Safety is the basic need of all clients

1. Identify clients correctly
2. Improve staff communications
3. Use medicines safely
4. Prevent infection
5. Check client medicines
6. Prevent clients from falling
7. Help clients be involved in their care
8. Identify client safety risks
9. Assess for changes and respond rapidly
10. Prevent errors in surgery

1. Pressure ulcers
2. Wrong type of blood transfusions
3. Falls
4. Hopital acquired infections
5. Deep vein thrombosis
6. Air embolism
7. Poor blood glucose control

Age children: get into everything, climb, drink, eat, etc.

teens: drugs, STD's, pregnancy, suicide

elderly: falls, sensory issues, medication issues, burns

Lifestyle Jobs: construction, farming, etc.

Recreation: drug & alcohol abuse

Sensory hearing, seeing, smelling, feeling

Mobility ie: stroke, or won't use walker, etc.

Emotions ie: depression, anger, etc.

Accidents ie: wound care error, etc.

1. Irritant contact dermatitis
2. Allergic contact dermatitis
3. Immediate hypersensitivity: most common, an type I IgE-mediated reaction

1. Infectious Agent: cleaning, disinfection, sterilization
2. Reservoir or Source: hygiene, dressing changes, disposal of fluid container, change soiled linen
3. Portal of Exit from Reservoir or Source: clean dressing over wounds, cover mouth/nose when coughing/sneezing
4. Mode of Transmission: wear gloves, masks, gowns, goggles; utilize medical or surgical asepsis; proper disposal of contaminated objects; handwashing
5. Portal of Entry to Host: sterile techniques, proper disposal of needles or sharps
6. Susceptile Host: intact immune system, exercise, balanced nutrition, skin integrity

Bacteria

Viruses

Fungi

Rickettsiae

Protozoal

Urinary Tract Infection

The longer the catheter is used the more likely you will develop a UTI.

People

Equipment

Water

Excretions

Skin

Secretions

Droplets

Direct contact

Ingestion

Fomites: inanimaite object that is contaminated. ie: doorknob

Airborne: in the air NOT droplets

Mucous membrane

GI tract

Respiratory track

Broken Skin

Immunosuppresed- anyone on chemotherapy, rheumatoid arthritis medication

Diabetics- especially long term insulin dependent

Surgery- especially with open wounds

Burns- especially over large areas

Cardiopulmonary- the drugs that treat it cause immunosuppression

Humman Immunodeficiency Virus (HIV)

Methicillin-resistant Staphylococcus Aureus (MRSA)

Vancomycin-resistant Enterococci (VRE)

Clostridium Difficlile (C. difficile)

Cleansing: removal of soil- use water and soap and scrub the surface. Done prior to disinfection or sterilization.

Disinfection: elimination of pathogens but not spores-use chemical solutions.

Sterilization: elimination of all microorganisms- Use steam, chemcials, or gas.

In medical asepsis not all microorganisms are killed

Objects are divided into clean or dirty

Clean objects: have a low numbe rof organisms and are not considered pathogenic.

Dirty objects: have a hgih number of microorganisms and are considered pathogenic.

Handwashing: rub 15 sec minimum

rinse forearms downward

Use paper towel to turn off the faucets

Gel: rub until dry

Also called 'sterile technique'

Includes putting on surgical scrubs, maintaining a surgical field, handling sterile equipment

Hand hygiene

Use of personal protective equipment as needed

Cough etiquette

Use of masks for certain procedures

Safe injection practices

Contact: Must wear gloves and if possibility of contact w/soiled items a gown

Droplet: Important to try to keep 3 feet away, if you can't wear a mask

Airborne: N95 respirator required for known/suspected tuberculosis and measles or varicella if not immune

Isolation precautions are most commonly in effect for MRSA and VRE; and also really important to wear a mask during dressing changes.

Bathing: shower, tub bath, assisted bath, complete bed bath, partial bath, therapeutic bath. The perfect time to do your full assessment.

Skin care: perineal care, back rubs. DO NOT rub patients legs. Bedridden pateints especially should have back rubs

Oral care: daily brushing/flossing. Must do first thing in the am!

Hair care: brush hair daily, shampoo regularly, shaving daily. If they are on blood thinners you MUSt use an electric razor.

Eye care: artificial eyes must be cleaned regularly, contact lenses

Ear care: NEVER put anything into the patient's ear, irrigate instead. Hearing aids.

Nose care: to clean use an applicator (Q-tip) and saline.

No longer used routinely in health care facilities
Rare exception are mitts that keep the patient from pulling tubes out
Emergency Dept. does have a restraint system to prevent the patient from injuring themselves or others
There must be a written order every 24 hours for restraints
There is a written protocol and training which you must attend when hired

AD PIE

Assessment

Diagnosis

Planning

Implementation

Evaluation

Data Collection:Subjective/Objective

Systematic- History, PE

Head to toe-5 minute

Focused assessment- what do you see @ this moment in time? ie: admission for difficulty breathing so you focus on that.

Weeding Out: What is the important relevant date?

Validating Data: Clarify, is it right?

Organizing & Categorize Date: Head to toe, systems, Gordon's Health Patterns.

1. Health perception health management
2. Nutritional metabolic-skin integrity
3. Elimination
4. Activity exercise
5. Sleep rest
6. Cognitive-perceptual
7. Self-perception self-concept
8. Role-relationship
9. Sexuality reproduction
10. Coping stress tolerance
11. Value belief

Patterns & relationships in the data

Inferences- decision based on data

Name the problem

Avoid judgement

Generalize knowledge

Transfer knowledge from one situation to another

Outcomes with evaluation criteria

Hypothesizing

Doing

Interventions

Trying out what might work

Were the outcomes met- 1st and foremost must know if the outcomes were met. Very important!

Did my actions (interventions) work?

What do I need to revise?

LLC

Look at your client's history and current state

Look at Maslow's hierarchy of needs

Choose the most urgent/important area to assess first

One Part NDx- Wellness diagnosis + syndrome Dx

Two Part NDx- Risk or possible nursing diagnosis

Title/label r/t etiology

Problem r/t Cause/risk factors/influencing factors

Three Part NDx- Actual nursing diagnosis

Title/label r/t etiology AEB S+S

Problem r/t Cause/risk factors/influencing factors AEB S+S

Subjective/Objective data are signs and symptoms= needed for an actual diagnosis.

A PROMT

Address the nursing diagnosis

Patient centered

Realistic/attainable

One behavior

Measurable

Time frame

ANAST

Adress the nursing diagnosis

Nurse performed

Assist client to meet outcomes

Specific to this client

Teaching

Need to make sure interventions are independent, collaborative, protocols, works with the client

1. look at the outcome- is it realistic/attainable?

2. look at interventions- effective? change approach?

3. look at assessment data- reassess PRN

4. look at NDx- accurate? need change?

Comprehensive/detailed- ie: admission hx & PE

Focused- ie: shift assessment

Ongoing- assessment is not stagnant, every interaction in an assessment

Subjective: Patients story, only their perceptions

Objective: Nurse's story, use of your senses

SWIPES!!!!

Consider pt comfort

Talk to your pt

Symmetry

Use your senses

Formulate system

Trust yourself!

Leave tender areas until end

1. Inspection- looking and utilizing your senses

2. Palpation

3. Percussion

4. Auscultation- listening with your stethescope

This order changes when listening to the abdomin, you must listen FIRST then palpate because you will alter the sounds if you palpate first.

You should be able to get all your information for the general survey (minus vitals) just by introducing yourself and shaking hands.

CRAPLES

Color

Respirations

Activity

Position

Level of consciousness

Expression

Safety

After craples do your vitals: T, P, R, BP, SpO2, pain

Age

Activity

Hormone level

Time of day

Site of reading

Hydration

Infection

Environment

F 96.8-100 po

C 36-38 po

Oral: take in sublingual pockets

No food w/in 15-30 minutes prior

No smoking w/in 15-30 minutes prior

Mouth breathers/tachypnea

Axillary: Hold probe b/t thorax & arm; hold arm snuggly

Leave reader in longer for more accurate reading

Rectal: use a probe cover/lube

watch for color code

insert approx 5/8 inch

lay patient in sims position

pyrexia (temp) is a defensive mechanism:

• Increased WBC production
• Stimulates interferon which fights viral infections
• Decreased iron concentration in blood suppresses bacteria growth
• Increases metabolism: 13% for every degree of celsius
• Increase HR, Resp, & BP, fluid intake
• Causes confusion in older folks

Beta-blockers will keep heart rate from increasing

"normal" adult 60-100 bpm

Bradycardia: <60

Tachycardia >100

*Record rate/rhythm/strength

It is important to know what someone's baseline is.

Take a radial pulse for 30 seconds and multiple by 2.

If you can not get a radial pulse or if it is irregular take it apically and count for the full minute.

Exercise

Pain

Smoking

Body position

Meds

Neuro injury

Hemoglobin function

You should know the baseline.

"normal" adult is 12-20 per minute

Measure in conjunction w/pulse

Tachypnea >20

Bradypnea <12

Apnea- absent/paused breathing

*Record rate, depth, rhythm & symmetry

1st sign of hypoxia is restlessness or confusion. Restlessness is never normal.

Rapid breathing followed by apnea.

A terminal breathing pattern.

Not normal.

pulse pressure = systole - diastole

ie: 120/80 = PP 40 mmHg

It tells you how well the heart is resting between pulses.

Age

Stress

Ethnicity

Gender

Diurnal variation

Medications

Most common site is the brachial artery with the backup being the popliteal artery. NEVER take BP on the same arm as a shunt!

Hypotension:

SBP <90 mmHG a decrease of 20-30 mmhg of baseline

Hypertension:

Pre Hypertension- SBP 120-139 mmHg DSP 80-89 mmHg

Stage I Hypertension- SBP 140-159 mmHg  DSP 90-99 mmHg

Stage II Hypertension- SBP >160 mmHg DSP >100 mmHg

A decrease in BP with postural change. Shouldn't be delegated.

Factors:

age

medications

hydration

neurogenic

Factors that affect SPO2:

Anything affecting O2 and/or it's transport

Factors that affect the reading of SPO2:

Light transmission

Blood contents

Nail coverings

Decrease arterial blood flow

Hemoglobin

*Record % amount of O2 inspired

ie: 97% on R/A

or 96% on 3 L n/c

Increase HR, BP, & Resp.

temp. usually doesn't change

Integumentary

Head & Neck

Thorax & Lungs

Heart & Vasc. System

Breasts

Abdomen

Musculoskeletal

Neuro

Reproductive System

Anus & Rectum

Includes the skin, hair, and nails.

Assess for:

Color

Moisture

Temperature

Texture

Turgor

Edema

Lesions

Good lighting-daylight if possible

Establish a baseline- look at least pigmented areas ie: palms

Look for underlying reddish tones common to all ethnicities

Size

Shape

Location

Flat/raised

Color

Distribution

Texture

Exudates

I. Olfactory

II. Optic

III. Oculomotor

IV. Trochlear

V. Trigeminal

VI. Abducens

VII. Facial

VIII. Vestibulochoclear

IX.Glossopharyngeal

X. Vagus

XI. Spinal Accessory

XII. Hypoglossal

Head

Inspection

Palpation

Symmetry

Proportion to body

Face

Inspection

Palpation of sinus

Symmetry

Muscle movement:

• smile
• grit teeth
• frown

Inspecting- symmetry

EOM's- extra occular movement

Pupil size, shape & response to light

Palpebral conjuctiva

Snellen Chart

Red reflex

Unresponsive pt- corneal reflex

Inspection

Palpation

Otoscopic exam

Hearing acuity

Nose: inspection, palpation, penlight exam

Sinus: palpation

Lips

Tongue

Mucosa

Gums

Teeth

Hard palate

Soft palate

Pharynx

Breath

Lymph nodes

Arteries

Veins

Trachea

Symmetry

Inspection: shape, symmetry, movement

Palpation

Percussion

Auscultation: breath sounds

Bronchial

Next to the trachea, upper sternum

Harsh, loud

Bronchovesicular

1st & 2nd intercostal spaces and b/t scapula

blowing continuous

Vesicular

lung periphery

soft, breezy

Rhonchi- "rhonchi in the bronchi"

May clear with cough

Upper airway junk

Crackles- From air moving thru fluid or opening of airways

May be fine- high pitched

Coarse- low pitched

Wheezes- Continuous, high pitched, musical, hissing

From air moving thru narrowed airways

Stridor- when airways are completely clamped shut.

Crepitus- sounds like rice krispies when press on chest. Happens w/leaking air from lungs.

A-P-E-T-M

Aortic = 2nd ICS

Pulmonic = 2nd ICS

Erb's Point = 3rd ICS

Tricuspid = 4th or 5th ICS

Mitral/Apex = 5th ICS

S1 "LUB"

systole

mitral & tricuspid valves closing

S2 "DUB"

diastole

aortic & pulmonic valves closing

Murmurs: turbulence of blood flow anywhere in cardiac cycle

S3

Possible fluid overload

May b normal in athletes, age <20

Ken-tuc-y (lub-dub-by)

S4

HTN, Cardiomyopathy, MI (Stiff ventricle)

Generally abnormal- heart damage

Ten-nes-see (le-lub-dub)

Pulse

Temperature

Capillary refill

Color

Compare symmetry

Most important that distal sites are in working order. Check profussion by feeling for the pulse in both sides at the same time. Do not *count* the beats in profussion. If you can not get a pedal pulse than you can use a doppler to hear.

Divide into quadrants- RLQ is the most important section to listen to

Inspection- symmetry, masses or pulsations, distention

Auscultation- must listen BEFORE palpation!

Percussion

Palpation- gentle

If you hear a "AAA" (abdominal aortic aneurism) just below the sternum DO NOT palpatate.

Inspection

Palpation

ROM

Muscle tone & strength

Looking for CSMs:

Color, Sensation, Movement

PQRST

Provoking factor

Quality

Region and radiation

Severity and symptoms

Timing

Mental status/LOC (level of consciouness)

Sensation

Cranial nerves

Motor system

Cerebella function

Reflexes

Client should be able to know who they are, where they are, why they are there, and the date/time

Decerebrate- when body is stimulated all muscles tense outwards. Body will hold itself off the bed but rigid like a board with arms/hands turned outward and toes pointing straight down.

Decorticate- Not as severe as decerebrate. When stimulated body takes on more of a fetal position pulling limbs to the center.

General survey (VS)- CRAPLES & Vitals

AAOx4, affect

Heart sounds

Lung sounds

Abd

Pulses, cap refill in UE, grips

Pulses, cap refill in LE, pushes

Evidence of your care

Communication tool

Continuity of care

Reimbursement purposes

Legal defense & protection

Important to remember:

our assessment

what we did about it

patient response

SBAR

Situation

Background

Assessment

Recomendation