using social, emotional and spiritual resources
- Recognizing that caring relationships connect us human to human and spirit to spirit.
Touch in Caring (3)
- Comforting approach that reaches out to patients to communicate concern and support
- Relational and involves contact (“therapeutic touch”) and noncontact touch (eye contact)
- Be aware of your patient’s cultural practices and past experiences (abuse)
3 types of touch
- Task-oriented touch: when performing a task or procedure.
- Caring touch: nonverbal communication which influences a patient’s comfort and security, enhances self-esteem, increases confidence of caregivers, and improves mental well-being (gently)
- Protective touch: a form of touch that protects a nurse and/or patient
Listening (2)
- Planned and deliberate act in which the listener is present and fully engages the patient in a nonjudgmental and accepting manner.
- Interpret and understand what the patient is saying
Leininger’s Transcultural Caring (3)
- Care is unique component that makes nursing different from other professions
- Care is an essential human need unlike cure
- Caring is personal and different for each person (nurse should understand cultural caring behaviors)
Leininger’s 4 Nursing Caring behaviors
- Knowing the patient’s values and beliefs
- Respecting privacy
- Acknowledging individual needs
- Interacting and listening to the patient and family
Watson’s Transpersonal Caring (4)
Caring is essential to maintain ethics and philosophical roots of nursing
Caring is meaningful conversations and interactions that address the patient’s needs
Caring is Transformative so relationship influences both nurse and the patient for better or worse
Caring is holistic model with focus promoting healing and wholeness while preserving humanity, harmony, and dignity (care > cure)
Swanson’s Theory of Caring (3)
Caring is a nurturing way of relating to an individual
Caring is central to nursing but not unique to nursing
Five Caring processes: knowing, being with, doing for, enabling, maintaining belief
Knowing (3)
- Knowing means striving to understand an event as it has meaning in the life of the other
- Knowing the patient as unique person helps to select the most appropriate and effective nursing therapies and interventions (nurse understands how illness, treatment, or rehabilitation affect the patient and family)
- Facilitated by continuity of care and clinical expertise
Complications of wound healing (4)
- Hemorrhage (bleeding from wound site)
- Infection (redness, drainage increase, increase WBC)
- Dehiscence (partial separation, may see increase serosanguinous fluid)
- Evisceration(full separation with organs outside body)
Factors influencing wound healing (7)
-nutrition
– Chronic diseases
– Poor peripheral perfusion
– Dehydration or edema
– Impaired mobility
– Immunosuppression
– Infection
Causes, Description, and healing of Secondary intention wound
Causes: Stage 2 Pressure ulcers, burns, severe laceration, or surgical wounds that have tissue loss or contamination
Description: Wound edges not approximated
Implications: Wound heals by granulation tissue formation, wound contraction, and epithelization
Causes, Description, and healing of tertiary intention wound
Causes: Wounds that are contaminated and require observation for signs of inflammation
Description: Wound that is left open for several days
Implications: Closure of wound is delayed until risk of infection is resolved; more scaring
Causes, Description, and healing of primary intention wound
Causes: surgical incision (sutures, staples), hematoma (internal bleeding)
Description: Wound that is closed
Implications: Healing occurs by epithelization; heals quickly within minimal scar formation
3 types of traumatic wounds
§ Abrasion: superficial with minimal bleeding, partial-thickness
§ Laceration: abrasion with more profuse bleeding
§ Puncture wound: usually small, circular with edges coming toward center; danger of internal bleeding or infection
Debridement and 4 method
Removal of dead, damaged, or infected tissue
Methods: mechanical (irrigation), autolytic (via WBCs), chemical (topical enzyme, Dakin, sterile maggots), sharp/surgical (quickest and best if signs of sepsis or cellulitis)
Doing for
Doing for the other as one would do for self if it were at all possible (protecting, comforting, preserving dignity)
Enabling
Facilitating the other’s passage through life transitions and unfamiliar events (supporting, validating, generating alternatives)
Maintaining belief
Sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning (believing in, maintain hope and realistic optimism)
Ethics of Care
- Concerned with relationships between people and with a nurse’s character and attitude towards others
- Sensitive to unequal relationships (nurse= patient advocate
- Mutual respect and trust necessary
Providing Presence (and 4 outcomes)
Person to person encounter conveying a closeness and sense of caring; involves being there and being with
Outcomes: relief of suffering, decrease anxiety, decrease in the sense of isolation and vulnerability, and personal growth
Being there vs being with
“Being there”: communication and understanding; nurse must be attentive to the perspectives of the patient and families
“Being with”: Being emotionally present to the other, conveying ability, sharing feelings, not burdening
What to do if evisceration happens? (4)
- Medical emergency;
- place sterile saline soaked gauze over incision until emergency surgery
- Observe for shock
- DO NOT TRY TO PUSH IT BACK IN
Albumin level
3.5-5.5; under 3.5 is a problem
What nutrients are important for skin integrity? (4)
-protein
-vitamin A
-Vitamin C
-Minerals (zinc and copper)
SKIN acronym
Skin Assessment: turgor, color, assess for non-blanching areas; assess for dryness; note color & shape of any lesions.
Know and assess any allergies; note bowel or urinary incontinence
Inspect bony prominences for skin color changes, assess wounds, pressure ulcers, measure depth, width, signs of granulation
Norton or Braden Scale; Nutrition status
7 things to note in wound assessment
- Location
- Appearance/Color (red, yellow, black)–presence of undermining, tracts, tunnels
- Cleanliness (clean, contaminated)
- Odor
- Presence of wound drains (type)
- Size (length, width, depth)
- Drainage
Types of wound drainage (4)
– Serous: clear, watery plasma
– Purulent: thick, yellow, green, tan, or brown
– Serosanguineous: pale, pink, watery; mixture of clear and red fluid
– Sanguineous: bright red; indicates bleeding
TURNIN acronym
Turn and reposition q 1-2 hours, maintain head of bed at or below 30 degrees of elevation. Maintain clean, dry skin and wrinkle free linens.
Use assistive devices as ordered (wheelchairs, etc.); use therapeutic bed/mattress for long term
ROM (active/passive) as needed; request OT and PT consult as needed
Nutritional intake
Inspect skin every 2 hours
Need to keep dry
Goal and what to use in wound cleaning and irrigation? (2)
Goal: to remove debris and exudate; keep wound moist to support movement of epithelial but not too moist to prevent maceration of periwound or bacterial growth
What to use: Use sterile saline solution and avoid harsh solutions
Gauze dressing
– most common, absorbent, wick away exudate and can use for packing
Difference between red, yellow, and black wounds
Red: healthy regeneration of tissue, granulation
Yellow: Presence of purulent drainage and slough
Black: Presence of eschar that hinders healing
Self-adhesive, transparent film dressing
– traps moisture, allows viewing, adheres to undamaged skin, does not need secondary dressing
Hydrocolloid dressing (2)
adhesive, occlusive; useful to absorb exudate, maintain wound moisture, slowly liquify necrotic debris; impermeable to bacteria
-used as prevention in high friction area and on IVs
Hydrogel (2)
– hydrates wounds, absorbs small amounts of exudate, debride by softening necrotic tissue; be wary of periwound maceration
—require secondary dressing
Calcium alginate (3)
– highly absorbent, no trauma when removed
– do not use on dry wounds
- require secondary dressing
Negative-pressure wound therapy (3)
§ suction promotes healing, reduces edema and contracture, collects exudate)—good if dehiscence occurs
§ Avoid when necrotic tissue with eschar present; fistulas, malignancy, evisceration or nerves exposes,
§ Express caution if high risk for hemorrhage, MRI, defibrillation
What are the main risk factors for pressure ulcers (6)
- Shear and friction from pulling pt in bed vs lifting them
- Decreased activity/mobility
- Poor nutrition/malnutrition
- Moisture
- Sensory perception
- Altered consciousness
Nursing interventions to prevent pressure ulcers (4)
-turning every 2 hrs
-keeping patint dry with clean linen
-keep head at or below 30 degrees to prevent shear and friction
-document I and O
3 factors of pressure injuries
-pressure intensity (occlusion of capillary leading to tissue ischemia)
-pressure duration (low pressure over long time, high pressure over short time)
-Tissue tolerance of shear, friction, moisture, and ability to redistribute pressure
Blanchable hyperemia versus Nonblanchable erythema
§ Blanchable hyperemia: skin blanches and redness returns after ischemic episode ends
§ Nonblanchable erythema: skin does not blanch when pressure applies; sign of deep tissue damage or pressure ulcer
Why should you not massage red site on patient skin?
It increases breakdown of capillaries
Braden Scale Factors (3)
-RN completes daily
-six measures on sensory perception, moisture, activity, mobility, nutrition, friction and shear
-No risk 18-23; Mild risk: 15-18. Moderate risk: 13-14. High risk: 10-12. Severe risk: less than 9
Pressure Ulcer Staging system purpose, benefits, and drawbacks
Purpose: describe depth of tissue loss at point of assessment; cannot progress from stage III to stage I
Benefits: indicates type of topical treatments and pressure-relieve surfaces that will promote healing
Drawback: unable to stage ulcer covered with necrotic tissue b/c necrotic tissue covers depth of ulcer
5 misconceptions about pain
a) Patients who abuse substances overreact to discomforts.
b) Patients with minor illnesses have less pain than those with severe physical alteration.
c) Administering pain medications regularly leads to drug addiction.
d) The amount of tissue damage in an injury accurately indicates pain intensity.
e) Patients who cannot speak do not feel pain
Diabetic Ulcer (description and appearance)
Pale with even edges, little granulation tissues, deep; on pressure pts of hands or feet
Patient history factors in diabetic ulcer (3)
-no claudication (arterial obstruction) reports
-peripheral neuropathy
-cool or warm feet
Interventions for diabetic Ulcers
-control diabetes
-rule out arterial disease
-pt education and prevent infection
Patient history factors in Venous Ulcer (5)
-chronic nonhealing ulcer (scaring may be present)
-no claudication (muscle pain when active) or rest pain (or neurologic deficit)
-moderate discomfort
-ankle or leg swelling and full veins
-pulse present
Cause of venous ulcer
Due to improper functioning of the valves in veins causing blood to pool in lower legs b-c can not return to heart
Interventions for Venous Stasis Ulcers (5)
-long term wound care (unna boot, damp-to-dry dressing)
-elevate extremity
-pt education and prevent infection
-DO NOT encourage prolonged sitting or standing
Venous Stasis Ulcer (description and appearance)
Shallow, superficial irregular shape border usually on lower leg and ankle
How often to monitor acute wound?
every 8 hours
Arterial Ulcer (description and appearance)
Full-thickness wound on lower leg feet, heels, or toes
“Punched out” appearance-smooth edges, smooth, shiny extremity
Patient history factors seen in arterial ulcer (6)
-pain while resting
-claudication after walking
-cold feet
-pallor with elevation
-skin or hair atrophy
-Gangrene or neurolgic deficits
Cause of arterial Ulcer
Refers to poor blood circulation to the lower leg and feet due to atherosclerosis leading to tissue ischemia
Not a pressure ulcer
Interventions for Arterial Ulcer (4)
-prevent trauma and infection
-provide warmth for areas to promote vasodilation
-pt education on foot care and appropriate exercise
-treat underlying cause (surgical, revasculation)
What interventions are contraindicated with arterial ulcer?
Elevation of leg above heart or compression therapy because it slows blood flow to the area
4 physiological factors which influence pain
- Age (older adults often underreport pain and slower but equal perception)
- Fatigue (increases perception, decreasing coping)
- Genetics (role in pain threshold, tolerance, metabolism of pain meds
- Neurological function (impaired reception or perception)
5 social factors which influence pain
-attention (less attention to pain, less pain)
-previous experience
-family and social support
-spiritual factors
-culture
4 psychological factors which influence pain
- anxiety
- coping styles
- Perception of Pain (Is it a threat, loss, punishment, or challenge?)
- Locus of control (internal vs external)
Acute/Transient pain (4)
-protective
-usually has identifiable cause and self limiting
-mild to severe (may have facial expressions, guarding, muscle tension
-hindered recovery if not adequately managed and may lead to chronic pain
What is the most reliable indicator of pain?
What the patient says or their behaviors (if nonverbal), vital signs are not reliable
7 physiological reactions to pain
- Tachycardia
- Tachypnea
- Elevated BP
- Increased blood glucose
- Diaphoresis
- Pupillary dilation
- Decreased gastric motility
Chronic pain (4)
-prolonged; > 6 months
-does not always have identifiable cause (idiopathic
-may not have physiological response (mild warm skin, pupils normal or dilated)
-leads to great personal suffering and pain management must be individualized
Nociceptive vs neuropathic pain
- Nociceptive- normal pain transmission; aching
- Neuropathic- from pathology; burning, sharp shooting including sympathetically mediated, deafferentation (loss of afferent CNS input), neuralgia, central pain
Stage I pressure ulcer appearance, Dressing (3), and treatment (2)
Intact skin with localized area of nonblanchable redness (not purple or maroon)
* Dressing: none, transparent, hydrocolloid
* Treatment: turning, adequate hydration
Stage II pressure ulcer appearance, treatment (3), and dressing (3)
Partial-thickness skin loss with exposed dermis; may be blister; no fat or deeper tissues visible
-no slough or eschar
Treatment: turning, nutrition, manage incontinence
Dressing: composite film, hydrocolloid or hydrogel (w. gauze or foam top)
Stage III Pressure ulcer appearance and dressing (5)
- Full-thickness skin loss with visible fat; no visible muscle, bone, or tendon
- slough, eschar, epibole, undermining, tunneling may occur (pain may not be felt)
- Dressing: hydrocolloid, hydrogel, calcium alginate, wet gauze, growth factors
Stage IV Pressure Ulcer appearance, treatment (1), and dressing (3)
- Full-thickness skin & tissue loss with exposed or palpable fascia, muscle, bone (not sanguineous drainage)
- Slough, eschar, tunneling, undermining, epibole may be present
- Treatment: perhaps surgical
- Dressing: hydrogel, calcium alginate, gauze
3 types of breakthrough pain
- Incident pain: Pain that is predictable and elicited by specific triggers, such as a voluntary act, involuntary act (coughing), or treatments
- End-of-dose failure pain: Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic
- Spontaneous pain: Pain that is unpredictable and not associated with any activity or event
Unstageable/Unclassified pressure ulcer and Dressing (4)
Fully obscured thickness skin and tissue loss due to slough or eschar; stage III or IV if eschar removed (do not remove stable eschar on heal or ischemic limb)
Dressing: none (w/ dry eschar not being removed), adherent film, gauze (w/ solution), enzymes
Suspected Deep Tissue Injury
Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister
3 types of barriers to effective pain management
-Patient fears about addiction and underreporting of pain
-Provider concerns about addiction, beliefs about patient’s pain level, inadequate assessments, and negative patient labels (drug seekers)
-systemic barriers around addiction
Difference b/w physical dependence, addiction, and tolerance *
- Physical dependence: state of adaptation with a specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
- Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
- Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time
6 non-pharmacological pain relief interventions
- Relaxation
- Guided imagery
- Distraction
- Herbals
- Massage
- Cold and heat application
What does moist and dry heat therapy do?
Moist heat: increases muscle and ligament flexibility to promote relaxation and healing
Dry heat: increases blood flow in tissues to reduce pain; can be used for longer period w/o tissue injury
-good for chronic pain
When to not use cold therapy? (2)
If patient is shivering or site already edematous
Do no use w/o physician order or directly on skin
When to not use hot therapy? (3)
If wound acute, locally inflamed, or actively bleeding
Do not use w/o physician order or directly on skin
What does cold therapy do?
Prevent edema, hemorrhage, muscle spasm, pain via anesthetizing and numbness effect
How often should you use cold therapy?
5 minutes at a time or stop when pt feels numb and no more than 2-5 times a day
6 safety measures for heat and cold applications
- Do not use on sensitive skin
- Encourage pt to report discomfort immediately
- Check temp of application
- Check patient and skin frequently every 20 minutes during therapy (observe for redness, pain, or tingling)
- Do not allow patient to adjust temperature settings
- Do not leave unattended a patient who is unable to sense temperature changes or move from the temperature source
Pharmacological pain relief interventions (5 with subtypes)
Analgesics (Nonopioid-mild to moderate; Opioid-severe)
Adjuvants/coanalgesics-neuropathic
Topical-Lidoderm patch for adult
Local-lidocaine injection prior to brief surgery
Regional- epidural to block nerve group
Patient- Controlled Analgesia (PCA) and its benefit and when not to use
§ self-administers opioids with little risk of overdose due to limited # of doses in hour or period of time)
§ Benefit: pain relief does not depend on nurse availability
§ Not recommended for post-op opioid naïve individuals
When does opioid tolerance happen?
Adverse effects except constipation will usually subside after 10 days use of around the clock meds
6 adverse effects of opioids
- Nausea and vomiting
- Respiratory depression
- Constipation
- Itching
- Urinary retention
- Altered mental status
3 notes on Opioid respiratory depression
- Sedation ALWAYS occurs before respiratory depression
- Check client’s level of consciousness and respiratory rate prior to giving
- Naloxone is reversal agent
When is pain assessed? And who can assess it?
At least once a shift
Before pain med administration
After pain med administration (1 hr after oral, 15-30 mins after IV)
RN, not UAP
What should you never tell a pt in pain?
NEVER tell a patient with severe unrelieved pain there is nothing else that can be done, you can refer to pain specialist and there are minor surgical procedures to relieve persistent pain
Migraine w/o aura Headache (5)
- Chronic, episodic disorder where BVs in brain overreact to a triggering event, causing spasms in arteries at base of brain, cerebral arteries dilate
- Long duration: 4-72 hours
- Familial, women > men
- Intense, throbbing unilateral pain
- Worsens with movement, photophobia or phonophobia, Nausea & vomiting
First/prodromal phase of migraine (4)
- Aura may last several minutes to 1 hr
- Well-defined focal neurologic dysfunction
- Pain usually preceded by visual disturbances
- Neurologic changes: numbness, acute confusion, aphasia, vertigo (spinning environment), unilateral weakness, drowsiness
Headache phase of migraine (2)
- Headache with N/V
- Unilateral, frontotemporal, throbbing pain in head which is worse behind one eye or ear
Termination phase of migraine (2)
- Pain changes to dull
- Headache with N/V lasts 4-72 hrs (elders may have aura w/o pain (visual migraine))
3 atypical migraines
- Status Migrainous: Headache lasting longer than 72 hours
- Migrainous infarction: Neurologic symptoms not completely reversible within 7 days; Ischemic infarct noted on neuroimaging
- Unclassified: Headache not fulfilling all of the criteria to be classified a migraine
Triggers of Migraine (6)
-menstruation
-food (caffeine, red wine, MSG)
- high intensity light
-stress
-weather changes
-sleep pattern changes
When is MRI done for migraines? (5)
- Other neurologic findings present
- History of seizures
- Findings not consistent with a migraine
- Change in the severity of the symptoms or frequency of attacks
- Clients > 50 years of age with new onset of headaches
Minnesota Multiphasic Personality Inventory-2
-Migraine screening tool
-Identify personality traits and possible mental health/behavioral health problems like depression that may contribute to the headache experience
Complementary and Alternative therapies for Migraines (6)
- Yoga, meditation, massage
- Exercise
- Biofeedback
- Vitamin B12
- Acupuncture and acupressure
- Darken room, lie down, cool cloth on head
Pharmacology for managing migraines (3)
- Mild migraines: Acetaminophen, NSAIDs
- Severe migraines: (use sparingly to avoid rebound headache)
*Almotriptan, Rizatriptan , Midrin
*Beta blocker, calcium channel blocker, or antiepileptic may also be used
Gout
Systemic disease in which uric acid deposits in joints and other body tissues, causing inflammation and pain, usually the metatarsophalangeal joint of the great toe.
6 lifestyle recommendations for gout
- Low-purine diet
- Avoid foods as organ meats, shellfish, and oily fish with bones (ex. sardines)
- Avoid excessive alcohol intake and fad “starvation” diets
- Avoid aspirin and diuretics
- Avoid excessive physical or emotional stress
- Drink plenty of fluids (unless contraindicated)
Diagnostic tests for gout (4)
- Erythrocyte sedimentation rate (ESR)
- Urinary uric acid level
- Kidney function tests (BUN and creatinine)
- Synovial fluid aspiration (arthocentestis)- definitive diagnostic test
Pharmacology for managing gout (acute and chronic)
- Acute management:
- combo of colchicine (anti-gout agent) and an NSAID
- IV colchicine works with 12 hours
- Chronic management:
- Uric acid reducers and excretion
- Allopurinol, febuxostat, or probenecid
Who is at risk for nutritional deficiencies? Who is at the greater risk?
Everyone is potentially at risk due to SES, race, food access, health literacy
The very young and older adults are the greatest risk
7 Lab and Scans for Nutrition
- Albumin
- Blood glucose
- Hemoglobin A1c—last 3 months of blood sugar
- Lipid profile
- Electrolytes
- Blood urea nitrogen (6-24)
- DXA scan (bone density scan)
3 tests to rule out anemia
Calcium, phosphorus, vitamin D levels
Recommended physical activity (2)
- Physical exercise for 30 minutes most days of the week (for average person)
-Adapt to the patient such as walking or ROM exercises
Parenteral nutrition (definition and 2 notes)
IV, short-term and good for patients unable to digest or absorb via GI tract (sepsis, burns, head trauma)
-short term because disuse of GI can influence microbiome
- labs constantly monitored
10 physical signs of nutritional status
- Underweight/Overweight
- Flaccid muscle tone, wasted appearance
- Irritability, confusion
- Rapid heart rate, elevated BP—due to stress; dehydration can cause rapid HR
- Easily fatigued
- Rough dry skin
- Beefy tongue, glossitis-inflammation of tongue (Geographic tongue)
- Pale conjunctiva (white if anemic)
- Brittle, spoon shape nails (Koilonychia)
- Dull, dry, brittle hair
Carbohydrates and Fiber
main source of energy in the diet. Each gram of carbohydrate produce 4 kcal/g and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, RBC and WBC production and cell function of the renal medulla
-fiber is insoluble (indigestible and does not contribute calories) or soluble
Proteins
source of energy (4 kcal/g) they are essential for the growth, maintenance and repair of body tissue. Collagen, hormones, enzymes, immune cells, DNA and RNA are all made of protein. In addition, blood clotting, fluid regulation and acid-base balance require proteins.
7 Environmental Factors which influence nutrition
- sedentary lifestyle
- work schedules
- poor meal choices
- eating away from home
- lack of access to full-service grocery stores
- high cost of healthy foods
- lack of access to safe places to play and exercise
Water and recommended amount
critical because cell function depends on a fluid environment
-Around 2000 mL/day with food/water for a normal/healthy person. (obese people have less water because muscle has more water)
Fat vs water soluble vitamins
Fat soluble (A, D, E, K—body stores these) and water soluble (B complex, C–body excretes what it doesn’t need in urine)–organic substances
Who has increased nutritional needs? (4)
Pregnant
Breastfeeding
Children (high protein, vitamin, mineral, and energy requirements for rapid growth)
Adolescents (calcium, iron, Iodine, vitamin D)
Who has decreased nutritional needs?
Older adults decrease energy need but vitamin and mineral needs stay the same
Advancing Diets
Generally NPO-> clear liquid -> full liquid
As tolerated it is up to the nurse to know when the patient is able to advance, which diet would be next, when to go back and so forth. Do not allow foods from previous diet until it is proven that new diet is tolerated
3 tips to assist patient with oral feedings
- Open difficult to open packages of mustard, salt, sugar and dressing
- If sight is a problem, orient the patient to the tray by the hours of the clock.
- Sit down when you are feeding the patient, this communicates to the patient that you are not too busy to feed them
8 ways to promote appetite
- Medications (cyproheptadine)–Persantine
- oral care
- put in false teeth
- keep room free of odors and clean
- find out food likes and dislikes
- Maintain patient comfort
- Small, frequent feeds
- Encourage visitors while eating
3 labs that are low in malnutrition
- Hemoglobin (also low with Anemia)
- Albumin & protein (Low->malnutrition (prealbumin is preferred for acute changes; albumin best for long-term; High-> dehydration)
- Iron (ferritin) levels
Enteral Nutrition
Preferred method of meeting nutritional needs if patient is unable to swallow or take in nutrients orally, yet has a fully functioning GI tract
NG tube (4)
Nose to stomach
Put in by nurse
Check for placement and residual
Unavailable for gastric ileus
J tube (5)
Nose to Jejunum
Put in by radiologist or special nurse
Check for statlock or suture
Check for residual (should be none)
Preferred if high risk of gastric reflux
PEG (4)
Percutaneous to stomach
Put in by surgeon
No need to check placement
Check residual
Preferred if feedings needed long term > 6 weeks
What does Enteral feeding order need? (5)
Formula name
Amount
Frequency
Free water amount
Residual amount to hold feedings
Ex. Jevity 1 can TID followed with 200 mL of free water.
Check residual before feeds. Hold feeding if residual over 150 mL/hr. Recheck in one hour.
6 Tips for Enteral Feeding
- Start slow and increase as patient tolerates every 8-12 hours (you know patient is tolerating if no or low residual or aspiration)
- Need free water
- Always check placement before feeding
- Hold Feedings over 500 mL
- Measure Gastric Residual Volume (GRV) every 4-6 hrs if receiving continuous feedings or immediately before bolus feeding
- Keep head of bed at 30-45 degrees during feeding and 30-60 minutes post feeding
5 Complications of Dysphagia
- Aspiration Pneumonia (may be silent w/o cough)
- May be silent without a cough
- Dehydration
- Decreased nutritional status and malnutrition
- Weight loss
7 precautions for Aspiration
- Observe during mealtimes
- Ask client about difficulties with foods
- Add thickener to thin liquids, pureed foods (Thicker liquids are easier to swallow)
- Encourage to swallow twice
- Observe for coughing/choking. Suction and orthopneic position as needed.
- Provide rest periods and allow time to slowly swallow food
- Observe mouth for pockets of food
What do you need prior to feeding Dysphagia client?
Barium Swallow Study with speech pathologist
Clinical Manifestations of Dysphagia (8)
- Coughing during eating or drinking
- Change in voice tone or quality
- Abnormal movements of tongue, lips, mouth
- Slow weak speech
- Abnormal gag
- Regurgitation
- Pharyngeal pooling
- Delayed or absent swallow
Clear liquid diet (3)
- Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles
- Easily digestible with no residue
- Seen post surgery
Bland Diet (4)
- Avoid stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and spicy seasonings
-BRAT - Discourage smoking, alcohol, aspirin, and NSAIDs
- Used with GI diseases
Dysphagia/Pureed Diet (2)
- As for clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy
- Seen after Cerebral Vascular incident, stroke, cancer, elderly
Low Cholesterol Diet
- 300 mg/day cholesterol, in keeping with AHA guidelines for serum lipid reduction
- Seen in post myocardial infraction
Gluten Free Diet (2)
- Eliminates wheat, oats, rye, barley
- Seen in malabsorption syndromes; Celiac, gluten insensitivity, abdominal discomfort
Full liquid (3)
- Same as clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt
- Anything that melts In the mouth
- Seen in advanced post-surgical
High Fiber Diet (2)
- Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits
- Seen in constipation of Opioids, lowers cholesterol
Low Sodium (2g Na) Diet (3)
- 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no added salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases
- Fresh fruits and vegetables, salt-free seasoning
- Seen in hypertension, fluid and electrolyte balance
Diabetic Diet (2)
- 1800 Cal by the American Diabetes Association
- focus on total energy, nutrient and food distribution; include a balanced intake of carbohydrates, fats, and proteins; varied caloric recommendations to accommodate patient’s metabolic demands
Mechanical Soft (2)
- Clear and full liquid, pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)
- Seen in Edentulous
Soft/Low Residue Diet (3)
- Addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut
- prevents bowel movements
- Seen in diverticulitis, Crohn’s or ulcerative Colitis
8 Nursing Interventions for Disoriented Client due to Sensory Distortions
- Provide a complete orientation and reorientation to the immediate environment as needed
- Ensure your nametag is on and visible
- Address patient by name, explain where they are, what day and time it is
- Offer short, simple, repeated explanations and reassurance
- Keep all objects in the same place
- Clear traffic to bathroom
- Plan time to talk with your patient
- Explain unfamiliar environmental noises
Aphasia definition (Difference b/w Expressive and Receptive)
Aphasia: inability to speak, interpret or understand language
Expressive Aphasia: motor type of aphasia where the patient has the inability to name common objects or express simple ideas in words or writing. The patient understands the question but doesn’t have the ability to answer.
Receptive Aphasia: inability to understand written or spoken language. A patient can express words but is unable to understand questions or comments of others. This is extremely traumatic to the individual
7 Interventions for Aphasia
- Assess for alternate communication methods (blinking, notepads, computers)
- Do not shout or speak loudly
- Do not patronize or speak in childish phrases
- Use short, simple questions if patient has problem comprehending
- Assess for anxiety
- Determine from family or previous shift if they have developed a way of communication with patient (ie sign language, winks, hand grasps)
- Make referral to speech therapist
3 Primary Preventions for Sensory Perception
- Use of safety devices (Eye protection, hearing protection, helmets)
- Silver nitrate in newborn’s eyes to prevent infection
- Proactive management of chronic conditions such as heart disease and diabetes (Chronic diseases may show in eyes)
Sensory Deficit
absence or decrease in the normal function of sensory reception and perception leads to confusion and f/e imbalances
8 factors which influence sensory function
- Age-related sensory changes (older adults at higher risk)
- Presence of Meaningful stimuli (pets, family, television)
- Amount of Stimuli
- Social Support
- Environmental (occupation)
- Culture
- Assistive Devices
- Medication
NCP Assessment of Sensory Deficits (5)
- Take a nursing history that include assessment and nature and characteristics of sensory alterations
- Ask the patient to self-rate as excellent, good, fair, poor or bad.
- Ask how the sensory loss affects their activities of daily living (ADLs)
- Ask the family of the patient if they noticed changes in the patient’s ADLs
- Ask the patient if they use any assistive devices, aids or help at home
Sensory Overload
receiving multiple sensory stimuli and the patient cannot disregard or selectively ignore some stimuli
Ex. ICU, constant pain, constant repositioning
7 Interventions for Patient with Sensory Overload
- Assess the patient for sensory overload
- Consistently reorient the patient
- Turn down lights in room
- Turn down alarms in room
- Keep talking in room to patient a minimum
- Keep conversations quiet outside the patient’s room and nursing station
- Institute quiet hours in your unit
NCP Evaluation for Sensory Deficits (4)
- Collaborate with family members to see if patient ability to interact and function within the environment has improved
- Evaluate patient’s satisfaction with interventions by looking for verbal and nonverbal cues
- Ask how can the health care team better assist the patient
- Compare baseline assessments to current assessment
How do sensory perception changes affect a person’s ability to interact with the environment? (3)
- May withdraw from fear of not being perceive
- Other senses may be heightened
- May adapt by turning their head and siting closer
3 types of sensory deprivation
- reduced sensory input
- elimination of patterns of meaning from input (strange environments)
- restrictive environments
7 Nursing interventions for sensory deprivation
- Provide reading material
- Crossword puzzles
- Turn on television to something patient wants to watch
- AM and PM hygiene care
- Plan time to talk with your patient
- Keep their cellphone charged and available
- Encourage family visits
6 tips for Caring for a Hearing Aid
- Clean accessible and functional
- Do not submerge in water
- When removed from patient, place in cup and write “hearing aid”
- Clean with soft cloth
- Keep extra batteries
- Assist patient in how to turn it up and down when it is new
Home Safety for patient with Auditory deficit (5)
- Amplify or alter environmental sounds-doorbell, phone, alarm clock
- Lighting that responds to noise
- Tell family to allow phone to ring longer
- Tell family to allow patient more time to get to the door
- Telephone communication devices (TCDs) are available to transfer phone speech to text to computer screen
Home Safety for patient with Visual deficit (4)
- Trouble walking downstairs and uneven surfaces (Use high color contrast)
- Need well-lit entrances and exits
- Administration of medications at home (who helps you?)
- Label medication with large print
Home Safety for patient with Olfactory deficit (5)
- Ask if patient has smoke alarms (lights)
- If patient smokes, tell them to make sure cigarettes are out
- Check food package dates
- Visually inspect food before eating
- Check pilot gas stove visually to make sure it is off
Home Safety for patient with Tactile deficit (5)
- Check skin regularly for breakdown
- Get a bath thermometer or have family member check temp of bath/shower water
- Discourage use of heating pads, hot water bottles
- Have faucets labeled “hot” and “cold”
- Temperature of hot water heater should be no higher than 120 degrees F-Ideal is 110
How often to do skin assessment?
within 24 hours of admission; daily afterward
