DOCUMENTATION - Doctor’s order – notify dr of significant changes that u observe

CHARTING OR DOCUMENTATION EXAMPLE ON YELLOW PAD

- Process of making an entry on a client record
- Aka recording COMMUNICATION TOOL
- Method of health personnel communication SBAR
CLIENT RECORD OR CHART - Standard way to communicate med info
- Formal, legal doc that provides evidence of p.t care - Improves accuracy n cuts down on dangerous errors
- Timely, complete, accurate, confidential, n specific to the client - Standardized, safe, simple way for nurses n doctors to share client info in
- For planning p.t care, quality assurance, research, education, sharp, clear way
reimbursement Before calling or referring:
On the legal side, accurate documentation shows that the care you provide meets - Assess the client
the needs and expressed wishes. It also proves that you’re following the accepted - Review chart for appropriate physician to call
standards of nursing care mandated by the law, your profession, and your health - Know admitting dx
care facility. - Read most recent progress notes n assessment from nurse of the prior shift
Poor documentation is the pivotal issue in many malpractice case. Medical - Have available chart, allergies, meds, iv fluids, lab results when speaking w/
records are used as evidence in cases involving disability, personal injury and physician
mental competency. S – SITUATION
- Brief statement of the problem
ELEMENTS OF EFFECTIVE DOCUMENTATION - Identify urself, unit, and client’s name
- Write neatly and legibly - What is happening now?
- Write in ink (black/blue) B – BACKGROUND
- Use standard abbrev & accepted terms - Concise overview of the situation
- Correct spelling & grammar - May include dx, med hx, dates, med info, names of physician involved
- Clear, concise sentences - What has happened in the past that is relevant?
- Correct errors properly A – ASSESSMENT
- Write on every line, DON’T LEAVE SPACE - Sum up of what is going on
- Document date and time - Consider results of lab test
- Sign each entry - If can’t create a clear assessment, just say it
- What is the prob/ issue in ur view
DOCUMENTATION SYSTEMS/ TYPES OF CHARTING R – RECOMMENDATION
1. FOCUS SYSTEM (FDAR) - Cleary state what u’re requesting
- Best in acute care settings on units where same care and procedures are - Be specific abt suggested action n time frame
repeated frequently - In verbal, repeat back any order for greatest accuracy
F – FOCUS - What do you think needs to happen now? What does the receiver want
- Write each focus as a nursing dx you to do?
- Deficient fluid vol, sign and symptom, patient behavior (inability to EXAMPLE ON YELLOW PAD
ambulate), special need (discharge need), significant event (surg)
D – DATA IPSG #1: IDENTIFY PATIENTS CORRECTLY
- Subjective and objective information describing the focus IPSG #2: IMPROVE EFFECTIVE COMMUNICATION
A – ACTION
- Immediate and future nursing actions based on ur assessment of the p.t’s HEALTH AND ILLNESS:
condition awa changes to plan of care as necessary, based on ur evaluation CONCEPT OF HEALTH AND WELLNESS
R – RESPONSE PERSONAL DEFINITIONS OF HEALTH:
- describes client’s response to nursing or medical care - Being free of symptoms of disease n pain as much as possible
EXAMPLE ON YELLOW PAD - Being able to be active n able to do what they want or must do
2. SOAPIE CHARTING - Being in good spirits most of the time
- Assessments n interventions apply to more than one prob so charting of WHO DEFINED HEALTH BY:
these findings is repetitious. Makes documentation time-consuming to - A state of complete physical, mental, and social well-being, not merely the
perform and read absence of disease or infirmity
- Emphasizes problems, routine care may be left undocumented unless flow HEALTH
sheets are used - Dynamic process that varies according to a person’s perception of well-
S – SUBJECTIVE DATA being
- Info to p.t / fam tell you the cc and other WELLNESS
O – OBJECTIVE DATA - Active process by w/c an indiv progresses towards maximum potential
- Factual, measurable data nurses gather during assessment, observed signs possible, regardless of current state of health
and symptoms, vital signs n lab test values - Process of becoming aware of and making choices toward a more
A – ASSESSMENT successful existence
- Conclusions based on collected subjective n objective data and formulated - Multi-dimensional
p.t problems or nursing diagnoses DIMENSIONS OF WELLNESS
- Dynamic n process changes as more/ diff subj n obj info becomes known 1. PHYSICAL
P – PLANNING - Ability to carry out daily tasks; practice of positive life-style habits
- Ur strategy for relieving p.t’s problem 2. SOCIAL
- Includes both immediate/short term actions and long term measures - To interact successfully w/ people
I – INTERVENTION 3. EMOTIONAL
- Measures u take to achieve an expected outcome. As p.t’s health status - To manage stress n express emotions appropriately
changes, you may need to modify ur intervention. Be sure to docu p.t’s - accept one’s limitations
understanding n acceptance of the initial plan in this sec of notes 4. INTELLECTUAL
E – EVALUATION - To learn and use info effectively for personal, family, career development
- Analysis of the effectiveness of ur interventions - Striving for continued growth n learning to deal w/ new challenges
EXAMPLES ON YELLOW PAD effectively
3. TRADITIONAL NARRATIVE 5. SPIRITUAL
- Narrative charting a chronological account of: - Belief in some force that serves to unite human beings and provide
a. Client’s status meaning and purpose to life
b. Nursing interventions performed - Person’s morals, values, and ethics
c. Client’s response 6. ENVIRONMENTAL
- Observe and take note: - To promote health measures that promote standard of living and quality of
- Change in client’s condition such as progression, regression or new probs life in community
- Client’s response to a treatment / medication CONCEPT OF ILLNESS AND DISEASE
- Lack of improvement in client’s condition DISEASE
- Client’s or fam response to teaching - Pathologic change in structure or function of body or mind
- Put ur thoughts in order: Etiology – cause of a disease
1. How did I first become aware of the prob ILLNESS
2. What has the client said abt the prob that’s significant - May or may not be related to a disease
3. What have I observed that’s related to the prob Ex. Person w/ stomach growth may not feel ill
4. What is my plan for dealing w/ the prob - HIGHLY SUBJECTIVE; only indiv person can say they’re ill
5. What steps have I taken to intervene Influenced by:
6. How has the client responded - Self-perceptions
 - Others’ perceptions - Jehovah witnesses’ oppose to blood transfusions
- Effect of changes in body structure n function 5. ENVIRONMENTAL FACTORS
- Effects of changes on roles n relationships - HOUSING, SANITATION, CLIMATE, POLLUTION
- Cultural and spiritual values n beliefs 6. SOCIOCULTURAL FACTORS
TYPE OF ILLNESS - ECONOMIC LVL, LIFESTYLE, FAMILY, CULTURE
1. ACUTE - Low-income grps are less likely to seek h.c to prevent or treat illness
- RAPID ONSET - High-income grps are more prone to stress-related habits n illness
- LESS THAN 6 MONTHS - Adolescents who sees nothing wrong w/ smoking or drinking cause parents
- Lasts for limited and relatively short period smoke n drink
- Flu, colds, appendicitis INTERNAL FACTORS
2. CHRONIC - PHYSICAL
- GRADUAL ONSET - EMOTIONAL
- LASTS 6 MONTHS OR LONGER - INTELLECTUAL
- Lasts for relatively long period - SPIRITUAL
- Periods of remission n exacerbation EXTERNAL FACTORS
- REMISSION – symptoms DISAPPEAR - ENVIRONMENTAL
- EXACERBATION – symptoms REAPPEAR - SOCIO-CULTURAL
- Heart disease, diabetes, asthma, arthritis HEALTH PROMOTION AND ILLNESS PREVENTION
ILLNESS BEHAVIOR HEALTH PROMOTION
- Way a person copes w/ alterations in function caused by a disease - Behavior motivated by personal desire to increase well-being
- Behavior of individual when they’re ill - Routine exercise and good nutrition maintains or enhance present lvl of
STAGES OF ILLNESS BEHAVIOR: health
1. EXPERIENCING SYMPTOMS ILLNESS PREVENTION
3 aspects: - Behavior motivated by a personal desire to avoid or detect disease
a. PHYSICAL – physical exp of symptom - Routine immunization
b. COGNITIVE – interpretation of symp LEVELS OF PREVENTIVE CARE
c. EMOTIONAL – fear or anxiety 1. PRIMARY
2. ASSUMING SICK ROLE - Reduction of risk factors BEFORE recurrence of disease
- Person gives up normal activities and assumes sick role - Exercise, smoking prevention, sex ed, immunizations, diet, breastfeeding
- Focus is on bodily functions and symptoms 2. SECONDARY
3. MEDICAL CARE CONTACT - Early detection of POTENTIAL for development of disease
- Person seeks professional advice for: - Breast self-exam, pap smear, mammogram, testicular self-examination,
a. Validation of real illness screenings (HIV, cholesterol, cancer)
b. Explanation of symptoms in understandable terms 3. TERTIARY
c. Reassurance that they’ll be alright or prediction of the outcome - Treatment of an EXISITING DISEASE to delay or prevent its progress
4. DEPENDENT CLIENT ROLE - Medications, med treatment, surg treatment. Physical therapy,
- P.t accepts dx and follows prescribed treatment plan rehabilitation
5. RECOVERY OR REHABILITATION
- Person give up dependent role n resumes normal activities ASEPSIS
- Final stage of illness behavior that is complete @ home - Freedom from disease causing microorganism
MODEL OF HEALTH - Absences of pathogens
1. MEDICAL MODEL (M.B BELLOC & L.BRESLOW 1972) - Aseptic technique is used to decrease possibility of transferring
- Health is state of being free of signs n symptoms of disease microorganisms from one place to another
- Illness is presence of signs or symptoms of disease RESIDENT FLORA
2. HEALTH-ILLNESS CONTINUUM (MCCANN/FLYNN & HEFFRON 1984) - collective vegetation in an area
- Health is constantly changing state w/ high level wellness and death being INFECTION
on opposite ends of a graduated scale or continuum - growth of microorganism in body tissue where they are not usually found
3. ROLE PERFORMANCE MODEL (PARSONS 1958) - ASYMPTOMATIC / SUBCLINICAL INFECTION – microorganism that produce
- Health is in terms of individual’s ability to perform work no clinical evidence of disease
- People who can fulfill their roles are healthy even if they appear clinically ill DISEASE
4. HIGH LEVEL WELLNESS (DUNN 1961) - Detectable alteration in normal tissue function
- Functioning to one’s maximum potential while maintaining balance n VIRULENCE
purposeful direction in the environment - ability of microorganism to produce disease
A. HIGH LEVEL WELLNESS IN A FAVORABLE ENVI COMMUNICABLE DISEASE
- Person who implements healthy lifestyle behaviors and has the resources - transferrable to individual by direct or indirect contact
to support his lifestyle PATHOGEN
B. EMERGENT HIGH-LEVEL WELLNESS IN AN UNFAVORABLE ENVI - ability to produce a disease
- Woman who knows the importance of healthy diet n exercise but does not - opportunistic pathogen
practice it bec of lack of time or high work demand TYPES OF ASEPSIS
C. PROTECTED POOR HEALTH IN A FAV ENVI 1. MEDICAL ASEPSIS
- Person w/ cancer whose needs are met by healthcare system n who has - Aka “clean technique”, kill microorg to prevent them from spreading
access to medical care - All practices intended to confine a specific microorganism to a specific area
D. POOR HEALTH IN AN UNFAV ENVI - Limits #, growth, and transmission of microorganism
- Young child who is starving in a drought-stricken country - clean - absence of almost all microorg
5. NEEDS FULFILLMENT MODEL - dirty – soiled, contaminated
- Health states in w/c needs are being sufficiently met to allow an individual 3 COMMONLY PRACTICED METHODS OF MED ASEPSIS
to function successfully in life w/ ability to achieve highest possible 1. SANITIZATION
potential - Cleaning practices and techniques that physically remove microorganism.
FACTORS AFFECTING HEALTH & ILLNESS - Handwashing, cleaning of client’s personal equipment, clothing & linen
1. PHYSICAL FACTORS 2. ANTISEPSIS
- AGE, SEX, RACE, GENETIC MAKE-UP, DEVELOPMENTAL LEVEL - Killing microorg and limiting their growth on the skin & non-living objects
- Children are more prone to acquire communicable diseases - Alcohol, povidone-iodine, hand scrubbing; treating cuts, wounds, burns
- Woman who has a family hx of breast cancer is @ risk for developing this 3. DISINFECTION
condition - Can’t be used on skin
2. EMOTIONAL FACTORS - Killing microorg on objects like bed tables, wheelchair, bp cuffs.
- How mind and body interact to affect body function n to respond body - Cannot destroy spres
conditions also influences health AUTOCLAVE MACHINE
- Student develops diarrhea prior to a test - Sterilize surgical instruments
3. INTELLECTUAL FACTORS - Uses high pressure and temperature to kill microorg and spores
- Cognitive ability, educational background, past experiences - Steam and gas autoclave
- Elderly woman who has only a 3rd grade attainment needs teaching abt
complicated diagnostic test 2. SURGICAL ASEPSIS/STERILE TECHNIQUE
- Young college student w/ diabetes who follows diabetic diet but continues - Practices that keep an area or obj free of all organism
to drink beer n eat pizza w/ friends several time a wk - Destroy all microorganism including SPORES
4. SPIRITUAL FACTORS - Spores – microscopic dormant structure formed by some pathogens that
- Spiritual and religious beliefs often survive common cleaning technique
- Roman Catholics require baptism for both live births and still born babies
 - VS Disinfection – destroys or kills most of microorganism except bacterial
spores METHODS OF TRANSMISSION
- Absence of microorg w/in any type if invasive procedures a. DIRECT TRANSMISSION
- SEPSIS – state of infection, organ injury or damage in response to infection, - Immediate n direct transfer of microorganism from person to person thru
take many forms including septic shock touching, biting, kissing, or sexual intercourse
- DROPLET is a direct transmission but can only occur if source and host are
PRINICIPLES OF STERILE TECHNIQUE: w/in 3ft of e/o (sneezing, coughing, spitting, talking)
NURSES-PATIENTS-HEALTH CARE FACILITY b. INDIRECT TRANSMISSION
1. VEHICLE BORNE
2 TYPES OF HANDWASHING o Transport and introduce infectious agent into a susceptible host
1. MEDICAL HANDWASHING thru food, water, blood, plasma, Fomites or inanimate object/
- Reduction of # of disease causing agents materials(toys, handkerchief, soiled clothes)
- 40-60, 2x hbd song 2. VECTOR BORNE
2. SURGICAL HANDWASHING o Animal or flying or crawling insects
- Complete elimination of disease causing agents and spores from surface o Occur by injecting salivary fluid during biting or depositing feces or
- 2-6 mins other materials on skin thru bite wound or traumatized skin
c. AIRBORNE TRANSMISSION
TYPES OF MICROORGANISMS CAUSING INFECTIONS - Droplets or dust
BACTERIA - DROPLET NUCLEI – residue of evaporated droplets emitted by an infected
- Most common infection-causing microorganism that may be transported host such as TB can remain in air for long periods
thru air, water, foods, soil, body tissues, and fluids - C. difficile (spores from soil) can become airborne
FUNGI 4. PORTAL OF ENTRY
- Yeast or molds - Skin is barrier to infectious agents
PARASITES - Break can readily serve as a portal of entry
- Protozoa, malarial causing, helminths or worms, anthropods (mites, fleas, - Mircroorg often enter body by same route they used to leave source
ticks) 5. SUSCEPTIBLE HOST
- Live on other living organisms - any person who is @ risk for infection
VIRUSES - compromised host – more likely to acquire an infection
- Enter living cells in order to reproduce, rhinovirus for common cold, - Variables: age, p.t receiving immune suppression treatment, p.t w/
hepatitis, herpes, HIV immune deficiency conditions
BODY DEFENSES AGAINST INFECTION
TYPES OF INFECTION 1. NONSPECIFIC DEFENSES
1. COLONIZATION - Protect person against all microorf regardless of prior exposure
- Strains of microorganisms become resident flora (not an infection) 2. SPECIFIC (IMMUNE) DEFENSES
- may grown n multiply but don’t cause disease - Directed against identifiable bacteria, viruses, fungi
- becomes infection if the microorganism succeeds invading part of the body 3. ANATOMIC & PHYSIOLOGICAL BARRIERS
where host’s defense mechanism are ineffective and pathogen cause tissue - Intact skin n mucous membranes
damage - Moist mucous membrane n cilia of nasal passages
- infection becomes disease when signs n symptoms of infection are unique - Alveolar macrophages
can be differentiated from other condition - Saliva
2. LOCAL INFECTION - Tears
- Limited to specific part of the body where microorganism remain - High acidity of stomach
3. SYSTEMIC INFECTION - Resident flora of large intestine
- When microorganism spread and damage diff parts of the body - Peristalsis
4. BACTEREMIA - Low pH of vagina
- When a culture of the person’s blood reveals microorganism - Urine flow through urethra
5. SEPTICEMIA
- Bacteremia results in system infection NONSPECIFIC DEFENSES
6. ACUTE INFECTION INFLAMMATORY RESPONSE
- Appear suddenly or last a short time - Inflammation “-itis”
7. CHRONIC INFECTION - Local n non specific defensive response of tissues to an infectious agent
- Occur slowly over a long period of time - Adapative mechanism that destroys or dilutes infectious agent, prevents
8. NOSOCOMIAL INFECTION further spread, n promotes repair of damaged tissue
- Associated w/ delivery of HCS in a HC facility 5 SIGNS
- Either develop during a client’s stay in a facility or manifest after discharge - REDNESS
- May also acquired by health personnel working the facility and can cause - PAIN
significant illness and time lost from work - HEAT
- ENDOGENOUS – cause nosocomial infection that originate from client - SWELLING
themselves (E.coli, Staph Aureus) - IMAPAIRED FUNCTION OF BODY PART
- EXOGENOUS – from hospital envi n personnel
- IATROGENIC – direct result of diagnostic or therapeutic NURSING MANAGEMENTS:
procedure(Bacteremia from IV line) 1. ASSESSING
- Consider compromised host - Client’s hx, conducts P.A, laboratory data
- Poor hygiene as major contributor - Nursing history – degree to w/c client is @ risk of developing an infection,
client complaints
CHAIN OF INFECTION - P.A – watch out for signs n symptoms of infection (localized swelling &
1. ETIOLOGIC AGENT redness, pain w/ palpation, palpable heat @ infected area, loss of function)
- Producing an infectious process - Systemic Infection: fever, increased PR & RR if fever is high, malaise and
- # of microorganism present loss of energy, anorexia, nausea, enlargement of lymph nodes
- Virulence and potency - Lab data: elevated WBC/leukocytes & ESR, urine, blood, sputum
- Ability to enter the body 2. DIAGNOSING
- Susceptibility of the host - Risk for infection – state w/c client is @ increased risk for being invaded by
- Ability to live in the host’s body pathogenic microorganism
- Risk factors: inadequate primary n secondary defenses
2. RESERVOIR - Hyperthermia
- Sources of microorganisms - Imbalanced nutrition
a. Other humans - Acute pain
b. Client’s own microorganism - Impaired social interaction/ isolation
c. Plants - Anxiety
d. Animals 3. PLANNING
e. General envi: food, water, feces GOALS – maintain/restore defense, avoid spread of infectious organism,
- CARRIER – person/animal reservoir of a specific infectious agent that reduce/alleviate probs w/ infection
usually does not manifest any clinical signs of disease STRATEGIES – use of meticulous med n surg aseptic tech, implementing measures
to support defense of susceptible host, teach client abt protective measures
3. PORTAL OF EXIT - If the infection cannot be prevented, the nurse’s goal is to prevent the
- Before an infection can establish itself in a host, microorganism must leave spread of the infection within and between persons and to treat the
the reservoir existing infection
 4. IMPLEMENTING 1. Report incident immediately
- Preventing nosocomial infections 2. Complete injury report
- Proper hand hygiene – most effective infection prevention, reduces 3. Seek appropriate evaluation and ff up
infection n spread of germs a. Identify and document the source individual when feasible and
- Environmental controls legal
- Sterile technique when warranted b. Test the source for hepa B, C, and HIV when feasible and consent
- Identification & management of clients @ risk is given
- ANTISEPTICS – inhibit growth of some microorg c. Make results of the test available to the source individual’s health
- DISINFECTANTS – destroy pathogens but spores care provider
- STERILIZING – moist heat, gas, boiling water, radiation d. Test blood exposed with consent for hepa B, C, and HIV
INFECTION PREVENTION & CONTROL e. Post exposure prophylaxis if medically indicated
- Bloodborne pathogens, standard precautions aka universal precautions, f. Medical and psychologic counseling
respiratory hygiene, isolation (to prevent spread) FOR PUNCTURE/LACERATION
ISOLATION PRECAUTIONS: 1. Encourage bleeding
- Strict isolation 2. Wash/clean the area with soap and water
- Contact isolation 3. Initiate first aid
- Respiratory isolation 4. Seek treatment if indicated
- Tuberculosis isolation FOR MUCOUS MEMBRANE EXPOSURE (eyes, nose, mouth)
- Enteric precaution - Flush with saline or water for 5 to 10 minutes
- Drainage/secretion precaution POSTEXPOSURE PROTOCOL (PEP): HIV
- Blood precaution 1. Start treatment, preferably within hours of exposure
DELINATE PRACTICES FOR SPECIFIC DISEASE: 2. For “high-risk” exposure (high blood volume and source with high HIV
- Use private rooms w/ special ventilation titer), 3-drug treatment recommended
- Cohorting clients infected w/ same organism 3. For “increased risk” exposure (high blood volume or source with high HIV
- Gowning to prevent gross soilage of clothes titer), 3-drug treatment recommended
STANDARD PRECAUTIONS 4. For “low risk” exposure (neither high blood volume nor source with high
- For all clients HIV titer), 2-drug treatment considered
- Decrease risk of transmitting recognized n unrecognized sources of 5. Drug prophylaxis continues for 4 weeks.
infection 6. Drug regimens vary.
- For blood, body fluids except sweat, nonintact skin, mucous membrane 7. New drugs and regimens continuously developed
TRANSMISSION-BASED PRECAUTION 8. Baseline HIV antibody tests done shortly after exposure
- May used alone or in combination but ALWAYS in addition to standard 9. Repeated at 6 weeks, 3 months, and 6 months after exposure
precaution POSTEXPOSURE PROTOCOL (PEP): HEPATITIS B
- Known or suspected infections spread: 1. Anti-HBs testing after last vaccine dose
- Airborne, droplet, contact 2. HBIG and/or hepatitis B vaccine within 1 to 7 days after exposure for
- Comprised client: w/leukemia, extensive skin impairments, major burns. nonimmune workers
POSTEXPOSURE PROTOCOL (PEP): HEPATITIS C
AIRBORNE PRECAUTIONS(nuclei <5 microns) 1. Anti-HCV and ALT at baseline
- MEASLES (RUBEOLA), TB, VARICELLA 2. Repeat 4–6 months after exposure
- Placed in negative air pressure room 5 MOMENTS OF HAND HYGIENE
- N95 respiratory 1. BEFORE TOUCHING PATIENT
DROPLET PRECAUTIONS (droplet >5 microns) 2. BEFORE ASPETIC TASK
- DIPTHERIA, PERTUSSIS, MUMPS, RUBELLA, PNEUMONIA 3. AFTER BODY FLUID EXPOSURE
- Regular mask if working w/in 3ft of client 4. AFTER TOUCHING PATIENT
- Place surgical mask on client during transport 5. AFTER TOUCHING PATIENT SURROUNDINGS
CONTACT PRECAUTIONS
- Easily transmitted by direct contact EVALUATING
- E.COLI, C. DIFFICILE, HEPA A, MRSA - Data collected, nurse judges whether client outcomes were achieved
- Gloves, gown - Need to reevaluate and change care plan if outcomes were not achieved
PERSONAL PROTECTIVE EQUIPMENT SAFETY CONSIDERATIONS
- Gloves, gowns, masks, eyewear - Hand hygiene is priority before any aseptic task
DONNING: - Ensure client understand how to prevent contamination of equipment and
- HAND, GOWN, MASK, GOOGLES, GLOVES know to refrain from sudden movements
DOFFING: - Choose appropriate PPE to decrease transmission
- GLOVES, GOGGLES, GOWN, MASK, HAND - Review hospital procedures & reqs for sterile technique
ISOLATION PRACTICES: - HCP who are ill should avoid invasive procedure, or if they can’t avoid,
A. ISOLATION double mask
- Negative pressure for clients w/ contagious disease (airborne conditions)
B. REVERSE ISOLATION DONNING N DOFFING PPE
- Positive pressure, for immunocomprised patients (decreased WBC,
chemotherapy, organ transplant) LEVELS OF PROTECTION
C. DISPOSAL OF SOILED SUPPLIES LEVEL 1 PPE
D. TRANSPORTING CLIENT W/ INFECTION - SURGICAL MASK & HAND HYGIENE ONLY
- Avoid unless absolutely necessary - FOR LOWEST RISK AREAS
- Nurses implements appropriate precautions - FOR ADMINISTRATIVE OFFICES
- Nurses notifies personnel in receiving are so they can maintain precautions - NO RECYCLING REQUIRED
E. PSYCHOSOCIAL NEEDS OF ISOLATION LEVEL 2 PPE
- Sensory deprivation - MASK, SHIELD, HAND HYGIENE
- Feelings of inferiority - LOW RISK AREAS
- Regular communication & activities - PERSONNEL WHO SEE NON COVID-19 P.T WHENEVER W/IN 6 FT
- Use least strict precaution LEVEL 3 PPE
F. STERILE TECHNIQUE - N95, GOOGLES, CAP, SHOE COVER, GOWN, GLOVES, HAND HYGIENE
- Free of all microorganism - DONNING: GOWN, MASK, GOOGLES, GLOVES
- Sterile field LEVEL 4 PPE
- Sterile gloves - N95, HAZMAT SUIT, CAP, 2X GLOVES, GOGGLES, SHOE COVER, GOWN
- Sterile gowns REMEMBER:
OCCUPATIONAL EXPOSURE 1. Doffing is more crucial than donning.
- Contact w/ potentially infectious materials during employee duties 2. Proper waste management is needed to reduce spread of contaminated PPEs
MAJOR MODES OF TRANSMISSION 3. For you respirators and/or those PPEs that are not disposable proper
1. PUNCTURE WOUNDS cleaning and disinfection is needed before using it again.
- Contaminated needles/sharps - For goggles and face shield, soap and water is recommended for cleaning
2. SKIN CONTACT Refrain from using alcohol containing agents. It may cause damage to the material.
- Infectious fluids enter thru wounds/damaged skin (acrylic)
3. MUCOUS MEMBRANE CONTACT - UV light can be used as a disinfectant. Exercise proper precaution in using UV light.
- Eyes, mouth, nose
PRACTICE GUIDELINES SAFTEY – ACCIDENTS OFTEN CAUSED BY HUMAN CONDUCT AND CAN BE
- After exposure to bloodborne pathogens PREVENTED
MASLOW’S HIERARCHY OF NOTES: - Put oral suctioning equipment in place
1. PHYSIOLOGY, BODY - Remain with the client. Do not restrain.
2. SAFETY, SECURITY - Loosen clothing around neck and chest.
3. LOVE, BELONGING - Turn client to lateral position.
4. SELF-ESTEEM - Remove anything that may cause injury
5. SELF-ACTUALIZATION - Time & observe the seizure
SAFETY - Apply oxygen
- Freedom from danger, harm, risk - Reorient client when seizure has subsided
- Freedom from accidental injury 7. CARBON MONOXIDE POISONING
FACTORS AFFECTING SAFETY 8. EXCESSIVE NOISE
1. AGE & DEVELOPMENT 9. ELECTRICAL HAZARDS
A. FETUS – exposure to smoking, alcohol consumption, drugs, x-rays, 10. FIREARMS
pesticides 11. RADIATION
B. NEWBORN & INFANTS – falling, suffocation, electric shock, - Limit time near the source.
automobile accidents - Provide as much distance as possible from the source.
C. TODDLERES – physical trauma from falling, banging objects, cuts, - Use shielding devices such as lead aprons when near the source.
drowning, poisoning 12. BIOTERRORISM ATTACK
D. PRESCHOOLERS – injury from traffic, choking, suffocation, harm from - MITIGATION – STEPS TO REDUCE VULNERABILITY TO DISASTER IMPACTS
people/animals, obstruction of airway - PREPAREDNESS – UNDERSTANDING HOW DISASTER MIGHT IMPACT
E. ADOLESCENTS – vehicular accidents, recreational accidents, firearms, COMMUNITY
abuse - RESPONSE – ADDRESSES IMMEDIATE THREATS
F. OLDER ADULTS – falling, burns, pediatrician & automobile accidents - RECOVERY – RESTORATION OF ALL ASPECTS
2. LIFESTYLE
- Unsafe home n work envi, neighborhood w/ high crime rate, access to When in doubt about a course of action, the nurse should consult the appropriate
guns, insufficient income, access to illicit drugs n risk taking behaviors written guidelines before proceeding.
3. MOBILITY & HEALTH STATUS
- People w/ impaired mobility are prone to injury RESTRAINTS – protective devices used to limit physical activity of client / part of the
- Paralysis, muscle weakness, diminished balance body
4. SENSORY-PRECEPTUAL ALTERATION - To avoid/prevent purposeful/accidental harm to client
- People w/ impaired touch, hearing, taste & smell, and vision - To do what is required to provide medically necessary treatment that could
5. COGNITIVE AWARENESS not be provided
- People lacking sleep, disoriented, mildly confused PHYSICAL RESTRAINTS
6. EMOTIONAL STATE - Manual method/physical/mechanical device attached to the client’s body
- Alters ability to perceive envi hazards CHEMICAL RESTRAINTS
7. ABILITY TO COMMUNICATE - Medications used to control behavior
- Aphasia, lang barriers, inability to read
8. SAFETY AWARENESS Legal implications of restraints
- Lack of knowledge - Restraints restrict the individual’s freedom
9. ENVIRONMENTAL FACTORS - Orders are renewed daily
- Diagnostic errors, domino effect nurse to client - Order must state reason and time period
10. HEALTH CARE SETTING - PRN order is prohibited
- failure of planned action, wrong plan to achieve aim, being late, - In all cases, restraints used only after every other possible means proved
interruption, stress, fatigue unsuccessful and was documented
11. BIOTERRORISM - Nurses must document need for restraint
- Natural calamities and acts of terrorism - May apply restraints but physician must see client w/in 1 hr for
- Attacks : anthrax, botulism, plague, small pox, tularemia, viral hemorrhagic evaluation
fevers - Written restraint order for an adult, valid only 4 hrs
STANDARDS FOR APPLYING RESTRAINTS
NURSING MANAGEMENT 1. BEHAVIOR MANAGEMENT STANDARD
1. ASSESSING - When client is a danger to self/others
- AGE N DEVELOPMENTAL LEVEL - Nurses may apply but physician must see client w/in 1 hr for evaluation
- GENERAL HEALTH STATUS 2. ACUTE MEDICAL & SURGICAL CARE
- MOBILITY STATUS - Temporary immobilization of client is required to perform a procedure
- SENSORY IMPAIRMENT 3. DOCTOR’S ORDER FOR RESTRAINTS
- COGNITIVE STATUS - Must state reason & time period
- EMOTIONAL STABILITY RESTRAINTS
- SUBSTANCE ABUSE - should be used only after every other possible means of ensuring safety
- HX OF ACCIDENT/INJURY have been unsuccessful and documented
2. DIAGNOSING - cannot be used for staff convenience or client punishment.
- RISK FOR INJURY, POISONING, SUFFOCATION, TRAUMA, CONTAMINATION, KINDS OF RESTRAINTS
ASPIRATION, DEFICIENT KNOWLEDGE, LATEX ALLERGY RESPONSE a. VEST RESTRAINTS
3. PLANNING - To ensure safety of confused/ sedated clients in beds/wheelchairs
- Prevent accidents & injury b. BELT/ SAFETY STRAP
- Identify hazards in home n community - To ensure safety of all clients who are being moved on
- Demonstrate safety practices stretcher/wheelchairs
- Experience a decrease in frequency of injury c. MITT / HAND RESTRAINTS
4. IMPLEMENTING - To prevent confused clients from using hands/fingers to scratch n injure
- Observation/prediction of potentially harmful situations themselves
- Client education d. LIMB RESTRAINTS
- To immobilize limb for therapeutic reasons
NATIONAL PATIENT SAFETY GOALS e. SWADDLING
- Analyzes system to find out why the error was made rather than finding - For infants
out who made the error EVALUATING
PREVENTING SPECIFIC HAZARDS - Desired outcomes reflect:
1. SCALDS AND BURNS - Acquired knowledge about hazards
- SCALD – burn from hot liquid or vapor - Behaviors that incorporate safety practices
- BURN – excessive exposure to thermal, chemical, electric, radioactive - Skills to perform in event of emergency
agents - Describe methods to prevent hazards
2. FIRES - Report use of home safety measures
- RACE: RESCUE, ACTIVATE, CONFINE, EXTINGUISH - Alter home environment to reduce risk of injury
- PASS: PULL, AIM, SQUEEZE, SWEEP - Describe emergency procedures for poisoning and fire
3. POSIONING - Describe age-specific risks, work safety risks, or community safety risks
4. SUFFOCATING OR CHOKING - Demonstrate correct use of child safety seats
5. FALLS - Demonstrate correct administration of cardiopulmonary resuscitation
- If client fell: ASSESS FOR INJURIES, NOTIFY PRIMARY CARE PROVIDER
6. SEIZURES WOUND CARE ASSESSMENT & DRESSING
- Pad the client’s bed WOUND
 - Disruption to the integrity of skin that leaves body vulnerable to pain n - Systemic infection – microorg spread from wound to vascular/ lymphatic
infection system (systemic medication)
TYPES OF WOUND ODOR
1. INCISION - No odor
- Caused by sharp instrument (knife, scalpel, scissors) - Slight odor – dressing is removed
- Open wound; deep/shallow - Moderate – upon entering when dressing is removed
- Once edges are sealed together incision becomes close wound - Strong – upon entering when dressing is intact
2. CONTUSION “PASA”
- Caused by blow from blunt instrument MOISTURE
- Closed wound - TYPES OF EXUDATE
3. ABRASION “GASGAS” A. SEROUS – clear, thin, watery fluid
- Surface scrape, intentional or not B. SEROSANGUINEOUS – thin, watery w/ light red or pink hue
- Open wound C. SANGUINEOUS – bright red, fresh blood
4. PUNCTURE D. PURULENT – thick, opaque, odorous
- Penetration of skin & often underlying tissues by sharp instrument, EDGES
intentional or not - ADVANCING – edges are pink, healing
- Open wound - NOT ADVANCING – edges are raised, rolled, red/dusky (reassess risk
- Tusok factors)
5. LACERATION RISK FACTORS FOR WOUND HEALING
- Tissues torn apart 1. DEVELOPMENTAL CONSIDERATIONS
- Open wound; edges are often jagged 2. LIFESTYLE
6. PENETRATING WOUND 3. NUTRITION
- Penetration of skin from bullet or metal frag 4. MEDICATIONS
- Open wound
WOUND DEGREE OF CONTAMINATION PHASES OF WOUND HEALING
CLEAN WOUNDS 1. INFLAMMATORY PHASE
- Minimal inflammation - Lasts 4-6 days
- Primarily closed wounds - Marked by edema, erythema, inflammation & pain
- respiratory, gastrointestinal, genital and urinary tracts are not entered. - Healing process triggered
CLEAN-CONTAMINATED WOUNDS - Immune system work to prevent colonisation
- surgical wounds 2. PROLIFERATIVE PHASE
- no evidence of infection - Lasts 4-24 days
- respiratory, gastrointestinal, genital and urinary tracts has been entered - Granulation tissue feels wound
CONTAMINATED WOUNDS - Edges begin to contract
- open, fresh, accidental, n surgical wounds have major break in sterile - Epithelial cells migrate
technique 3. MATURATION PHASE
- show evidence of inflammation - Lasts 21 -2 years
DIRTY OR INFECTED WOUNDS - Depends on patient & wound related factors
- contains dead tissue - Filled-in wound is covered n strengthened
- evidence of clinical infection such as purulent discharge - Scar tissue forms
WOUNDS ACCORDING TO DEPTH WOUND DRESSING
1. PARTIAL THICKNESS - to protect the wound from mechanical injury.
- wounds that extend only into first 2 layers of skin - to protect the wound from microbial contamination.
2. FULL THICKNESS - to provide or maintain moist wound healing.
- damage extends below epidermis n dermis into subcutaneous tissue or - to provide thermal insulation.
beyond - to absorb drainage or debride a wound or both.
- to prevent hemorrhage (pressure dressing or elastic bandages.
PRESSURE ULCERS - to splint or immobilize the wound site and facilitate healing and prevent
- damage to an area of skin caused by constant pressure on area for a long injury.
time
- can lessen blood flow to the affected are, may lead to tissue damage and
tissue death
- previously called decubitus ulcer, bed sores
STAGES OF PRESSURE ULCER
STAGE 1: non blanching erythema, w/ intact epidermis
STAGE 2: partial thickness ulcer involving 2 dermis
STAGE 3: full thickness 2 dermis to subcutaneous
STAGE 4: deep tissue destruction thru fascia

WOUND RISK ASSESSMENT

1. BRADEN RISK ASSESSMENT SCALE
- Standardized, evidence-based assessment tool
- Used for client’s developing pressure ulcers
- Mild risk: 15-18
- Moderate: 13-14
- High: 10-12
- Severe: <9
2. NORTON’S PRESSURE AREA RISK ASSESSMENT
- Developed in 1960s
- Asses risk for pressure ulcer in adult p.t
- Five subscale score
- Lower Norton score = higher lvl of risk for pressure ulcer development
TIME
TISSUE
- Usually described by color
- Epithelial: pink/pearly white (protect)
- Granulating: red and moist, well vascularized and bleeds easily (protect)
- Slough: yellow, brown, grey, made of dead cells/debris (debride)
- Necrotic: hard, dry, black, dead tissue that prevents wound healing
(debride)
INFECTION/INFLAMMATION/ODOR
- Essential part of wound healing
- Contamination – presence of microorg are contained and do not multiply
(clean)
- Colonization – microorg multiple but do not provoke host response
- Local infection – invasion by an agent, multiplies and produces effects to
the client (topical antimicrobial)