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NUR 231 Test 1 Notes Bundle

by: Issy Notetaker

NUR 231 Test 1 Notes Bundle NUR 231

Issy Notetaker
GPA 3.96
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey

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About this Document

This is a bundle of all the notes I took for NUR 231 Test 1. It is 60 pages of notes from the book, lecture, and clinical.
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey
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This 58 page Bundle was uploaded by Issy Notetaker on Friday September 18, 2015. The Bundle belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 195 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.

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Date Created: 09/18/15
Fundamentals Book Notes Chapter 26 Objectives Clinical Lecture 0 Documentation O 0000 0 Written or printed material used as recording device for proof of pt actionactivities Vital that proper documentation is made in medical records Vital that Accurate Comprehensive and Flexible Detailed Ensures continuing care saves time minimizes risk of errors Quality of care depends on correct documentation All care providers need the same information Information is transferred verbally electronically and in a written manner 0 Con dentiality O O 0 Keep information con dential don39t discuss with those not involved w Pt Pt have right to own medical record Written permission of release is needed HIPAA is the privacy legislation Health Insurance Portability and Accountability Act Provides pt w more control over health information Not allowed to look in chart that you aren39t working on Part of student nurse professional practice Only have information for safe effective care Don t have pt identi ers room DOB MR Disclosure forms are minimum legally and ethically responsible to follow HC providers must notify pt of privacy policy Medical records can be used for data collection research or continuing educa on Only can information that can be used is that that has been given permission Communicate pt health information Chart is con dential permanent legal document Document time of care along w continuing accout Nurses only review what is needed for safe pt care Never print records for personal needs never leave a computer logged on and alone have all screens pointed away of general population view don39t include pt identi ers Standards 0 O O O Govern information and documentation type an accountability Determine frequency Pt records are used as evidence in court All pt admitted must have these assessments Physical Psychosocial Environmental Selfcare Knowledge level Discharge needs Win Nursing process context From institution TJC NCQA HIPAA Federal and State Regulatory agencies Department ofJustice and the Center for Medicare and Medicaid Services TJC Makes US care better by giving accreditation and shutting down guidelines focus on communication and aIarms InterDis Communication 0 O O O O 0 Record is continuous account of status all members of team can access 70 of error are from bad communication Contain Identi cation the Demographics Informed consent Admission data and Nursing diagnosisproblems Record of treatment and evaluation Medical history diagnosis discipline progress notes Therapeutic orders Physical Assessment Diagnostic results Education Summary of procedures and discharge plan and summary Change of shift telephone handoff and incident reports are all methods of interdis communication Done via verbal written audiotaped Communicate interdis by conference Consultations one professional gives advice to another on pt care Referrals arrangement of services 0 Purpose of records 0 O Source of data from all members of team for Communication Legal documentation Education Financial Billing Research AuditingMonitoring Communication Needs and progress Therapies Plan of care Consultations Educann Discharge planning Most current and accurate Base on assessment ndings and pt information Legal documentation Defense for cIaim Indicate Individualized care 0 Goal directed care based on assessment 0 Describe exact event 0 Follow agency standards Chart right after care Mistakes Failing to record health and drug information nursing actions medication given and reactions discontinued medications Not legible or incomplete 0 Financial billing DRGs diagnostic related groups Establish reimbursement based on diagnosis Documentation clari es 0 Education Identify patterns in records and anticipate type of care needed 0 Research Gather statistical data on frequency complications recoveries and death For investigation of interventions or health problems Contributes to EBP o Auditingmonitoring Quality improvement programs Ongoing and objective data collection Informed standards to maintain excellent nursing care Determine if standards of care were met Identify needs for improvement Help to make changes to policies 0 Guidelines for Quality Documentation and Reporting 0 Needed for effective and ef cient individualized care 0 Five need characteristics Factual ONLY SUBJECTIVE Descriptive Hears smeIIs feeIs Avoid vague terms Observations of behaviors If subjective is noted put in Accurate Exact measurements Determine change in status Clear and Concise Institution has a standard list of abbreviations symbols and acronyms Incorrect spelling results in errors Transcribe Carefully Date each entry and sign w RN after Complete 0 Appropriate and Essential Information Thorough communication is needed Describe care given and changes Use flow sheets or graphic records More reIevantmore detailed C C C u n and support w objective Current Timely military time Delays unsafe care 0 Document at time of Vital signs Pain assessment Administration of meds and treatment Prep for tests and surgery Change is status and noti ed persons Admission transfer discharge or death Treatment for sudden change Response OOOOOOOO Organized Logical order Concise clear to the point 0 Make list bf entering into system RERED what was written 0 Methods of Documentation 0 Paper and Electronic Paper Separate for each visit 0 Information is easily lost for visit to visit Electronic Health Record EHR accessed and added to whenever the pt seeks care in any setting 0 Provides information at any time and any place 0 Includes al information from each visit tests and diagnosis Easier to access 0 Clinical data for quality issue linking of interventions and outcomes and make EB decisions Improves care 0 Includes guiding critiquing and basic support tools 0 Allow comparison from ongoing data and baseline maintains ongoing record for education easier to access Electronic Medical Record EMR Is part of the EHR but is speci c to time and place 0 Narrative Traditional storylike format Disadvantages Repe ous Time consuming Sort through lots of information o ProblemOriented Medical Record Emphasizes pt problems and organizes them by problemdiagnosis Team members all contribute to a list Coordinates a common care plan Sections 0 Database Contains all assessment data for that pt 0 Used for identifying problems an planning of care 0 Stays w pt through visit 0 Problem List 0 Identify all problems and make a list 0 In chronological order in front of record new one will be added 0 Care Plan 0 Documents plan in many formats 0 Diagnosis expected outcomes and intervention 0 Progress Notes 0 SOAPIE Subjective Objective Assessment Plan Intervention Evaluation Collect information draw conclusions and develop pIn of care Medical records origin 0 PIE Problem Intervention Evaluation Problem oriented nursing origin Narrative doesn39t include assessment information Continuing problems are documented dain 0 Focus Charting DAR Data Action Response Address concerns Integrates all nursing process emphasizes concerns put into all clinical settings 0 Source Records Chart as new section for each discipline DetaiIs that are speci c are in each section 0 Charting by Exception CBE Documents deviations form norms Reduces time and emphasizes problems Rede ned norms are in documentation forms Notes only written when not in norm Assessments are standardized Easy to track changes 0 Case Management Plan and Critical Pathways Case Management model of care delivery and is interdisciplinary Critical Pathways include problems key interventions and expected outcomes 0 Each member use the same for monitoring of progress 0 No nurses notes row sheets or nursing care plans 0 Not met goaIs unexpected outcomes and interventions are caII variances 0 Activities in critical pathway is so met 0 Positive is when completed more quickly 0 Negative is when slower or not completed at all 0 Identify and change care to meet needs Common Record Keeping forms Usually derived from institutional standards of practices or guidelines 0 Admission nursing history forms Complete nursing history Relevant nursing diagnosis or problems Identi es baseline data 0 Flow Sheet and Graphic Data Quick and easy entering of assessment data Current information all members can access Critical and acute care use these commonly 0 Pt Care summary or Kardex Electronic Summary automatically updates as new info is added Kardex is portable le that eliminates needs to continuously refer to chart 0 Standardized Care Plans Ef cient and improve continuing care Preestablished guidelines for pt w similar problems that modi ed to t individual Add goals and outcomes and dates based on pt Useful for quality of care audits Don39t replace judgement and decision making must be updated regularly 0 Discharge Summary Save costs ensure reimbursement Discharge prep is important to be timely and effective Leave with needed resources Begins at admission allowing for longer planning times Involve pt and fam Include meds diet resources followups emergency contact 0 Acuity Records NOT part of medical record Determine hours of care and needed staff Pt level is determined by computer based on type and amount of interventions in 24 hr 1totay dependent and 5independent Home Care Documentation 0 Information is from fam Different from other documentation Speci c guidelines for reimbursement Provide all HC workers and information Quality control and Justi cation for reimbursement Document ALL services Pt assessment referral and intake forms interprofessional plan medications reports to others OOOOO 0 Long Term HC Documentation 0 Careful documentation is needed for right reimbursement 0 Use RAIMDS Standardized protocols for assessment and planning 0 Supports interdisciplinary approach 0 Communication is key 0 Reporting Timely accurate relevant o Handoff Any time care is transferred from one to another Provide better continuity and individualized care Change of shift and transfer reports 0 Follow order basic identi cation information reason for admission and testtherapies changes Ensures safety Up to date information Facetoface writing or verbally phone audiotape Quick and ef cient Important to note changes in priority conditions Include Condition required care treatments meds services and change that have occurred or are anticipated EXACT information emotional support need concise priorities 0 Telephone Reports only when signi cant changes have occurred 0 Needs to be clear accurate and concise Use SBAR Document who to and when the call was made who made the call what information was given an received and veri cation that it was read back and later signed by provider 0 State name and relationship to pt date time content c When order is given of telephone or verbally Usually occur at night or during emergencies only used when needed Frequent cause of errors Receiver writes complete order down reads it back an receives conformation for orderer Provider later veri es via signing Know state board and agency policy speak slowly and clearly on both ends ask to spell out medication question drug dosage or changes 0 Incident or Occurrence Occurs when something goes not according to routine Falls needle sticks med errors ect Helps to identify trends providing justi cation for changes Important for improvements Contact HCP when these happen Don39t note in medical record but document an objective description of incident Follow agency policy and le w risk management Health Informatics O O 0 Use of computer an information science in biomedical sciences Focus on pt and care process enhance quality and ef cacy of care Use of EMR and ERH Nursing Informatics 0 Record interpret and reporting of data for its application and use in critical thinking Recognize patterns that develop an evidence base to research and apply knowledge to for correct interventions Data is more ef ciently used to quality of care research and providing education when information technology is used Information Tech IT management and processing of information Advances that help to group and support information Clinical CIS and Administrative information systems NIS Nursing information system Order entry Iab radiology and pharmacy systems that coordinate care Documents process of nursing process activities and give resources for managing care Product of Nursing informatics Nursing computer and information science for communication information and knowledge that supports decision making Ef cient and Effective care Supports nursing function an gives exibility Improves access to information and decision making tooIs Helps w error reduction AIIow quick sharing of information gathered and plans made Designs 0 Nursing Process organizes win formats admin post op care plan discharge 0 Helps to direct nurse through assessment categories and once data is entered it offers intervention and diagnosis 0 Must make individualized care 0 Protocol or Critical Pathway design interdis format o All providers document care given 0 Allows selection of protocols o Identi es variances of anticipated outcomes Clinical Decision support systems CDSSs Support decision making 0 Based on rules and if then link information produce aIters Current and EB information 0 Improve care O Advantages Increased time w pt Access to information Quality documentation Reduced errors and costs Increased job satisfaction Better compliance Development of clinical database Privacy Con dentiality and Security 0 Top priority 0 Fire walls and antivirus spyware Automatic sign off 0 Place computers and servers in restricted areas or using privacy lters 0 Access and log ins w passwords Don39t share 0 Random times for changes in passwords Handling and Disposal of Information Safeguard information that is printed sherd when no longerneeded Printing and Faxing is primary source for unauthorized release Clinical Information Systems Monitoring system Order Entry and labs radiology and pharm systems Automatically record and save measurements Computerized provider order entry have built in reminders and alerts for correct test diagnosis and medications Eliminates transcribing and illegible writing 0 Common Malpractice 0 00000 Chapter 27 0 Safety 0 O O 0 Don t document correct time Don39t record verbal order sign verbal order Pre charting Wrong information is documented Don t give report or giving an incomplete Narrative form Basic human need Reduces risks Illnessinjury Reduces costs Foster by focusing on improvement ndings reports tech EBP education and resources Professional responsibility Quality and Safety Education for Nurses QSEN Competency is acquired when professional shows knowledgeable skill and performance individually and through the system 0 Assess for and maintain safe environmentjob Knowledge Base 0 Environment Physical and psychosocial Safe effective and optimal functional ability Meets basic needs 0 Physiological must be met rst 0 02 Supplemental follow strict codes for storage and use and factors decreasing available amount Smoking is leading cause of fatal and nonfatal injuries in the home w sup 02 0 Nutrition Meet state regulations FDA regulations 0 Temp Decreases hazards Physical Highest risk children pregnant women elderly compromised immune system Comfortable 6575 F or 183239C Cold for long period Frostbite Hypothermia Heat Heatstroke or Heat exhaustion High Risk Elderly homeless children those on drugs or alcohol chronically ill 0 Unintentional 5th leading cause of death 0 Vehicles 0 Poison 0 Falling Use of seat belts airbags booster and car seats Back seat is safest Riskhighest in teens Older adult skill decline after 75 Drugs meds liquids gases lmpair organ function High Risk Toddlers Emergency treatment is needed Call poison control DON T INDUCE VOMI39ITING unless told to do so by poison control High risk Elderly 64 Major problem Many factor in uence 0 Physiological Impaired vision balance problems walking aids 0 Physical Poor lighting throw rugs little to no safety rails or aids Different factors in uence fall impact 0 Point of impact height position Leading cause is smoking Falling asleep w lit cig Wrongful use of equipment in kitchen Install detectors and extinguishers and teach occupants to use extinguisher 0 Disaster Natural Destroy homes and cause death Bioterrorism Bio Chem or radiological o Mainly biological in form of iHness Pathogen transmission 0 Common is by hands 0 Use aseptic technique when using hand hygiene o Immunizations decreaseprevents o Controlling pest populations decreasesprevents 0 Proper disposal of wastes Pollution 0 Water Air Increases pulmonary disease Soil Noise 0 Nursing Knowledge 0 In uencing factors Developmental Stage Tailor education to needs preferences and lifestyle InfantPreschooler 0 Injuries are leading cause of death when gt1 0 Accidentspreventable through education of parents and removal of dangers SchoolAge 0 Environment grows 0 Teach safety Helmets proper gear for sports rules Adolescent o More independent 0 Peers are a greater in uence 0 Engage in RiskTaking behaviors D Increases accidents Able to drive 0 Assess for substance use and abuse or interest in drugs 0 0 Begin engaging in sex STDs when improperly knowledgeable Adult 0 Risks associated w lifestyle and various habits Smoking drinking stress job 0 Older Adult 0 Physiological factors meds disease increase fall and accident risk 0 Environmental factors greatly affect risks 0 Decreased by group exercise assessment and reviewing of medications and annual checkups Individual 0 Lifestyle 0 Choices affect safety Mobility o Impaired Higher risk for falls due to lack of balance and weakness High risk for emotional hazards Impaired SensoryCommunication O O 0 Cognitive Greater risk Alter awareness VisualHearing Language Communication Tactile Don t perceive potential danger Can39t express needs as well Lack of Awareness Unaware of hazards and situations they are foundin Home inspections can help to educate and reduce probability of these hazards becoming a medical emergency Risks in Agency39s O O O 0 Medical errors8th leading cause of death Be aware of regulation and organization initiatives Know individual patient risk factors everyone is different Encourage patients to speak up Strive to meet goals Report all incidents Allows assessment of trends Allows to see what needs improving Be aware engage prevent stop become advocate for safety Know environmental risks you are introduced to Read MSDS Assess and help to prevent Falls Minorsevere Extend stay 0 Increase costs PatientInherent Patient caused accident selfin icted Procedure related Caused by HCP Med errors device use improper performance Prevent by following policies and procedures 0 Use proper hand hygiene be in a non distracting area for high risk use proper technique Equipment Related Malfunction improper up keep misuse Report and tag malfunctioning equipment 0 Follow up and schedule safety checks 0 Report related deaths to FDA and manufacturer 0 Critical Thinking O O O O O Ongoing Requires anticipation of needs and proper good judgement Use multidiscipline knowledge experiences attitudes and standards of practice Created a DETAILED assessment Guides conclusions 0 Nursing Process 0 Provides clinical decision making 0 Assessment Through Patient Eyes 0 Patient view yours on safety Consult about perceptions of environment and ways to reduce change hazards in environment 0 Note possible immediate and future risks 0 Note individual and environmental risks History 0 Wellness Underlying conditions affecting safety 0 Review General Survey developmental status and medications along w their effects Health Care Environment 0 Are there hazards in the immediate area Collaborate with different departments so everything if working and is safe 0 Fall risk 0 REQUIRED and ESSENTAIL 0 Done upon admission when condition changes and after fall 0 Continuous assessment 0 Families are useful resources 0 Inform patient and fam About risks 0 Medical Errors 0 Be alert 0 Know what factors increase errors Fatigue Decreased concentration 0 Use 2 identi ers Disasters 0 Be prepared for increased amount of patients 0 Run Disaster drills 0 Use proper communication 0 Make accurate and timely assessments Home Environment 0 Hazard assessment is essential Assess knowledge and ability 0 Focus on avoiding and reducing risks for injury 0 Diagnosis Analyze and cluster data collected in assessment Include factors that were found to be in uencing Inappropriate interventions increase risks 0 Planning Interventions should prevent and minimize risks Address all needs Experience helps adaptation to each new patient Goals and Outcomes Collaborate w patient and patient support 0 Active inputmore alert to hazards Measureable and Achievable Setting Priorities Prioritize to create safe and ef cient care Mobility problems increase skin and fall risks Interventions should be based on priorities of risk factors developmental stage health lifestyle and culture 0 Understand need for independence 0 Keep patient actively involved 0 Remember to educate Teamwork and Collaboration Important Communicate risks Use SBAR Patients need to know resources in community for help 0 Implementation Effective use of tech an practices Effective use of strategies that reduce a patients risk to themselves or others Use pamphlets and iers to reduce the need for memorization Incorporate for all settings Emphasize promotion and prevention measures Promotion 0 Safe lifestyle and practices reduce risks Incorporate passive and active strategies 0 Developmental Interventions o InfantPreschooler Adults protect from injury Don39t see themselves as in danger Show how to promote child safety and importance of immunizations 0 School Age Explore more and are more active Teach school and play safety 0 Adolescent Involve outside the home interventions and educa on Be role model High incidence of suicide Know risks of this age Lifestyle factors affect risks most Promote modi cation in lifestyle to reduce risks 0 Stress inadequate nutrition Enforce exercise and proper nutrition along w sleep y Reduce risk for falls Compensate for changes related to aging Provide info for local resources helping elderly maintain independence Educate for risk of falls driving risks and burn risks Promote use of re ectors Environmental Interventions Basic Needs 02 prevent contact w re nutrition basic food handling temp General Prevention Lighting security environment modi cation re safety Acute Care poison control medication storage hand hygiene proper disposal of materials ad safe sex 0 Use Standard precautions Make patient safe 0 O O CaHtht Respond quickly Remove clutter Take steps to reduce risks 0 Falls 0 o o 0 Follow prevention protocol Include fam Apply assistance devices and check condition of this equipment regularly Rubber on walkers Observe fall risk patients frequently and inform them of risk factors Restraints 0 OOOOOO Side 000 0 Fires 0 OOO Temporary Require PO Not a solution Watch for psychological distress and symptoms lndividualize approaches Explain purpose and precautions Monitor appropriately Every 2 hours for adult and 1 for child Order must be renewed every 4 hours for adult and 2 for children for max of 24 PO is based on face to face assessment AS NEEDED ORDERS CAN39T BE MADE Proper documentation is required Evaluation of response is required Try alternatives before resorting to restraints Alarm mats Posey bed Ambularms Rails Increase mobility and stability Not a restraint Common Know policy bed should be at lowest possible position Normally Electrical or anesthetic Prevention is best intervention Have evacuation plan If occurs Protect patient Report Contain Use twoman carry if needed Ask those who can to walk keep Life support patients respiratory status with ambu bag 0 Electrical Hazards 0 Equipment must be inspected and well maintained 0 Use proper grounding techniques Seizures 0 Generally 25 minutes Grand Mal 0 Note if aura was present to patient 0 Status Epilepticus is emergency lasting 5 minutes 0 Radiation 0 Used in diagnosis and treatment 0 Wear shielding devices Disasters 0 Know the emergency policy plan 0 Know infection control plans 0 Evaluation Patients eye s Were expectations met 0 Ask them questions regarding care and level of comfort in knowledge Involve family Patient Outcomes Based on expected outcome established in planning 0 Were they met 0 Determine if new ones need to be created Continuously assess and evaluate Chapter 28 0 Infection Prevention and Control 0 Increase in the number of contract caused infections Infection prevention and control is on the rise Issue regarding pt safety Nurses are primary role Antibiotic resistance increased exposure invasive procedures increase risks Recognize sources understand protection measures 0 Teach patients about transmission odes and preventative measures 0 Knowledge Base 0 Nature Infection when pathogen invades host and causes disease 0 Results from the multiplication of pathogen and alteration of tissue function Colonization There is no tissue or invasion damage just presence and growth 0000 O Communicable Transmittable directly Symptomatic Cause signs and symptoms Asymptomatic Not signs and symptoms 0 Chain of infection Presence infection Requires Pathogen Reservoir Exit from reservoir Transmission mode Entry port Host that is susceptible As long as chain is uninterrupted infection can occur Pathogen Resident or transient ora 0 Resident Normal survive and are permanent residents not virulent 0 Transient Transferred from elsewhere attach when come into contact w object readily transmitted removed via hand hygiene Virulence the pathogens ability to cause disease Reservoir Area of survival multiplication and housing until transferred Water food fomites animals Hands equipment patients Especially in HC environment Two categories 0 Acute symptomatic o Asymptomatic carriers Food 0 Provides nourishment 02 o Aerobic o Anaerobic Water 0 Most need moisture 0 Surgical wounds are thriving area 0 Spores resist drying Temp 0 Certain ranges for certain bacteria Speci c to species 0 Most for humans are 2043C 0 Cold prevent growth Bacteriostatic o Destroys Bactericidal o Acidity Bacteria thrive in alkaline 0 Light 0 Thrive in dark Port of Exit 0 Need to enter other host Skin and Mucous Membranes Any break allow exit Respir Tract Sneezing or coughing Uriniary Elimination GI Tract Elimination surgical drainage saliva Reproductive During sexual contact Blood can become reservoir if infected Transmission 0 Each microbe has speci c Interrupt by using hand hygiene Air unwashed hands equipment Entry 0 Same routes as exit Host Susceptibility Degree of resistance an individual has to a speci c pathogen Natural defenses and risk factors in uence 0 Infectious Process 0 Localized localized symptoms Use standard precautions PPE and hand hygiene Block spread 0 Systemic Affects entire body Can become fatal if undetected 0 Nurse apply antibiotic and note response Nutrition and rest are critical 0 Defenses Normal Flora Residential to body not normally disease causing Maintain health Disrupt normalsusceptibe to infection 0 Broadspectrum antibiotics destroy normal ora reducing defenses can lead to superinfection Body System 0 Each organ has own defense In ammation Vascular reaction delivering uid blood nutrients to site of injury Neutralizes and discards pathogens along w repairing Systemic when other signs and symptoms appear 0 Once triggered 0 Vascular Response Acute to begin Vasodilation Redness and warmth Swelling edema and pain Phagocytosis Neutrophils and Monocytes Leukocytosis Increase in WBCs 15000 20000mm3 Fever 0 Exudates uid discharged from cells and blood vessels Serous Clear Sanguineous RBCs Purulent WBCs and Bacteria Cleared through lymphatic system 0 Tissue repair Replaced w healthy new cells If long healing time granulation tissue Scar tissue forms 0 HCAssociated Infection HAI HAI or nonsocomial Due to invasive procedures antibiotic multidrug resistance breaks in control methods Those who acquire Multiple illness poor nutrition lowered resistance underlying medical conditions Critical illness increases possibility Iatrogenic Infections occurs from therapeutic procedures 0 Hand Hygiene and aseptic techniques reduce possibility Exogenous Microbe found outside individual 0 NOT IN NORMAL FLORA Endogenous Flora becomes altered and results in an overgrowth yeast infection In uences of HC personal w direct contact and type of invasive procedures length of stay Some can be a combination of the three infection types UTI from catheter insertion Open wounds are common sites Increase costs not reimbursed bc shouldn39t happen High risk Elderly Nursing Knowledge 0 Follow infection prevention techniques 0 Psychological state and safety is compromised when put in isolation for infection Reduce Discussion infection cycle reason for isolation be friendly 0 Know patients reactions to infections In uences on Prevention and Control 0 Many 0 Age Infants are most susceptible bc immature Breast fed have better Immune system mature w age and experiences Elderly have a decline in immunity 0 Nutrition 0 Stress Reduction in nutrition status decreases immune response and increases time for healing GAD Alarm stageincrease in energy use o If continuous decreases immune system exhaustion reduction in energy no resistance 0 Disease process Disease of immune system increase risks Weaken defenses Chronic diseaseincrease in susceptibility Those w burns have high susceptibility Nursing Process 0 Assessment How does patient feel bout illness and infection risk Asses defenses susceptibility and knowledge Reviews systems travels risks for communicable diseases immunizations Medication history 0 Find one that increase susceptibility Lab results will tell if more susceptible Make early recognition of susceptibility to better prepare Patient Eye 0 Speci c question about risk 0 Assess physical psychological social and economic in uences Ask if infection in uences social life or home life resources fam involvement 0 Ask expectations Defense Mech Use physical assessment and medical condition 0 Increased risk occurs when any line of defense is decreases Susceptibility Medical Therapy 0 Can compromise 0 Do any of the medications decrease immune system 0 Assess all side effects and uses of medication reason for use Clinical Appearance 0 Local or systemic 0 Local Redness Swelling Infected drainage Pain or tenderness ask ROM 0 Systemic Generalized symptoms fever fatigue vomiting enlarged lymph nodes 0 Notice change in alertness and activity level Elderly have reduce swelling and in ammation increased fatigue Lab Data 0 Review ASAP 0 Increased WBC or blood culture indicate infection but need more assessment 0 Know standard of facility 0 Diagnosis Gather Objective data and subjective Review and cluster Patterns suggest a diagnosis Validate by inspecting again and reviewing data Diagnosis requires accurate related to factor in data 0 Planning Goals and Outcomes ReaHsUc Guides interventions to be direct for a purpose and MUST BE MEASUABLE 0 Prevention of additional exposure 0 Controlling existing infection 0 Maintain the resistance 0 Making sure patient knows infection prevention 0 One diagnosis will affect others interrelated Priorities 0 Establish them for each different diagnosis Improvements or declines in condition change priorities Teamwork and Collaboration Prevention and control from different disciplines Know patient to better select interventions Consulting someone in infection control is a good idea Ensure safe home and discharge plan 0 Home care should ensure correct infection control 0 Implementation Health Promotion 0 Strengthen defenses of host 0 Nutrition rest ect Minimize of reservoirs organisms control entry and exit ports use aseptic and sterile techniques 0 Reduce chance of exposure 0 Isolation Acute Care Eliminate infectious agents increase an support defenses prescribe most effective treatment W systemic prevent fever complications maintain hydration have adequate rest W localized remove debris promote healing wound are apply gloves se correct dressings use aseptic techniques Encourage natural defenses and increase hygiene measures Asepsis when pathogenic microbes are absent from eld Minimize spread and onset Practices reduce risk of infection Medical Asepsis Clean technique used to decrease present microbes and prevent any further transmission lnclude patient beliefs and values Contaminated unsterileunclean that can contaminated others Standard Precautions Prevent add control infections Hand Hygiene instant alcohol or soap or surgical scrub o Alcohols are just as effective as soap and water 0 When visibly soiled use soap and water if not use alcohol based 0 Alcohol based before and after contact w patients and use of gloves 0 lnstruct patient and visitors on proper hand hygiene Cleaning Disinfection and Sterilization Reduces and eliminates microbes Cleaning 0 Removal of all soil lf reusable needs thorough cleaning Follow manufacturer recommendations Use protective barriers when needed Process Rinse w cold running water Wash w soap and warm water Rinse thoroughly Use brush and remove soil Rinse in warm water 0000 Dry Clean brush gloves and sink used according to policy Disinfection and Sterilization o Disinfection eliminate many or all microbes from inanimate objects High level used for patient care item o Sterilization Complete elimination or destruction of microbes and spores Level of cleaning depends on use 0 Know HC policies 0 In uences on ef cacy Concentration and duration of solution Pathogen type and number Surface area Temperature Soap presence Organic Materials 0 Patient Safety Know transmission modes and controlling methods Patient gets own set of care items Be careful wen handling exudate Know biohazard bag locations Know OSHA regulations Teach cough etiquette Keep soiled items from touching personal items PREVENT SKIN BREAKDOWN Help with oral hygiene Keep urinary catheter an drainage tub closed and intact Use proper wound cleaning 0 Clean outward from wound 0 Clean gauze should be for each revolution Isolation Separation and Restriction of movement Not all communicable diseases require this Use PPE depend on what is being performed 0 Based on transmission mode Precautions 0 Contact direct or indirect Hand Hygiene 0 Droplet Large droplets traveling 36 feet Surgical mask 0 Airborne Smaller droplets remaining in the air Negative air ow room and wear suit when entering room 0 Protective environment Limited population Positive air ow 12 changes and hour 0 Use proper hand hygiene dispose properly of contaminated items use infectious process knowledge and protect possibly exposed persons Psychological Implication o Loneliness disruption of relationships 0 Can be harmful 0 Feel unclean and rejected 0 Listen to concerns explain nature of disease and purpose Make sure pt understands difference bw lean and unclean Know risk of depression 0 Environment 0 Negative air ow Prevent spread of infection Positive air ow Prevent spread into room Card showing precautions should be posted outside room Worn for protection from infectious materials Gowns Protect clothing Fluid resistant Cover all outer garments Remove carefully Respiratory Protection Full face for splashing or spraying Masks for airborne risks Prevents transmission and protects mucous membrane Minimal talking should occur Special respiratory devices are needed for airborne protection Eye Protection Glasses or goggles Gloves Prevent transmission via direct or indirect contact Wear clean new gloves Remove promptly after use and perform hand hygiene When full PPE Hand hygiene then gown mask eye wear gloves Specimen Collection 0 Collected when suspected to contain infectious organisms 0 Use clan gloves and sterile equipment 0 Seal all containers tightly Bagging trashlinen o Prevent accidental exposure 0 Don39t over ll o Securely tie 0 Check color coding of facility Transporting Patients Give clean gowns for robes If airborne infection mask is needed on patient Cover w extra sheet 0 Make sure equipment is cleaned before reuse OOO Role of Infection Control Trained in prevention and control Useful resource Advising an guide educate develop policies and procedures Consu Gather information Notify health departments Monitor Infection Prevention and Control for Personnel in Hospital OSHA and CDC have policies and procedures guidelines and rules to the protection of all employees Education programs are also available Educann Pt Have to learn prevention and control practices for the home Surgical Asepsis Sterile procedure for wound care surgical procedures and separates contaminated frim sterile eld Removes all microorganisms from an area Contaminated of touched by an unsterile object Use when 0 Breaking skin line 0 Skin integrity is broken 0 Insertion into sterile body cavity Bedside 0 Hand hygiene and sterile gloves OR 0 Cap gown mask eye protection gloves Patient Prep 0 Explain Avoid sudden movement Don39t touch sterile supplies Avoid cough sneeze or talking 0 Assess needs of patient before beginning 0 Help assume comfortable position Principles of 0 Area where objects can be easily handled and protected from contamination 0 Surface for proper placement Sterile kit sterile towel draped surface 0 Only STERILE touching STERILE is still sterile 0 Only STERILE objects should be placed on STERILE eld 0 STERILE object outside of vision range or below waste is CONTAMINATED o STERILE objects become CONTAMINATED if prolonged exposure to air 0 When STERILE comes into contact w WET it is CONTAMINATED o Fluid ows w gravity 0 Edges of sterile FIELD are CONTAMINATED Performing o Assemble all needed equipment plus some 0 Don39t leave 0 Explain all steps 0 Discard immediately if contaminated Donning and Removing 0 Apply clean cap rst then mask then eyewear 0 Change mask if it becomes moist 0 Remove in order Gloves face shield gown the mask 0 Hand Hygiene Opening Sterile o Kept in clean enclosed rooms 0 Chemical tape has indication of sterilization 0 Perform hand hygiene before opening and keep above waist Flat Surface 0 Tear away cover keeping inside sterile 0 Use inner package a sterile eld While Holding 0 Hold in non dom 0 Open pulling ap away from you Preparing eld 0 Free of microbes 0 Use inner surface of wrapper as surface or use sterile drape 0 Add by placing directly on or use forceps to transfer 0 You can wear gloves but they can39t touch wrappers and items need to be handed over by an assistant Pouring solutions 0 Inside of bottle is sterile 0 Place cap w inside up and pour a bit of solution into disposable cap Sterilizes neck and tip of bottle 0 Now pour solution slowing into sterile receptacle 0 Hold bottle just outside of sterile eld Surgical Scrub 0 Remove all jewelry and trim nails o Scrub from ngertips to elbows o 5 minute scrub is standard 0 Applying Sterile Gloves 0 Open Before dressing changes or catheter insertion 0 Closed After applying sterile gown and in ORs 0 Choose right size Donning Sterile Gown Allows handing of sterile items Reduces risk of contamination Bar er Applied after mask cap and scrub Areas not in constant view are unsterile 00000 0 Evaluation Washing hands is the most effective way to prevent the spread of infection Determine if goals and outcomes were properly achieved Through Pt Eyes 0 Understand needed measures to reduce and prevent growth ad spread Know pt perceptions about spread and effect of infection Outcomes Compare 0 Observe changes 0 Review Labs Exposure Issues 0 Everyone is at risk from accidental needle sticks 0 Place in Needle safety containers 0 Report needle stick immediately 0 Follow ups are required for testing Declination forms are needed if vaccinations aren39t met Chapter 39 Hygiene 0 Affects comfort safety W3 0 Cleaning and grooming Bathing nails teeth cleaning positive selfimage Determine ability of pt to do own selfcare and hygiene Close contact will help to foster the relationship bw nurse and pt lnclude assessment and interventions during hygiene care Allow patient to do as much as possible and assess their abilities Make sure they are comfortable 0 Knowledge Base 0 Understanding of Anatomy and physiology 0 Promote normal structure and function of tissues OOOOO o Pathophysiology will help in the identi cation of a preventing abnormal or decreased function 0 Hygiene practices should be adapted to the individual needs and to reduce the risk of injury 0 Identify abnormalities during hygiene practices 0 The Skin Protection Secretion excretion temp regulation sensation Epidermis shield from loss of water entry Dermal layers contain nerves glands follicles and vessels Sebum Bactericidal Subcutaneous Nerves Blood and lymph vessels fat cells loose connective tissues 0 Heat insulator Shows changes Color thickness texture temp hydration If intact functions are optimal 0 Feet Hands Nails Special attention to reduce injury and odor In uence hygiene care ability Conditions impairing hand function decrease selfcare abilities Foot conditions change gait causing mm pain Nails Normal are transparent smooth convex pink bed and white ti 0 Disease changes shape thickness and curve 0 Oral Cavity Mucosa is pink and glistening soft smooth moist Xerostomia Dry mouth Saliva glands cleanse the mouth Healthy teeth are white sooth shiny aligned In amed and infected gums result in dif culty chewing 0 Hair Many things in uence growth distribution and pattern 0 Eyes Ear Nose Careful attention is needed Prevent irritation and injury when cleaning Ask for changes in these senses Nursing Knowledge 0 No two pt are the same 0 Individualize each hygiene practice for each pt 0 In uencing Factors Social 0 In uence type of product used frequency and nature 0 Parent in uence children until adolescence Adolescents have media and peer in uences Work groups shape adult hygiene Personal 0 When to perform 0 Shower vs Bathe 0 Products used 0 Knowing preference increases individualized care Body Image Subjective concept of themselves 0 Effects maintenance of hygiene Extra teaching may be required for those who have less hygiene practices 0 Extra time may need to be spent with pt who have a body alteration and are uncomfortable or in pain SES 0 Resources in uence products and type of hygiene performed 0 Help promote basic resources and nd basic resources Health Beliefs and Motivation 0 Teaching is needed to learn basic care but motivation is needed for the pt to continue in the home 0 When the recognize a potential risk they are more likely to take prevention measures ie dental health Cultural Different culturesdifferent practices Cleanliness holds different values 0 Avoid changing cultural practices unless it affects pt heath Be supportive of religious practice and bring in religious person to help Developmental Stage 0 Aging affects body structures ability to perform 0 Skin 0 Thin at birth and loosely bound Frictionbruising Skin breaksinfection little immune system 0 Toddler tighter better immune system parentcaregiver provides hygiene and teach hygiene o Adolescence Glands are more active and acne develops frequent bathing is needed to remove odor and oil Girl Soft and smooth and thicker Boys thickening and darker color 0 Adult depends on environment Normal Elastic hydrated rm smooth 0 Elderly Thinning loses elasticity increase bruising more water loss dry Too frequently bathing can cause irritation and loss in integrity 0 Feet and Nails 0 O O Mouth 0 O 0 With age chronic foot problems develop Dexterity and exibility decrease Foot pain is common in older Teething at 68 month Permanent at 6 Teeth and gums need proper hygiene to remain in good condition With age and other factor gums lose vascular support and elasticity Edentulous Wout teeth Elderly often require dentures Assess gums and palate Comes and goes w age puberty shaving and old age 0 Eye Ears Nose O Alterations in hygiene are required when these senses are changed Physical condition 0 Some are wout dexterity or energy and can t perform selfcare o Sensory de cits casting lV lines 0 Include rest periods for those who are fatigue easily or have medications that make the drowsy Decreased ROM do to pain to treat effect 0 Assist when needed but leave room for independent care 0 Consider cognitive impairment and the possibility of fearful confused and aggressive behavior 0 Critical Thinking Anticipate analyze and make informed judgements and decisions Integrate all knowledge known about pt conditions and anticipate extra needs of the patient Help combine existing and new hygiene techniques Approach care with the knowledge that the plan must be individualized and changed to t the patient 0 Nursing Process 0 O O O 0 Assessment Have complete nursing history and physical assessment Determine priority areas at beginning Asses pt own ability 0 Know kind and amount you will be performing Through Pt Eyes 0 Know pt perspective on the matter 0 Avoid making it routine and same for every pt Know frequency time of day and amount of needed assistance ASK what the PATIENT wants Know the pt view on their own hygiene Assessment of SelfCare Ability Mm strength Flexibility Balance and acuityDetection of temperature changes and sensitivity Mental state and function Observe how they perform their selfcare Assess vitals Determine needed amounts of assistance Fam can assist 0 Determine the ways frequency and mount of help they can provide Assessment of Skin Note the Color texture thickness turgor temperature hydration Normal Smooth and warm supple and good turgor Note lesions dryness Determine how clean by looking at the skin appearance odor Assess hard to see areas around genitals for signs of irritation red color moisture an debris Palpate individual skin folds Assess under all orthopedic devices and tapes or stockings Use sensitivity when assessing genital and rectal areas Be aware that those with a darker skin pigmentation may be harder to see pressure ulcers or other skin break down Feet and Nails Determine footwear and care practices 0 Look over ENTIRE foot 0 Look for lesions irritation or in ammation 0 Assess circulation Assess sensation Ask if foot pain is the pt limping or uneven gait Assess nails for color cracking and in ammation 0 Ask about frequency of nail care and polishing Oral Cavity lnspect all areas for color moisture and texture Inadequate oral care or certain medical treatments results in lesions dry mouth ect o Accompanied by localized pain is common 0 Asses w gloves on Hair and Hair Care 0 Assess scalp for frequency information 0 Clean shiny untangled scalp is free of lesions 0 Can the pt perform complete hair care 0 Inspect for pedicuosis capitis head lice 0 Use gloves tongue blade and hand hygiene Alopecia brittle hair leading to patchy hair Eyes Ears Nose Note condition and function Note if in amed drainage redness Wear gloves Note presence of cerumen in ear earwax Nasal mucosa is pink and moist Sensory Aids Asses knowledge and care methods used Hygiene care Practices 0 Shows preferences Detect areas requiring assistance Cultural ln uences Ask what is more comfortable Pt at Risk for Hygiene Problems Risks are due to medication or therapy knowledge immobilization condition Anticipate problems associated with medication side effects emotion physical and psychological states 0 Diagnosis Cluster data Identify de ning areas that lead to NANDA labels BE thorough Properly de ne and support de ning characteristics 0 Not what the pt is at risk for in order to properly guide interventions to prevention 0 Planning Gather multidisciplinary information to support multiple diagnoses Have pt involved in comments goals and outcomes and selecting priorities Goals and Outcomes Make individualized hygiene measures goals and outcomes Setting Priorities 0 Condition in uence 0 Based on need for assistance extend of problems and nature of diagnosis 0 Timing is based on needed frequency plan uninterrupted hygiene Teamwork and Collaboration O 0 Work with NAP they often perform the hygiene care 0 Family is used for assistance 0 Explore options with family and pt Implementation Use caring to reduce anxiety Gentle approaches soft voice Assist and prepare for independent selfcare Teach techniques and inform about resources Start with AIDET Health Promotion 0 Education and counseling and proper techniques and practices 0 Help tailor to each individual pt 0 Make relevant include their knowledge level motivation preference ad beliefs 0 Tailor to facilities that the pt has access to 0 Help to avoid injury by adding in tips and tricks with the instructions given 0 Teach and enforce infection prevention and control 0 Make sure pt has an understanding of proper practices and knowledge Acute Restorative and Continuing Hygiene is in all settings 0 Timing and amount varies o More frequent in acute than in restorative and continuing Bathing and Skin Care 0 When entering begin w AIDET and clean off source of table for placement of objects 0 Morning care is usually done by night shift 0 Keep in mind the norm for the patient 0 Routine lndividualize based on what the pt nds best 0 Timing abilities Use cleansing therapeutic and medicated baths o If cognitively impaired skin check more often 0 Watch for break down and infection more closely and frequently 0 Provide coaching support and practice when family is assisting Complete Bed Bath Turning and recieiving back care can be exhausting 0 Assess if able to do this by asses HR before during and after 0 Partial Bed Bath Partial hygiene to older and dependent pt who are bed ridden 0 Wear glove to avoid touch uid 0 Control factors that can cause a break in skin integrity Determine is soap is need for bed bath 0 Use emollient containing soaps for decreased skin integrity 0 Avoid HOT water For bath Provide privacy Maintain safety Maintain warmth Promote independence 0 Anticipate needs Educate about skin health and proper care Bag Baths 0 Decrease amount of bacteria that was found to linger in a bath basin Perineal Care 0 This care includes cleansing areas of the genital and anal regions 0 High Risk High risk for infection pt and women on penod 0 Try to have perform own Don39t let embarrassment let this care be overlooked 0 Listen for burning complaints soreness or pain 0 Inspect area and linens for discharge OOOO Back Rub Follows bath Ef eurage long slow stroke reduce anxiety and it39s related symptoms Reduce noise and ensure comfort Foot and Nail Care Make sure it is a part of normal care Check policy to determine what actions need a PO Teach techniques If they pt has Diabetes instruct to follow American Diabetes Association guidelines proper foot care Oral Hygiene Begin with this Apply clean gloved before beginning Poor oral health can cause a reduction in the mouths ability to ght pathogen Move bed into sitting position and move it up higher Place towel over chest and put rail down before beginning Brush Floss and Rinsing enhance WB comfort and appetite O O Brushing 2 times a day uoride toothpaste Straight handle small enough to reach all areas of the mouth enlarged handle may be needed for those with dexterity problems Brush ALL surfaces fully Buy new one every 3 months Flossing removed bw teeth once a day 0 Encourage well balanced diet to improve oral health 0 Encourage dental visits 0 Inspect the mouth thoroughly for breaks and sores Patients With Special Needs 0 Some need to clean teeth more often 0 O Diabetics Dentures Tops are sealed in so nger along gums and pull down to break the seal Place in water Bottom plate should come right out Put rail up and bed down when in bathroom cleaning dentures Place towel in sink while cleaning Don39t leave out of the mouth for too long bc gums can change Leave in the bathroom or put in bedside drawer lf unconscious pay special attention not to cause aspirations O O 0000 0 Use to nurses for providing care Explain process and sensations that will be felt even if unconscious Whenever turning pt do oral care Turn on side to reduce risk of aspirations Lay towel ad basin under Use sponge stick and wring out before place in mouth to prevent buildup of uid Use lip balm Stomatisis in ammation of oral cavity that is caused by medication and some cancer treatments 0 0 Burning and pain are symptoms Rinse w saline 2 times a day if pain is too much for brushing Denture Care 0 O O 0 Clean on regular schedule Must be handled w care Must be removed at night and placed in water glass Make sure they t properly and don39t cause pain Hair and Scalp care WB and selfimage depend on this Brushing and Combing 0 Frequently do these to keep untangled Obtain permission before braiding Promote sticking to the normal routine Identify cultural practices Use a ne comb natural light and lice killing shampoo when head lice is found Shampooing 0 Frequency depend on the person o If limited mobility try sink or bath shampooing lf limited rotation teach angles that are appropriate Be cautious when dealing with neck or head injurie s 0 Can shampoo in bed w special trough 0 Style and dry Shaving 0 After shampooing or bath 0 Careful not to cut 0 Skin should be softened moistened Mustache and Beard Care 0 Daily grooming is needed Care of Eyes Ears and Nose Give special attention 0 Basic Eye 0 Clean moisten washcloth don39t apply direct pressure 0 Clean inner to outer 0 Don39t use soap Eyeglasses 0 Be careful 0 Cool water cleans with soft cloth 0 Contacts 0 Removed nightly for cleansing and disinfecting 0 Some may be worn in over night 0 All must be removed from time to time 0 Clean frequently w warm water and allow to dry 0 Arti cial Eyes 0 Had an enucleation removal 0 Some are permanent and some are removable 0 Made of glass or plastic 0 Clean w warm saline 0 Ear Care 0 Clean w end of moistened washcloth rotated in canal o Instruct not to use Q tips bobby pins or other objects OOOO 0 PO is required for irrigation of ear to remove wax 3 pull Pinna Up and Back and gently clean with warm water 0 Hearing Aid 0 In the Canal collects more ear wax o In the Ear has ner tuning but more noticeable 0 Behind the Ear is large and used for progressive heanngloss Nasal o Blowing but not harshly suf ciently cleans 0 Wet warm cloth or Q tip ca also be used when blowing is not possible 0 Gentle suctioning also Room Environment 0 Comfort 0 Depends on patient 0 O O 0 Temp varies from person to person Usually 2023 C Ventilation to reduce odors Control Noise level Adjust lighting 0 Equipment 0 o 0 Beds 0 o 0000 O O Linens O O O O 0 Evaluation Basic furniture is there Allow personal possessions Position lights where pt wants them Firm w metal frame Can change position Bed Making Keep clean Frequent inspection Check frequently for food and soiling Never reach over when changing linen but move around Make open when pt will be moved into bed Make closed when room is not being used Avoid bringing in excess Must be laundered Apply clean when soiling has occurred When new pt is moved into room that mattress and all linens are to be cleaned and disinfected Through Pt eyes 0 What were pt responses Expectations are important to modify care approaches 0 Evaluate responses and effectiveness Outcomes o If not met revise plan an interventions Three main concepts to take away Infection Control Privacy or con dentiality and Safety Chapter 44 0 Nutrition 0 Essential and basic component of health 0 Food is needed for bodily activities and functions of cells and systems 0 Food Security access to safe suf cient and nutritious foods for maintenance of lifestyle and available consistently and household has the means to obtain this food Holds meaning ceremonies social religious o Nightingale stressed the role in science 0 Nutrition therapy and counseling is now part of nursing to manage or treat diseases 0 Optimal nutrition is to be available to all 0 Be aware of requirements and needs for others 0 Scienti c Knowledge Base 0 Nutrients Biochemical Units BMR energy to maintain lifesustaining activities In uenced by age body mass gender fever starvation menstruation illness injury infection activity thyroid function REE resting energy expenditure or resting metabolic rate Amount energy consumed in 2 hr period to maintain all internal activities Requirements met y kcal intake Exceed needsweight gain Nutrients elements for normal function of processes 0 Nutrient Dense more nutrients per kcal high is fruits and vegies low is sugar Carbohydrate CHO Main energy source glucose 1gram4kcal Monosaccharides Glucose Fructose Disaccharides Sucrose Lactose Maltose Mono and Di are simple carbs Poly Glycogen complex water insoluble o Insoluble ber is nondigestable o Soluble dissolve in water and are digestible O Proteins 1 gram4kcal Essential for synthesis of tissue clotting stability transport Water Amino Acid AA is simplest form HOCN 0 Essential need to come from diet 0 Nonessential can be synthesized from the body Complex protein is combination of protein with a non protein Iipoprotein Compete or high quality protein has all AA in it Incomplete are missing 1 AA and need to be eaten in complementary pair Nitrogen Balance inputoutput o baance is needed growth pregnancy maintenance of lean mm mass and organs and heaHng o baance results in destruction of tissues Most calories dense 1g 9 kcaI 2030 of diet Composed of triglycerides and fatty acids 0 Fatty acids are saturated all single bonds or unsaturated 1 double or triple bonds can be mono or poly 0 Fatty acids are essential or nonessential 6070 of total body weight higher in lean people Mm Mass contains more water than any other tissue Infants have highest and older have the least Can39t survive for more than a few days III person has increased needs for uid intake and decreased ability to excrete Vitamins Organic small amounts Essential Catalysts in reactions Neutralize free radicals Needed amounts depend on intake and highest inn fresh foods Types 0 Fatsoluble ADEK Stored in fat Through intake 0 WaterSoluble C and B complex Aren39t stored and needed daily Minerals Inorganic Catalysts Macro 100mg dain 0 Balance pH MicroTrace lt100mg daily 0 Anatomy and Physiology Digestion mechanical breakdown into simplest form Enzymes are catalysts to speed up reactions that break food down Each method is interdependent on the others mechanical chemical hormonal Begins in mouth down esophagus into fundus body antrum pyloric sphincter duodenum major digestion occur in small intestine Absorption Small intestine is primary site w use of villi Carbs proteins minerals watersoluble vitamins are absorbed by small intestine moved to liver sent out portal vein Fatty Acids are absorbed into lymphatic system 8590 of water is absorbed in small intestine Electrolytes and minerals re absorbed in colon Remaining is eliminated in feces Metabolism and Storage Metabolism all biochemical reactions win cells 0 Anabolic building building mm o Catabolic Breakingoccurs in N balance or starvation o Converts nutrients to energy Some require nutrients are stored in tissue 0 Mainlly adipose but protein is stored as mm mass 0 Fatty acids are stored as ketone for energy when there is no glucose 0 Glycogen for fastingis stored in liver Metabolism is 3 processes 0 Catabolism of glycogen into glucose C02 and water Glycogenolysis o Anabolism of Glucose into glycogen glycogenesis o Catabolism of AA and glycerol into glucose gluconeogenesis Elimination Chyme become feces in large intestine 0 Dietary Guidelines DRls Dietary Reference Intake acceptable range amounts for gender and age Four components 0 EAR Estimated Average Requirement maintain body function in 50 of pop 0 RDA recommended daily allowance needs of 98 of the pop 0 Al Adequate Intake Suggested intake Nursing Knowledge Base 0 O 0 UL upper level Highest level posing no risks Food Guidelines 0 Recommended food amount intake for 5 food groups for American over 2 0 Consider cultural preferences Choosemyplate is a good resource Daily values are made of RDI and DRV Don t replace DRI Based on of diet of 2000 kcal per day Food is incorporated into traditions and rituals Requirements depend on developmental stage body comp activity pregnancy and lactation disease presence Factors In uencing Nutrition Environmental Factors Sedentary lifestyle work schedules poor meal choices 0 Lack of access to health food stores availability to fast foods lack of places to exercise and play Developmental Needs 0 Infant through School Age 0 Rapid growth and need for more protein vitamin minerals and energy occurs in infancy able to absorb simple carbs proteins and small amount of fats Breastfeeding should be only source of food for rst 6 months ten add complementary foods in 6 12 months w breastfeeding Bene ts for mother and baby Formula About same nutrient amounts as breastmilk Babies should NOT be given straight cow39s milk until after the rst year Introduction to Solid Food IronForti ed cereals are rst food Foods w higher incidence of allergies should be added later Should be added one at a time w a week in between each Introduce before feeding milk Toddler has slowed growth rate and need less kcal and more protein Strong food preferences Should have 3 meals w 3 healthy snacks Should drink whole milk until age 2 Preschoolers are similar to toddlers but consume more more nutrient dense 0 School age 612 grow at slow and steady rate Limit high calorie foods and maintain good activity 0 Childhood obesity is on the rise Need for the promotion of a healthy lifestyle Adolescence O O O 0 Energy needs need to meet metabolic demands Protein requirement increases Nutritional de ciencies are common due to fad diets and lack of healthy food intake Skipping meals and fast food are contributing to this and obesity Forti ed and fruits and vegetables food are better for snacking along with increasing activity levels Anorexia and bulimia are common occurrences Carbs simple and complex are main source of energy along with an increased need for protein but NOT fat Hydration is really important too Parents strongly in uence what the child eats by keeping healthy food at home and setting an example Pregnancy win four years of beginning period poses risks Malnutrition at the time of conception increases risks and Middle Adults Reduction in needs after puberty Pregnancy Poor nutrition low BW and decrease in survival chance More emphasis on quality rather than quantity Protein and calcium intake needs to increase Folic acid is also at increased need Lactation Need 500 more kcal daily More protein is needed than during pregnancy but same need for calcium as during pregnancy 0 Older Adults 0 O O Decreased need for energy lower metabolic rate Vitamin and mineral needs remain unchanged Changes related to age include taste smell appetites These can affect foods eaten and amounts eaten Pain dentures or teeth can affect eating Higher risk for drug interactions 0 Thirst sensation is decreased increasing risk for dehydration 0 Some avoid meats bc hard to chew need soups for protein 0 Need high calcium amounts 0 Those homebound have increased risks food insecur y O 0 Alternative Food Patterns Special diets based on ethnicity culture and religions aren39t wrong Vegetarian Diet Consumption of plant food 0 Nursing Process 0 Assessment Ovolactovegetarian No meat but eggs and milk are okay Lactovegetarian No egg but milk Vegans only plant food Children on vegetarian diet are at risk for protein and vitamin de ciencies Thoroughly assess for malnutrition or at risk pt Those that are malnourished are at higher risks for complications Through Pt Eyes Asses nutrition Gather data about in uences on nutrition Ask about preferences values regarding nutrition and expectations Understand pt beliefs and values about food and assess traditions rituals culture and needs 0 Determine from foo purchase prep and intake Screening quick method to identify malnutrition or risk for Gather data on condition stability assessment and if disease process accelerates Use objective measures and subjective measures combined Tools 0 Subjective Global Assessment obtains history wt and physical assessment ls simple and cheap 0 Mini Nutritional Assessment developed for older adults 18 items divided into assessment and screening 11 or less in screening complete assessment Total score of lt17 means malnutrition o Malnutrition Screening Tool useful in many settings 0 Assess when conditions interfere with digestion or absorption for risk Congenital abnormalities and surgical revisions of GI tract lV infusion feeding Chronic disease increased metabolic requirements infant or older adults Anthropometry Measurement system of body size and make up 0 Measure ht and wt same time same scale same clothing 0 Compare 0 Ideal Body weight is what person should weigh Other measurements include 0 Height to wrist circumference MAC TSF MAMC 0 Changes over time are more valuable than one measurement 0 BMI Lab Biochemical Tests 0 Need more than one to diagnose malnutrition Many factors can alter test 0 Common test 0 Plasma proteins different proteins are better for determining different diseases 0 Nitrogen balance Diet and Health History 0 Focus on common intakes of foods and liquids lnclude preferences allergies Activity level and illness for energy intake 0 Health status age culture religion SES preferences psychological factors drugsalcohol use supplements Use questionnaires Collaborate w RD to meet nutritional needs Physical Examination 0 Most important aspect Nutrition affects all systems Recheck all relevant areas 0 Clinical signs of nutritional status should be observed Dysphagia Dif culty swallowing Caused by 0 Myogenic o Neurogenic o Obstructive o Other disorders 0 Cause other complications 0 Aspiration o Pneumonia 0 Diagnosis Cluster all data for actual or at risk Determine diagnosis and related factors 0 Planning Need for long term changes Multidis planning is needed Refer to RD for help Goals and Outcomes o Dehydration 0 Weight loss Look out for signs of gagging change in voice and delayed swallowing and silent aspiration Leads to decreased nutrition intake Screening increases likelihood of nding dysphagia 0 Medical record review observation of eating 0 Requires interdis communication 0 Swallow Study might be done w video ouroscopy done by speech pathologist Physiological therapeutic individualized Education and counseling are important 0 Understand why diet is helping them Know in uencing factors pain shortness of breath sadness Know pt feelings about wt and diet Require pt and multidis team input Setting Priorities Pt and fam must collaborate w nurse Managing pain is usually at the top Teamwork and Collaboration Treatment continues after hospital stay Discharge should include nutritional interventions for when returning home Communicate goals and interventions to whole team 0 Implementation Chosen on ability to eat and digest overall health and long term needs Health Promotion Education about healthy diets and nutrition Incorporate knowledge into lifestyle Early identi cation of problems or risks is key Educate about community resources Consider income and preferences when planning meals Plan meals week in advance Support those who want to lose weight and can39t seem to Give information about groups Educate about food safety Acute Care Testing and pre disrupt eating Continuously assess status Create interventions that promote intake NPO patients on IV uid for 7 days are at increased risk Advancing Diets O 0 Special diets for those w decreased immune system Clear Clear when at room temp and Full Liquid creamers and plups Pureed Mechanical soft low residue high ber low sodium low cholesterol diabetic Promoting Appetite O O 0 Keep environment clean provide oral hygiene Offer small frequent meals Encourage socialization while eating also educate Assisting w oral Feeding O O O O 0 Remember Safety Independence Dignity Assess aspiration risk 30 min rest before an seat upright at 90 degrees Feed slowly and in small sizes if coughchoke remove food immediately Ask simple questions right temp What food would you like Enteral Tube Feeding 0 00000 lnto GI tract Used if unable to swallow Safe and economical nutrition Receive formula Can be given by nurse or fam Continuous Intermittent short periods of feeding and not feeding Bolus Only put in what is ordered and runs about 30 minutes Open Must clean bag every 8 hours must replace bag every 24 hours Closed must be changed every 24 hours Must be veri ed by x ray before rst feeding Aspirate and listen w 30 mL or air and then pull up residual measure pH and amount and then return ush feed ush Fourtypes Polymeric milk based 12kcalmL Modular single macronutrient and added to other foods to meet needs 384 kcalmL Elemental predigested nutrients for partially dysfunctional GI tract 13 kcalmL Specialty meet certain needs in certain illnesses 12 kcalmL Started at slow rates and gradually increased Fill syringe only 12 full at a time Reduces sepsis decreases mortality maintains structure and function of intestines Keep head of bed elevated to reduce risk of aspiration minimum 30 but preferred 45 degrees must stay in this position for 30 minutes after feeding Measure residual volumes every 46 hours Must flush w 30mL water before and after feeding unless PO say otherwise Enteral Access Tubes When able to digest but not ingest Inserted through nose surgically or endoscopically If less than 4 weeks total nose path may be used Sometimes placement is needed in the intestine Adult tube 812 Fr and 3644 inches Ensured placement is done w xray Parenteral Nutrition 0 O 0000 Nutrition is intravenous AA dextrose electrolytes vitamins and trace elements Must be carefully monitored Can be given in the home When unable to digest or absorb PN is needed Intravenous fat emulsions can be added for kcal but are added through peripheral line White or opaque in color Initiating Parenteral Nutrition Insert catheter and con rm w x ray Cover w sterile dressing No more than 12 of estimated needs in st 2448 hours Gradually increased 0 Preventing Complications O 0 Monitor pt w CVC for 55 of pulmonary distress Turn onto L lateral decubitus position and perform Valsalva maneuver to prevent air emboli Flush lines to prevent occlusion Change tubing every 24 hr to prevent sepsis during dressing changes be sterile Give Vitamin K O 0 Monitor blood glucose Don39t stop infusion if too much and don39t increase rate if falling behind Restorative and Continuing Care Medical Nutrition Therapy 0 Evaluation 0 0 Use of nutrition to treat illness injury or condition Needed for metabolizing nutrients correct de ciencies and eliminate food causing harm GI Diseases Peptic Ulcers are controlled w regular meals and meds Avoid acidic foods 0 Teach well balanced and healthy diet and to avoid large meals In ammatory Bowel Elemental diets or PN Malabsorption Gluten free diet Diverticulitis Moderate or low residue diet until infection leaves 0 After high ber diet is recommended Diabetes Mellitus Type 1 dietary restrictions and insulin Type 2 exercise and diet Cardiovascular Disease Diet therapy Lean meats and veges Balancing intake w output maintaining healthy weight Cancer Meet increase metabolic demand Malnutrition is common Small frequent meals are encouraged HIVAIDS Body wasting and wt loss are common Malnutrition and inadequate intake are the common causes Small Frequent nutrient dense foods are the best Through pt Eyes Expectation that nurse will recognize failing treatment and x it Pt outcomes 0 Not always rapid results Ask how Pt feels about changes made Revise pans when outcomes are not met Chapter 46 Elimination o Alterations from the norm are early 55 of problems 0 Regular is essential o Depends on balance of patterns and habit 0 Be supportive Scienti c Knowledge Base 0 Hollow tubes lined w a mucous membrane 0 Absorb nutrientsprepare nutrients for absorption provide temp storage 0 Electrolyte balancekey function of GI system 0 Receives secretions from gallbladder and pancreas o Mouth Digestion begins here and ends in small intestine Mechanical and chemical breakdown o Esophagus Upper sphincter Peristalsis CardiacLower sphincter prevents re ux o Stomach Storage Mixing Emptying HCI is produced and secreted 0 Small Intestine Segmentation creates peristalsis Peristalsis Mixes chime and digestive movements Digestion and Absorption Goes from liquid like to paste like when reaching large colon Three sections Duodenum Jejunum carb and protein absorption lleum Water Fats Bile salts certain Vitamins and Iron absorption 0 Duo and Jej do most absorbing 0 Large Intestine Lower GI tract Larger diameter Cecum Colon Ascending Transverse Descending Sigmoid Absorption Water Sodium Chloride Secretion bicarbonate for a chloride Elimination Rectum bacteria convert fecal matter into nal form o Anus Empty until jet before de cation Primary organ of elimination for bowel Chyme enters by ileocecal valve 34 major movements a day with largest and hour after mealtime Sensory nerves for control Contraction and relaxation of sphincter allow for release 0 Defecation Sensory Awareness Voluntary sphincter control Adequate rectal capacity and compliance Begins in L colon pushing feces to rectum Distension occurs relaxing internal sphincter External relaxes abdominal mm contract increasing pressure and oushing stool out Valsalva Maneuver is sometimes used 0 Nursing Knowledge Base 0 Factors In uencing Bowel Elimination Age 0 Infant Small capacity quick passage lack of mm control 0 23 neuromm control 0 Older adults have decrease in absorption an peristalsis emptying slows 0 Dif culty controlling sphincters also occurs Diet 0 Regular intakeRegular pattern 0 More bermore ushing of fats and wastes Bulk foods pass more quickly bc stretch re ex Gas forming foods increase peristalsis Food intoleranceallergy Fluid Intake Intake changes character 0 Reduced intake slows movement Physical Activity Promotes peristalsis Psychological Factors Prolonged Emotional Stress impairs function Digestive process is sped up Personal Habits Using own toilet rather than another 0 Work schedule preventing use of facility 0 Being in hospital and having to use bed pan Position during Defecation Squatting is best 0 In bed immobilized makes it more dif cult Pain Suppress need when in pain Pregnancy Fetus exerts pressure on rectum and it impairs function Constipation occurs Straining can lead to permanent hemorrhoids Surgery and Anesthesia Cause cessation of peristalsis lasting 2448 hours paralytic ieus Medications Some promote or slow Laxatives and cathartics Diagnostic Test Require bowel quotprepquot to ensure emptying Can39t eatdrink a certain time before 0 Changes occur right after having normal diet again 0 Common Bowl Elimination Problems Constipation symptom Signi cant hazard Reopens wounds and causes pressure Improper diet lack of exercise and medication lmpaction From constipation that is not relieved Wedged fecal matter in rectum Can extend into sigmoid colon Can result in intestinal obstruction Diarrhea Increase in number passage of liquid unformed feces From inadequate digestion absorption and secretion Expensive and dangerous 0 Contamination 0 Skin ulceration 0 Severe dehydration electrolyte imbalance Older and infants are at high risk If taking antibiotics or EN feeding risk is increased C diff mild to severe 0 Hand hygiene is best protection InconUnence Inability to control passage Harms body image 0 Causes skin breakdown if not controlled Flatulence Gas that is trapped causing distension Pain and cramping can occur Hemorrhoids Dilated engorged veins 0 Internal or external 0 Cause pain 0 Bowel Diversions When normal passage is affected arti cial openings are created eostomy or Colostomy Ostomies Temp or permanent Location determines stoo consistency eostomy bypasses all of large intestineiquid stoo Medical problem determines placement Loop Colostomy 0 Medical emergency 0 In transverse colon 0 Supporting device is inserted under and transverse is opened an sutured to abdomen 0 Supporting device is remove in 710 days 0 End Colostomy 0 Some at proximal end w dista removed or sewn closed 0 Double Barrel 0 Divides intestine and sews both ends to abdomen Alternative Procedures eoana Pouch Anastomosis o Removes coon o Creates pouch from small intestine and connects it to anus Kock Continent eostomy 0 Change small intestine into spherical reservoir 0 Continent stme nipple valve draining into catheter MacedoMalone Antegrade Continence Enema 0 soates ap of colon and places in foley catheter o Enemas are given daily 0 PsychologicalConsiderations Body image changes Anxiety on how to manage Emotional support is needed Doesn39t interfere w activities and is concealed Aging affects ability to maintain Nursing Process 0 Assessment Bowel patterns and abnormalities Through Pt Eyes 0 Want knowledge on promotion and maintenance or normal patterns 0 Culture and preferences should be kept in min Nursing History 0 Review of all bowe patterns and habits 0 Note what they describe as normal or abnormal Determine normal pattern Frequency and time Description subjective of characteristics determines pt normal color shape consistency Routines to promote normal elimination Use of arti cial aids Presence and status of diversions Ostomy Changes in appetite History of diet exercise paindiscomfort social Fluid intake Surgery or illnesses affecting GI tract Medication history Emotional state Mobility and dexterity Physical Assessment Mouth 0 Ability to chew 0 Teeth tongue gums dentures 0 Look for sores Abdomen 0 Assess 0 Note bowel sounds o Gently palpate for tenderness 0 Look for masses and lumps Rectum 0 Inspect for lesions in ammation discoloration hemorrhoids Lab Tests Can detect tumor bleeding parasites and infection Fecal Specimens o Obtained accurately labeled properly and transported in time Use medical asepsis and wear gloves 0 Hand hygiene is needed 0 Teach to avoid coming into contact w water or urine 0 Into clean dry bedpan or special container under toilet o Performed w microscope 0 Label and tightly seal 0 Fecal Occult Blood test can be performed at home Measures blood amounts in stool Useful for noticing colon cancer Blue is positive Fecal Characteristics 0 Reveals information about elimination alterations 0 Pt is best source of this information 0 Diagnostic Examinations 0 Diagnosis Determine risk associated w diagnosis and institute measures to promote normal function 0 Planning Use information from many sources Rely on professional standards Goals and Outcomes Incorporate pt routines and patterns as much as possible Consider preexisting conditions Have pt set regular habits ad routines Setting Priorities Pain is a the top Teamwork and Collaboration Include family Assistance is needed for bedpan use Multidis use lab tests 0 Implementation Teach about proper diet and uid intake and factors affecting peristalsis Learn importance of regular movements exercise and measures for when elimination problems occur Health Promotion Direct or Indirect Special training might be required Crash Cart must be at the bedside Modern sedation might be needed Take time Urge will occur and establish time around that 1 hour after a meal Help by offering bedpan or assisting to restroom Make sure interventions don39t interfere w routine P vacy Promotion of normal 0 Sitting position 0 Positioning on bedpan Sitting is uncomfortable Position is important for mm strain and comfort Sit 30 degree and lift hips by bending knees and slide pan under Or Lower into supine and roll on side Apply powder to buttocks and place pan rmly against and down into bed Pace hand on fore hip and one on the pan ask pt to roll back onto pan and then raise bed and place pillow or rolled towel under lower back Bend knees P vacy O O 0000 Acute Care Keep elimination needs in mind and intervene to help keep the norm Medication 0 IMPORTANT When pt nished respond immediately to call light to remove pan by asking to roll off or raise hips Assist in wiping Empty pan and spry clean Document characteristics of feces Ask often if it is needed Some promote while others stopslow Cathartic and Laxatives O O O 0 Short term action Cathartics are stronger Many forms Excessive use leads to abnormal patterns and diarrhea and alterations in absorption occurs impairs normal re ex Antidiarrheal Agents 0 Most strong are opiates decrease mm tone Enemas o lnstillation of a solution in rectum and sigmoid O O Promotes defecation Solution breaks up fecal matter stretches wall and hit defecation re ex Cleansing Complete elimination Fleet 120 mL Becoming more common Deep breath squeeze and roll from bottom Tap Water Hypotonic exerting pressure Net movement of water is low and stimulates movement Normal Saline Safest Volume infused stimulates peristalsis Hype onm Pull uid out of wall and puts it into fecal matter promoting elimination Soap Suds Added to tap water creating irritation to stimulate peristalsis After high lay on left side 5001000mL water Soap goes in after water room temp and mix gently no bubbles 0 Oil Retention Lubricate rectum Retain for several hour if possible 0 Others Carminative For gas Medicated Enema Administration 0 First check PO 0 Gather Supplies 0 O Commercially packaged disposable units Wear gloves Lube Toilet paper Cover and lay on L side gravity Explain Insert and SLWOLY raise bag 1218 inches above lf cramping slow ow If still clamp If still remove At end slowly lower pull out wrap in toilet paper Ask to hold as long as they can Help onto toilet and tell not to ush Place slippers and commodebedpan close Help back into bed and provide pericare Don t give more than three 0 Digital Removal of Stool O O 0 If impaction use ngers Last resort PO is needed Continuing an Restorative Care 0 Care of Ostomies O O Ef uent Needs to use meticulous skin care lrrigating a Colostomy O O O Regulates emptying colon Never use enema to irrigate colostomy Fit in daily routines Pouching Ostomies O Protects kin contain feces odor free comfortable 0 Consider type size and location 0 Twopiece vs onepiece Skin barrier attached or separate 0 Evaluation Right t is necessary Nutritional Consideration 0 Low ber to start out and the gradually work up to high ber 0 Eat slowly o Chew completely Avoid gaseous foods Bowel Training 0 Helps to defecate normally 0 Daily routine Maintenance of food and uid intake 0 High ber vs low for certain conditions Promotion of Regular Exercise 0 Daily helps elimination Hemorrhoids 0 Soft painless bowes Skin Integrity 0 Protect w petroatum zinc oxide and ointments Regular pain free elimination of soft stools Relieved problems Evaluate level of knowledge on eliminations ostomies and ski integrity


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