test 2 Flashcards
Structures involved in the digestive system
Mouth Teeth Tongue Pharynx Esophagus Stomach Small intestine Large intestine Anus
Accessory organs Digestion
Salivary gland
Liver
Gallbladder
Pancreas
Mouth
First part of the digestive tract
Contains tongue and teeth and receives secretions from the salivary glands
Tongue composed of mostly skeletal muscle; the most movable organ of the mouth
Adults have 32 permanent teeth
Cuspids, incisors, bicuspids, and molars
Mouth
Receives food and breaks it down into smaller pieces; mixes food with saliva and starts the digestive process
Parotid glands
Largest salivary glands One on each side Located anterior and inferior to the ear Secrete saliva into the mouth Begins digestion of starches
Pharynx
Connects the nasal and oral cavities to the esophagus; food is forced into the pharynx by the tongue
Esophagus
Muscular tube approximately 20 cm long
Propels food into the stomach from the pharynx using muscular contraction
Lining secretes mucus
Stomach
Located in the upper-left quadrant of the abdomen; has a capacity of approximately 1.5 L/ Has two sphincters Is a temporary storage place for food Mixes food with digestive juices Changes food into a semiliquid state Begins the digestion of proteins Absorbs vitamin B12
Small intestine (duodenum, jejunum, ileum):
Small intestine (duodenum, jejunum, ileum): mixes food with secretions from liver and pancreas; finishes digestion; absorbs nutrients
Large intestine
(ascending, transverse, descending, and sigmoid colon; rectum; anus; cecum): absorbs fluid and electrolytes; eliminates waste products
Liver and gallbladder
concentrate, store, and secrete bile into the duodenum
Pancreas
: secretes digestive juices; produces insulin
Aging on Gi tract
Dental caries and tooth loss Decreased gag reflex Decreased sense of tasteDecreased muscle tone at sphincters Decreased gastric secretions Decreased peristalsis
Metabolism
Process in which large molecules are broken down into smaller molecules
Makes energy available to the organism
Enables absorbed nutrients to enter bloodstream following digestion
Digestion converts food into chemical substances such as proteins and simple sugars to be used by the body for energy production and cellular metabolism
USDA Pyramid
Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products
Includes lean meats, poultry, fish, beans, eggs, and nuts
Is low in saturated fats, trans fats, cholesterol, sodium, and added sugars
Protein
Constant supply essential for rebuilding and replacing body tissues Plays a role in hormone production, fluid balance, antibody production, and transportation of nutrients Supplies approximately 4 calories/g Composed of amino acids 9 essential 11 nonessential Animal sources Plant sources
Protein amount
Average DRI
Protein intake should be 10% to 15% of the total daily calories
May vary depending on activity level, state of health, and availability of protein food sourcesProtein deficiency
Marasmus
Kwashiorkor
Protein excess
Stressful to the liver and kidneys
Kidneys must rid the body of excess waste products
Liver function is strained with the excess load of protein to metabolize
Can lead to excess fat in the diet
Vegetarian Diets
Lacto-ovo-vegetarian- can have eggs and milk
Lactovegetarian no eggs or dairy
Vegan
vegetarian diets health
Well-planned vegetarian diets offer health benefits
Decreased risk of heart disease, hypertension, diabetes, and obesity
Vegans may have a diet deficient in
Vitamin B6, vitamin B12, iron, zinc, riboflavin, and vitamin D
Carbohydrates
The body’s main source of energy Should make up 50% to 60% of the daily diet Supply 4 calories/g Regulate protein and fat metabolism, fight infection, and promote growth of body tissues Three main types: Simple complex fiber
Simple carbohydrates
Glucose is the metabolized form of sugar found in the body and is found in:
Table sugar, the major sweetener found in foods
Fruit sugar
Milk sugar
Quickly absorbed into the bloodstream
Cause a quick rise in serum glucose
Complex carbs
Breads, pasta, cereals, and rice
Broken down into simple sugars for use by the body
Provide a more consistent serum glucose level than simple sugars provide
Recommended that 85% to 95% of consumed carbohydrates are complex carbohydrates
Fiber Carbs
The portion of the carbohydrate that cannot be broken down during digestion Passes through the intestine undigested Increases bulk in the stool Aids in elimination May decrease absorption of fat Recommended intake:
Fats
An essential nutrient
Supplies a concentrated form of energy
Supplies 9 calories/g consumed
Provides source of fatty acids
Adds flavor to foods and contributes to texture
Dissolves and transports fat-soluble vitamins and fat-soluble phytonutrients (carotenoids)
Insulates and controls body temperature
Makes food smell appetizing
Cushions and protects body organs
Facilitates transmission of nerve impulses
Gives feeling of fullness after eatingMade up of fatty acids and glycerol
Fatty acids are classified as saturated or unsaturated
Fatty liquids at room temperature are called oils
Oils containing unsaturated fats:
Corn oil, safflower oil, canola oil
omega 3’s
The most unsaturated form of fatty acid
Found in salmon, halibut, sardines, tuna, canola oil, soybean oil, chicken, eggs, and walnuts
Should be added to the diet as sources of unsaturated fats
HDL
LDL
Triglycerides
Vitamins
Essential nutrients that must be taken in through food sources or supplements
Water-soluble vitamins
Easily absorbed into the bloodstream for use by the body
B-complex vitamins and vitamin C
Fat-soluble vitamins
Absorbed in the small intestine the same as other fats by action of bile in the duodenum and stored in the liver
A, D, E, and K
minerals
Inorganic substances found in animals and plants
Essential for metabolism and cellular function
Major minerals
Calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine
Trace minerals
Iron, copper, iodine, manganese, cobalt, zinc, molybdenum, selenium, fluoride, chromium
Water
Water is the most essential of all nutrients
Water requirement is 1 mL/calorie of intake
Used in every body process, from digestion to absorption to elimination or secretion; large amount must be stored in the body
General rule: intake needs to be equal to recorded output plus 500 mL
Factors effecting nutrition
Age: infants, toddlers, preschool, school-age, adolescents, adults, older adults
Illness
Emotional status
Economic status
Religion: Islam, Judaism, Seventh-Day Adventist
Culture: African American, Hispanic, Asian
Assessment, Nursing Diagnosis, Planning
Implementation, Teaching
Evaluation
Infants nutrition
Birth Weight
Breast milk recommended
Formulas
Modified form of cow’s milk, made more digestible with added carbohydrate and fat content
Solids introduced in diet at 4 to 6 months
Preschool /toddler
Ages 2 to 5 years
Consume less milk and increase intake of solids
Provide small servings
Offer foods that are easy to chew
Avoid combination foods
Toddlers prefer single-item foods that do not touch each other on the plate
Try colorful foods (e.g., peas, carrots)
Provide a pleasant environment at mealtimes
Provide plates and utensils in a size that can be easily handled by a small child
Use dishes that are colorful and/or contain pictures of favorite characters
Avoid forcing a child to eat
School age child
May desire sweet, non-nutritive foods such as soda, candy, cake, and ice cream
Provide well-balanced breakfast before school
Provide nutritious after-school snacks
High-calorie, high-sodium preferences may predispose to obesity
Adolescents
Tend to consume many fast foods, either from restaurants or vending machines
During growth spurt the body requires more calories as well as nutrients
Adolescent females require increased levels of iron after the menstrual cycle begins
Adulthood
Rely on fast foods and convenience foods Obesity and hypertension prevalent Have increased fat and sodium intake Have increased sugar intake Lack exercise
Older adults
Most at risk for inadequate nutrition
May need to decrease calories if activity level is decreased
Physical limitations make food preparation more difficult
Arrange for companionship during meals
Some older adults have limited incomes and must limit food choices
Teaching Patients prior to discharge
Nurses teach patients about their:
- Disease or disorder
- Diet and medications
- Treatment and self-care
- Prior to discharge, the patient must be taught how to care for himself at home
* Patient teaching begins at time of admission. -Preventing illness or promoting wellness
Factors that affect teaching
Cultural values, confidence and abilities, readiness to learn
Prior to teaching patients you should
-Do an Assessment of patient learning needs
Prepare a plan, assess learning needs
-Form a teaching plan
Collaborate with other health professionals
Modes of learning include
-Visual learning Through what they see -Auditory learning Through what they hear -Kinesthetic learning By actually performing a task or handling items
To prepare a teaching plan, assess patient for:
Knowledge of his disease
Diet (if related to disease or condition)
Activity regimen or limitations
Medications (prescription and OTC)
Self-care at home
Prioritize learning needs so you can concentrate on teaching essential knowledge first
Factors that effect learning
Assess for factors that might interfere with the patient’s ability to learn
Poor vision or hearing, impaired motor function, illiteracy, and impaired cognition
Age may interfere with the strength or dexterity for performing certain tasks
Special Considerations for Teaching the Elderly LEARNING
Provide good lighting
Provide printed teaching materials in large type
Encourage patient to wear glasses if needed
Encourage patient to wear and adjust hearing aids
Use short sentences and pause frequently
Keep medical terms to a minimum
Ask questions at frequent intervals
Cultural learning
Need to work within patient’s values and cultural system. Values and expectations can interfere with patient’s ability to cooperate and learn needed skills for self-care. The patient’s cultural values and personal expectations regarding treatment and recovery may differ from those of the nurse and other health care providers.
It is important to plan patient teaching that respects and demonstrates understanding of cultural and religious beliefs. If not, it is unlikely to be accepted by the patient.
Confidence and Abilities Teaching
- Often patients express a lack of self-confidence.
- Teaching may need to be broken down into very small steps .
- Assess what patients already know about the skills they need to learn so that you can build on their current knowledge base.
Patients readiness to learn
- Assess patient’s readiness to learn.
- Motivation plays a large role in effective learning.
- Work with patients to show them the advantages of learning what they need to know.
The Teaching Plan
- Preparing the teaching plan includes:
- Analyzing assessment data
- Establishing behavioral objectives
- Creating a plan to assist patient in reaching the goals in a timely and effective manner
- Essential that teaching plan be developed collaboratively, with input from all of the disciplines involved in the patient’s care(Interdisciplinary)
Resources for Teaching
- Books, audiovisual materials, pamphlets, and hands-on equipment
- Local government agencies often provide printed and online listings of community public service programs
- Hospital social workers and patient representatives also good sources of information
Implementing the plan (teaching)
- Teaching done when visitors, physician rounds, and treatments will not cause interruptions
- One-on-one or in a group setting
- Patient should be comfortable
- Keep teaching session short
- Involve patient in the process
- You may need to incorporate teaching into daily care
Evaluation of teaching
- Involves obtaining feedback from the patient regarding what was taught
- Use this feedback to determine whether effective learning has in fact taken place
Documenting patient teaching
- Every staff nurse legally responsible for providing patient education: documentation is essential
- Patient education flow sheet may be used
- Nurse’s notes should include:
- Specific content taught
- Method of teaching used
- Evidence of evaluation with specific results
Coordination with discharge planning (teaching)
- Specific learning needs should be discussed with all involved parties, including the patient, and the plan for teaching shared
- Primary physician’s office
- Home health services
- Family or significant others
- Printed plan must be sent home with the patient
Infection
-Infection: entry into the body of an infectious agent (a microorganism) that then multiplies and causes tissue damage
-Pathogens: microorganisms capable of causing disease
-Some microorganisms produce toxins and others release endotoxins
Infection may result in illness and disease
Organisms Causing Pathology
- Bacteria
- Prions
- Viruses
- Protozoa
- Rickettsias
- Fungi
- Helminths
- Others—mycoplasmas, Chlamydia
Bacteria
-Single-celled microorganisms lacking a nucleus
-Reproduce every few minutes up to several weeks
-Classified according to need for oxygen, shape, and gram stainingNeed for oxygen
Aerobic: Anaerobic:
-Gram staining
-Gram-positive bacteria-Gram-negative *bacteria Shape
Cocci: spherical shape
Bacilli: Rod shaped
Spirochetes: Spiral
Importance of Bacterial identification
- Identified by chemical testing and growing cultures
- Sensitivity testing determines which antibiotic can kill the organism
- Some are drug-resistant
MOST MULTI-DRUG resistant bacteria
Multidrug-resistant organisms
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Vancomycin-resistant Enterococcus (VRE)
- Extended-spectrum beta-lactamase–producing (ESBL) gonorrhea GNR (Neisseria gonorrhoeae)
- Clostridium difficile (C. diff)
- Penicillin-resistant Streptococcus pneumoniae
PRIONS
- Protein particles that lack nucleic acids and are not inactivated by usual procedures for destroying viruses
- Do not trigger an immune response
- Cause degenerative neurologic disease, such as variant Creutzfeldt-Jakob disease (mad cow disease)
VIRUSES
- Extremely small; seen only with an electron microscope
- Composed of particles of nucleic acids, either DNA or RNA, with a protein coat
- Grow and replicate only within a living cell; survival and replication depend on host tissue
Protozoa
-One-celled microscopic organisms belonging to the animal kingdom
-Examples of pathogenic protozoa
Plasmodium species: causes malaria
Entamoeba histolytica: causes amebic dysentery
Other strains capable of causing diarrhea
RICKETTSIA
- Small round or rod-shaped organisms
- Transmitted by the BITES of FLEAS, LICE,MICE, and TICKS
- Can multiply only in host cells
- Causes Rocky Mountain spotted fever and typhus
FUNGI
- Tiny primitive organisms of the plant kingdom that contain no chlorophyll
- Include yeast and mold
- Feed off living animals and decaying organic matter
- Reproduce by use of spores
- Cause candidiasis and tinea pedis (athlete’s foot)
HELMINTHS
- Parasitic worms or flukes
- Belong to the animal kingdom
- Pinworms, which mostly affect children, most common helminths worldwide
- Roundworms and tapeworms are other helminths
Mycoplasmas
Very small organisms without a cell wall
Cause infections of respiratory or genital tract
Example: Mycoplasma pneumoniae
Chlamydia
Affects the genitourinary and reproductive tracts
Increasingly more common in the past 20 years
Process of INFECTION
An infectious disease is spread from one person to another; a continuous chain
LINKS in the CHAIN OF INFX
Causative agent (link 1) Reservoir (link 2) Portal of exit (link 3) Mode of transfer (link 4) Portal of entry (link 5) Susceptible host (link 6)
Causative agent LINK 1 in chain of INFx
- Any microorganism or biologic agent capable of causing disease..Bacteria, viruses, protozoa, rickettsias, fungi, helminths
- Virulence of the agent is affected by its ability to:
- Adhere to mucosal surfaces or skin
- Penetrate mucous membranes
- Multiply once in the body
- Secrete harmful enzymes or toxins
- Resist phagocytosis
Reservoir (Link 2) chain of infx
-Places where microorganisms are found
Infected wounds, human or animal waste, animals and insects, contaminated food and water, and the person with an infection
-Precautions to prevent the spread of infection
Good hand hygiene
Sterile technique
PORTAL OF EXIT (link 3) chain of infx
-Route by which pathogen leaves its host
-Gastrointestinal tract
Feces may transport the typhoid bacillus from an infected person
-Respiratory tract
-Microorganisms are released with coughing or sneezing
-Measles, mumps, pulmonary tuberculosis can be transmitted by exit from the respiratory tract
Skin and mucous membranes, Open wounds
MODES OF TRANSFER (link 4) chain of infx
-Direct personal contact with body excreta or drainage from an ulcer, infected wound, boil, or chancre
-Indirect contact with contaminated inanimate objects, such as needles, eating utensils, and dressings
-Vectors, such as mosquitoes, that harbor infectious agents and transmit through bites and stings
-Droplet infection, or contamination by the aerosol route through sneezing and coughing
Spread of infection from one body part to another
Portal of ENTRY (link 5) chain of Infx
- Enter the body through eyes, mouth, nose, trachea, skin, mucous membranes
- To prevent entry of microorganisms:
- Use only sterile and clean items in patient care
- Use barrier precautions (gloves, masks, condoms)
- Safely handle food and water
- Use good personal hygiene
- Avoid high-risk behaviors
- Use protection from insect bites and stings
Susceptible host (link 6) chain of infx
- A human host may be susceptible by virtue of:
1. Age
2. State of health
3. Broken skin
Susceptibility of the Elderly INFX
- Factors placing the elderly at risk for infection
- Poor nutrition
- Immobility
- Poor hygiene
- Chronic illness
- Physiologic changes such as thinner skin
BODY DEFENSES AGAINST INFX
-Intact skin is the first line of defense against infection
–Secretions (lysozyme) from mucous membranes lining the respiratory, gastrointestinal, and reproductive tracts
- Cilia
- Kupffer cells
- Gastric secretions
KUPFFER CELL
are specialized macrophages located in the liver lining the walls of the sinusoids that form part of the reticuloendothelial system (RES) (also called mononuclear phagocyte system).
BODY 2nd line of defense against INFX
- Fever: slows growth of many pathogens until other defenses can be mobilized
- Leukocytosis
- Phagocytosis
- Inflammation
- Interferon
Inflammatory response INFX
- Localized protective response brought on by injury or destruction of tissue
- Blood vessels dilate, bring more blood to area, causing redness, warmth, edema
Passive artificially acquired immunity:
1
Artificially acquired immunity:
1
Naturally acquired passive immunity:
1
Passive acquired immunity:
1
Asepsis:
making the environment and objects free of microorganisms
Medical asepsis:
-reducing number of organisms or reducing the risk of transmission of organisms
-Prevents the spread of infection from person to person or reinfection of the same person
Involves cleanliness and protecting items from contamination and disinfecting contaminated items
Surgical asepsis:
- preparing and handling instruments and materials in a way that prevents the patient’s -exposure to living microorganisms
- Involves sterilization of all surgical instruments used in surgery and of supplies used to invade the body such as catheters or needles
HAND HYGIENE
- One of the most effective ways to reduce number of microorganisms on the hands
- Gloves should be used to prevent contact with any body fluids
- Health care workers must perform hand hygiene before and after giving care to a patient
Standard Precautions
-Hand hygiene
-Gloves,Mask, eye protection, face shield
Gown
-Patient care equipment
-Environmental control
-Linens
-Occupational health and blood-borne pathogens
-Patient placement
GOWN
- Clean barrier gown that is impermeable to fluid
- Must be impermeable to water
- Removed after use, being careful not to contaminate the skin or clothing
MASK
- Applied before entering a room if chance of contact with an airborne pathogen or splashed body fluids
- Placed over the nose and mouth and secured by an elastic band or ties
- N95 respirator mask worn when entering area where pulmonary tuberculosis or other dangerous airborne microorganisms are present
PROTECTIVE EYE WEAR
- To prevent fluid from entering the eye area and coming in contact with the mucosa or surface of the eye through splattering or aerosolization
- May be goggles, a face shield, or glasses with side and top pieces
HEAD COVER
- Worn if danger of contamination of the hair or if microorganisms resident in the hair might endanger the patient
- Remove carefully
SHOE COVERS
- Shoes are covered so that pathogens are not carried out of the room
- Covers are removed when exiting the room
GLOVES
- Used for Standard Precautions
- Worn when there is a chance that there will be contact with blood or body fluids, mucous membranes, nonintact skin, or secretions
- Reduce the possibility of transmission of microorganisms from the nurse to the patient
LATEX ALLERGY
-May cause redness, local inflammation, and pruritus of the hands, and anaphylaxis
Prevention
-Use gloves appropriately, not for routine tasks
-Removed directly over a trash receptacle without “snapping” them off
-Do not use petroleum-based lotions under latex gloves
DISPOSAL OF SHARPS
- Placed directly into a special red puncture-resistant sharps biohazard container immediately after use
- All needles, IV cannulas, and items that might cause a skin break are placed in the sharps container
Contaminated waste
- Must be disposed of in sealed, impermeable plastic bags marked “Hazardous Waste” or “Biohazard”
- Includes soiled dressings, used sanitary pads, suction drainage containers, and any other item that has been in contact with body fluids
CLEANING to reduce risk of INFX
-Pathogens can be killed or inactivated by disinfection, sterilization, or sanitizing agents
- Clean and remove debris in cold water
- Wash and scrub in hot water; use a stiff-bristled brush
- Rinse with hot water; dry
DISINFECTION
-Eliminates some organisms after cleaning
- Uses compounds such as phenol, alcohol, or chlorine
- Recommended disinfectant: 1 part chlorine bleach to 10 parts water
-Uses bacteriostatic or bactericidal agents
STERILIZATION
**Best method for eliminating microorganisms Five methods of sterilization 1. Steam/moist heat 2. Dry heat/hot air 3. Ethylene oxide 4. Low-temperature gas plasma 5. Radiation
Asepsis in the Home Environment
- A 1:10 solution of chlorine bleach and water can be used on counters and bathrooms
- Run the dishwasher on the “sanitize” cycle
- Frequent “damp” dusting and vacuuming reduces microorganisms
-Forceps, scissors, and other instruments can be washed with hot water and detergent, then soaked in bleach solution
Infection Control Surveillance
- Infection control practitioner
- Responsible for ensuring infection prevention and control measures are followed
- Works with the health care staff to ensure they
- understand which patient care and environmental cleaning measures are to be used
- Assesses for spread of infection
INFECTION PROCESS
Stage 1: incubation period
Stage 2: prodromal period
Stage 3: the illness period
Stage 4: the convalescent period
PATIENTS with HIGHEST RISK (HAI’S)
Patients at greatest risk include those with:
- Surgical incisions with or without drains
- Artificial airways
- Urinary catheters
- Intravenous (IV) lines
- Implanted prosthetic devices
- Repeated injections or venipunctures
- Immune compromise
Health care Associated Infections (HAI’s)
- Transmitted while receiving health care services
- Health care workers can also contract an HAI
Infection Prevention and Control
-Uses medical and surgical asepsis, Standard Precautions, and Transmission-Based Precautions
-Strict aseptic technique
Used in invasive diagnostic and therapeutic procedures (IV catheters, urinary catheters, surgical procedures)
-Isolation used to prevent contact between patient and others
Infection prevention and control involves
- Infection prevention and control involves:
- Monitoring diagnostic reports related to infection
- Observing patients for signs of infection
- Implementing procedures to contain microorganisms
- Properly handling, sterilizing, or disposing of contaminated items
- Using approved sanitation methods
- Recognizing individuals at high risk for infection and implementing appropriate protection
Tier 1: Standard Precautions
Delineate methods for avoiding direct contact with body secretions except sweat… GLOVES… USED ON EVERY PATIENT
Tier 2: Transmission-Based Precautions
Transmission-Based Precautions
- Interrupting mode of transmission by identifying specific secretions,body fluids,tissues,or excretions that might be infective.
- *Transmission-Based Precautions used alone or in combination but always in addition to Standard Precautions
Transmission-Based Precautions
- Standard Precautions—All patients, whether or not visible blood present.
- Airborne Precautions—N95 mask,
- Droplet Precautions—MASK
- Contact Precautions—
ISOLATION
means of preventing contact between patient and others to prevent spread of Infx. Emphasis is placed on containing microorganisms and preventing their spread.
TWO PREMISES underlie current system of isolation
- First: is that infection may be present before the Dx is made.
- Second: The greatest risk of transmitting infx for most organisms, comes from direct contact by the caregivers hands or equipment that has been soiled by blood, body fluids, and other potential infectious materials.
- Standard precautions- delineate methods for avoiding direct contact with all body secretions.
Guidelines for Patient Care Contact
-Never touch anything with bare hands that comes from a body surface or cavity
- Gloves are to be worn for contact with body fluids of any sort, including:
- Saliva, Urine, Feces, Blood
*The only times gloves are not worn is for contact with intact skin or unsoiled articles
Assessment (data collection) INFX
- Assessment (data collection)
- Assess for signs of infection that may require Transmission-Based Precautions
- Wounds should be assessed each shift for infection
- Monitor the patient’s temperature
- Admission lab studies may indicate infection
Nursing diagnosis INFX
Risk for infection, r/t surgical wound, open wound, or weakened condition
PLANNING INFX
- Expected outcomes would include “No health care–associated infection is evident”
- When using Transmission-Based Precautions that require putting on personal protective equipment, the nurse must prepare before each entry into the patient’s room
IMPLEMENTATION INFX
- Patient teaching is needed on disease process, modes of transmission, and precautions to prevent spread of infection
- Standard Precautions used for each contact with patient
- Transmission-Based Precautions implemented based on patient’s infection status.
- EXPLAIN TRANSMISSION BASED PRECUATIONS TO ALL VISITORS and ENSURE THEY UNDERSTAND!
- HAND HYGIENE
HAND HYGIENE
- *Most important in preventing infection transmission
- Before and after contact with patient, wound care, or invasive procedure
- Before donning gloves and after removing them
Personal protective equipment (PPE)
- Disposable gloves
- Masks
- Gown
- Goggles or face shield
ISOLATION PRECAUTIONS specimen removal
- Specimen removal—label specimen container before entering room, collect specimen and place it in a leakproof container without contaminating the outside
- Linens—handle as little as possible; roll up and place inside linen hamper inside patient’s room -Never carry un-baged linens in the hallways-risk infecting surrounding areasTrash—disposable soiled equipment should be placed in plastic bags lining the waste receptacle; a biohazard (red) bag may be needed
ISOLATION precautions equipment
- Other equipment—reusable equipment cleaned if visibly soiled, then sent to central supply to be disinfected
- Natural defenses—institute measures to enhance the patient’s natural body defenses, such as protect intact skin; promote a balanced diet; provide opportunity for sleep; decrease stress
- Sharps—never recap a needle before disposal; all sharps are dropped into sharps containers, which are replaced when two-thirds full
ISOLATION precautions: patient placement
-Patient placement—patients who need Transmission Precautions should be placed in a private room or with another patient infected with the same organism
ISOLATION precautions: Transportation
-Transporting the patient—avoid unless absolutely necessary; patient is given standard mask to wear outside the room
Infection Prevention and Control in the Home
- Keep clothing and linens away from others until washed.
- Teach patient and family proper hand hygiene techniques.
- Disinfect bathroom with 1:10 bleach/water solution.
- Wash dishes in scalding water and let air dry. Use heavy plastic jug with secure top to hold needles
- Use clean gloves for wound care or dressing changes, and teach family how to remove soiled gloves.
- Clean patient’s room frequently
Protective isolation
- Patient in special room with its own ventilation system
- No one with active infection allowed in patient’s room
- Remain aware of your facility’s policies and procedures regarding protective isolation, and follow them at all times
Psychological Aspects of Isolation
- The patient in Transmission-Based Isolation Precautions is at risk for decreased self-esteem and sensory deprivation
- Signs: boredom, slow thought, disorganized thoughts, excessive sleeping during the day, anxiety, hallucinations, panic attacks
Infection Prevention and Control for the Nurse
-OSHA regulations protect health care workers from exposure to blood-borne pathogens in the workplace.
Three main modes of occupational exposure to blood-borne pathogens are:
- Puncture wounds from contaminated needles or other sharps.
- Skin contact, allowing blood, body fluids, and other potentially infectious materials to enter through damaged or broken skin.
- Mucous membrane contact, allowing infectious materials to enter through the mucous membranes of the eyes, mouth, and nose.
Surgical Asepsis FOUR RULES
Four rules of surgical asepsis:
- Know what is sterile
- Know what is not sterile
- Separate sterile from unsterile
- Remedy contamination immediately
Goal: keep an area free from microorganisms
SURGICAL SCRUB
- More lengthy and vigorous than regular hand hygiene
- Remove as many microorganisms as possible without damaging the skin
- Timing based on actual time spent scrubbing, not including rinse time
- Usually 2 to 4 minutes
- Brushless technique with antimicrobial agent may be used
OPENING STERILE PACKAGES
- Perform hand hygiene
- Open sterile package away from the body
- Touch only the outside wrapper
- Do not reach across a sterile field
- Always face the sterile field
- Allow at least 6 inches between the body and the sterile field
EVALUATION INFX
- Patient recovering without additional instances of infection from other organisms or infection of other body areas
- Assessing whether the patient’s infection has been transmitted to any health care worker or any other patient on the unit or in the hospital
- Infection prevention and control is the responsibility of EVERY NURSE!!!
HEALTH STATUS :INITAL DETAILED ASSESSMENT
-Performed on an almost continual basis Initial detailed assessment on admission Includes: -Physical examination -History and demographic data -Information pertinent to daily care -Current health problems **Focused assessment on every successive shift
Assessment: Data Collection
- Nurses must be aware of how the illness is affecting the patient’s life,Not only health, all other areas
- Assess for cultural preferences and health beliefs. *Phrase questions in a positive, nonthreatening way
The initial or admission assessment should include an interview to determine:
-Social data
-Marital status, occupation, visual or hearing deficits
-Dentures, prostheses
-ALLERGIES—food, drug, or other
-Medications being taken (including OTC and herbal supplements)
-Diet, Any limitations or special foods
-Smoking, Use of alcohol
-Activities of daily living
Previous surgeries
Health problems, current and past
Reason for admission
Physical data :Initial assessment
-Head and neck
-Chest, heart, and lungs
-Abdomen
-Genitourinary system
-Extremities and musculoskeletal system
-Endocrine system
-Provides a complete picture of physiologic functioning
-Comprehensive, in-depth
Includes all systems of the body
-Brief, scanning type of examination
Confined to a specific body part or system
Physical assessment: Inspection and observation
-Inspect visually the various parts of the body and the behavioral responses of patients
- Visual observation of:
- General appearance
- Contours of the body
- Skin tone and color, rashes, scars, lesions
- Deformities or extremity weakness
Physical Examination Techniques: Palpation
-Performed using the hands and fingertips to touch and feel various parts of the body Used to ascertain: -Size, shape, and position of body parts -Texture, temperature, and moisture of skin -Presence of muscle spasm or rigidity -Pain, tenderness, or swelling -Presence of a growth -Restriction in body part movement -Skin temperature and turgor -Presence of edema
Physical Examination Techniques: Percussion
- Another method of obtaining information about body structures
- Light, quick tapping on the body surface to produce sounds
- Variations in the sounds reflect characteristics of organs or structures below the surface
- Percussion helps in determining:
- Size of organs
- Location of organs
- Density of organs
- Presence of air or fluids in tissue or in a body cavity
Physical Examination Techniques: Auscultation
-Listening to presence or absence of body sounds using a stethoscope
-Particularly useful for:
Lung sounds: use the diaphragm for all lobes
-Heart sounds
Use the diaphragm for normal S1-S2 and to count heart rate
Use the bell for some abnormal heart sounds
-Abdomen (bowel sounds)
Physical Examination Techniques: Olfaction (Smelling)
- Using the nose to identify odors characteristic of certain problems, such as:
- Breath odor for sweetness, acetone, or alcohol
- Wound odors
- Odors from discharges such as vaginal infections
Basic Physical Examination
- Height and weight (without shoes)
- Infant without diaper (never leave unattended)
- Vital sign measurement
- Review of body systems
- Head and neck, chest, heart, and lungs
- Skin and extremities
- Abdomen
- Genitalia, anus, and rectum
ASSESSMENT :Review of Body Systems: Head and Neck
- General appearance
- Appearance of the eyes
- Condition of the hair
- Difficulty in hearing or seeing
- Pupils equal in size and accommodated to light
- Corneas clear (or is there opacity?)
ASSESSMENT Body Systems: Chest, Heart, and Lungs
- Is the chest symmetric?
- Are shoulders at equal height?
- Is there any lordosis, kyphosis, or scoliosis?
- Any signs of dyspnea?
- Is there a noticeable point of maximal impulse PMI?
- Heart sounds normal? (S1-S2)
- Apical pulse rate normal?
ASSESSMENT Body Systems: Lung Sounds
- Using the diaphragm of the stethoscope, listen:
- Over the trachea
- Over the upper area of the chest
- Over the central chest and back
- Sounds
- -Vesicular
- Bronchovesicular
- Adventitious
ASSESSMENT of Body Systems: Skin and Extremities
Inspect skin for:
- Rashes or lesions
- Flaking or dryness
- Signs of dehydration or edema (shoe or ring tightness)
- Turgor
- Capillary refill (less than 3 seconds)
- Assess peripheral pulses
ASSESSMENT of Body Systems: Abdomen
- Bowel sounds should be assessed in all four quadrants on admission
- Normal (5 to 30 sounds/min)
- Hypoactive
- Hyperactive
- Silent
- Distention or tenderness
ASSESSMENT of Body Systems: Genitalia, Anus, and Rectum
- Unless patient has a specific complaint in these areas, the nurse does not visually assess them
- They may be assessed, however, when bathing the patient, performing perineal care, or assisting with toileting
- Ask the patient if there are any problems with these areas
RNS HOPE
- A systematic way to perform such an assessment
- Rest and activity
- Nutrition, fluids, and electrolytes
- Safety and security
- Hygiene
- Oxygenation
- Psychosocial and learning
- Elimination
FOCUSED ASSESSMENT
- Brief examinations
- Occurs when a complete head-to-toe assessment is not needed
- Shorter shift head to toe assessments
Positioning and Draping PATIENT
+Most examinations begin with patient seated on the end of the examination table with a drape over the lap and legs
+Patient assumes supine position and drape is pulled up over the upper body so chest and/or abdomen can be exposed
-Lithotomy position
-Knee-chest position
-Lateral or Sims’ position
-Prone position
Elements of the Physical Examination
- Bladder should be emptied
- Ask patient to disrobe and put on an examination gown
- Prepare exam table
- Necessary equipment for the physical examination is made ready
- Examinations
- Pelvic exam and Pap smear
- Rectal examination of the prostate
- Body systems
- Interior of the eye
- Ears are examined
Special Focused Examinations: Neurologic check
Neurologic check
- Performed at regular intervals on patients who have had a head injury or brain surgery
- Pupil size is measured
- Patient is asked to track the nurse’s finger or an object as it is moved to six different positions
- Glasgow Coma Scale is used in most hospitals to score the neurologic exam
Patient and Family Teaching-Evaluation
Topics can include the following:
-The need for regular physical examinations
Recommended periodic diagnostic tests
-The need for immunizations
-The necessity of regular dental examinations
-The warning signs of cancer
-The way to perform self-breast examination
-The method of performing self-testicular examination
Assessment (Data Collection)
- During assessment, the nurse collects patient health data
- Data are gathered on specific topics, organized into a database, and documented
- LPN/LVNs may be asked to collect data as part of the assessment
Basic needs assessment based on:
Maslow’s hierarchy of basic needs:
- physiologic:sex,pt safety,h2o,food hygiene
- Safety/security; psychological comfort/environment/assistance in meeting needs.
- love&belonging/affection intimacy/loving
- self esteem: independence/competence/exploration/roles/motivation/learning/leisure/ spiritual beliefs
- self actualization
Approaches to patient assessment
- Functional health patterns assessment as formulated by Mary Gordon
- Focused assessment (focuses on a specific problem)
- Basic needs assessment based on Maslow’s hierarchy of basic needs
Mary Gordon
Functional health patterns assessment as formulated by? Eleven health patterns
Mary Gordon 11 health patterns
- Health Perception and Health Management. Data collection is focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.
- Nutrition and Metabolism Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.
- Elimination. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.
- Activity and Exercise. Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.
- Cognition and Perception. Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.
- Sleep and Rest. Assessment is focused on the person’s sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.
- Self-Perception and Self-Concept. Assessment is focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth. The person’s level of self-esteem and response to threats to his or her self-concept may be identified.
- Roles and Relationships. Assessment is focused on the person’s roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.
- Sexuality and Reproduction. Assessment is focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified.
- Coping and Stress Tolerance. Assessment is focused on the person’s perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person’s coping strategies in terms of stress tolerance may be further evaluated.
- Values and Belief. Assessment is focused on the person’s values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.
The Interview; ASSESSMENT
-Based on gathering data—is not a social interaction
-Good communication essential
-Communication may be:
Verbal, Nonverbal, noting body posture, facial expressions, movement, and gestures
INTERVIEW: Consists of three basic stages
- The opening, during which rapport is established with the patient
- The body of the interview, during which necessary questions are presented
- The closing, during which information is summarized
CHART REVIEW
- Data collection tool; helps obtain information to interview patient or prepare for the day’s patient assignment
- Chart review should include:
- Face sheet and physician’s orders
- Nurses’ notes (at least the past 24 hours)
- Physicians’ progress notes and history and —-physical examination
- Medication administration record
- Surgery operative report and pathology report
- Diagnostic tests
- Nursing admission history and assessment
- Fall risk assessment and skin assessment
- Nursing care plan or problem list
The Physical Examination
- Use techniques of inspection, auscultation, palpation, and percussion
- Carried out in a systematic manner
- Head-to-toe examination
- Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem
Head-to-Toe Assessment: Initial assessment
- Breathing
- How the patient is feeling
- General appearance
- Skin color
- Affect
Head-to-Toe Assessment: HEAD
-Level of consciousness
-Awake, alert, and oriented
-Ability to communicate
Language spoken, any communication deficits
-Mentation status
-Able to comprehend, form thoughts
-Appearance of the eyes
-Pupil size, light reaction
Head-to-Toe Assessment: Vital Signs
- Temperature
- Pulse rate
- Rhythm, strength, apical, radial
- Respirations
- Rate, pattern, depth; oxygen saturation
- Blood pressure
- Within normal limits
- Compare with previous readings
Head-to-Toe Assessment:Heart <3 and lungs
Heart and lungs
- Heart sounds, normal S1-S2
- Lungs
- Lung sounds
- Rales, wheezes, diminished breath sounds
- Abdomen
- Shape, hardness, bowel sounds, last bowel movement, voiding, appetite, nausea
Head-to-Toe Assessment: Extremities
- Ability to move all extremities well
- Ability to move within normal range
- Skin turgor, color, temperature
- Peripheral pulses
- Edema
Head-to-Toe Assessment: Tubes and equipment
- Tubes and equipment
- Oxygen cannula, chest tubes
- NG tubes, PEG tubes, jejunostomy tube
- Urinary catheter
- Type and amount of drainage
- Dressings and drainage
- Pulse oximeter
- Traction devices
- Pain status
Head-to-Toe Assessment: LONG TERM CARE
- Extensive initial assessment performed when patient enters long-term care facility
- Reassessment at fixed intervals and as the patient’s condition changes
- Physical assessment, health history, medication history, and a functional assessment performed
Head-to-Toe Assessment: HOME HEALTH CARE
- Initial patient assessment in the home is usually performed by the RN
- The LPN/LVN, when doing private duty in a home, will need to perform daily assessments and maintain necessary documentation
- Changes found on assessment should be reported to the RN supervisor
Assessment in Home Health Care
- Initial patient assessment in the home is usually performed by the RN
- The LPN/LVN, when doing private duty in a home, will need to perform daily assessments and maintain necessary documentation
- Changes found on assessment should be reported to the RN supervisor
Analysis: assessment
- Database analyzed for cues that deviate from the norm
- Pieces of data are sorted
- Related data are grouped or clustered
- Missing data are identified
- Inferences are made regarding the patient’s problems
Nursing Diagnosis
-A nursing diagnosis statement indicates the patient’s actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms)
Etiologic Factors
- Causes of the problem
- Signs are abnormalities that can be verified by repeat examination and are objective data
- Symptoms are data the patient has said are occurring that cannot be verified by examination; symptoms are subjective data
Defining Characteristics
- Characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that patient
- Supply the evidence that the nursing diagnosis is valid
Prioritization of Problems
- Problems ranked according to their importance
- Physiologic needs for basic survival take precedence (i.e., airway and circulation)
- After physiologic needs are met, safety problems take priority
- Every nurse must attempt to look at each patient holistically, keeping psychosocial needs in mind while working on physical problems
Nursing Diagnosis in Long-Term CARE
- LPN/LVN employed in a long-term care facility begins the care planning process when patient is admitted
- The supervising RN determines appropriate nursing diagnoses, reviews the care plan, modifies it as needed, and finalizes it for the chart
Nursing Diagnosis in Home Health Care
- Nursing diagnosis must include problems identified in the family’s ability to cope with the illness or situation and teaching needs for care of the patient
- Care plan encompasses patient and whole family
Planning: Goals and Expected Outcomes
-Goal: what is to be achieved by nursing intervention
-Short-term goals
Achievable within 7 to 10 days or before discharge
-Long-term goals
Take many weeks or months to achieve
Often relate to rehabilitation
-Expected outcome: statement of goal patient is to achieve as a result of nursing intervention
Interventions (Nursing Orders)
- Designed to alleviate problems and to achieve expected outcomes
- Should include giving medications and performing ordered treatments
- Individualized to the patient’s needs
Documentation
- Planning not complete until plan is documented and is part of patient’s medical record
- Plans constructed by LPN/LVNs must be reviewed by the RN before they are placed in the chart
- The plan of care should be reviewed and updated once every 24 hours
IMPLEMENTATION
- Implementing care follows assessment, nursing diagnosis, and planning
- The phase of the nursing process in which nursing interventions (or orders) are carried out
PRIORITY SETTING
- Change-of-shift report should give clues as to the priority of each action to be implemented
- Priorities of care may need to be altered if patient’s condition becomes more acute
Considerations for Care Delivery
- Before carrying out specific interventions listed on the plan of care, identify:
- Reason for the intervention
- Rationale for the intervention
- Usual standard of care
- Expected outcome
- Potential dangers
- Some interventions may require an independent nursing action (not requiring a physician’s order)
Interdisciplinary Care
- Some agencies use interdisciplinary care plans, clinical pathways, or care maps to guide care
- Interdisciplinary approach to managing patient care
- An outgrowth of managed care
- Still uses the nursing process
- Usually standardized to a medical diagnosis and customized to each patient
- Care plan not part of patient’s chart when an interdisciplinary care plan is used; however, nursing process still used
Implementing Care
- Employees and students expected to perform at standard of care listed in the procedure manual
- For efficient time use, consider which interventions for a patient can be combined
Implementation in Long-Term Care
- Routine care delegated to nursing assistants
- Exercise interventions performed by nursing assistants, physical therapy aides, or restorative aides
- Medications may be administered by LVNs/LPNs or nursing assistants with certification in medication administration
- Nurse performs any invasive or sterile procedure
Implementation in Home Health Care
-In home health, family may be implementing the interventions
-Nurse making home visits teaches family to:
Administer medications
Change dressings
Perform range-of-motion exercises
Perform treatments
-The nurse performs any invasive procedures or procedures where strict sterility is mandatory
Documentation of the Nursing Process
- Each intervention must be documented in the patient’s chart
- Examples: medications administered, dressings changed, vital signs measured
- Procedures not documented are considered not performed
- Care is documented on flow sheets daily
Evaluation
- Based on NFLPN Standard 4c—Evaluation
- Once interventions have been implemented, they must be evaluated for effectiveness in reaching the patient’s goals or outcomes
- Patient should provide feedback about whether the expected outcome has been met
Evaluation in Long-Term Care and Home Health Care
- Patient and family should be consulted to find out if the care plan is meeting needs adequately
- If expected outcomes are not being met, the interventions are revised
Revising the Nursing Care Plan
- If goals/outcomes are not being reached, the plan must be revised (a continual process)
- If goals are reached and the problem is resolved, it is evaluated, signed off in the nurses’ notes as met, and removed from the plan of care
Quality Improvement
- Outcome-based quality improvement to determine whether outcomes are effective
- Agency-wide evaluation of care delivered by all departments against standards set for each department
- Audits at predetermined intervals
- Evaluation goal: continuous quality improvement
Constructing a Nursing Care Plan
- RN may construct the initial nursing care plan
- If patient admitted to long-term care facility when RN is not available, LPN/LVN may assemble a preliminary nursing care plan that an RN will review and validate as needed the next day
- Students, like nurses, must be prepared to care for the patient. A nursing care plan for their assigned patients provides that information.
Constructing a Nursing Care Plan (8 steps)
- Collect patient data for a database
- Analyze the database for potential problems
- Choose appropriate nursing diagnoses
- Rank the nursing diagnoses in order of priority
- Plan the care by defining goals and writing expected outcomes
- Plan nursing care by choosing appropriate nursing interventions
- Implement the nursing interventions
- Evaluate outcomes of each nursing intervention; determine whether progress toward achieving expected outcomes has been made
Purposes of Documentation
- Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
- Is a guide for reimbursement of costs of care
- May serve as evidence of care in a court of law
- Shows the use of the nursing process
- Provides data for quality assurance studies
- Is a legal record that can be used as evidence of events that occurred or treatments given
- Contains observations by the nurses about the patient’s condition, care, and treatment delivere
- Shows progress toward expected outcome
Documentation and the Nursing Process
- Written nursing care plan or interdisciplinary care plan is framework for documentation
- Charting organized by nursing diagnosis or -problem
- Implementation of each intervention documented on flow sheet or in nursing notes
- Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals
The Medical Record
- Contains data about patient’s stay in a facility
- Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart
- Patient information should not be discussed with anyone not directly involved in the patient’s care
Methods of Documentation (Charting)
- Source-oriented (narrative) charting
- Problem-oriented medical record (POMR) ——charting
- Focus charting
- Charting by exception
- Computer-assisted charting
- Case management system charting
Source-Oriented or Narrative Charting
- Organized according to source of information
- Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient’s care
- Narrative charting requires documentation of patient care in chronologic order
Source-Oriented or Narrative Charting: advantages disadvantages
- *Advantages**
- Information in chronologic order
- Documents patient’s baseline condition for each shift
- Indicates aspects of all steps of the nursing process
- *Disadvantages**
- Documents all findings: makes it difficult to separate pertinent from irrelevant information
- Requires extensive charting time by the staff
- Discourages physicians and other health team members from reading all parts of the chart
Problem-Oriented Medical Record Charting (POMR)
- Focuses on patient status rather than on medical or nursing care
- Five basic parts: database, problem list, plan, progress notes, and discharge summary
Problem-Oriented Medical Record Charting (POMR): ADVANTAGES
Advantages
Documents care by focusing on patients’ problems
Promotes problem-solving approach to care
Improves continuity of care and communication by keeping relevant data all in one place
Allows easy auditing of patient records in evaluating staff performance or quality of patient care
**Disadvantages ***
Results in loss of chronologic charting
More difficult to track trends in patient status
Fragments data because more flow sheets required
PIE Charting
P—problem identification
I—interventions
E—evaluation
Follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes
