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This 17 page Class Notes was uploaded by Heber Wolff on Sunday October 11, 2015. The Class Notes belongs to NRAD201 at Cuesta College taught by Staff in Fall. Since its upload, it has received 38 views. For similar materials see /class/221243/nrad201-cuesta-college in Nursing Registered Assoc. Deg at Cuesta College.
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Date Created: 10/11/15
Hand Hygiene amp Standard Precautions NRAD 201B August 22 2008 What is Hand Hygiene I General term that applies to handwashing With 7 Plain soap and Water 7 Antiseptic soap and Water 7 Antiseptic hand rub 7 Surgical hand antisepsis When is Hand Hygiene Done Hands vimbly soiled Before eating amp after using restroom Before patient Contact Before putting on gloves After removing gloves After Contact With patient s intact skin I After Contact With any body 111 I After Contact With obJects in patient room I When moving from contaminated body site to clean site during care for patient When 5 Soap amp Wm Used szxbly mamas xeikuum At hem of 5m x xeqmmd by has may Soap and Wm Procedure m m u mmwmkywmh cmnesbmxksmshnnt mm a m ham nub Fxngmpibeluwunni Rmseunh amass 9 Wm x mcmcuhtmmaon nythoxaughly lStoSUiecmds it Tmo ixmetunh cxub of dxy long mm Waterless Antiseptic Agent Anher mm um am mqu we aim Ann hm ma mb Only 1 oholrbned mama momma dby cnc s No wceiituw zxmeid Dues m M wt 3km Handmb Procedure Apply leeOmmended l ofhand Follow manufacturer 7 J 4 l 5 Volume leeOmmendsuon Rub together covenng all surfaces untll dry Should take about 20 sec for hands to dry Hand Hygiene F 39 Do notwash gloved hands ng5 should not break gloves or harm patlent No arti cial flngemalls or extenders Natural nails less than 1 lnch long Chlpped nail pollsh creates slte for mlcrobes Avold soapwater handwashlng slmultaneous use ofhandrub amp Hand Lotion Use Use onlywsleebssed hand 10th ns Avold ollrbased lotlons neml ml 0 petroleum based products weakens latex ollbssed lotlons do not affect Vlnyl gloves What is PPE PPE Personal Protective equipment Any device used to Protect Workers from serious injuries or illnesses While doing their jo s Protects eyes head face hands feet and ears Includes 7 Barrier Products ie gloves masks gown goggles shoe covers hat 7 ResPiratory device ie resuscitation face mask 7 SPecialized clotliingequiPment ie lead aPron How Does PPE Prevent Infection Spread Acts as barrier between infectious materials and skin mouth nose or eyes Protects wearers from infection amp reduces chance that healthcare workers will infect or contaminate others All PPE cleared by FDA must be able to block Passage of small Particles size of most infectious materials PPE Glove Considerations Wear if any Potential exists to Contact blood body fluids contaminated items non7intact skin your skin or Pt s Remove gloves after caring for Patient Do not wear outside ofPatient room Basic Glove Categories 7Latex or nonrlatex ie vinyl 7 Sterile or non7sterile ie clean hange during care if moving from contaminated body site to clean body ate when working With Patient Mandatory if Patient is under Contact Precautions gloves are to be worn in Patient room at all times When Are Gloves Not Needed None ofthe followmg panent care acuvmes require gloves unless one of condmons on previous suds exists 7 Taking ml sxgns BP Temperature amp Pulse 7 Bammg 7 Dressmg 7 smug backrub 7 Tmnspomng 7 nd out 0 couscmg meal rays 7 Adm mnstenng ml medications 7 Changmg lmens When Removing PPE Remove m manner that W111 avoxd Contact surfaces amp your bare More PPE amp Standard Precautions Watemmpermeable gowns Mask amp eye protection Panent care equipment Environment cleanmg amp dxsmfectxon Lmen prevent contammatmg 5km mucous membranes amp c othmg Sharp oblects discard m puncture proof contamers NRAD 201B Physical Assessment Abdomen Information gathered D From the patient subjective When was your last BM I What ms it like smalllarge hardsoil Have you been passing gas charted as atus I Do you feel full or bloated From the nurse s observations objective U ofmeals taken emesis especially a ermeals Physical assessment Inspection u Landmarks Craven p 404 N right upper quadrant RUQ left upper quadrant LUQ right lower quadrant RLQ left lower quadrant LLQ W Epigastric region an Umbilical region Hypogastric or suprapubic S r I n D Week 6F08 NRAD 201B Auscultation El Performed before palpation El Utilizes diaphragm of stethoscope Bowel sounds are high pitched El Begin RLQ bowel sounds are normally present here Proceed to auscultate all four quadranm if necessary Bowel Sounds El Active normal irregular gurgling tinkling 5 30xmin It is not necessary to count Hyperactive Loud high pitched rushing Increased frequency U U Hypoactive lt 5xmin Short quiet sounds Absent Palpation Light palpation all four quadrants El Normal so smooth nontender pain free guarding Abnormal Rigid tense hard rm tenderness pain U guarding Week 6F08 NRAD 201B Large abdomen versus Distension I n L Ohe e39 Distension u rnspection Uniformly u rnspection Single round rounded Umbilicus dee curve Umbilicusmay atten nken or protrude skin may glisten D Auswlmonmowel u Auscultationabsentdecreased sounds present high pitched hyperactive wearly obstruction associated u palpation Normal Wm quotammg 3 Pa quot u Palgation Firm or rigid muscle spasrn abdominal wall tendernesspain guarding ndings 7 soft nontend Abnormal abdominal complications Appendicitis Bowel Obstruction or paralytic ileus Cholecystitis Pelvic In amatory Disease Perforated Ulcer Peritonitis Ectopic Pregnancy UUUUUUUUU Documentation Examples El States I m hungry Active bowel sounds noted Abdomen softnontender on palpation M Bright SN El Complains of abdominal pain Bowel sounds hypoactive Abdomen distendedfirm with tenderness noted RLQ Vomited 50mL tan colored uid M Bright SN Week 6F08 NRAD 201B Documentation examples El States I passed gas when I got up this morning Bowel sounds hypoactive Abdomen firm without tenderness on palpation Ate 50 clear liquid breakfast without nauseavomiting M Bright SN El States My stomach hurts all over I haven t had a BM in two days Bowel sounds active Abdomen large soft non tender on palpation M Bright SN Week 6F08 NRAD 201B k m a j Documenting the Priorities y F WK 4 Documentation Focus Focus on the Priorities the reader should be able to tell why the patient requires hospitalization from your notes What are the priorities for a post operative appendectomy patient What are the priorities for a patient with acute a What are the priorities for a patient with a tntal knee arth roplasty y ic39 UK 4 ursmg FOCGSS ocumen a lOn Two kinds ofdocumentation check list narrative C eck list a picture of patient at the beginning of shift your early assessment time is important Narrative things you can39t put on a check list Condition changes Prioritized Nursing intenentions throughout shift Implementation of new medical orders such as ambulatJ39on uid restric ion Outcomes of cargJJrovided including progress toward Sta lis goals Your documentation should re ect how you carried 0 care This includes teaching Week 8 DocumentationF SBS NRAD 201B Documentation Narrative documentation should include r An opening statement that indicates you have sumed care and your patient39s status at the bginning of your shift 0715 report received awake anxious for breakfastquot 0715 report received confused restless calling out for wifequot A closing statement that indicates your patient s status at the m of your shift and that you have turned over care A E y Documentation continued Narrajtive documentation should Inclu e physician visits and imglementation of priority now or ers urgent stat or prn39s including preassessment and response time a client left unit and returned to unit eg radiology include mode of transportation diagnostic tests performed at the bedside ECHO EEG EKG r lab specimens obtained and sent to lab Documentation continued Do not document what the primary nurse said what the physician said or other members of the healthcare team Dr Smith going to contact wife Do not document what you are going to do only what you have done Will observe for bleeding every hrs Do not document your opinions or conclusions just the facts DVT forming In L calf Week 8 DocumentationF SBS NRAD 201B SE e ursmg I OCESS Documentation should describe progression ofthe patient39s stains The nursing process is dynamic you ma charting outcomes in your opening statement related to interventions implemented at the end of the last shift Resizing quietly now a er 0530 pain medquot Document the absence of important signs and symptom Pt admitted with GI bleeding document t a t ere is no evidence of b eeding Pt admitted with chest pain39 documenting I absence of chest pain is a prior ty Assessment precedes intervention Pain assssment then document medication given or other pain relief intenenu39on 2130 co back pain 510 Medicated back rubquot 2245 rsting quietly eyes closedquot Bladder assssment before Foley catheter insertion 1400 Abd distended bladder scanner 900 mlquot 1430 Dr Smith contacted 16 Foley catheter placed wo dif culty Toler well Clear yellow urinequot Abd assessment prior to nasogastric tube insertion 1120 Abd distended rm no bowel soundsquot 1200 Dr Smith contacted 14 NG tube inserted 4toJow suction Lenl anxiou couuhinu uaqqinqquot A y 4 Abnormal Assessments Require Intervention document requires an intenen patient co pain 510 what did you do about it declined T lenol Dr Smith contacted Vicodin given w re ief 10 a r minquot atient has rales in lower bases bilaterally did you sit client u and have im deep reathe Did ou check 02 aturation did you contact physician Any priority abnormal assessment ndings that you tion Documented Interventions require an Outcome Followup pain rating after your intervention breath sounds pulse oximetw after deep breathing Week 8 DocumentationF SBS NRAD 201B i Ex y Being Concise Consider concise siatemenis rather than repetitive documentation 0730 50 mL dark amber urine output Fluids encouraged drank 250 mL Bright SN 1400 Shift intake 750 mL Urine now yellow shift output 450mL M Bright SN A y 4 What to avoid documenting Don39t rely on RN noti edquot unless you can39t carry out the intervention yourself Avoid resting quietlyquot unless this is a change in condition for your client Avoid subjective judgmenis such as Client angryquot Document client39s statement or behaviors that made you think he was angry void vague statements What do you man when ou say tolerated wellquot be speci c what did you assss that made you think this Documen i amp 4 How wi I be a e to ocumen with multiple clients Document as soon as possible after care is rendered Don t save it all for the end of the shift Keep notes on report sheets Use flow sheets to the maximum when available Do not repeat information documented on ow sheets in your narrative unless required for clari Week 8 D ocumentationF SBS NRAD 201B Bedside Blood Glucose Testing y F c k 4 Bedside Blood Glucose Testing Rationale Monitor clients at risk for hypo rhyperglyc mia Monitor effectiveness of insulin or 0 Who is at risk V 39 39 J Diabetics Patients receiving steroids Patients receiving total w i parenteral nutrition TPN en v Per physician39s orde Bedside Blood Glucose Testing Wh For patients eating typically AC and HS mo 39 39 eiy two 1 Patients on total ver four hours arenteral nutrition TPN typicallye 6 ours r RN can do ifcrisis situation arises Patient assess Prior results trends l Any signssymptoms of hypo or hyperglycemia Risk for bleeding anticoagulanls Skin of potential puncture site Week 8 DocumentationF SBS NRAD 201B i Ex y Bedside Blood Glucose Testing Criu39cal Thinkingexpected versus unexpected rsulls Inte e 39 n lo 5 gt Correlating values with assessment 1 Insulin may be ordered based on blood sugar rsulls Symptomatic hypoglycemia should be trated promptly Lab con rmation of critica low or highquot test rsulls as required per Facility policy Facility Policy amp Procedure Know your facilities Policy and Procedures Cleaning the puncture site 1 Critical values then Quality Control testing should be done How to clean the glucose meter Choosing a Puncture Site Fingers are the preferred site in adults Thumbs are excluded the rst joint close to the tip Rotate pu ncm re sites and ngers Week 8 DocumentationF SBS NRAD 201B Procedure Information Physician39s order Your operator ID number or bar code i Patient ID number or bar code Gloves gt Sterile lancet Cotton ba s v Glucose test strip r Glucose meter A Soap and water or alcohol swab 5F W 4 Identify the patient using the two identi ers Explain the procedure to the patient be puncmred and cleanse according l1 agency po 39cy Have patient hold hand in dependent position Ifhand is cool 7 consider techniques m warm ngers Pa 39ent may ave preference for which finger to use Prepare the glucose meter and test strip for tsting cording l1 manufacturers instructions and facility policy Don clean gloves Massage gently from base of nger toward puncture site to encourage ow of blood Perform puncture warn patient before you puncture Procedure Apply blood sample to test strip according to manufacturers instructions re you have an adequate sample before ammpting to apply to mst strip Provide hemostasis Note test rsulls and share rsulls with patient Enter any required commenls into meter and then turn off Correctly dispose ofall used equipment LanceE are diqaosed h sharps conminerl All other imms in regular trash Week 8 DocumentationF SBS NRAD 201B VZ mag Documentation Document results according to facility policy Results need to be communicated to the RN promptly E y vx 4 Critical Elements Use equipment correctly and efficiently Cleanse patient s finger per facility M1 Don clean gloves Collect adequate blood sample and provide hemostasis Week 8 DocumentationF SBS
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