Fundamentals Review

Unit 1 Reduction of Risk Potential

Vital Signs Objectives: At the completion of this unit, the student should be able to: Identify the measurements that comprise the vital signs. State the normal body temperature as measured in three different areas of the body. Demonstrate the ability to measure temperature by the various methods. Explain the terms febrile and afebrile. Demonstrate the ability to accurately describe and measure a radial, apical, and apical-radial pulse. Discuss and describe the abnormal pulse rates bradycardia, tachycardia. Demonstrate the ability to count accurately and describe the respiration of a client. Discuss and describe abnormal respirations bradypnea, tachypnea, Cheyne-Stokes, and Kussmauls respirations. Discuss the terms systolic and diastolic. State the normal range of BP for an adult. State the various parts of the stethoscope and their uses. Demonstrate the ability to accurately measure blood pressure. Define Hypertension, Hypotension, and Shock Measure Height and Weight Discuss the importance of comparing client vital signs to baseline vital signs. Reinforce client teaching about abnormal vital signs.

Factors Influencing Temperature

Time of Day= awakening generally low-normal. Afternoon generally high-normal due to metabolic processes, activity and atmosphere) Environment Temperature= cold weather, hot weather Age of Patient-Regulation of temperature mechanism not well developed in infancy, and lowers with elderly. Ingestion of hot and cold liquids Smoking Environment. Physical Exercise- muscle action generates heat and core temperature Menstrual Cycle and Pregnancy- temperature drops slightly just before ovulation, then raises 1 degree above normal during ovulation. After a day or two preceding it drops back to normal. During pregnancy during high normal Emotional Stress- increases temperature Disease Condition-bacteria, virus and toxins invoke the inflammatory response. Fever is a protective defense mechanism that the body uses to fight toxins. Drugs- Some medications can cause chemical reaction that causes and elevated temperature. During blood administration - temperature change can be a reaction

Routes of Temperature
Axillary
Least accurate Raise arm and check for lesions or broken or inflamed skin Nurse must hold in place under arm Hold in place usually 3-8 minutes

Rectal invasive- core

Insert into rectum .5 to 1.5inches 3-5 minutes Nurse should hold thermometer in place to prevent injury Contraindicated in diarrhea, rectal disease, rectal surgery, or cardiac disorders, some cancer patients and patients with thrombocytopenia If pressure or resistance is encountered, remove probe and wipe away lubricant Lubricated probe used

Routes of Temperature
Oral invasive
Not used if patient is unconscious, delirious, or not responsible for own actions. Not used with an infant or young child. Contraindicated in surgery or injury to nose or mouth Wait 15-30 minutes if patient has had a hot or cold drink or smoked. Chewing gum can affect temperature. Probe placed under tongue at the base of the sublingual pocket on either side. Lips must be kept closed around probe
Not used if patient is unconscious, delirious, or not responsible for own actions. Not used with an infant or young child. Contraindicated in surgery or injury to nose or mouth Wait 15-30 minutes if patient has had a hot or cold drink or smoked. Chewing gum can affect temperature. Probe placed under tongue at the base of the sublingual pocket on either side. Lips must be kept closed around probe

Temporal

Tympanic Invasive- core

Probe placed in the ear canal until it seals the opening Ear wax may alter readings Adult: Up, back and out; Child: down, back, and out

Measuring Pulse
Pulse
Adult Rate 60-100 bpm Average rate for an adult 72-80 Normal rate for a newborn 120-160 bpm Tachycardia pulse greater than 100bpm Bradycardia pulse rate below 60bpm

Radial
Use first and second or third and second fingers. Do not use the thumb- has strong pulse. Place fingers in groove along thumb side. Count for 30 sec multiply x 2 if regular If irregular take apical pulse

Apical
Count for 1 full minute Apical should be measured if any question occurs especially dysrhythmia Apical always used for Cardiac Clients

Apical-radial- differences between the apical and radial. Difference is pulse deficit.

Respirations
Do not let the patient know you are counting respirations, they may alter their breathing Count chest rise and fall for 30 sec, multiply by 2 Normal adult 12-20 per minute Eupnea- normal breathing Tachypnea- greater than 20 per minute Bradypnea- less than 10 per minute Narcotics Excitement, exercise, pain and fever Dyspnea-difficult or painful breathing Orthopnea-Difficulty breathing on back Apnea absence of respirations Cyanosis - Bluish tinged skin due to lack of oxygen being carried on the hemoglobin

Blood Pressure (BP)

Systolic pressure -contraction phase of the heart. BP is the highest, charted as top number Diastolic pressure or diastole-relaxation phase of the heart BP is the lowest charted as bottom number Systolic 90-120 Diastolic 60-80 Pre-Hypertensive 120/80 -140/90 Hypertension 140/90 or above Hypotension 90/60 Pulse Pressure - Difference between systole and diastole ex: 140/90 Pulse pressure = 50 Sphygmomanometer BP cuff

Sphygmomanometer
Select a cuff whose bladder encircles at least 2/3 the limb at its midpoint and is at least as wide as 40% of mid limb circumference. Support patients forearm at level of the heart with the palm of the hand upward Center cuff bladder so that the lower edge is about 1-2 inches above the inner aspect of the elbow Wrap cuff snugly and uniformly about the circumference of the arm. Cuff variations
Too Wide= BP will be falsely low Cuff too small=BP reading will be falsely high Cuff over clothes=creates noises or interferes with sound perception

Guidelines for Measuring BP

Have patient rest for 5 minutes Support arm on surface. Palpate brachial artery. Have manometer at eye level Gauge on cuff should be zero Place cuff and stethoscope directly on skin Palpate for systolic
Palpate the brachial artery or radial artery Inflate cuff while palpating artery. Note level pulse disappears, add 30 to this number.

Deflate Cuff

Measuring BP
diaphragm of stethoscope is placed firmly but lightly over the artery with all surface edges in contact with the skin. Inflate cuff to 30mmHg above where the pulse disappeared upon palpation. Once cuff is starting to deflate while obtaining systolic and diastolic readings, Do not stop mid way and begin again gives false. Listen for different sounds. Systolic pressure (First sound heard) diastolic pressure (last sound heard) Smoking, exercise, position-may affect BP, after smoking wait to take BP 15-30 minutes

 A physician may order Orthostatics on patient to determine fluid volume status or other things. Measure patients HR, BP, Lying, Sitting, Standing Positve Test is when the pulse is increased by 20 or more bpm and the systolic blood pressure drops by 20mmhg or more 2 min after position change. If patient has dizziness or syncope also means a positive test. Patients are at risk for falling with orthostatics SAFETY ISSUE!!!!

Orthostatics

Pain
Assessed and recorded with the other vital signs. Location of pain: Where is the Pain? Intensity:0-10 scale Character: Is it sharp or dull Frequency: How long have you had this pain? Does it come and go. Duration: when you are in pain, how long does it last? Paint me a Picture of your pain?

Indicators of Pain
Moaning, crying, irritability, inability to sleep, grimacing. Restlessness, rigid posture Elevation in BP, Pulse, RR Temp may go down Nausea Diaphoresis

Pain Scales
0-10 Scale 0= No Pain 10= Worst Pain imaginable

0-5 Scale, Used with children

Nonpharmacological Interventions for Pain

Physical
Progressive muscle relaxation Massage Transcutaneous electrical nerve stimulation (TENS) Heat/Cold application

Psychological/Cognitive
Music Biofeedback Imagery Education

Nonpharmacological Interventions for Pain

Physical
Progressive muscle relaxation Massage Transcutaneous electrical nerve stimulation (TENS) Heat/Cold application

Psychological/Cognitive
Music Biofeedback Imagery Education

Height and Weight

Height
Patient should remove shoes and stand erect. A measuring stick or tape may be attached vertically to the weight scales or wall. Standing scales may have a metal rod, which is attached to the back of the scale and swings out over the top of the patients head.

Weight

Patients should be weighed at the same time of day, on the same scale, and in the same type of clothing to allow an objective comparison of subsequent weighing. Weights are usually ordered daily in acute care settings Patient should void before weighing.

Charting Vital Signs

Vital Signs should be written down as soon as the measurements are obtained. Abnormal vital signs should be noted in nurses notes as well as graphic sheet All abnormal vital signs should be reported to charge nurse or physician. Documentation of reporting is also important. LOOK AT THE PATIENT!!!!! It is very important to compare vital signs with patients normal values or values that you find on the chart. What might be abnormal for one client may be normal for another. You may also ask the client what is normal for them.

Informed Consent

Must be voluntary and informed Patients must not be medicated with narcotics Once given can be withdrawn by patient verbally or written Technically you should obtain verbal consent before any nursing procedure or treatment The physician, surgeon, or qualified medical personal performing the procedure is responsible for explaining the procedure, risks and benefits, and possible alternative options. Person who is over the age of 18 and competent must sign for his or her treatment. Competent-legally fit (mentally and emotionally) Incompetent-unconscious, under the influence of mind-altering drugs (including etoh and prescription drugs) If a childs parents are divorced, the custodial parent is the legal representative.

HIPAA- Health Insurance Portability and Accountability Act 1996

Breach of Confidentiality

Release of information to anyone other than those persons directly associated with caring for the patient, without written permission. I.e. Report in Cafeteria, talking in elevators, telling spouses or family about patients with patient identifiers and without written permission.
Suspected abuse and Public Health Hazards where reporting is required by law is an exception

Legal Responsibilities

It is the nurse responsibility to follow the standards of nursing practice in the state in which they are practicing. Employers are not permitted under any circumstances to require nurses to work out of the scope of practice. Student nurses, although they are not yet licensed, are held to the same standards as licensed nurses. Negligence For Negligence to be claimed the, nurse must have failed to do something that any reasonable or prudent nurse would have done in the same situation and some injury must result from the nurse failure to act. It is considered negligence not to report another professionals misconduct. Assault - Threat to harm another Battery - Actual physical contact that has been refused or carried out against the persons will. Procedure without consent

Patient Identification
JCAHO Standards
Use of two patient identifiers when providing care, treatment and services is required. Room number or location is not a patient identifier Ask patient to state full name and birth date Check ID bracelet Verify with a picture form the chart Verify with another care professional

Client Allergies
Allergies to food and medication should be noted on the medical administration record (MAR)
Shell fish Eggs Latex Iodine

Nurses should ask patients each time before administering medications or a procedure what allergies the patient may have. If there is a procedure or medication the patient is allergic to the nurse should notify the physician.

Hazards
Falls Bedroom or bathroom Causes:
Slippery floors, bathtubs and showers throw rugs poor lighting cluttered floors pets

Factors:
impaired physical mobility altered mental status sensory and/or motor deficits

Fall Interventions
Orient Patient to Environment Keep environment free of clutter. Fall precautions. Toilet patient q2hr- often the patient falls trying to get to the bathroom Adequate Lighting (night light) Call bell within the patients reach Instruction on use of call bell Answer the call bell Personal belongings within reach Non Slip Shoes- no socks Assist patients out of bed No long hanging garments Grab bars in bathroom Rails in halls Wipe up all spills Clean up clutter Bed in low position when not working with patient Have patient stand slowly Lock Wheels on equipment Bed alarms

Fire Safety: First Action

Move anyone in immediate danger If a fire occurs, the nurse should immediately report the type of fire and its exact location. R Rescue A Alarm C Contain E Evacuate/Extinguish

Body Mechanics: General Rules

Make sure your body is in good alignment and that you have a wide base of support. Use the stronger and larger muscles of your body. i.e.. Shoulders, upper arms, thighs, and hips. Keep objects close to your body when lifting, moving, or carrying them. Avoid unnecessary bending or reaching. If possible, have the height of the bed and over bed table level with your waist when give care. Face the area in which you are working to prevent unnecessary twisting. Push, slide, or pull heavy objects whenever possible rather than lifting them. Get help from a co-worker to move heavy objects or patients whenever necessary. Squat to lift heavy objects from the floor. Push against the strong hip and thigh muscles to raise yourself to a standing position.

Key Points for Restraints

Least restrictive method Used to protect patient not for staff convenience Require a written physicians order Restraints cannot be written PRN (or as needed) Restraints are used only after trying other methods to control or protect person Unnecessary restraint is false imprisonment Must follow manufacturers instructions Slip knot should be used to allow for quick release by staff in case of emergency!!! Basic needs must be met by the nursing team Patient must be comfortable Movement of the restrained part must be limited and safe Skin Assessment Q2 Hours

Coolness of skin Change in color Numbness, pain, edema, or loss of sensation or movement Restraint must be removed or released every 2 hours and ROM performed with restrained extremities

Documentation for Restraints

Type of Restraint Reason for Restraint Alternatives Used prior to Restraint Time of application Time of Removal Type of care given when restraint removed Color and condition of persons skin Complaints of pain, numbness, tingling in the restrained extremity Pulse present or absent Toileting offered Hydration and food offered If CIRCULATION IS COMPROMISED REMOVE RESTRAINT!!

Alternative to Restraints
Orient client and Family Explain Procedures and Txs Encourage Family Presence Assign confused and disoriented clients to rooms near nurses station Provide Auditory and Visual stimulation Maintain toileting routines Eliminate bothersome txs ASAP Relexation Techniques Exercise and Ambulation Schedules

Handeling Hazardous and Infectious Materials

Demonstrate knowledge of facility protocols for handling hazardous and Infectious Waste Identify and employ methods to control the spread of infectious agents. OSHA Occupational Safety and Health Administration MSDS Materials Safety Data Sheet

MSDS Sheets
Material Safety Data Sheets
There should be a MSDS sheet for each biohazard substance stored or used on the nursing unit. These sheets are consulted for recommended methods of storage, labeling, handling spills, and disposal.

Cleaning & Disinfecting

Cleaning
Don Clean Gloves Rinse article under cool water (emulsifies dirt for removal) Wash article with detergent and warm water (softens dirt for easy removal) Use scrub brush to remove material in grooves Dry article thoroughly (Prevents growth of microorganisms)

Disinfection
Used on Equipment not SKIN!! Rinse with water (soap may react with disinfectant) Recommended disinfectant is chlorine bleach and water at a ratio of 1:10 1 cup of bleach:10 cups of water

 Used to document what happened, the facts about the incident, and who was involved or witnessed it. Used for evaluating safety guidelines Serves as a recall of an occurrence that may result in injury or damages and a future lawsuit. Staff should not be reluctant to complete report, the information may be helpful to implement important changes that may save lives. Incident reports are generally not filed as part of the patients chart. No reference to the incident report is made in the patients chart!! Dos & Donts Do be objective, just the facts DO list date, time, care given, the patient and name of physician. Do report what was the interventions after the incident. Dont admit liability or give unnecessary details. DONT CHART IN NURSES NOTES!!

Incident Reports

Reportable Incidents
Accidental omission of orders Circumstances that led to injury or a risk for client injury Client Falls Medication Administration Errors Needlestick Injuries Procedure-related or equipment-related accidents Visitor having symptoms of illness

Standard & Universal Precautions

Universal Precautions - A method of infection controlrecommended by the CDCin which all human blood, certain body fluids, as well as fresh tissues and cells of human origin are handled as if they are known to be infected with HIV, HBV, and/or other blood-borne pathogens The standard precautions synthesize the major features of universal precautions (designed to reduce the risk of transmission of bloodborne pathogens) and body substance isolation (designed to reduce the risk of pathogens from moist body substances) and apply them to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status. Standard precautions apply to:
(1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain blood (3) nonintact skin (4) mucous membranes

The precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

Personal Protective Equipment=PPE

Used by health care workers to protect themselves and other patient from the transmission of blood-borne, air borne, contact organisms. Gloves-used at any time there may be contact with body substances or with items that have been contaminated with body substances. Gloves are NEVER reused or washed. Goggles and/or Masks: At any time there is a opportunity to be splashed with blood or body substances, goggles, special glasses, mask, or a face shield is to be worn. Gown: A moisture-impermeable gown or plastic apron is to be worn if there is a possibility of blood or body substances penetrating the clothing. Hair covering: A cap or head cover is used if there is a danger of contamination of the head or hair. Shoe covers: Skin around the ankles should be covered whenever there is a chance of splashing of body fluids

Disposal of Equipment
An effective mechanism must be designed to handle infectious material.
Specially labeled bag (ie. Red bag) Sharps Containers used properly.

Linens- Soiled linen is handled as little as possible.

Roll it up place inside bag lined linen hamper in room. When bag is 2/3 full, tie it closed and send it to the laundry. Always hold away from uniform and wear a gown if necessary.

Needles/sharps
Immediately after use, needles and other sharps should be placed in puncture-resistant containers. Needles are not recapped after use. Sharps- Any equipment that may pierce the skin. Waste materials that are contaminated must be discarded in red plastic bags (biohazard)

Precautions
Droplet
Transmission is by contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets. Droplets are generated from the source person primarily during coughing, sneezing, talking, and performance of certain procedures such as suctioning and bronchoscopy. Transmission of large-particle droplets requires close contact between source and recipient persons because droplets do not remain suspended in the air and generally travel only short distances (usually 3 feet or less). Special air handling and ventilation are not required to prevent droplet transmission because droplets do not remain suspended in the air. ExamplesDiphtheria, pertussis, scarlet fever, mumps, rubella.

Airborne
Airborne droplet nuclei consist of small-particle residue (5 m or smaller in size) of evaporated droplets that may remain suspended in the air for a long time. Airborne transmission occurs by dissemination of either airborne droplet nuclei or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed by air currents and may be inhaled or deposited on a susceptible host from the source patient. Special air handling and ventilation are required to prevent airborne transmission. Examples-Measles, Varicella, TB

Contact
Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person. This can occur when health care personnel perform patient-care activities that require physical contact, such as turning or bathing the patient. Direct-contact transmission can also occur between two patients, such as by hand contact, with one patient serving as the source of infectious microorganisms and the other as a susceptible host. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment. Contact Precautions apply to specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. Example- MRSA, CDiff, Herpes Simplex virus, impetigo, scabies, herpes zoster

Isolation
Usually ordered by physician, however nurses may initiate these precautions. Most agencies require nurses to obtain a culture from a wound and to initiate isolation precautions based on hospital policy. Signs should be posted in a prominent location outside the patients room indicating the type of isolation/precautions, preparation prior to entering the room and the supplies that are needed. Protective or Reverse isolation
Incorporated when a patient is immunocompromised; protects him from exposure; all PPEs are worn; no one with an active infection allowed in patients room. Ex: HIV, cancer, transplant patient

Psychological Aspects
Risk for decreased self esteem Sensory deprivation
Keep patient stimulated with games, phone, TV, etc. Watch for signs of sensory deprivation: such as boredom, disorganization, anxiety, hallucinations, panic, excessive sleeping. Remove patient from isolation as soon as safely possible.

Medical Asepsis clean technique

Helps prevent nosocomial or hospital acquired infections Uses practices to REDUCE the number, growth, and spread of microorganisms. Clean - Objects are considered to have the presence of some microorganisms that are usually not pathogenic. Dirty - Considered to have a high number of microorganisms, with some that are potentially pathogenic. Common Medical Asepsis
Hand washing Changing Linens Disinfecting Equipment Cleaning floors Cleaning Hospital Furniture Dispose of needles with syringes and other sharp items in puncture-resistant container. No recapping after use of needles

Hand washing
One of the most effective ways to reduce the number of microorganisms on the hands and preventing the transfer of microorganisms. The three essential elements
Soap, or chemicals Water Friction - Most important element of the three because it physically removes soil and transient flora.

Remove rings After arriving at work Before leaving work Between patient contacts After eating and smoking After excretion of body waste including urination and defecation After contact with body fluids Before and after performing invasive procedures Before and after the use of gloves
20 seconds is recommended to remove transient flora from the hands Time it takes to sing Happy Birthday. High-risk areas, such as nurseries, require about a 2 minute hand wash

Surgical Asepsis Sterile Technique

Practices that eliminate all microorganisms and spores from an object or area that comes in invasive contact Refers to handling sterile equipment and establishing and maintaining sterile fields Autoclave is the use of moist heat under pressure; often used in hospitals and clinics Boling water is the easiest method to sterilize at home.

Some Invasive Procedures

Foley catheter insertion Sterile Dressings Any Sterile Procedures

Rules of Sterile Asepsis

Be aware of What is Sterile Be aware of What is NOT Sterile Separate Sterile from non Sterile Always keep your sterile field visible. If you can not see your field it is contaminated. Remedy contamination immediately. Open packages away from you The GOAL of surgical asepsis is to keep an area free of microorganisms.

Microorganisms
Microorganisms - Organism only visible with a microscope. Pathogens - Microorganisms that cause diseases in humans.
Bacteria Viruses Fungi Protozoa Rickettsia Prions

Chain of Infection
Pathogens - Microorganisms that cause diseases in humans.
Bacteria, Viruses, Fungi, Protozoa, Rickettsia, Prions
Link One: Causative Agent Entity that is capable of causing disease-biological, chemical, physical Main concern is biological Link Two: Reservoir- source of infection-example-from infected patient. Link three: Portal of Exit- feces, blood, urine, sputum Link Four: Mode of Transfer contact, airborne, droplet ex: sneezing, coughing, sexual contact Link Five: Portal of entry: wound, ingestion, inhalation, non intact skin. Link Six: Host- organism that can be affected by an agent. Generally a human in considered a host. Factors effecting transmission Age Weak state of health Broken skin

Mode of Transfer
Direct Contact: Actual touching of an infected animal or person with a communicable disease. Kissing and sexual intercourse are two means of direct transmission. Indirect Contact- Contact with objects that have been contaminated by an infected person. EX: Dressing of infection patient are touched and then another patient is touched without washing hands. Droplet Contact- Spray or mist ejected from the nose or mouth when coughing, sneezing or talking Airborne Contact -Evaporated droplets of an infectious agent Vechicle: Contaminated food, water, drugs, or blood Vector: organism that caries disease- insect, tick, mosquito.

Body Defenses Against Infection

First Line of Defense is Skin Second Line of Defense: Fever Leukocytosis Phagocytosis Inflammation and the action of interferon Third Line of Defense Immune Response: Body reacts to foreign substances. Antigens: Substances that are foreign to a host that stimulate an immune response. i.e.: Bacteria, Viruses, Protozoa Non biologic: venom, transplanted organs,

Customs, Beliefs & Values

Customs Habitual practices, or the usual way of acting under certain circumstances i.e.. Christmas, Lent, Death, Eye Contact, Birth, Consent, Receiving Blood, Organ Transplant. Beliefs
Norms and rules that guide human behavior Situation= Expected Outcome No Guarantee that a belief is ALWAYS TRUE or false Faith Healers are highly regarded in some cultures Medical treatment is preferred in other cultures

Values Goals to which behavior is directed Actions will usually equal values Sometimes difficult to assess Important in Chronic Disease States

Cultural Blindness & Cultural Imposition

Cultural Blindness Occurs when the nurse ignores the patients difference and proceeds to give care as if those differences dont exist. I know you dont believe in eating red meat but you have to get your protein levels up Cultural Imposition Imposing the cultural norms of the nurse and hospital on the patient and family You are here in my hospital, and you will just have to do things our way Always give care based on the patients culture, beliefs, values and attitudes Always be accepting of the patients beliefs

INAPPROPRIATE!

Oral Hygiene
Usually includes brushing and flossing the teeth or caring for dentures
Paper Towel in sink padding not to damage dentures Soak dentures in plastic cup over night
Hold over basin over water lines with towel when washing-slippery-prevents breaking

Do not use hot water (warps) Store in container in cold water

Prevents mouth odors and infections Keeps the mouth and teeth clean Increases comfort Improves palate for food

Illness and disease may cause bad taste Some drugs and diseases cause redness and edema of tongue Dry mouth is common from some drugs, oxygen, decreased fluid intake, and anxiety

Unconscious Client
Need more frequent mouth care Dried crusts (sordes) containing mucus, microorganisms, and epithelial cells shed from the mucous membrane and are common on the lips and teeth of unconscious patients. May use toothettes, swabs, applicators dipped in mouthwash. Glycerin swabs may not be used due to recent information that bacteria growth may be increased. Mouth care is usually given Q2hours Lip balm may be applied to the lips to help prevent cracking. Petroleum Jelly is not used based on possibility of combustion with oxygen Patient may have dysphagia and must be protected from aspiration. Always assess for gag reflex first.
Position supine with head turned well to the side so that excess fluid can drain from mouth. Use small amounts of fluid to help reduce risk. Minimal oral suction at bedside.

Key Points for Bath

Maintain Safety Tub bath may cause a person to feel faint, weak or tired, monitor frequently Bath no longer than 20 minutes Bath mat in tub Clean before and after use Shower chairs may be used in shower stalls-lock wheels Place needed items within the persons reach Drain the tub before person gets out Have person use safety bars when getting in and out of tub Avoid using bath oils-makes the surface slippery Stay within hearing distance of the shower or tub if the person can be left alone Water temperature 110-115 F book states 105 degrees F Privacy for Bath

Warmth

Close door Pull curtain if giving bed bath Keep client covered while bathing

Close window and door Keep covered-exposed only areas to be washed

Shaving
Promotes comfort and well being Follow standard precautions Hold skin taut Shave in the direction of hair growth Report nicks or cuts Use electric razor for client on anticoagulants, chemotherapy, low platelet count.

Nails
Cleaning and trimming fingernails is easier after soaking in warm soapy water for 5-10 minutes Use orangewood stick to clean under nails Use nail clippers to cut toenails straight across to prevent them from growing into the skin along the sides Observe color of nail beds Need to have physicians order to cut toenails of a diabetic client or one with poor circulation to the lower extremities.

Dressing Clients
Clients may need assistance with dressing. Always use care when clients have Ivs, Foleys, or other tubes that may be dislodged when dressing Always start on the uneffected side, ie: if the patient has an IV in the left arm, remove clothing from the right arm first Always follow patients preferences

Bedmaking Safety Concerns

Hold away from your uniform to avoid contaminates Place on clean surface until you need them Straighten clean linens if loose or wrinkled during the day and at bedtime Check for crumbs after meals Wear gloves to remove soiled linens Change linens immediately when soiled with body fluids Roll soiled linen away from you Carry soiled linen away from your body Place soiled linen into hamper or linen bag Be sure client is safe and comfortable during linen change Change linens as soon as they become wet, soiled, or damp Sloppy, soiled linen can embarrass client Contaminated linen can spread disease Wrinkled linen can cause skin breakdown Never place soiled linen on floor, overbed table, or other furniture Always wash hands before and after touching linens Never shake linens! Do not tuck pillow under chin when applying pillowcase Raise bed to comfortable working height If possible, change linen when client is out of bed

Bedmaking Types
Closed Bed
Not being used by client Top linens not folded back Bed is ready for a new client

Open Bed
Being used by client Top linens folded back so client can get into bed Top linens may be folded back to about 24 inches from foot of bed Closed bed becomes an open bed when top linens are folded back

Surgical Bed

Made so client can move from stretcher to bed Also called postoperative bed; recovery bed; anesthetic bed Should be made when client has left for surgery Linens are fan folded to the side or foot of the bed

Bedmaking Making Occupied Bed

Linens are changed with client in bed Cover client with bath blanket and turn him/her to far side while removing soiled bottom linens Make that side of bed before proceeding to the other side

Roll client over the fan folded bottom linens onto the newly made side Remove bottom linens and make other side of bed Keep side rail by client up so client can hold it

Ambulation
Assess patients strength, coordination, and activity tolerance before you ambulate a client. Stand slightly behind and to the side of the client on the clients weak side for support Support the client with one hand around the waist and the other hand holding the clients hand that is nearest to you. Walk slowly on the same foot with the client. Let the client pace and lead if possible. If the client is wearing a transfer a belt, grasp it with one hand at the small of the back You must be alert to the clients stability and be ready to assist quickly.

Joint Mobility
Muscles and joints must be used to keep their strength, flexibility, and function If a muscle is not active, it will decrease in size and strength(atrophy) If the muscle is not active for long enough, the muscle will deform into what is called a contracture and stop functioning. Contracture: permanent shortening of a muscle and the eventual shortening of associated ligaments and tendons. Exercising joints and muscles with range-of-motion excercises helps function. ROM usually 2Xday Atrophy: a reduction in size or wasting away of cell, tissue, part or organ

Joint Mobility
Contracture: permanent shortening of a muscle and the eventual shortening of associated ligaments and tendons. Exercising joints and muscles with rangeof-motion excercises helps function. ROM usually 2Xday

Type of Movements
Hyperextension- Straightening past the normal position to stretch the muscles and connective tissues of the joint. Abduction-moves a part of the body away from the body or other parts Adduction-moves a part of the body toward the body or other body parts. Rotation- Circular turning of a joint Internal Rotation- Turning the joint inward, toward the center of the body External Rotation-turns the joint outward, away from the center of the body Flexion- Bending of a limb or body part Extension-Straightening of a limb or body part Pronation-Turning the joint down Supinantion- Turning the joint up

Transferring Patients
Transferring- moving clients out of bed and chair Patient should wear non-skid footwear Be alert for instability. Return client immediately to bed any client feeling faint, dizzy or unsteady. Position furniture where you want it before you move the client. BE SURE BRAKES ARE LOCKED on w/c Use transfer or gait belt as indicated. Line wheelchairs with cushions or blankets to prevent discomfort Be aware of clients with a weak side and adjust movements as needed. Be familiar and properly trained with any assistance devices that may be employed. Ensure equipment is in working order. Patients who find standing difficult may use a transfer belt to maintain stability and safety.

Transferring Patients
Before transferring a client to a chair or ambulating, dangle client limbs first. Dangling-Sit client up on the edge of bed. Especially if client has been confined to bed or has circulation problems. If a client has a weak side, place the chair so the clients strong side will lead through out the move Use your leg muscle to stand straight up and lift client with you. PLAN AHEAD and EDUCATE Patient Be aware that clients may grab at your neck

Repositioning Clients
You must follow the rules of body mechanics when moving and lifting clients in bed. The client must be protected from injury-keep in good body alignment. Friction must be reduced to protect the clients skin- roll or lift, use lift sheet. Check to see if there are any limitations or restrictions in positioning or moving the client Decide how the client will be moved and how many helpers you need Plan ahead and have adequate help for the procedure Keep the client covered and screened to protect the right to privacy Protect any tubes or drainage containers connected to the patient Move the patient to the side of the bed before turning the patient. Patient should be in the supine position when being moved to the side of bed Patients are moved to the side of the bed in segments. Upper part first.

Moving Patients
At least two nurses using a lift sheet move the patient up in bed, standing on opposite sides of the bed at the patients shoulder level. Ensure a pillow is at the top of the bed to prevent head injury of the patient.

Patient Comfort
Patients should be repositioned every 2 hoursreduces pressure to the same area and helps maintain skin integrity. Turning patients helps avoid prolonged flexion of any one body part Body parts are supported in alignment to promote comfort and prevent undue muscle strain. Spinal cord patients must be log rolled Alignment can be maintained and discomfort from muscle strain relieved by the use of supportive aids.

Type of Movements
Hyperextension- Straightening past the normal position to stretch the muscles and connective tissues of the joint. Abduction-moves a part of the body away from the body or other parts Adduction-moves a part of the body toward the body or other body parts. Rotation- Circular turning of a joint Internal Rotation- Turning the joint inward, toward the center of the body External Rotation-turns the joint outward, away from the center of the body Flexion- Bending of a limb or body part Extension-Straightening of a limb or body part Pronation-Turning the joint down Supination- Turning the joint up

Patient Positions
Supine: Patient lying on back Lateral or side lying: patient on side, with pillows for support Prone: patient positioned on stomachpotential hazard could be plantar flexion. Can use a small pillow below the diaphragm All other positions are variations of these three.

Prevention of Pressure Ulcers

Assess Skin Reposition at least Q2 hours Keep heels off bed Avoid positioning on the trochanter Use a lift sheet Use pressure reducing devices Do not massage reddened skin as it has already suffered temporary damage. Do not massage directly over bony prominences Wash and Dry the incontinent patient promptly Avoid mechanical and/or physical injury from improperly fitting splints, braces, casts, and prostheses

Prevention of Pressure Ulcers

Avoid burns caused by excessively hot or cold applications such as hot-water bottles, ice bags, heating pads, and heat lamps. Use proper technique for positioning Provide adequate nutrition and fluid intake.

Pressure Ulcer Stages

Stage 1

Area of red, deep pink, or mottled skin Warmth, edema Indurations Stage 2 Partial Skin loss Looks like abrasion, blister, or shallow crater Warmth

Stage III Full thickness Loss Subcutaneous tissue damaged or necrotic Resembles a deep crater

Stage IV
Full thickness loss with extensive damage to muscle, bone, or supporting structures May appear dry and black in color Eschar: touch necrotic tissue (when present, unable to stage the wound)

Antiembolism Stockings
Knee High Thigh High Full Length
Measure patients leg length and circumference for the stocking ordered. Apply powder for ease of application Assess pedal pulse, color, temperature of extremety at most distal point pre and post application.

Mechanical Lift
Used to lift patients who either cannot move or have difficulty moving to and from beds, wheelchairs, and tubs One care giver operate the lift while another guides the patient Always check equipment before procedures to make sure it functions properly. Ensure the bed and lift are locked.

Crutches
Length of crutch should be from the base of the foot to within two or three inches of the armpit. If crutches are too tall, it will injure the axilla and interfere with circulation and brachial plexus The forward movement of crutches will depend on the size, stability, and skill of the person. Eight to Ten inches is a safe initial distance.

Crutch Walking
The distance between the axilla and the arm pieces on the crutches should be two finger widths apart Elbows should be slightly flexed, 20 to 30 degrees, when walking Stand on affected side of client Instruct patient to look out and up Stop ambulating if numbness or tingling in the hands or arms.

Sitting with Crutches

Place the unaffected leg against the front of the chair Move the crutches to the affected side, and grasp the chairs arm with the hand on the unaffected side. Flex the knee of the unaffected leg to lower into chair while placing affected leg straight out. Reverse process for standing. Stairs with Crutches Down
Moves the crutches and the affected leg down Moses the unaffected leg down.

Up
Moves unaffected leg up first Moves affected leg and crutches up

Cane
Always held at hip level on the patients strong side Check the rubber tip of the cane to ensure that it is in good condition. Height of cane should cause the patients arm to bend slightly while the patient stands erect. Cane is held on strong side

Walker
Height of walker should cause the patients arms to bend slightly while the patient stands erect. Patient holds on to both sides of walker With feet spread about six inches apart for balance, the walker is lifted and moved six inches forward Then small steps to walker

Rest
Client at rest: feels mentally relaxed, free from worry, physically calm

Rest = free from mental or physical exertion Bed rest prescribed by MD does necessarily mean the patient is resting. Emotional or metabolic stressors may cause a patient to be restless

Factors Affecting Sleep

1. Physical Illness Pain Position Fear Anxiety and Depression Drugs and Substances Lifestyle Rotating shifts Change in mealtimes Stress Exercise and Fatigue 7. Sleep Patterns
Starting time and duration
Everyone has increased sleep tendency from 2 7 a.m. Sleeping later = Falling asleep later the next night

2. 3. 4.

8.

5. 6.

9.

Environment Ventilation Lighting Sound Presence or absence of partner Nutrition Weight gain causes longer sleep periods Weight loss can cause reduction in total sleep

Promoting Sleep
1. Provide a quiet, undisturbed environment that causes the least interference with sleep 2. Provide comfort measures such as toileting, a back rub, comfortable bed 3. Decrease excessive noise form conversation and environment 4. Have patient ambulate early in evening 5. Provide decaffeinated beverage (milk) 6. Perform all procedures prior to 9 p.m. if possible

NURSE-PATIENT RELATIONSHIP
Helper role rather than a social role Characteristics of therapeutic relationship - effective communication skills - non judgmental attitude - empathy and genuineness - a desire to help and respect for the individual - honesty and confidentiality - acceptance and hope

ACTIVE LISTENING
1. 2. 3. 4. 5. 6. 7. 8. 9. Maintain eye contact Give full attention Conscious effort to block out distractions Do not interrupt Maintain an open body posture Focus on the speakers face Leaning forward Nodding slightly State what you understand, ends the process

Therapeutic Communication Techniques 1. Promoting communication between sender & receiver, obtaining feedback 2. Focusing on communicator 3. Use silence & open-ended questions 4. Restating message 5. Therapeutic touch 6. Clarifying 6. Give general leads 7. Give information 8. Encourage elaboration 9. Look at alternatives 10. Summarize 11. Stay with patient if they are upset or grieving

Blocks to Effective Communication

1. 2. 3. 4. 5. 6. 7. Changing the subject Offering false assurance Making defensive comments Asking probing questions Using clichs Giving advice Not listening attentively

Examination Techniques
Inspection and Observation Purposeful, through, visual assessment of patient Auscultation Listen to body functions or absence of sounds through a stethoscope Palpation Performed using the hands and finger tips to touch and feel various parts of the body Finger pads placed flat against skin, exerting slight pressure Press in depth of - 1 inch (not over 1 inch) Percussion Method of obtaining information about body structures Light, quick tapping on surface produce sounds Variation in the sounds reflect characteristics structures below the surface.

Additional Reading Fundamental Concepts and Skills For Nursing by Susan DeWit
Pg. 547 Midstream/clear catch urine specimen Pg. 551-553 placing and removing bedpan Pg. 822-823 Applying elastic bandages Pg. 827-829 Assisting with aids to mobilization Pg. 249-251 Opening Sterile packs and preparing a sterile field Pg. 253-255 Sterile Gloves Pg. 265-268 positioning a patient Pg. 273-276 ROM Pg. 277-280 Transferring a patient Pg. 296-300 Bed Bath Pg. 304-306 Oral care for the unconscious patient Pg. 306-307 Denture Care