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ATI Topic Descriptors Basic Care and Comfort (13) Plan A Hygiene Care: Evaluating Appropriate Use of Assistive Devices Cane instructions: Maintain two points of support on the ground at all times Keep the cane on the stronger side of the body Support body wt on both legs, move cane forward 6-10 inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg Dentures: Clients who have fragile oral mucosa require gentle brushing and flossing. Perform denture care for the client who is unable to do it himself Remove dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture. Place dentures in a denture cup or emesis basin Brush them with a soft brush and denture cleaner Rinse them with water Store the dentures, or assist the client with reinserting the dentures Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for Pain Management Music decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music
Prostate Surgeries: Calculating a Clientʼs Output When Receiving Continuous Bladder Irrigations purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or sediment can collect within tubing resulting in bladder sistention and buildup of stagnant urine) Med-Surg p. 1443 after prostate surgery, irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter. with CBI, irrigating soln is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. The inflow and outflow of irrigant must be continuously monitored. If outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If the outflow is blocked and patency cannot be reestablished by manual irrigation, the CBI is stopped and the physician notified. Record amount of urine output and character of urine every eight (8) hours or as per physicianʼs orders. (To obtain urine output, subtract amount of fluid instilled into bladder from total output.) intermittent irrigation dorsal recumbent or supine position avoid cold solution bec may result in bladder spasm clamp cath just below soft injection port cleanse injection port with antiseptic swab (same port as specimen collection) insert needle through port at 30degree angle slowly inject fluid into cath and bladder withdraw syringe remove clamp and allow solution to drain into drainage bag if ordered by MD, keep clamped to allow solution to remain in bladder for short time (20-30min) Closed continuous irrigation Recording and Reporting
Record type and amt of irrigation soln used, amt returned as drainage and the character of drainage Record and report any findings such as complaints of bladder spasms, inability to instill fluid into bladder and/or presence of blood clots. Urinary Elimination: Kegel Exercises for Urinary Incontinence sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( to learn the muscle) then practiced at nonvoiding times instruct client to contract muscle for a count of 3, hold and release for a count of 3, and repeat this 10x. Client should repeat these cycles for 25-30x 3x/day for 6 months. Client should do this 5x.day Bowel Elimination Needs: Client Education Regarding Colostomy Care Stoma s/b pink. Dusky blue stoma---ischemia Brown-black stoma---necrosis mild to moderate swelling for 1st 2-3 weeks after surgery intact skin barriers with no evidence of leakage do not need to be changed daily and can remain in place for 3-5 days. skin should be washed with mild soap, warm water and dried thoroughly before barrier applied pouch must fit snugly to prevent leakage around stoma. The opening around the appliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks and does not reach usual size for 6-8 weeks empty pouch before it is 1/3 full to prevent leakage cleanse skin and use skin barriers and deodorizers to prevent skin breakdown and malodor
apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in; let dry 1-2 min apply non-allergic paper tape around the pectin skin barrier in a picture frame method. Burns: Non-pharmacologic Comfort Interventions for Dressing Changes Med/Surg p. 534-535 Distractions Relaxation tapes visualization guided imagery biofeedback meditation used as adjuncts to traditional pharmacologic txs of pain Visualization and guided imagery can be helpful to the nurse as well as the pt nurse ask the pt about a favorite hobby or recent vacation nurse can explore these areas further by asking questions that make the pt visualize and describe a favorite hobby or recent vacation by using this method, both the nurse and the pt must focus on things besides the task at hand. (ie dressing change) to keep the conversation flowing Relaxation tapes can be helpful when played at night to help the pt fall asleep. Application of Heat and Cold: Assess Need for Heat/Cold Applications Application of Cold: Ensure Safe Use of Cold Applications Potter/Perry p. 1253-1254 Cold and heat applications relieve pain and promote healing. selection varies with clientʼs conditions. moist heat can help relieve the pain from a tension HA cold heat can reduce the acute pain from inflamed joints avoid injury to skin by checking the temp and avoiding direct application of the cold or hot surface to the skin esp at risk: spinal cord or other neuro injury, older adults, confused clients
Ice massage or cold therapy are particularly effective for pain relief. Ice massage: apply the ice with firm pressure followed by slow steady, circular massage Cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located between the brain and the pain site. takes 5-10 minutes to apply cold each client responds differently to the site of the application that is the most effective application near the actual site of pain tends to work best a client feels cold, burning and aching sensations and numbness. When numbness occurs, the ice should be removed. cold is particularly effective for tooth or mouth pain when ice is place on the web of the hand between the thumb and index finger cold applications are also effective before invasive needle punctures Heat application donʼt lay on heating element bec burning could occur Assessment for Temperature Tolerance (P/P p. 1549) before applying either, the nurse should assess the clientʼs physical condition for signs of potential intolerance to heat and cold first observe the area to be txʼd alterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleeding or localized areas of inflammation increase the clientʼs risk of injury. baseline skin assessment provides a guide for evaluating skin changes that might occur during therapy assessment includes id of conditions that contraindicate heat or cold therapy: an active area of bleeding should not be covered by a warm application bec bleeding will continue warm applications are contraindicated when client has an acute, localized inflammation such as appendicitis bec the heat could cause the appendix to rupture.
if client has CV problems, it is unwise to apply heat to large portions of the body bec the resulting massive vasodilation may disrupt blood supply to vital organs. cold is contraindicated if the site of injury is already edematous cold furth retards circulation to the area and prevents absorption of the interstitial fluid. if client has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area cold contraindicated in presence of neuropathy (client unable to perceive temp changes) cold contraindicated in shivering (intensifies shivering and dangerously increase body temp) If MD orders cold therapy to lower extremity, assess for cap refill, observing skin color and palpating skin temp, distal pulses and edematous areas if signs of circulatory inadequacy, question order if confused or unresponsive, make freq observations of skin integrity after therapy begins assess condition of equip used before applying heat and cold, understand normal body responses to local temp variations, assess the integrity of the body part, determine the clientʼs ability to sense temp variations and ensure proper operation of equipment. Crohnʼs Disease: Selecting a Low-Fiber, Low-Residue Diet No raw vegetables, vegs not strained, dried beans, peas, and legumes No raw fruits, fruits with skins, seeds No nuts, raisins, rich desserts no whole grain breads or cereals no fried, smoked, pickled or cured meats, no alcohol, fruit juices with pulp Dumping Syndrome: Client Education Regarding Dietary Interventions meal size must be reduced accordingly (6 small feedings) no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullness dry foods with low-carb content and moderate protein and fat content
proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullness short rest period after each meal Cholecystitis: Dietary Restrictions Low in fat, and sometimes a wt reduction diet is also recommended (4-6 weeks take fat soluble vit supplements Palliative Care: Client/ Family Teaching caring interventions rather than curing interventions for any age, diagnosis, any time, and not just during the last few months of life preservation of dignity becomes the goal of palliative care allows clientʼs to make more informed choices, achieve better alleviation of sx and have more opportunity to work on issues of life closure establish a caring relationship with both client and family management of sx of disease and therapies Preparing the Dying Clientʼs Family (P/P 588) Objectives: family will be able to provide appropriate physical care for the dying client in home family will be able to provide appropriate psychological support to the dying client. Describe and demonstrate feeding techniques and selection of foods to facilitate ease of chewing and swallowing Demonstrate bathing, mouth care, and other hygiene measures and allow family to perform return demo show video on simple transfer techniques to prevent injury to themselves and client, help family to practice instruct family on need to enforce rest periods
teach family to recognize s/s to expect as the clientʼs condition worsens and provide info on who to call in an emergency discuss ways to support the dying person and listen to needs and fears solicit questions from family and provide info as needed. Evaluation: Have the family members demo physical care techniques ask family members to describe how they vary approaches to care when the client has sx such as pain or fatigue ask the family to discuss how they feel about their ability to support the client . Cognitive Disorders: Promoting Independence in Hygiene for A Client with Alzheimerʼs Disease Stage S/S Stage 1, Forgetfulness Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception Stage 2, Confusion Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities Stage 3, Ambulatory dementia loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn
Stage S/S Stage 4, End Stage Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirror Assess teaching needs for the client and especially for the family members when the clientʼs cognitive ability is progressively declining. Review the resources avail to the family as the clientʼs health declines. A wide variety of home care and community resources may be avail to the family in many areas of the country, and these resources may allow the client to remain at home rather than in an institution Perform self assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients with progressive dementia NCP Med/Surg 1592 Monitor ptʼs ability for independent self-care to plan appropriate interventions specific to pt unique problems Use consistent repetition of daily health routines as a means of establishing them bec memory loss impairs ptʼs ability to plan and complete specific sequential activities assist pt in accepting dependency to ensure that all needs are met. teach family to encourage independence and to intervene only when the pt is unable to perform to promote independence Bathing/Hygiene provide desired personal articles, such as bath soap and hairbrush, to enhance memory and provide care facilitate ptʼs bathing self as appropriate to facilitate independence and provide appropriate help in hygiene Dressing/Grooming provide ptʼs clothes in accessible area to facilitate dressing Be available for assistance in dressing as necessary to facilitate independence and provide appropriate help in dressing
Toileting Assist pt to toilet as specified intervals to promote regularity facilitate toilet hygiene after completion of elimination to prevent discomfort and skin breakdown. Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203) If untreated lead to three problems insomnia abnormal movements or sensation during sleep or when awakening at night, or excessive daytime sleepiness. Four categories Dyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndrome Parasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts
Nocturnal leg cramps REM Sleep disturbances nightmares REM Sleep behavior disorder sleep paralysis Other Parasomnias sleep bruxism (teeth grinding) sleep enuresis (bed-wetting) SIDS Sleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism Central degenerative disorders Other Med Disorders Nocturnal cardiac ischemia COPD PUD Proposed sleep Disorders Menstruation-associated sleep disorders Sleep choking syndrome Pregnancy associated sleep disorders Questions to Ask to Assess for Sleep Disorders Insomnia How easily do you fall asleep Do you fall asleep and have difficulty staying asleep? How many times do you awaken Do you awaken early from sleep What time do awaken for good? What causes you to awaken early? What do you do to prepare for sleep? To improve you sleep? What do you think about as you try to fall asleep
How often do you have trouble sleeping Sleep Apnea Do you snore loudly? Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate report this) Do you experience HAs after awakening Do you have difficulty staying awake during the day Does anyone else in your family snore loudly or stop breathing during sleep? Narcolepsy Are you tired during the day Do you fall asleep at inopportune times? Do you have episodes of losing muscle control or falling to the floor have you ever had the feeling of being unable to move or talk just before falling asleep Do you have vivid lifelike dreams when going to sleep or waking up? Basic Care and Comfort (13) Plan B Mobility and Immobility: Recognizing Proper Use of Crutches Crutch instructions Do not alter crutches after proper fit has been determined Follow crutch gait prescribed by physical therapy support body wt at hand grips with elbows flexed 30 degrees position crutches on unaffected side when sitting or rising from chair. Elkin---pg 135 Use of crutches may be a temporary aid for persons with strains, in a cast or following surgical treatments crutches may be routinely and continuously used for those with congenital or acquired MS abnormalities, neuromuscular weakness, or paralysis or they may be used after amputations. Crutch measurement includes three areas:
clientʼs height distance between crutch pad and axilla angle of elbow flexion [make sure shoes are on before measuring] Standing crutches 4-6 in in front of feet and side of feet Crutch pads two to three fingers between top of crutch and axilla Elbow should be flexed (30 degrees ATI) ***any tingling in torso means crutches are used incorrectly or wrong size if crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy) if crutch too short---bent over and uncomfortable low handgrips cause radial nerve damage high handgrips cause clientʼs elbow to be sharply flexed and strength and stability are decreased 4-point gait requires wt bearing on both legs often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients improves balance by providing wider base of support R crutch, L foot, L crutch, R foot 3 point gait requires wt bearing on 1 foot affected leg does not touch ground may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot 2-point gait requires partial wt bearing on each foot faster than 4-point gait requires more balance crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together. Swing to gait freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
easier of the two swing gaits requires ability to bear body wt partially on both legs Swing through gait requires client have ability to sustain partial wt bearing on both feet Stairs ( up) unaffected leg on step, both crutches come to step, repeat (down) move crutches to stair below, move affected leg forward, then unaffected leg Pain Management: Nonpharmacological Pain Management P/P---ch 42 P/P---pg 1250 Nonpharmacological interventions include cognitive-behavioral and physical approaches best if taught when not experiencing pain Goals of cognitive-behavioral interventions change clientʼs perceptions of pain alter pain behavior provide clients with greater sense of control Goals of physical approaches providing comfort correcting physical dysfunction altering physiological responses reducing fears associated with pain-related immobility Relaxation and Guided Imagery Relaxation mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel decrease in temp numbness of a body part use as feedback free of noise light sheet or blanket use with guided imagery or separate
progressive takes about 15 min pay attn to body noting areas of tension, tense areas replaced with warmth and relation some times better if eyes closed background music can help combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups. Guided Imagery client creates an image in the mind, concentrate on that image and gradually becomes less aware of pain Distraction RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input directs attention to something else and reduces awareness of pain even increases tolerance 1 disadvantage if works, may question the existence of pain works best for short, intense pain lasting a few minutes ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions singing praying describing photos or pictures aloud listening to music playing games may include ambulation, deep breathing, visitors, television, and music Music decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff
highly effective in reducing postop pain if pain acute, increase volume of music Biofeedback behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those responses used to produce deep relaxation and is effective for muscle tension and migraine HA Cutaneous stimulation stimulation of the skin to relieve pain massage warm bath ice bag for inflammation transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation) causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home reduce pain perception and help reduce muscle tension RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy Acupressure/Acupuncture vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points elevation of edematous extremities to promote venous return and decrease swelling Urinary Elimination Needs: Preventing Incontinence Use timed voidings to increase intervals between voidings/decrease voiding frequency perform pelvic floor (Kegel) exercises perform relaxation techniques offer undergarments while client is retraining teach client not to ignore urge to void provide positive reinforcement as client maintains continence
Urinary Elimination: Providing Catheter Care Prevent infection Maintain unobstructed flow of urine through the cath drainage system Perineal Hygiene perineal hygiene 2x/day or prn for client with retention cath soap and water are effective can be delegated to AP Catheter care assess urethral meatus and surrounding tissue for inflammation, swelling and discharge. Note amt, color, odor, and consistency of discharge. Ask client if any burning or discharge is felt with towel, soap and water, wipe in a circular motion along length of catheter for 4 inches apply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MD Mobility and Immobility: Evaluating for Complications of Immobility Complications of Immobility Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Respiratory--maintain patent airway, teach the client to turn, cough and deep achieve optimal lung expansion and gas breath q 1-2 hr exchange and mobilize airway secretions yawn every hour use incentive spirometer CPT 2000ml fluid
Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Cardiovascular---maintain CV fx, increase increase activity activity tolerance and prevent thrombus avoid valsalva maneuver formation stool softener ROM avoid pillows under knees use elastic stockings SCD give low dose heparin Metabolic---decrease injuries to skin and provide high calorie high protein diet with maintain metabolism within normal fxing additional vits B and C monitor oral intake Elimination--maintain or achieve normal maintain hydration (at least 2000 mL urinary and bowel elimination patterns stool softener bladder and bowel training insert cath if bladder distended Musculoskeletal--maintain or regain body change position in bed q 2 hrs alignment and stability decrease skin and ROM MS system changes, achieve full or nutritional intake optimal ROM and prevent contractures CPM Psychosocial--maintain normal sleep/wake coping skills patter, achieve socialization and achieve maintain orientation independent completion of self care develop schedule Gastroenteral Feedings: Monitoring Tube Feedings Monitoring for tube placement initial placement is confirmed with xray monitor gastric contents for pH. A good indication of appropriate placement is obtaining gastric contents with a pH between 0-4 Injecting air into the tube and listening over the abdomen is not an acceptable practice
Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual < 100mL return aspirated contents or follow protocol Flush tubing with 30-60 mL of H20 Acute Glomerulonephritis: Dietary Choice Acute Glomerulonephritis: insoluble immune complexes develop and become trapped in the glomerular tissue producing swelling and capillary cell death Maintain prescribed dietary restrictions Fluid restriction (24 hr output + 500 mL) Sodium restriction Protein restriction (if azotemia is present) Edema is treated by restricting sodium and fluid intake Dietary protein intake may be restricted if there is evidence of nitrogenous wastes. Varies with degree of proteinuria. Low protein, low sodium, fluid restricted diet Rest and Sleep: Interventions to Promote Sleep for Hospitalized Clients Assist the client in establishing and following a bedtime routine Attempt to minimize the number of times the client is awakened during the night while hospitalized Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort Instruct the client to: Exercise regularly at least 2 hr before bed time Arrange the sleep environment to what is comfortable Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtime Apply CPAP devices as ordered by PCP for clients with sleep apnea
As a last resort, provide a pharmacological agent as prescribed. ATI Topic Descriptors Plan A Health Promotion and Maintenance (13) Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736) Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates relaxed muscles allow rapid bleeding from the endometrial arterieries at the placental site bleeding continues until uterine muscle fibers contact to stop the flow of blood. retention of a large segment of the placenta does not allow the uterus to contract firmly and therefore can cause uterine atony Major signs of uterine atony include: fundus that is difficult to locate a soft or boggy feel when the fundus is located a uterus that becomes firm as it is massaged byt loses its tone when massage is stopped a fundus that is located above the expected levels which is at or near the umbilicus excessive lochia especially if it is bright red excessive clots expelled if a peripad is saturated in an hour, a lg amt of blood is considered to have been lost saturation in 15 min represents an excessive loss of blood in the early PP period a constant steady trickle is just as dangeiours if uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus one hand is placed just above the symphysis pubis o support the lower uterine segment while the other hand getnly but firmly massages the fundus in a cirucular motion clots are expressed by applying firm but gently pressure on the fundus in the direction of the vagina
critical that uterus is contracted firmly before clots are expressed pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage and rapid shock. ATI book p.304 uterine atony is hypotonic uterus that is not firm described as boggy. if untreated will result in postpartum hemorrhage and may result in uterine inversion Nursing assessments monitor for s/s of uterine atony which include a uterus that is larger than normal and boggy with possible lateral displacement on pelvic exam prolonged lochia discharge irregulaor or excessive bleeding Assessments for uterine atony include: fundal height, consistency and location lochia quantity, color, and consistency Normal Physiological Changes of Pregnancy: Calculating the clientʼs delivery date ATI p. 34 Nageleʼs rule: take the first day of the last menstrual period, subtract 3 months and add 7 days and 1 year. McDonaldʼs method measure uterine fundal height in centimeteres from the symphysis pubis to the top of the uterine fundus (between 18 to 30 weeks gestation age). The calculation is as follows the gestational age is estimated to be equal to fundal height. Cesarean Birth: Appropriate Client Positioning ATI p. 218
Positioning the client in a supine position with a wedge under one hip to laterally tilt her and keep her off her vena cava and descending aorta. This will help maintain optimal perfusion of oxygenated blood to the fetus during the procedure. Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p. 85 Nonstress Test monitor the response of the FHR to fetal movement client pushes a button attached to the monitor whenever she feels a fetal movement that is noted on the paper tracing. NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 or more times during a 20 min period placenta is adequately perfused and the fetus is well-oxygenated NST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetal movements occur in 40 min. if so, further assessment such as a contraction stress test or biophysical profile is indicated Disadvantages: high rate of false nonreactive results with the fetal movement response blunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturity client should be in a reclining chair or in a semi-fowlersʼ or left lateral position if there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen over the fetal head to awaken a sleeping fetus If still nonreactive, anticipate a CST or a BPP Newborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424 Hypoglycemia : serum glucose level of less than 40mg/dL differs from preterm and term newborn
Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as a blood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as a blood glucose level of < 25 mg/dL Untreated hypoglycemia can result in mental retardation S/S poor feeding jitteriness. tremors hypothermia diaphoresis weak shrill cry lethargy flaccid muscle tone seizures/coma assessments: monitoring BG level closely monitoring IV if unable to orally feed monitoring for signs of hypoglycemia monitoring VS and temp Nursing interventions obtaining blood per heel stick for glucose monitoring freq oral and/or gavage feeding or continuous parenteral nutrition is provided early after birth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death) Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136 True Labor Contractions regular frequency stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measures Cervix progressive change in dilation and effacement moves to anterior portion bloody show
Fetus presenting part engages in pelvis False Labor Contractions painless, irregular freq, and intermittent decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop with comfort measures such as oral hydration Cervix (assessed by vaginal exam) no significant change in dilation or effacement often remains in posterior position no significant bloody show Fetus presenting part is not engaged in fetus Bonding: Promoting Maternal Psychosocial Adaptation During the Taking-In Phase ATI p. 290 Taking In Phase--begins immediately following birth lasting a few hours to a couple of days. Characteristics include passive-dependent behavior and relying on others to meet needs for comfort, rest, closeness, and nourishment. the client focuses on her own needs and is concerned about the overall health of her newborn. She is excited and talkative, repeatedly reviewing the labor and birth experience. Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soon after birth in an en face position Encourage the parents to bond with the infant through cuddling, feeding, diapering and inspecting the infant provide a quiet and private environment that enhances the family bonding process. provide frequent praise, support and reassurance to the mother during the taking-hold phase as she moves toward independence in care of the newborn and adjusts to the maternal role encourage the mother/parents to discuss their feelings, fears, and anxieties about caring for their newborn
Toddler: Recognizing Expected Body-Image Changes ATI the toddler appreciates the usefulness of various body parts toddlers develop gender identity by age 3 Wongʼs Nursing Care of Children (p. 608) Growth slows considerably during toddlerhood. avg wt @ 2 years is 12 kg. head circumference slows and is usually equal to chest circumference by 1-2 years. Chest circumference continues to increase and exceeds head circumference during the toddler years. After the 2nd year the the chest circumference exceeds the abdominal measurement which in addition to the growth of the lower extremities, gives the child, a taller leaner appearance. However, the toddler retains a squat, “pot-bellied” appearance bec of less well- developed abdominal musculature and short legs. Legs retain a slightly bowed or curved appearance during the second year form the weight of the relatively large trunk. Adolescent (12-20 years): Planning Age-Appropriate Health Promotion Education Substance abuse: Drug Abuse Resistance Education (DARE) and other similar programs provide assistance in preventing experimentation Sexual Experimentation:
Abstinence is highly recommended. if sexually activity is occurring the use of birth control is recommended Sexually Transmitted Diseases: Adolescents should undergo external genitalia exams, PAP smears, and cervical and urethral cultures (specific to gender). Rectal and oral cultures may also need to be taken The adolescent should be counseled about risk taking behaviors and their exposure to STDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDs Pregnancy identification of pregnant adolescents should be done to ensure that nutrition and support is offered to promote the health of the adolescent and the fetus. Following infant delivery, education should be given to prevent future pregnancies. Injury prevention encourage attendance at driverʼs ed courses. Emphasize the need for compliance with seat belt use teach the dangers of combining substance abuse with driving (MADD) Insist on helmet use with bicycles, motorcycles, skateboards, roller blades and snowboards screen for substance abuse teach the adolescent not to swim alone teach proper use of sporting equipment Age-appropriate activities: nonviolent video games nonviolent music sports caring for a pet career training programs
reading social events Contraception: Recognizing Correct Use of Condoms ATI p. 6 Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semen from entering the uterus Client Instruction man places condom on his erect penis, leaving an empty space at the tip for a sperm reservoir following ejaculation, the man withdraws his penis from the womanʼs vagina while holding condom rim to prevent any semen spillage to vulva or vaginal area may be used in conjunction with spermicidal gel or cream to increase effectiveness. only water soluble lubricants should be used with latex condoms to avoid condom breakage. Immunizations: Recognizing Complications to Report ATI p. 279 anaphylaxis review sx with parents prodromal sx--uneasiness, impending doom, restlessness, irritability, severe anxiety, HA, dizziness, parethesia, disorientation cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia cutaneous manifestations are often followed by bronchiolar constriction-- narrowing of the airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often life- threatening laryngeal edema instruct parents to call 991 or other emergency number and to keep the child quiet until help arrives Encephalitis, seizures, and.or neuritis review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizure Thrombocytopenia usually associated with measles vaccination teach parents to observe for bleeding
instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs. Older Adult (0ver 65 years): Assessing Risk for Social Isolation Two forms of isolation may be a choice, the result of a desire not to interact with others may be a response to conditions that inhibit the ability or the opportunity to interact wiht others. vulnerable to its consequences vulnerability increased in the absence of the support of other adults as may occur with loss of the work role or relocation to unfamiliar surroundings. impaired hearing, diminished vision, and reduced mobility all contribute to reduced interaction with others and isolation the loss of the ability to drive may limit older adultsʼ ability to live independently as well as contributing to isolation some withdraw bec of feelings of rejection older adults see themselves as unattractive and rejected bec of changes in their personal appearance due to normal aging nurse can assist lonely older adults to rebuild social networks and reverse patterns of isolation outreach programs meals on wheels socialization needs daily telephone call by volunteers need for activities such as outings Spinal Cord Injury: Promoting Independence In Self-Care Spinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control of elimination The level of cord involved dictates the consequences of spinal cord injury. For example, injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec of proximity of the phrenic nerve. Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremities Tetraplegia C1-C8 Paraplegia T1-L4
Level of Injury Movement Remaining Rehab Potential C1-C3 movement in neck and ability to drive electric Often fatal injury, vagus above, loss of innervation to wheelchair equipped with nerve domination of heart, diaphragm, absence of portable ventilator by using respiration, blood vessels, independent respiratory fx chin control or mouth stick, and all organs below injury headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct others C4 sensation and movement in Same as C1-C3 vagus nerve domination of neck and above; may be heart, respirations and all able to breathe without a vessels and organs below ventilator injury C5 full neck, partial shoulder, Ability to drive electric vagus nerve domination of back, biceps; gross elbow, wheelchair with mobile hand heart, respirations, and all inability to roll over or use supports; indoor mobility in vessels and organs below hands; decreased manual wheelchair; able to the injury respiratory reserve feed self with setup and adaptive equipment; attendant care 10 hrs per day C6 shoulder and upper back ability to assist with transfer vagus nerve domination of abduction and rotation at and perform some self-care; heart, respirations, and all shoulder, full biceps to feed self with hand devices; vessels and organs below elbow flexion, wrist push wheelchair on smooth, the injury extension, weak grasp of flat surface; drive adapted thumb, decreased van from wheelchair; respiratory reserve independent computer use with adaptive equipment; attendant care 6 hrs per day
Level of Injury Movement Remaining Rehab Potential C7-C8 All triceps to elbow ability to transfer self to vagus nerve domination of extension, finger extensors wheelchair; roll over and sit heart, respirations, and all and flexors, good grasp with up in bed; push self on most vessels and organs below some decreased strength, surfaces; perform most self- the injury decreased respiratory care; independent use of reserve wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day T1-T6 full innervation of upper full independence in self- Sympathetic innervation to extremities, back essential care and in wheelchair heart, vagus nerve intrinsic muscles of hand; ability to drive car with hand domination of all vessels full strength and dexterity of controls (in most patients); and organs below injury grasp; decreased trunk independent standing in stability, decreased standing frame respiratory reserve T6-T12 Full stable thoracic muscle Full independent us of Vagus nerve domination and upper back; functional wheelchair; ability to stand only of leg vessels, GI and intercostals, resulting in erect with full leg brace, genitourinary organs increased respiratory ambulate on crutches with reserve swing (although gait difficult); inability to climb stairs L1- L2 Varying control of legs and Good sitting balance; full Vagus nerve domination of pelvis, instability of lower use of wheelchair; leg vessels back ambulation with long leg braces Level of Injury Movement Remaining Rehabilitation Potential L3-L4 Quadriceps and hip flexors, Completely independent Partial vagus nerve absence of hamstring ambulation with short leg domination of leg vessels, function, flail ankles braces and canes; inability GI and genitourinary organs to stand for long periods The success of rehabilitation depends on many variables, including the following:
• level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patient • family support It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The goal of SCI rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially. Health Promotion and Maintenance Plan B Antepartum Diagnostic Interventions: Prenatal Fetal Heart Rate Monitoring Nonstress Test (see below) Contraction Stress test (CST) an assessment performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contractions to determine how the fetus will tolerate the stress of labor. A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 sec each must be obtained to use for assessment data Nipple stimulated CST consists of the woman lightly brushing her palm across the nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins The same process is repeated after a 5 min rest period Hyperstimulation of the uterus (uterine contraction longer than 90 sec or more freq than q 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is uncuccessful Oxytocin admin CST is used if nipple stimulation fails and consists of IV admin of oxytocin to induce uterine contractions Contractions started with oxytocin may be difficult to stop and can lead to preterm labor
A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterine contractions, there are no late decels of the FHR A positive CST (abnormal finding) is indicated with persistent and consistent late decels on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable decels may indicate cord compression and early decls may indicate fetal head compression. Nursing Management For a CST, the nurse should Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document Complete an assessment without artificial stimulation if contractions are occurring spontaneously Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs. Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction pattern Complications Hyperstimulation of the uterus Preterm labor Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 min Biophysical Profile (BPP) uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. Five variables Reactive FHR: reactive nonstress test = 2, nonreactive = 0
Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or less than 30 sec duration = 0 Gross body movements: at least 3 body or limb extensions with return to flexion in 30 min = 2, less than 3 episodes = 0 Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension and flexion, lack of flexion, or absent of movement = 0 Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2 perpendicular planes = 2; pockets absent or less than 1 cm = 0 For BPP the nurse should follow the same management as ultrasound Complications of Pregnancy: Recognizing Abnormal Findings Bleeding during Pregnancy vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the cause Spontaneous Abortion when a pregnancy is terminated before 20 weeks gestation (the point of fetal viability) or fetal wt less than 500 g. Assessments vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy passage of tissue (products of conception) mild to severe uterine atony backache rupture of membranes dilation of the cervix fever abdominal tenderness s/s of hemorrhage such as hypotension Ectopic Pregnancy
abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage. Assessments one or two missed menses unilateral stabbing pain and tenderness in the lower abdominal quadrant scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area). referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx) N/V freq after tube rupture sx of hemorrhage and shock Gestational Trophoblastic Disease proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysis Assessments rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
Incompetent Cervix painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation. Assessments pink stained vaginal discharge or bleeding increase in pelvic pressure possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infection Placenta Previa when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface Assessments painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position a palpable placenta VS that are usual and within normal limits Abruptio Placenta
the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death Assessments sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender a firm rigid uterus with contractions (uterine hypertonicity) fetal distress sx of hypovolemic shock Hyperemesis Gravidarum excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria. Assessments excessive vomiting for prolonged periods dehydration with possible electrolyte imbalance wt loss decreased blood pressure increased pulse rate poor skin turgor Gestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy,
woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters. Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain. Eclampsia is severe preeclampsia sx along with the onset of seizure activity or coma. Assessments progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies rapid wt gain 2 kg per wk in the second and third trimester fetal distress Gestational Diabetes an impaired toleratnce to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level should fall between 60-120 mg/dL Assessments hunger and thirst freq urination blurred vision excess wt gain during pregnancy TORCH infections group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic affects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus
infection sign/symptom T-toxoplasmosis influenza sx or lymphadenopathy O-other infection dependent on infection R-rubella (german measles) rash, muscle aches, joint pain, mild lymphedema, fetal consequences including miscarriage, congenital anomalies and death C-cytomegalovirus (member of Herpes asymptomatic or mononucleosis-like sx virus family) H-Herpes simples virus (HSV) lesions initial outbreak Circumcision: Evaluating Effectiveness of Discharge Teaching Postop parent teaching: Teach the parents to keep the area clean. Change the infantʼs diaper at least every 4 hr and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. The diaper should be fan folded to prevent pressure on the circumcised area Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. A tub bath should not be given until the circumcision is completely healed. Until then, warm water should be gently trickled over the penis Notify the PCP if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the infant. Tell the parents a film of yellowish mucus may form over the glans by day 2 and it is important not to wash this off Teach the parents to avoid using premoistened towelettes to clean the penis bec they contain alcohol. Inform the parents that the newborn may be fussy or may sleep for several hrs after the circumcision
Inform the parents that the circumcision will heal completely within a couple of weeks. Discharge Teaching: Evaluating Clientʼs Understanding of Bulb Syringe Use Oral and Nasal Suctioning teach the parents to use a bulb syringe to suction any excess mucus from the nose and mouth parents should suction the mouth first and then the nose, one nostril at a time the bulb should be compressed before inserting it into the infantʼs mouth or nose when suctioning the infantʼs mouth, always insert the bulb on the sides of the infantʼs mouth not in the middle and do not touch the back of the throat to avoid the gag reflex Postpartum Physiological Changes and Nursing Care: Performing Fundal Assessment Document the fundal height, location and uterine consistency Determine the fundal ht by placing fingers on the abdomen and measuring how many fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the umbilical level Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full bladder) Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. Toddler: Provide Education on Age-Specific Growth and Development Stages of Development Theorist Type of Development Stage Erickson Psychosocial Autonomy vs Shame Freud Psychosocial Anal
Theorist Type of Development Stage Piaget Cognitive Sensorimotor Transitions to preoperational Physical Development anterior fontanel close by 18 months of age Wt: At 30 months the toddler should weigh 4x his birth wt. Ht: the toddler grows by 7.5 cm (3 in) per year Developmental Skills development of steady gait climbing stairs jumping and standing on one foot for short periods stacking blocks in increasingly higher numbers drawing stick figures undressing and feeding self toilet training Cognitive Development concept of object permanence is fully developed Toddlers demonstrate memory of events that relate to them language increase to about 400 words with the toddler speaking in 2-3 word phrases pre-operational thought does not allow for the toddler to understand other viewpoints, but it does allow toddlers to symbolize objects and people in order to imitate activities they have seen previously Psychosocial Development
independence is paramount for the toddler who is attempting to do everything for himself separation anxiety continues to occur when a parent leaves the child Moral Development Moral development is closely associated with cognitive development Egocentric--toddlers are unable to see anotherʼs perspective; they can only view thing from their point of view. the toddlerʼs punishment and obedience orientation begins with a sense of good behavior is rewarded and bad behavior is punished. Self Concept Development toddlers progressively see themselves as separate from their parents and increase their explorations away from them Age Appropriate Activities Solitary play evolves into parallel play where the toddler observes other children and then may engage in activities nearby filling and emptying containers playing with blocks reading books playing with toys that can be pushed and pulled tossing a ball Infant (Birth to 1 yr): Identifying Normal Physical Assessment Findings Physical Development The infantʼs posterior fontanel closes at 2-3 months of age The infantʼs size is tracked by wt, ht, and head circumference
Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) per month the last 6 months. The infant triples birth wt by the end of the first year Ht: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in) per month the last 6 months. Head Circumference: The circumference of the infantʼs head increases 1.25 cm (0.5 in) per month the first 6 months Following size, the infant develops gross motor skills Holds head up at 3 months Rolls over at 5-6 months Holds head steady when sitting at 6 months Gets to sitting position alone and can pull up to a standing position at 9 months Stand hold on at 12 months Stands alone at 12 months Fine motor development follows next in the sequence Brings hans together grasps rattle looks for items that are dropped from view transfers an object from one hand to the other (6 months) rakes finger food with hand ( 6 months) uses thumb-finger to grasp items (9 months) Bangs two toys together (9 months) Can nest one object inside another (12 months) Scoliosis: Recognizing Signs During Routine Screening School age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts.
Marked curvatures in posture are abnormal. A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosis inspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebral column is easily assessed in children bec of their propensity for constant motion durin exam ATI Topic Descriptors Management of Care (24) Plan A Advance Directives: Recognize Purpose (ATI) Advance directive are written instructions that allow a client to convey his wishes regarding medical tx for situations when those wishes can no longer be personally communicated. All clients admitted to a health care facility be asked if they have an advance directive. The client without an advance directive must be given written information that outlines his rights r/t health care decisions and how to formulate an advance directive. A health care representative should be available to help with this process Living wills allows the client to specify end of life decisions she does or does not sanction when unable to speak for herself. For example, the client can specify use or refusal of: CPR, if cardiac or respiratory arrest occurs Artificial nutrition through IV or tube feedings Prolonged maintenance on a respirator if unable to breathe adequately alone Living wills must be specific and be signed by two witnesses. They can minimize conflict and confusion regarding health care decisions that need to be made vary from state to state
A durable power of attorney for health care (health proxy) is an indiv designated to make health care decisions for a client who is unable based upon the clientʼs living will Based upon the clientʼs advance directives, the physician writes orders for life- sustaining tx. Examples include: DNR Medical interventions (eg comfort measures only, IV fluids but no intubation, full tx) Use of ABX Artificially administered nutrition through a tube. Nursing responsibilities regarding advance directives include: provide written information regarding advance directives document the clients advance directive status ensure that the advance directive is current and reflective of the clientʼs current decisions. inform all members of the health care team of the clients advance directive. (P/P) Two basic advance directives living will written documents that direct tx in accordance with a clientʼs wishes in the event of a terminal illness or condition. may be difficult to interpret two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document if health care workers follow the directions of the living will, they are immune from liability durable power of attorney for health care
designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf. In order for living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment The determination of legal competency is made by a judge, and the determination of decisional capacity is usually made by the physician and family. The implementation of the advance directive is done within the context of the health care team and the health care institution. When clients are legally incompetent and are unable to make health care decisions, the courts balance the stateʼs interest with what the client would have wanted. Client Advocacy: Intervening on behalf of the Client As an advocate, nurses must ensure that clients are informed of their rights and have adequate information on which to base health care decisions Nurses must be careful to “assist” clients with health care decisions and not “direct” or “control” their decisions Situations in which the nurse may advocate for the client or assist the client to advocate for herself include: End of life decisions Access to health care Protection of client privacy Informed consent Substandard practice Essential Components of Advocacy
Skills risk taking vision self-confidence Articulate communication assertiveness Values caring autonomy respect empowerment The nurse protects the clientʼs human and legal rights and provides assistance in asserting those rights if the need arises keep in mind the clientʼs religion and culture Discharge Planning: Interventions to Promote Timely Client Discharges The process begins at time of admission Plans are developed with client and family input, focusing on active participation by the client to facilitate a timely discharge Serves as a starting point for continuity of care for the client by the caregiver, home health nurse, or receiving facility. The need for additional client or family support is included with recommendations for support services such as home health, outpatient therapy and respite care. Discharge Summary includes: Step by step instructions for procedures to be done at home Precautions to take when performing procedures or administering meds S/s of complications that should be reported Names and numbers of health care providers and community services the client/family can contact. Plans for follow up care and therapies
Time of discharge, mode of transportation, and who accompanied the client. This should begin when the client is admitted to the facility unless the facility is to be the clientʼs permanent residence assess whether or not the client will be able to return to his previous residence determine whether or not the client will nee and/or have someone to assist him at home assess the residence to see if adaptations are required to accommodate the client prior to discharge make a referral to the social worker to arrange for community services required by the client at discharge communicate client health status and needs to community service providers. Clients Rights: Recognizing Client Rights Regarding Review of Records Only health care team members directly responsible for the clientʼs care should be allowed access to the clientʼs records. The client has the right to review his medical record and request information as necessary for understanding. Clientʼs rights To inspect and copy PHI To ask the health care agency to amend the PHI that is contained in a record if the PHI is inaccurate To request a list of disclosures made regarding the PHI as specified by HIPAA To request to restrict the way the health care agency uses or discloses PHI regarding tx, payment or health care operations unless info is needed to provide emergency tx To request that the healthcare agency communicates with the client in a certain way or at a certain location ; the request must specify how or where the clientʼs wishes to be contacted. Collaboration with Interdisciplinary Team: Methods for Collaboration An interdisciplinary team is a group of health care professionals from different disciplines Collaboration is used by interdisciplinary teams to make health care decisions about clients with multiple problems. Collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. Key elements of collaboration include:
Effective communication skills Mutual respect and trust Shared decision making The nurse contributes Knowledge of nursing care and its management A holistic understanding of the client, her health care needs,and health care systems Nurse-primary care provider collaboration should be fostered to create a climate of mutual respect and collaborative practice Collaboration can occur among different levels of nurses and nurses with different areas of expertise. Nursing Interventions: Use effective communication skills Participate in client rounds and interdisciplinary team meetings Present info relevant to the clientʼs health status and tx regimen Attend interdisciplinary clinical conferences/case presentations. COPD: Planning Strategies for Fatigue ATI---determine the clientʼs physical limitations and structure activity to include periods of rest promote adequate nutrition increased work of breathing increases caloric demands Med-Surg Energy Conservation Techniques pacing and pursing (pacing activity and using pursed lip breathing with activities
assuming the tripod position and a mirror placed on the table during use of an electric razor or hair dryer conserves more energy than when the pt stands in front of a mirror to shave or blow dry hair. use 02 during activities of hygiene bec these are energy consuming pt should be encouraged to make a schedule and plan daily and weekly activities so as to leave plenty of time for rest periods pt should also try to sit as much as possible when performing activities exhale when pushing, pulling or exerting effort during and activity and inhale during rest. walking is the best exercise for COPD coordinated walking with slow, pursed-lip breathing without breath holding. breathe in and out through now while taking one step then to breathe out through pursed lips while taking 2-4 steps walk 15-20 minutes a day with gradual increases use MDI 10 minutes before exercises Conflict Resolution: Identify Strategies Conflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an inevitable part of professional, social, and personal life and can result in constructive or destructive consequences Constructive Consequences Destructive Consequences stimulates growth and open and honest can produce divisiveness communication may foster rivalry and compeitition increases group cohesion and commitment misperceptions, distrust, and frustration to common goals can be created facilitates understanding and problem group dissatisfaction with the outcome may solving occur motivates group to change Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout
The desired goal in resolving conflict in both parties is to reach a satisfactory resolution. This is a win-win situation Conflict Resolution Strategies Strategy Characteristics Compromising Each party gives up something To consider this a win-win solution, both parties must give up something equally valuable. If one party gives up more than the other it can become a win-lose situation Competing One party pursues a desired solution at the expense of others This is a win-lose solution Managers may use this when a quick or unpopular decision must be made The party who loses something may experience anger, frustration, and a desire for retribution Cooperating/Accommodating One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. this is a lose-win solution. The original problem may not actually be resolved. The solution may contribute to future conflict
Strategy Characteristics Smoothing One party attempts to “smooth” other party, decreasing the emotional component of the conflict Often used to preserve or maintain a peaceful work environment The focus may be on what is agreed upon, leaving conflict largely unresolved This is usually a lose-lose solution Avoiding Both parties know there is a conflict, but they refuse to face it or attempt to resolve it. May be appropriate for minor conflicts or when one party holds more power than the other party or if the issue may work itself out over time Since the conflict remains, it may surface again at a later date and escalate over time this is usually a lose-lose solution Conflict Resolution Advantages Disadvantages Technique Avoiding--ignoring the does not make a big deal conflict can become bigger conflict out of nothing; conflict may than anticipated be minor in comparison to other priorities Accommodating--- one side is more concerned one side holds more power smoothing or cooperating. with the issue than the other and can force the other side One side gives in to the side to give in other side Competing---forcing; the two produces a winner; good Produces a loser; leaves or three sides are forced to when time is short and anger and resentment on compete for the goal stakes are high losing sides
Conflict Resolution Advantages Disadvantages Technique Compromising---each side no one should win or lose may cause a return to the gives up something and but both should gain conflict if what is given up gains something something; good for becomes more important disagreements between than the original goal indiv Negotiating---high level stakes are high and solution agreements are permanent, discussion that seeks is rather permanent; often even though each side has agreement but not involves powerful groups gains and losses necessarily consensus Collaborating--both sides best solution for the conflict takes a lot of time; requires work together to develop and encompasses all the commitment to success optimal outcome goals to each side Confronting--immediate and does not allow conflict o may leave impression that obvious movement to stop take root; very powerful conflict is not tolerated conflict at the very start Genitalia and Rectum: Providing Privacy Preparation of the client (for Female pelvic exam) Client is asked to empty her bladder so that urine is not accidently expelled during the exam. Client is assisted in assuming the lithotomy position in bed or on an exam table for an external genitalia assessment and is assisted in stirrups if a speculum exam is to be performed. The nurse places a hand to the edge of the table and then instructs the client to move until touching the hand. The clientʼs arms should be at her side or folded across the chest to prevent tightening of abdominal muscles A square drape or sheet is given to the client. She holds one corner over the sternum, the adjacent corners fall over each knee, and the fourth corner covers the perineum. Close the door, or pull room curtains around the bathing area. While bathing the client, expose only the areas being bathed. During bowel elimination, the nurse should maintain the clientʼs privacy.
this is especially important for a client using a bedpan. The call light and a supply of toilet paper should be within easy reach. Respond immediately. Consultation: Referral in Response to a Client Concern A consultant is a professional who provides expert advice in a particular area. A consultation is requested to determine what tx/services the client requires. Consultations provide expertise to clients who require a particular type of knowledge or service (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist for a client whose risk for suicide needs to be assessed) Coordination of the consultantʼs recommendations with other health care providersʼ recommendations is necessary to protect the client form conflicting and potentially dangerous orders. Consultation is a process in which a specialist is sought to identify methods of care or tx plans to meet the needs of a client. Consultation is needed when the nurse encounters a problem that cannot be solved using nursing knowledge, skills, and available resources Consultation also is needed when the exact problem remains unclear; a consultant can objectively and more clearly assess and identify the exact nature of the problem Referrals are made so that the client can access the care identified by the PCP or consultant The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg, hospice care, home health aide) Discharge referrals are based on client needs in r/t actual and potential problems and may enlist the aid of: social services specialized therapists (eg PT,OT, speech) care providers (home health nurses, hospice nurse) Knowledge of community resources i necessary to appropriately link the client with needed services Consultation (interventions) Initiate the necessary consults or notify the PCP of the clientʼs needs so the consult can be initiated. Provide the consultant with all pertinent info about the problem
Incorporate the consultantʼs recommendations into the clientʼs plan of care Facilitate coordination of the consultantʼs recommendations with other health care providers; recommendations to protect the client from conflicting and potentially dangerous orders. Referrals (Interventions) To ensure continuity of care by the use of referrals, the nurse should: Initiate the discharge plan upon the clientʼs admission. Evaluate client/family competencies in r/t home care prior to discharge. Involve the client and family in care planning Collaborate with other health care professionals to ensure all health care needs are met Complete referral forms to ensure proper reimbursement for services ordered. Client Education: Document Client Teaching Client teaching documentation Information presented, method of instruction (eg discussion, demonstration, videotape, booklet), client response, including questions and evidence of understanding such as return demo or change in behavior. Nursing documentation must be accurate to correctly record information regarding the clientʼs care. The purpose of reporting is to provide continuity of care for client when several nurses provide care. Reporting should be conducted in a confidential manner. Evaluation of Client Teaching Observe the client demonstrating the learned activity (best for eval of psychomotor learning) Ask questions. Listen to the client explain the info learned use written tools to measure accuracy of information
Request the clientʼs self-eval of progress Observe verbal and nonverbal communication Revise the care plan as needed. Delegation: Use of the Five Rights of Delegation Right Task The right task is one that is delegable for a specific client, such as tasks that are repetitive, require little supervision and are relatively noninvasive. Identify what tasks are appropriate to delegate for each specific client. Delegate activities to appropriate levels of team members (eg LPN, AP) based on professional standards of practice, legal and facility guidelines, and available resources. Ex: Right Task Wrong Task Delegate LPN to perform a dressing Delegate LPN to develop the care plan for change on a client with cellulitis. a client with cellulitis. Delegate AP to assist a client with Delegate AP to administer a neb tx to a pneumonia to use a bedpan client with pneumonia. Right Circumstances The appropriate client, available resources, and other relevant factors are considered. In an acute care setting, clientʼs conditions can change quickly. good clinical decision making is needed to determine what to delegate. If the circumstances have been assessed or are deemed too complicated, the nurse takes the responsibility and does not delegate to the AP. Ex:
Right Circumstance Wrong Circumstance Delegate AP to take and record check-in Delegate AP to take VS on a client VS of office clients. receiving IV therapy for hypovolemic shock. Delegate AP to assist in obtaining VS from a stable postop client. Delegate AP to assist in obtain VS from a postop client who required naloxone (Narcan) for depressed respirations. Right person the right person is delegating the right tasks to the right person to be performed on the right person. Assess and verify the competency of the health care team member. the task must be within the team memberʼs scope of practice the team member must have the necessary competence/training Continually review the performance of the team member and determine care competency. Assess team member performance based on standards, and when necessary, take steps to remediate failure to meet standards. Ex: Right person Wrong Person Delegate an LPN to administer enteral Delegate an AP to administer enteral feedings to a client with a head injury. feedings to a client with a head injury. Delegate LPN to perform trach care on a Delegate an AP to perform trach care on a client client. Right Direction/ Communication
A clear, concise, description of the task, including its objective, limits, and expectations is given. Communication must be ongoing between RN and AP during a shift of care. Communicate either in writing or orally: Data that need to be collected Method and timeline for reporting, including when to report concerns/assessment findings Specific task(s) to be performed; client specific instructions Expected results, timelines, and expectations for follow-up communication. Ex: Right direction/communication Wrong direction/communication Delegate AP the task of assisting the client Delegate AP the task of assisting the client in room 312 with a shower, to be in room 312 with morning hygiene. completed by 0900. Delegate AP the task of obtaining a urine Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not catch urine specimen from the client in informing her of what type of urine room 423, bed 2 specimen, or which specific client in the room needs the specimen. Right Supervision Appropriate monitoring, evaluation, intervention as needed and feedback are provided. AP should feel comfortable to ask questions and seek assistance. Ex:
Right Supervision Wrong Supervision An RN delegates to an LPN the task of An RN delegates to an LPN the task of administering enteral feedings to a client providing client teaching to a client without (after the RN performs a physical a written care plan in place. assessment to evaluate the clientʼs tolerance to feedings thus far). An RN delegates an AP to ambulate a client prior to performing an admission An RN delegates to an AP the task of assessment. ambulating a client after completing the admission assessment Care that cannot be delegated: Nursing process. Assessment Diagnosis Planning Evaluation Nursing judgment. Delegation: Monitoring Outcomes of Delegated Tasks Another important step in delegation is evaluation of clientʼs outcomes. The RN must give constructive and appropriate feedback. The RN should always give specific feedback in regard to any mistakes that were made, explaining how the mistakes could have been avoiding. Giving feedback in private is the professional way and preserves the APs dignity. The RN may discover the need to review a procedure with staff and offer demonstration or even recommend that additional training by scheduled with the education dept. Delegation: Assigning Tasks To AP Based On Role parameters and Skill Required Assess the knowledge and skills of the delegate open ended questions Match tasks to the delegateʼs skills know what skills are included in the training program of the facility Communicate clearly
alway provide unambiguous and clear directions by describing a task, the desired outcome, time period within which the task should be completed. never give task through another staff member Listen attentively Provide feedback. Roles/Tasks for AP/LPN Task AP LPN RN Developing a teaching plan for a client newly dxʼd with diabetes x mellitus Assessing a client admitted for surgery x Collecting VS q 30 min for a client who is 1 hr post cardiac cath x x x Calculating a clientʼs I/O x x x Administering blood to a client x Monitoring a clientʼs condition during blood transfusions and IV admin x x Providing oral and bathing hygiene to an immobilized client x x x Initiating client referrals x Dressing change of an uncomplicated wound x x Routine nasotracheal suctioning x x Receiving report from surgery nurse regarding a client to be admitted x to a unit from the PACU Initiating a continuous IV infusion of dopamine with dosage titration x based on hemodynamic measurements Administering subcutaneous insulin x x Assessing and documenting a clientʼs decubitus ulcer x x Evaluating a clientʼs advance directive status x
Task AP LPN RN Providing written information regarding advance directives x x Initial feeding of a client who had a stroke and is at risk for aspiration x Assisting a client with toileting x x x Developing a plan of care for a client x Administering an oral med x x Assisting a client with ambulation x x x Administering an IM pain med x x Checking a clientʼs feeding tube placement and patency x x Turning a client q 2 hr x x x Calculating and monitoring TPN flow rate x Disaster Planning and Emergency Management: Prioritizing Delivery of Client Care Triage is the process of separating casualties and allocating tx on the basis of the victimsʼ potentials for survival. Highest priority is always given to victims who have life-threatening injuries but who have a high probability of survival once stabilized. Second priority is given to victims with injuries that have systemic complications that are not yet life threatening and could wait 45-60 min for tx Last priority is given to those victims with local injuries without immediate complications and who can wait several hours for medical attention, or those who have minimal probability of surviving. Ethics and Values: Appropriate Response to Experiencing Negative Feelings about a Client
Countertransference refers to the feelings and thoughts that service providers have toward the client. The provider may harbor certain images of the client that result in “blind spots” which can be destructive or disruptive to the therapeutic process. This nontherapeutic event can be resolved with consultation, supervision, or both. Nurses must be aware of possible countertransference responses. Beneficence---the care give is in the best interest of the client. Client Education: Assisting Clients to Access current Health Information Using Information Technology Client education assists individuals, families, and communities in achieving optimal health. Teaching in interactive, promotes learning, and leads to a change in a behavior. Information technology can be used to enhance access to and delivery of knowledge Client Education: Selecting Appropriate Information Technology for Adolescent Client Education Adolescents are in transition between childhood and adulthood. Transition between concrete operations to formal operations in reasoning. Use logic and reasoning to grasp simultaneous influence of several variables to invent a systematic procedure for keeping track of results of experiments. Peer teaching is very effective. Teens benefit from visiting others who are coping successfully with similar problems. Group instruction/discussion is a very powerful way to help teens belong to a group
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  • 1. ATI Topic Descriptors Basic Care and Comfort (13) Plan A Hygiene Care: Evaluating Appropriate Use of Assistive Devices Cane instructions: Maintain two points of support on the ground at all times Keep the cane on the stronger side of the body Support body wt on both legs, move cane forward 6-10 inches, then move the weaker leg forward toward the cane. Next, advance the stronger leg Dentures: Clients who have fragile oral mucosa require gentle brushing and flossing. Perform denture care for the client who is unable to do it himself Remove dentures with a gloved hand, pulling down and out at the front of the upper denture, and lifting up and out at the front of the lower denture. Place dentures in a denture cup or emesis basin Brush them with a soft brush and denture cleaner Rinse them with water Store the dentures, or assist the client with reinserting the dentures Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for Pain Management Music decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15-30 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff highly effective in reducing postop pain if pain acute, increase volume of music
  • 2. Prostate Surgeries: Calculating a Clientʼs Output When Receiving Continuous Bladder Irrigations purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or sediment can collect within tubing resulting in bladder sistention and buildup of stagnant urine) Med-Surg p. 1443 after prostate surgery, irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. if bladder manually irrigated, 50ml of irrigating soln should be instilled and then withdrawn with a syringe to remove clots that may be in bladder and catheter. with CBI, irrigating soln is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. The inflow and outflow of irrigant must be continuously monitored. If outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If the outflow is blocked and patency cannot be reestablished by manual irrigation, the CBI is stopped and the physician notified. Record amount of urine output and character of urine every eight (8) hours or as per physicianʼs orders. (To obtain urine output, subtract amount of fluid instilled into bladder from total output.) intermittent irrigation dorsal recumbent or supine position avoid cold solution bec may result in bladder spasm clamp cath just below soft injection port cleanse injection port with antiseptic swab (same port as specimen collection) insert needle through port at 30degree angle slowly inject fluid into cath and bladder withdraw syringe remove clamp and allow solution to drain into drainage bag if ordered by MD, keep clamped to allow solution to remain in bladder for short time (20-30min) Closed continuous irrigation Recording and Reporting
  • 3. Record type and amt of irrigation soln used, amt returned as drainage and the character of drainage Record and report any findings such as complaints of bladder spasms, inability to instill fluid into bladder and/or presence of blood clots. Urinary Elimination: Kegel Exercises for Urinary Incontinence sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( to learn the muscle) then practiced at nonvoiding times instruct client to contract muscle for a count of 3, hold and release for a count of 3, and repeat this 10x. Client should repeat these cycles for 25-30x 3x/day for 6 months. Client should do this 5x.day Bowel Elimination Needs: Client Education Regarding Colostomy Care Stoma s/b pink. Dusky blue stoma---ischemia Brown-black stoma---necrosis mild to moderate swelling for 1st 2-3 weeks after surgery intact skin barriers with no evidence of leakage do not need to be changed daily and can remain in place for 3-5 days. skin should be washed with mild soap, warm water and dried thoroughly before barrier applied pouch must fit snugly to prevent leakage around stoma. The opening around the appliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks and does not reach usual size for 6-8 weeks empty pouch before it is 1/3 full to prevent leakage cleanse skin and use skin barriers and deodorizers to prevent skin breakdown and malodor
  • 4. apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in; let dry 1-2 min apply non-allergic paper tape around the pectin skin barrier in a picture frame method. Burns: Non-pharmacologic Comfort Interventions for Dressing Changes Med/Surg p. 534-535 Distractions Relaxation tapes visualization guided imagery biofeedback meditation used as adjuncts to traditional pharmacologic txs of pain Visualization and guided imagery can be helpful to the nurse as well as the pt nurse ask the pt about a favorite hobby or recent vacation nurse can explore these areas further by asking questions that make the pt visualize and describe a favorite hobby or recent vacation by using this method, both the nurse and the pt must focus on things besides the task at hand. (ie dressing change) to keep the conversation flowing Relaxation tapes can be helpful when played at night to help the pt fall asleep. Application of Heat and Cold: Assess Need for Heat/Cold Applications Application of Cold: Ensure Safe Use of Cold Applications Potter/Perry p. 1253-1254 Cold and heat applications relieve pain and promote healing. selection varies with clientʼs conditions. moist heat can help relieve the pain from a tension HA cold heat can reduce the acute pain from inflamed joints avoid injury to skin by checking the temp and avoiding direct application of the cold or hot surface to the skin esp at risk: spinal cord or other neuro injury, older adults, confused clients
  • 5. Ice massage or cold therapy are particularly effective for pain relief. Ice massage: apply the ice with firm pressure followed by slow steady, circular massage Cold may be applied to pain site on the opposite side of the body corresponding to the pain site or on a site located between the brain and the pain site. takes 5-10 minutes to apply cold each client responds differently to the site of the application that is the most effective application near the actual site of pain tends to work best a client feels cold, burning and aching sensations and numbness. When numbness occurs, the ice should be removed. cold is particularly effective for tooth or mouth pain when ice is place on the web of the hand between the thumb and index finger cold applications are also effective before invasive needle punctures Heat application donʼt lay on heating element bec burning could occur Assessment for Temperature Tolerance (P/P p. 1549) before applying either, the nurse should assess the clientʼs physical condition for signs of potential intolerance to heat and cold first observe the area to be txʼd alterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleeding or localized areas of inflammation increase the clientʼs risk of injury. baseline skin assessment provides a guide for evaluating skin changes that might occur during therapy assessment includes id of conditions that contraindicate heat or cold therapy: an active area of bleeding should not be covered by a warm application bec bleeding will continue warm applications are contraindicated when client has an acute, localized inflammation such as appendicitis bec the heat could cause the appendix to rupture.
  • 6. if client has CV problems, it is unwise to apply heat to large portions of the body bec the resulting massive vasodilation may disrupt blood supply to vital organs. cold is contraindicated if the site of injury is already edematous cold furth retards circulation to the area and prevents absorption of the interstitial fluid. if client has impaired circulation (arteriosclerosis), cold further reduces blood supply to affected area cold contraindicated in presence of neuropathy (client unable to perceive temp changes) cold contraindicated in shivering (intensifies shivering and dangerously increase body temp) If MD orders cold therapy to lower extremity, assess for cap refill, observing skin color and palpating skin temp, distal pulses and edematous areas if signs of circulatory inadequacy, question order if confused or unresponsive, make freq observations of skin integrity after therapy begins assess condition of equip used before applying heat and cold, understand normal body responses to local temp variations, assess the integrity of the body part, determine the clientʼs ability to sense temp variations and ensure proper operation of equipment. Crohnʼs Disease: Selecting a Low-Fiber, Low-Residue Diet No raw vegetables, vegs not strained, dried beans, peas, and legumes No raw fruits, fruits with skins, seeds No nuts, raisins, rich desserts no whole grain breads or cereals no fried, smoked, pickled or cured meats, no alcohol, fruit juices with pulp Dumping Syndrome: Client Education Regarding Dietary Interventions meal size must be reduced accordingly (6 small feedings) no drinking fluids with meals (30-45 min before or after meals) helps prevent distention or a feeling of fullness dry foods with low-carb content and moderate protein and fat content
  • 7. proteins and fats are increased promotes rebuilding of body tissues and to meet energy needs specifically meat, cheese, eggs and mild products no concentrated sweets (honey, sugar, jelly, jam) cause dizziness, diarrhea, a sense of fullness short rest period after each meal Cholecystitis: Dietary Restrictions Low in fat, and sometimes a wt reduction diet is also recommended (4-6 weeks take fat soluble vit supplements Palliative Care: Client/ Family Teaching caring interventions rather than curing interventions for any age, diagnosis, any time, and not just during the last few months of life preservation of dignity becomes the goal of palliative care allows clientʼs to make more informed choices, achieve better alleviation of sx and have more opportunity to work on issues of life closure establish a caring relationship with both client and family management of sx of disease and therapies Preparing the Dying Clientʼs Family (P/P 588) Objectives: family will be able to provide appropriate physical care for the dying client in home family will be able to provide appropriate psychological support to the dying client. Describe and demonstrate feeding techniques and selection of foods to facilitate ease of chewing and swallowing Demonstrate bathing, mouth care, and other hygiene measures and allow family to perform return demo show video on simple transfer techniques to prevent injury to themselves and client, help family to practice instruct family on need to enforce rest periods
  • 8. teach family to recognize s/s to expect as the clientʼs condition worsens and provide info on who to call in an emergency discuss ways to support the dying person and listen to needs and fears solicit questions from family and provide info as needed. Evaluation: Have the family members demo physical care techniques ask family members to describe how they vary approaches to care when the client has sx such as pain or fatigue ask the family to discuss how they feel about their ability to support the client . Cognitive Disorders: Promoting Independence in Hygiene for A Client with Alzheimerʼs Disease Stage S/S Stage 1, Forgetfulness Short term memory loss Decreased Attn Span Subtle Personality Changes Mild cognitive deficits Difficulty with depth perception Stage 2, Confusion Obvious memory loss Confusion, impaired judgement, confabulation Wandering behavior Sundowning (more confusion in late afternoon/early evening) Irritability and agitation Poor spatial orientation, impaired motor skills Intensification of sx when the client is stressed, fatigued, or in an unfamiliar environment Depression r/t awareness of reduced capacities Stage 3, Ambulatory dementia loss of reasoning ability Increasing loss of expressive language Loss of ability to perform ADLs More Withdrawn
  • 9. Stage S/S Stage 4, End Stage Impaired or absent cognitive, communication and/or motor skills Bowel and bladder incontinence Inability to recognize family members or self in mirror Assess teaching needs for the client and especially for the family members when the clientʼs cognitive ability is progressively declining. Review the resources avail to the family as the clientʼs health declines. A wide variety of home care and community resources may be avail to the family in many areas of the country, and these resources may allow the client to remain at home rather than in an institution Perform self assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients with progressive dementia NCP Med/Surg 1592 Monitor ptʼs ability for independent self-care to plan appropriate interventions specific to pt unique problems Use consistent repetition of daily health routines as a means of establishing them bec memory loss impairs ptʼs ability to plan and complete specific sequential activities assist pt in accepting dependency to ensure that all needs are met. teach family to encourage independence and to intervene only when the pt is unable to perform to promote independence Bathing/Hygiene provide desired personal articles, such as bath soap and hairbrush, to enhance memory and provide care facilitate ptʼs bathing self as appropriate to facilitate independence and provide appropriate help in hygiene Dressing/Grooming provide ptʼs clothes in accessible area to facilitate dressing Be available for assistance in dressing as necessary to facilitate independence and provide appropriate help in dressing
  • 10. Toileting Assist pt to toilet as specified intervals to promote regularity facilitate toilet hygiene after completion of elimination to prevent discomfort and skin breakdown. Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203) If untreated lead to three problems insomnia abnormal movements or sensation during sleep or when awakening at night, or excessive daytime sleepiness. Four categories Dyssomnias (origins in body systems ) Intrinsic (initiating and maintaining sleep) psychophysiological insomnia narcolepsy periodic limb movement disorders sleep apnea syndromes Extrinsic (outside the body) inadequate sleep hygiene insufficient sleep syndrome hypnotic dependent sleep disorders alcohol dependent sleep disorders Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired) Time Zone Change Shift work sleep disorder Delayed sleep phase syndrome Parasomnias (undesirable behaviors that occur during sleep) Arousal Disorders Sleepwalking Sleep terrors Sleep-Wake Transition Disorders Sleeptalking Sleep starts
  • 11. Nocturnal leg cramps REM Sleep disturbances nightmares REM Sleep behavior disorder sleep paralysis Other Parasomnias sleep bruxism (teeth grinding) sleep enuresis (bed-wetting) SIDS Sleep Disorders associated with Med-Psych Disorders Psych Disorders Mood disorders Anxiety disorders Psychoses Alcoholism Neurologic Disorders Dementia Parkinsonism Central degenerative disorders Other Med Disorders Nocturnal cardiac ischemia COPD PUD Proposed sleep Disorders Menstruation-associated sleep disorders Sleep choking syndrome Pregnancy associated sleep disorders Questions to Ask to Assess for Sleep Disorders Insomnia How easily do you fall asleep Do you fall asleep and have difficulty staying asleep? How many times do you awaken Do you awaken early from sleep What time do awaken for good? What causes you to awaken early? What do you do to prepare for sleep? To improve you sleep? What do you think about as you try to fall asleep
  • 12. How often do you have trouble sleeping Sleep Apnea Do you snore loudly? Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate report this) Do you experience HAs after awakening Do you have difficulty staying awake during the day Does anyone else in your family snore loudly or stop breathing during sleep? Narcolepsy Are you tired during the day Do you fall asleep at inopportune times? Do you have episodes of losing muscle control or falling to the floor have you ever had the feeling of being unable to move or talk just before falling asleep Do you have vivid lifelike dreams when going to sleep or waking up? Basic Care and Comfort (13) Plan B Mobility and Immobility: Recognizing Proper Use of Crutches Crutch instructions Do not alter crutches after proper fit has been determined Follow crutch gait prescribed by physical therapy support body wt at hand grips with elbows flexed 30 degrees position crutches on unaffected side when sitting or rising from chair. Elkin---pg 135 Use of crutches may be a temporary aid for persons with strains, in a cast or following surgical treatments crutches may be routinely and continuously used for those with congenital or acquired MS abnormalities, neuromuscular weakness, or paralysis or they may be used after amputations. Crutch measurement includes three areas:
  • 13. clientʼs height distance between crutch pad and axilla angle of elbow flexion [make sure shoes are on before measuring] Standing crutches 4-6 in in front of feet and side of feet Crutch pads two to three fingers between top of crutch and axilla Elbow should be flexed (30 degrees ATI) ***any tingling in torso means crutches are used incorrectly or wrong size if crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy) if crutch too short---bent over and uncomfortable low handgrips cause radial nerve damage high handgrips cause clientʼs elbow to be sharply flexed and strength and stability are decreased 4-point gait requires wt bearing on both legs often used when client has paralysis, as in spastic children with CP may also be used for arthritic clients improves balance by providing wider base of support R crutch, L foot, L crutch, R foot 3 point gait requires wt bearing on 1 foot affected leg does not touch ground may be useful for client with broken leg or sprained ankle R/L crutches, unaffected foot, R/L crutches, unaffected foot 2-point gait requires partial wt bearing on each foot faster than 4-point gait requires more balance crutch movements are similar to arm movements while walking L crutch and R foot together, R crutch and L foot together. Swing to gait freq used by clients whose lower extremities are paralyzed or who wear wt-supporting braces on their legs
  • 14. easier of the two swing gaits requires ability to bear body wt partially on both legs Swing through gait requires client have ability to sustain partial wt bearing on both feet Stairs ( up) unaffected leg on step, both crutches come to step, repeat (down) move crutches to stair below, move affected leg forward, then unaffected leg Pain Management: Nonpharmacological Pain Management P/P---ch 42 P/P---pg 1250 Nonpharmacological interventions include cognitive-behavioral and physical approaches best if taught when not experiencing pain Goals of cognitive-behavioral interventions change clientʼs perceptions of pain alter pain behavior provide clients with greater sense of control Goals of physical approaches providing comfort correcting physical dysfunction altering physiological responses reducing fears associated with pain-related immobility Relaxation and Guided Imagery Relaxation mental and physical freedom from tension or stress provide self control when discomfort or pain occurs reverse physical and emotional stress of pain can be used at any phase of health or illness not taught when client is in acute discomfort bec inability to concentrate describe common sensations client may feel decrease in temp numbness of a body part use as feedback free of noise light sheet or blanket use with guided imagery or separate
  • 15. progressive takes about 15 min pay attn to body noting areas of tension, tense areas replaced with warmth and relation some times better if eyes closed background music can help combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups. Guided Imagery client creates an image in the mind, concentrate on that image and gradually becomes less aware of pain Distraction RAS (reticular activating system) inhibits painful stimuli if a person receives sufficient or excessive sensory input directs attention to something else and reduces awareness of pain even increases tolerance 1 disadvantage if works, may question the existence of pain works best for short, intense pain lasting a few minutes ex: invasive procedure or while waiting for analgesic to work RN assesses activities enjoyed by client that may act as distractions singing praying describing photos or pictures aloud listening to music playing games may include ambulation, deep breathing, visitors, television, and music Music decreases physiological pain, stress and anxiety by diverting the personʼs attention away from the pain and creating a relaxation response. let client select the type of music music produces an altered state of consciousness through sound, silence, space and time must be listened to for 15 minutes to be therapeutic earphones help client concentrate on music while avoiding other clients or staff
  • 16. highly effective in reducing postop pain if pain acute, increase volume of music Biofeedback behavioral therapy that involves giving individuals information about physiological responses (BP and tension) and ways to exercise voluntary control over those responses used to produce deep relaxation and is effective for muscle tension and migraine HA Cutaneous stimulation stimulation of the skin to relieve pain massage warm bath ice bag for inflammation transcutaneous electrical nerve stimulation (TENS) (also called counter stimulation) causes release of endorphins thus blocking transmission of painful stimulation advantage: measures can be used in the home reduce pain perception and help reduce muscle tension RN eliminates sources of environmental noise, helps client to assume a comfortable position, explains purpose of therapy Acupressure/Acupuncture vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points elevation of edematous extremities to promote venous return and decrease swelling Urinary Elimination Needs: Preventing Incontinence Use timed voidings to increase intervals between voidings/decrease voiding frequency perform pelvic floor (Kegel) exercises perform relaxation techniques offer undergarments while client is retraining teach client not to ignore urge to void provide positive reinforcement as client maintains continence
  • 17. Urinary Elimination: Providing Catheter Care Prevent infection Maintain unobstructed flow of urine through the cath drainage system Perineal Hygiene perineal hygiene 2x/day or prn for client with retention cath soap and water are effective can be delegated to AP Catheter care assess urethral meatus and surrounding tissue for inflammation, swelling and discharge. Note amt, color, odor, and consistency of discharge. Ask client if any burning or discharge is felt with towel, soap and water, wipe in a circular motion along length of catheter for 4 inches apply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MD Mobility and Immobility: Evaluating for Complications of Immobility Complications of Immobility Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Respiratory--maintain patent airway, teach the client to turn, cough and deep achieve optimal lung expansion and gas breath q 1-2 hr exchange and mobilize airway secretions yawn every hour use incentive spirometer CPT 2000ml fluid
  • 18. Integumentary--Maintain intact skin turn the client q 1-2 hr decrease pressure limit sitting in chair to less than 2 hr Cardiovascular---maintain CV fx, increase increase activity activity tolerance and prevent thrombus avoid valsalva maneuver formation stool softener ROM avoid pillows under knees use elastic stockings SCD give low dose heparin Metabolic---decrease injuries to skin and provide high calorie high protein diet with maintain metabolism within normal fxing additional vits B and C monitor oral intake Elimination--maintain or achieve normal maintain hydration (at least 2000 mL urinary and bowel elimination patterns stool softener bladder and bowel training insert cath if bladder distended Musculoskeletal--maintain or regain body change position in bed q 2 hrs alignment and stability decrease skin and ROM MS system changes, achieve full or nutritional intake optimal ROM and prevent contractures CPM Psychosocial--maintain normal sleep/wake coping skills patter, achieve socialization and achieve maintain orientation independent completion of self care develop schedule Gastroenteral Feedings: Monitoring Tube Feedings Monitoring for tube placement initial placement is confirmed with xray monitor gastric contents for pH. A good indication of appropriate placement is obtaining gastric contents with a pH between 0-4 Injecting air into the tube and listening over the abdomen is not an acceptable practice
  • 19. Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual < 100mL return aspirated contents or follow protocol Flush tubing with 30-60 mL of H20 Acute Glomerulonephritis: Dietary Choice Acute Glomerulonephritis: insoluble immune complexes develop and become trapped in the glomerular tissue producing swelling and capillary cell death Maintain prescribed dietary restrictions Fluid restriction (24 hr output + 500 mL) Sodium restriction Protein restriction (if azotemia is present) Edema is treated by restricting sodium and fluid intake Dietary protein intake may be restricted if there is evidence of nitrogenous wastes. Varies with degree of proteinuria. Low protein, low sodium, fluid restricted diet Rest and Sleep: Interventions to Promote Sleep for Hospitalized Clients Assist the client in establishing and following a bedtime routine Attempt to minimize the number of times the client is awakened during the night while hospitalized Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort Instruct the client to: Exercise regularly at least 2 hr before bed time Arrange the sleep environment to what is comfortable Limit alcohol, caffeine, and nicotine in the late afternoon and evening Engage in muscle relaxation before bedtime Apply CPAP devices as ordered by PCP for clients with sleep apnea
  • 20. As a last resort, provide a pharmacological agent as prescribed. ATI Topic Descriptors Plan A Health Promotion and Maintenance (13) Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736) Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates relaxed muscles allow rapid bleeding from the endometrial arterieries at the placental site bleeding continues until uterine muscle fibers contact to stop the flow of blood. retention of a large segment of the placenta does not allow the uterus to contract firmly and therefore can cause uterine atony Major signs of uterine atony include: fundus that is difficult to locate a soft or boggy feel when the fundus is located a uterus that becomes firm as it is massaged byt loses its tone when massage is stopped a fundus that is located above the expected levels which is at or near the umbilicus excessive lochia especially if it is bright red excessive clots expelled if a peripad is saturated in an hour, a lg amt of blood is considered to have been lost saturation in 15 min represents an excessive loss of blood in the early PP period a constant steady trickle is just as dangeiours if uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus one hand is placed just above the symphysis pubis o support the lower uterine segment while the other hand getnly but firmly massages the fundus in a cirucular motion clots are expressed by applying firm but gently pressure on the fundus in the direction of the vagina
  • 21. critical that uterus is contracted firmly before clots are expressed pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage and rapid shock. ATI book p.304 uterine atony is hypotonic uterus that is not firm described as boggy. if untreated will result in postpartum hemorrhage and may result in uterine inversion Nursing assessments monitor for s/s of uterine atony which include a uterus that is larger than normal and boggy with possible lateral displacement on pelvic exam prolonged lochia discharge irregulaor or excessive bleeding Assessments for uterine atony include: fundal height, consistency and location lochia quantity, color, and consistency Normal Physiological Changes of Pregnancy: Calculating the clientʼs delivery date ATI p. 34 Nageleʼs rule: take the first day of the last menstrual period, subtract 3 months and add 7 days and 1 year. McDonaldʼs method measure uterine fundal height in centimeteres from the symphysis pubis to the top of the uterine fundus (between 18 to 30 weeks gestation age). The calculation is as follows the gestational age is estimated to be equal to fundal height. Cesarean Birth: Appropriate Client Positioning ATI p. 218
  • 22. Positioning the client in a supine position with a wedge under one hip to laterally tilt her and keep her off her vena cava and descending aorta. This will help maintain optimal perfusion of oxygenated blood to the fetus during the procedure. Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p. 85 Nonstress Test monitor the response of the FHR to fetal movement client pushes a button attached to the monitor whenever she feels a fetal movement that is noted on the paper tracing. NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 or more times during a 20 min period placenta is adequately perfused and the fetus is well-oxygenated NST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetal movements occur in 40 min. if so, further assessment such as a contraction stress test or biophysical profile is indicated Disadvantages: high rate of false nonreactive results with the fetal movement response blunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturity client should be in a reclining chair or in a semi-fowlersʼ or left lateral position if there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source, usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen over the fetal head to awaken a sleeping fetus If still nonreactive, anticipate a CST or a BPP Newborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424 Hypoglycemia : serum glucose level of less than 40mg/dL differs from preterm and term newborn
  • 23. Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as a blood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as a blood glucose level of < 25 mg/dL Untreated hypoglycemia can result in mental retardation S/S poor feeding jitteriness. tremors hypothermia diaphoresis weak shrill cry lethargy flaccid muscle tone seizures/coma assessments: monitoring BG level closely monitoring IV if unable to orally feed monitoring for signs of hypoglycemia monitoring VS and temp Nursing interventions obtaining blood per heel stick for glucose monitoring freq oral and/or gavage feeding or continuous parenteral nutrition is provided early after birth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death) Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136 True Labor Contractions regular frequency stronger, last longer and are more freq felt in lower back, radiating to abdomen walking can increase contraction intensity continue despite comfort measures Cervix progressive change in dilation and effacement moves to anterior portion bloody show
  • 24. Fetus presenting part engages in pelvis False Labor Contractions painless, irregular freq, and intermittent decrease in freq, duration, and intensity with walking or position changes felt in lower back or abdomen above umbilicus often stop with comfort measures such as oral hydration Cervix (assessed by vaginal exam) no significant change in dilation or effacement often remains in posterior position no significant bloody show Fetus presenting part is not engaged in fetus Bonding: Promoting Maternal Psychosocial Adaptation During the Taking-In Phase ATI p. 290 Taking In Phase--begins immediately following birth lasting a few hours to a couple of days. Characteristics include passive-dependent behavior and relying on others to meet needs for comfort, rest, closeness, and nourishment. the client focuses on her own needs and is concerned about the overall health of her newborn. She is excited and talkative, repeatedly reviewing the labor and birth experience. Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soon after birth in an en face position Encourage the parents to bond with the infant through cuddling, feeding, diapering and inspecting the infant provide a quiet and private environment that enhances the family bonding process. provide frequent praise, support and reassurance to the mother during the taking-hold phase as she moves toward independence in care of the newborn and adjusts to the maternal role encourage the mother/parents to discuss their feelings, fears, and anxieties about caring for their newborn
  • 25. Toddler: Recognizing Expected Body-Image Changes ATI the toddler appreciates the usefulness of various body parts toddlers develop gender identity by age 3 Wongʼs Nursing Care of Children (p. 608) Growth slows considerably during toddlerhood. avg wt @ 2 years is 12 kg. head circumference slows and is usually equal to chest circumference by 1-2 years. Chest circumference continues to increase and exceeds head circumference during the toddler years. After the 2nd year the the chest circumference exceeds the abdominal measurement which in addition to the growth of the lower extremities, gives the child, a taller leaner appearance. However, the toddler retains a squat, “pot-bellied” appearance bec of less well- developed abdominal musculature and short legs. Legs retain a slightly bowed or curved appearance during the second year form the weight of the relatively large trunk. Adolescent (12-20 years): Planning Age-Appropriate Health Promotion Education Substance abuse: Drug Abuse Resistance Education (DARE) and other similar programs provide assistance in preventing experimentation Sexual Experimentation:
  • 26. Abstinence is highly recommended. if sexually activity is occurring the use of birth control is recommended Sexually Transmitted Diseases: Adolescents should undergo external genitalia exams, PAP smears, and cervical and urethral cultures (specific to gender). Rectal and oral cultures may also need to be taken The adolescent should be counseled about risk taking behaviors and their exposure to STDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDs Pregnancy identification of pregnant adolescents should be done to ensure that nutrition and support is offered to promote the health of the adolescent and the fetus. Following infant delivery, education should be given to prevent future pregnancies. Injury prevention encourage attendance at driverʼs ed courses. Emphasize the need for compliance with seat belt use teach the dangers of combining substance abuse with driving (MADD) Insist on helmet use with bicycles, motorcycles, skateboards, roller blades and snowboards screen for substance abuse teach the adolescent not to swim alone teach proper use of sporting equipment Age-appropriate activities: nonviolent video games nonviolent music sports caring for a pet career training programs
  • 27. reading social events Contraception: Recognizing Correct Use of Condoms ATI p. 6 Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semen from entering the uterus Client Instruction man places condom on his erect penis, leaving an empty space at the tip for a sperm reservoir following ejaculation, the man withdraws his penis from the womanʼs vagina while holding condom rim to prevent any semen spillage to vulva or vaginal area may be used in conjunction with spermicidal gel or cream to increase effectiveness. only water soluble lubricants should be used with latex condoms to avoid condom breakage. Immunizations: Recognizing Complications to Report ATI p. 279 anaphylaxis review sx with parents prodromal sx--uneasiness, impending doom, restlessness, irritability, severe anxiety, HA, dizziness, parethesia, disorientation cutaneous signs are the most common initial sign,child may complain of feeling warm. angioedema is most noticeable in the eyelids, lips, tongue, hands, feet and genitalia cutaneous manifestations are often followed by bronchiolar constriction-- narrowing of the airway, dilated pulmonary circulation causes pulmonary edema and hemorrhages and there is often life- threatening laryngeal edema instruct parents to call 991 or other emergency number and to keep the child quiet until help arrives Encephalitis, seizures, and.or neuritis review sx with parents. instruct parents when to seek medical care teach parents to prevent injury during a seizure Thrombocytopenia usually associated with measles vaccination teach parents to observe for bleeding
  • 28. instruct the parents to call the primary care provider if bleeding, bruising, or re dot-like rash occurs. Older Adult (0ver 65 years): Assessing Risk for Social Isolation Two forms of isolation may be a choice, the result of a desire not to interact with others may be a response to conditions that inhibit the ability or the opportunity to interact wiht others. vulnerable to its consequences vulnerability increased in the absence of the support of other adults as may occur with loss of the work role or relocation to unfamiliar surroundings. impaired hearing, diminished vision, and reduced mobility all contribute to reduced interaction with others and isolation the loss of the ability to drive may limit older adultsʼ ability to live independently as well as contributing to isolation some withdraw bec of feelings of rejection older adults see themselves as unattractive and rejected bec of changes in their personal appearance due to normal aging nurse can assist lonely older adults to rebuild social networks and reverse patterns of isolation outreach programs meals on wheels socialization needs daily telephone call by volunteers need for activities such as outings Spinal Cord Injury: Promoting Independence In Self-Care Spinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control of elimination The level of cord involved dictates the consequences of spinal cord injury. For example, injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec of proximity of the phrenic nerve. Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremities Tetraplegia C1-C8 Paraplegia T1-L4
  • 29. Level of Injury Movement Remaining Rehab Potential C1-C3 movement in neck and ability to drive electric Often fatal injury, vagus above, loss of innervation to wheelchair equipped with nerve domination of heart, diaphragm, absence of portable ventilator by using respiration, blood vessels, independent respiratory fx chin control or mouth stick, and all organs below injury headrest to stabilize head; computer use with mouth stick, head wand, or noise control; 24 hr attendant care, able to instruct others C4 sensation and movement in Same as C1-C3 vagus nerve domination of neck and above; may be heart, respirations and all able to breathe without a vessels and organs below ventilator injury C5 full neck, partial shoulder, Ability to drive electric vagus nerve domination of back, biceps; gross elbow, wheelchair with mobile hand heart, respirations, and all inability to roll over or use supports; indoor mobility in vessels and organs below hands; decreased manual wheelchair; able to the injury respiratory reserve feed self with setup and adaptive equipment; attendant care 10 hrs per day C6 shoulder and upper back ability to assist with transfer vagus nerve domination of abduction and rotation at and perform some self-care; heart, respirations, and all shoulder, full biceps to feed self with hand devices; vessels and organs below elbow flexion, wrist push wheelchair on smooth, the injury extension, weak grasp of flat surface; drive adapted thumb, decreased van from wheelchair; respiratory reserve independent computer use with adaptive equipment; attendant care 6 hrs per day
  • 30. Level of Injury Movement Remaining Rehab Potential C7-C8 All triceps to elbow ability to transfer self to vagus nerve domination of extension, finger extensors wheelchair; roll over and sit heart, respirations, and all and flexors, good grasp with up in bed; push self on most vessels and organs below some decreased strength, surfaces; perform most self- the injury decreased respiratory care; independent use of reserve wheelchair; ability to drive care with powered hand controls (in some pts); attendant care 0-6 hrs per day T1-T6 full innervation of upper full independence in self- Sympathetic innervation to extremities, back essential care and in wheelchair heart, vagus nerve intrinsic muscles of hand; ability to drive car with hand domination of all vessels full strength and dexterity of controls (in most patients); and organs below injury grasp; decreased trunk independent standing in stability, decreased standing frame respiratory reserve T6-T12 Full stable thoracic muscle Full independent us of Vagus nerve domination and upper back; functional wheelchair; ability to stand only of leg vessels, GI and intercostals, resulting in erect with full leg brace, genitourinary organs increased respiratory ambulate on crutches with reserve swing (although gait difficult); inability to climb stairs L1- L2 Varying control of legs and Good sitting balance; full Vagus nerve domination of pelvis, instability of lower use of wheelchair; leg vessels back ambulation with long leg braces Level of Injury Movement Remaining Rehabilitation Potential L3-L4 Quadriceps and hip flexors, Completely independent Partial vagus nerve absence of hamstring ambulation with short leg domination of leg vessels, function, flail ankles braces and canes; inability GI and genitourinary organs to stand for long periods The success of rehabilitation depends on many variables, including the following:
  • 31. • level and severity of the SCI • type and degree of resulting impairments and disabilities • overall health of the patient • family support It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The goal of SCI rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially. Health Promotion and Maintenance Plan B Antepartum Diagnostic Interventions: Prenatal Fetal Heart Rate Monitoring Nonstress Test (see below) Contraction Stress test (CST) an assessment performed to stimulate contractions (which decrease placental blood flow) and analyze the FHR in conjunction with the contractions to determine how the fetus will tolerate the stress of labor. A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 sec each must be obtained to use for assessment data Nipple stimulated CST consists of the woman lightly brushing her palm across the nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins The same process is repeated after a 5 min rest period Hyperstimulation of the uterus (uterine contraction longer than 90 sec or more freq than q 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is uncuccessful Oxytocin admin CST is used if nipple stimulation fails and consists of IV admin of oxytocin to induce uterine contractions Contractions started with oxytocin may be difficult to stop and can lead to preterm labor
  • 32. A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterine contractions, there are no late decels of the FHR A positive CST (abnormal finding) is indicated with persistent and consistent late decels on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable decels may indicate cord compression and early decls may indicate fetal head compression. Nursing Management For a CST, the nurse should Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min and document Complete an assessment without artificial stimulation if contractions are occurring spontaneously Initiate nipple stimulation if there are no contractions. Instruct the client to roll a nipple between her thumb and fingers or brush her palm across her nipple. the client should stop when a uterine contraction occurs. Monitor and provide adequate rest periods for the client to avoid hyperstimulation of the uterus. Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine contraction pattern Complications Hyperstimulation of the uterus Preterm labor Monitor for contractions lasting longer than 90 sec and/or occurring more freq than q 2 min Biophysical Profile (BPP) uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. Five variables Reactive FHR: reactive nonstress test = 2, nonreactive = 0
  • 33. Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or less than 30 sec duration = 0 Gross body movements: at least 3 body or limb extensions with return to flexion in 30 min = 2, less than 3 episodes = 0 Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension and flexion, lack of flexion, or absent of movement = 0 Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2 perpendicular planes = 2; pockets absent or less than 1 cm = 0 For BPP the nurse should follow the same management as ultrasound Complications of Pregnancy: Recognizing Abnormal Findings Bleeding during Pregnancy vaginal bleeding during pregnancy is always abnormal and must be carefully investigated in order to determine the cause Spontaneous Abortion when a pregnancy is terminated before 20 weeks gestation (the point of fetal viability) or fetal wt less than 500 g. Assessments vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy passage of tissue (products of conception) mild to severe uterine atony backache rupture of membranes dilation of the cervix fever abdominal tenderness s/s of hemorrhage such as hypotension Ectopic Pregnancy
  • 34. abnormal implantation of the fertilized ovum outside of the uterine cavity. The implantation is usually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage. Assessments one or two missed menses unilateral stabbing pain and tenderness in the lower abdominal quadrant scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area). referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common sx) N/V freq after tube rupture sx of hemorrhage and shock Gestational Trophoblastic Disease proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluid-filled and takes on the appearance of grape-like clusters. the embryo fails to develop beyond a primitive start and these structures are associated with choriocarcinoma which is a rapidly metastasizing malignancy. Two types of molar growths are identifies by chromosomal analysis Assessments rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues for a few days or intermittently for a few weeks bleeding accompanied by discharge from the clear fluid-filled vesciles excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks gestation)
  • 35. Incompetent Cervix painless, passive dilation of the cervix in the absence of uterine contractions. The cervix is incapable of supporting the wt and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy. This usually occurs around week 20 of gestation. Assessments pink stained vaginal discharge or bleeding increase in pelvic pressure possible gush of fluid (rupture of membranes) uterine contractions with the expulsion of the fetus postop (cerclage) monitoring for uterine contractions, rupture of membranes and signs of infection Placenta Previa when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface Assessments painless, bright red vaginal bleeding that increases as the cervix dilates a soft relaxed, nontender uterus with normal tone a fundal ht greater than usually expected for gestational age a fetus in a breech, oblique or transverse position a palpable placenta VS that are usual and within normal limits Abruptio Placenta
  • 36. the premature separation of the placenta from the uterus, which can be a partial or complete detachment. This separation occurs after 20 wks gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death Assessments sudden onset of intense localized uterine pain vaginal bleeding that is bright red or dark A board like abdomen that is tender a firm rigid uterus with contractions (uterine hypertonicity) fetal distress sx of hypovolemic shock Hyperemesis Gravidarum excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte imbalance, ketosis, and acetonuria. Assessments excessive vomiting for prolonged periods dehydration with possible electrolyte imbalance wt loss decreased blood pressure increased pulse rate poor skin turgor Gestational Hypertension/Pregnancy Induced Hypertension begins after the 20th wk of pregnancy,
  • 37. woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of 30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of more than 2 kg per wk in the 2nd and 3rd trimesters. Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (HA and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and RUQ pain. Eclampsia is severe preeclampsia sx along with the onset of seizure activity or coma. Assessments progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening HtN, cerebral involvement, and developing coagulopathies rapid wt gain 2 kg per wk in the second and third trimester fetal distress Gestational Diabetes an impaired toleratnce to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level should fall between 60-120 mg/dL Assessments hunger and thirst freq urination blurred vision excess wt gain during pregnancy TORCH infections group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic affects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus
  • 38. infection sign/symptom T-toxoplasmosis influenza sx or lymphadenopathy O-other infection dependent on infection R-rubella (german measles) rash, muscle aches, joint pain, mild lymphedema, fetal consequences including miscarriage, congenital anomalies and death C-cytomegalovirus (member of Herpes asymptomatic or mononucleosis-like sx virus family) H-Herpes simples virus (HSV) lesions initial outbreak Circumcision: Evaluating Effectiveness of Discharge Teaching Postop parent teaching: Teach the parents to keep the area clean. Change the infantʼs diaper at least every 4 hr and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. The diaper should be fan folded to prevent pressure on the circumcised area Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. A tub bath should not be given until the circumcision is completely healed. Until then, warm water should be gently trickled over the penis Notify the PCP if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the infant. Tell the parents a film of yellowish mucus may form over the glans by day 2 and it is important not to wash this off Teach the parents to avoid using premoistened towelettes to clean the penis bec they contain alcohol. Inform the parents that the newborn may be fussy or may sleep for several hrs after the circumcision
  • 39. Inform the parents that the circumcision will heal completely within a couple of weeks. Discharge Teaching: Evaluating Clientʼs Understanding of Bulb Syringe Use Oral and Nasal Suctioning teach the parents to use a bulb syringe to suction any excess mucus from the nose and mouth parents should suction the mouth first and then the nose, one nostril at a time the bulb should be compressed before inserting it into the infantʼs mouth or nose when suctioning the infantʼs mouth, always insert the bulb on the sides of the infantʼs mouth not in the middle and do not touch the back of the throat to avoid the gag reflex Postpartum Physiological Changes and Nursing Care: Performing Fundal Assessment Document the fundal height, location and uterine consistency Determine the fundal ht by placing fingers on the abdomen and measuring how many fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the umbilical level Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full bladder) Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly massage the fundus in a circular motion. Toddler: Provide Education on Age-Specific Growth and Development Stages of Development Theorist Type of Development Stage Erickson Psychosocial Autonomy vs Shame Freud Psychosocial Anal
  • 40. Theorist Type of Development Stage Piaget Cognitive Sensorimotor Transitions to preoperational Physical Development anterior fontanel close by 18 months of age Wt: At 30 months the toddler should weigh 4x his birth wt. Ht: the toddler grows by 7.5 cm (3 in) per year Developmental Skills development of steady gait climbing stairs jumping and standing on one foot for short periods stacking blocks in increasingly higher numbers drawing stick figures undressing and feeding self toilet training Cognitive Development concept of object permanence is fully developed Toddlers demonstrate memory of events that relate to them language increase to about 400 words with the toddler speaking in 2-3 word phrases pre-operational thought does not allow for the toddler to understand other viewpoints, but it does allow toddlers to symbolize objects and people in order to imitate activities they have seen previously Psychosocial Development
  • 41. independence is paramount for the toddler who is attempting to do everything for himself separation anxiety continues to occur when a parent leaves the child Moral Development Moral development is closely associated with cognitive development Egocentric--toddlers are unable to see anotherʼs perspective; they can only view thing from their point of view. the toddlerʼs punishment and obedience orientation begins with a sense of good behavior is rewarded and bad behavior is punished. Self Concept Development toddlers progressively see themselves as separate from their parents and increase their explorations away from them Age Appropriate Activities Solitary play evolves into parallel play where the toddler observes other children and then may engage in activities nearby filling and emptying containers playing with blocks reading books playing with toys that can be pushed and pulled tossing a ball Infant (Birth to 1 yr): Identifying Normal Physical Assessment Findings Physical Development The infantʼs posterior fontanel closes at 2-3 months of age The infantʼs size is tracked by wt, ht, and head circumference
  • 42. Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) per month the last 6 months. The infant triples birth wt by the end of the first year Ht: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in) per month the last 6 months. Head Circumference: The circumference of the infantʼs head increases 1.25 cm (0.5 in) per month the first 6 months Following size, the infant develops gross motor skills Holds head up at 3 months Rolls over at 5-6 months Holds head steady when sitting at 6 months Gets to sitting position alone and can pull up to a standing position at 9 months Stand hold on at 12 months Stands alone at 12 months Fine motor development follows next in the sequence Brings hans together grasps rattle looks for items that are dropped from view transfers an object from one hand to the other (6 months) rakes finger food with hand ( 6 months) uses thumb-finger to grasp items (9 months) Bangs two toys together (9 months) Can nest one object inside another (12 months) Scoliosis: Recognizing Signs During Routine Screening School age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts.
  • 43. Marked curvatures in posture are abnormal. A slight limp, a crooked hemline, or ℅ a sore back are other s/s of scoliosis inspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebral column is easily assessed in children bec of their propensity for constant motion durin exam ATI Topic Descriptors Management of Care (24) Plan A Advance Directives: Recognize Purpose (ATI) Advance directive are written instructions that allow a client to convey his wishes regarding medical tx for situations when those wishes can no longer be personally communicated. All clients admitted to a health care facility be asked if they have an advance directive. The client without an advance directive must be given written information that outlines his rights r/t health care decisions and how to formulate an advance directive. A health care representative should be available to help with this process Living wills allows the client to specify end of life decisions she does or does not sanction when unable to speak for herself. For example, the client can specify use or refusal of: CPR, if cardiac or respiratory arrest occurs Artificial nutrition through IV or tube feedings Prolonged maintenance on a respirator if unable to breathe adequately alone Living wills must be specific and be signed by two witnesses. They can minimize conflict and confusion regarding health care decisions that need to be made vary from state to state
  • 44. A durable power of attorney for health care (health proxy) is an indiv designated to make health care decisions for a client who is unable based upon the clientʼs living will Based upon the clientʼs advance directives, the physician writes orders for life- sustaining tx. Examples include: DNR Medical interventions (eg comfort measures only, IV fluids but no intubation, full tx) Use of ABX Artificially administered nutrition through a tube. Nursing responsibilities regarding advance directives include: provide written information regarding advance directives document the clients advance directive status ensure that the advance directive is current and reflective of the clientʼs current decisions. inform all members of the health care team of the clients advance directive. (P/P) Two basic advance directives living will written documents that direct tx in accordance with a clientʼs wishes in the event of a terminal illness or condition. may be difficult to interpret two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document if health care workers follow the directions of the living will, they are immune from liability durable power of attorney for health care
  • 45. designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on his or her own behalf. In order for living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment The determination of legal competency is made by a judge, and the determination of decisional capacity is usually made by the physician and family. The implementation of the advance directive is done within the context of the health care team and the health care institution. When clients are legally incompetent and are unable to make health care decisions, the courts balance the stateʼs interest with what the client would have wanted. Client Advocacy: Intervening on behalf of the Client As an advocate, nurses must ensure that clients are informed of their rights and have adequate information on which to base health care decisions Nurses must be careful to “assist” clients with health care decisions and not “direct” or “control” their decisions Situations in which the nurse may advocate for the client or assist the client to advocate for herself include: End of life decisions Access to health care Protection of client privacy Informed consent Substandard practice Essential Components of Advocacy
  • 46. Skills risk taking vision self-confidence Articulate communication assertiveness Values caring autonomy respect empowerment The nurse protects the clientʼs human and legal rights and provides assistance in asserting those rights if the need arises keep in mind the clientʼs religion and culture Discharge Planning: Interventions to Promote Timely Client Discharges The process begins at time of admission Plans are developed with client and family input, focusing on active participation by the client to facilitate a timely discharge Serves as a starting point for continuity of care for the client by the caregiver, home health nurse, or receiving facility. The need for additional client or family support is included with recommendations for support services such as home health, outpatient therapy and respite care. Discharge Summary includes: Step by step instructions for procedures to be done at home Precautions to take when performing procedures or administering meds S/s of complications that should be reported Names and numbers of health care providers and community services the client/family can contact. Plans for follow up care and therapies
  • 47. Time of discharge, mode of transportation, and who accompanied the client. This should begin when the client is admitted to the facility unless the facility is to be the clientʼs permanent residence assess whether or not the client will be able to return to his previous residence determine whether or not the client will nee and/or have someone to assist him at home assess the residence to see if adaptations are required to accommodate the client prior to discharge make a referral to the social worker to arrange for community services required by the client at discharge communicate client health status and needs to community service providers. Clients Rights: Recognizing Client Rights Regarding Review of Records Only health care team members directly responsible for the clientʼs care should be allowed access to the clientʼs records. The client has the right to review his medical record and request information as necessary for understanding. Clientʼs rights To inspect and copy PHI To ask the health care agency to amend the PHI that is contained in a record if the PHI is inaccurate To request a list of disclosures made regarding the PHI as specified by HIPAA To request to restrict the way the health care agency uses or discloses PHI regarding tx, payment or health care operations unless info is needed to provide emergency tx To request that the healthcare agency communicates with the client in a certain way or at a certain location ; the request must specify how or where the clientʼs wishes to be contacted. Collaboration with Interdisciplinary Team: Methods for Collaboration An interdisciplinary team is a group of health care professionals from different disciplines Collaboration is used by interdisciplinary teams to make health care decisions about clients with multiple problems. Collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. Key elements of collaboration include:
  • 48. Effective communication skills Mutual respect and trust Shared decision making The nurse contributes Knowledge of nursing care and its management A holistic understanding of the client, her health care needs,and health care systems Nurse-primary care provider collaboration should be fostered to create a climate of mutual respect and collaborative practice Collaboration can occur among different levels of nurses and nurses with different areas of expertise. Nursing Interventions: Use effective communication skills Participate in client rounds and interdisciplinary team meetings Present info relevant to the clientʼs health status and tx regimen Attend interdisciplinary clinical conferences/case presentations. COPD: Planning Strategies for Fatigue ATI---determine the clientʼs physical limitations and structure activity to include periods of rest promote adequate nutrition increased work of breathing increases caloric demands Med-Surg Energy Conservation Techniques pacing and pursing (pacing activity and using pursed lip breathing with activities
  • 49. assuming the tripod position and a mirror placed on the table during use of an electric razor or hair dryer conserves more energy than when the pt stands in front of a mirror to shave or blow dry hair. use 02 during activities of hygiene bec these are energy consuming pt should be encouraged to make a schedule and plan daily and weekly activities so as to leave plenty of time for rest periods pt should also try to sit as much as possible when performing activities exhale when pushing, pulling or exerting effort during and activity and inhale during rest. walking is the best exercise for COPD coordinated walking with slow, pursed-lip breathing without breath holding. breathe in and out through now while taking one step then to breathe out through pursed lips while taking 2-4 steps walk 15-20 minutes a day with gradual increases use MDI 10 minutes before exercises Conflict Resolution: Identify Strategies Conflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors, values, opinions, or actions between individuals. Conflict is an inevitable part of professional, social, and personal life and can result in constructive or destructive consequences Constructive Consequences Destructive Consequences stimulates growth and open and honest can produce divisiveness communication may foster rivalry and compeitition increases group cohesion and commitment misperceptions, distrust, and frustration to common goals can be created facilitates understanding and problem group dissatisfaction with the outcome may solving occur motivates group to change Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout
  • 50. The desired goal in resolving conflict in both parties is to reach a satisfactory resolution. This is a win-win situation Conflict Resolution Strategies Strategy Characteristics Compromising Each party gives up something To consider this a win-win solution, both parties must give up something equally valuable. If one party gives up more than the other it can become a win-lose situation Competing One party pursues a desired solution at the expense of others This is a win-lose solution Managers may use this when a quick or unpopular decision must be made The party who loses something may experience anger, frustration, and a desire for retribution Cooperating/Accommodating One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. this is a lose-win solution. The original problem may not actually be resolved. The solution may contribute to future conflict
  • 51. Strategy Characteristics Smoothing One party attempts to “smooth” other party, decreasing the emotional component of the conflict Often used to preserve or maintain a peaceful work environment The focus may be on what is agreed upon, leaving conflict largely unresolved This is usually a lose-lose solution Avoiding Both parties know there is a conflict, but they refuse to face it or attempt to resolve it. May be appropriate for minor conflicts or when one party holds more power than the other party or if the issue may work itself out over time Since the conflict remains, it may surface again at a later date and escalate over time this is usually a lose-lose solution Conflict Resolution Advantages Disadvantages Technique Avoiding--ignoring the does not make a big deal conflict can become bigger conflict out of nothing; conflict may than anticipated be minor in comparison to other priorities Accommodating--- one side is more concerned one side holds more power smoothing or cooperating. with the issue than the other and can force the other side One side gives in to the side to give in other side Competing---forcing; the two produces a winner; good Produces a loser; leaves or three sides are forced to when time is short and anger and resentment on compete for the goal stakes are high losing sides
  • 52. Conflict Resolution Advantages Disadvantages Technique Compromising---each side no one should win or lose may cause a return to the gives up something and but both should gain conflict if what is given up gains something something; good for becomes more important disagreements between than the original goal indiv Negotiating---high level stakes are high and solution agreements are permanent, discussion that seeks is rather permanent; often even though each side has agreement but not involves powerful groups gains and losses necessarily consensus Collaborating--both sides best solution for the conflict takes a lot of time; requires work together to develop and encompasses all the commitment to success optimal outcome goals to each side Confronting--immediate and does not allow conflict o may leave impression that obvious movement to stop take root; very powerful conflict is not tolerated conflict at the very start Genitalia and Rectum: Providing Privacy Preparation of the client (for Female pelvic exam) Client is asked to empty her bladder so that urine is not accidently expelled during the exam. Client is assisted in assuming the lithotomy position in bed or on an exam table for an external genitalia assessment and is assisted in stirrups if a speculum exam is to be performed. The nurse places a hand to the edge of the table and then instructs the client to move until touching the hand. The clientʼs arms should be at her side or folded across the chest to prevent tightening of abdominal muscles A square drape or sheet is given to the client. She holds one corner over the sternum, the adjacent corners fall over each knee, and the fourth corner covers the perineum. Close the door, or pull room curtains around the bathing area. While bathing the client, expose only the areas being bathed. During bowel elimination, the nurse should maintain the clientʼs privacy.
  • 53. this is especially important for a client using a bedpan. The call light and a supply of toilet paper should be within easy reach. Respond immediately. Consultation: Referral in Response to a Client Concern A consultant is a professional who provides expert advice in a particular area. A consultation is requested to determine what tx/services the client requires. Consultations provide expertise to clients who require a particular type of knowledge or service (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist for a client whose risk for suicide needs to be assessed) Coordination of the consultantʼs recommendations with other health care providersʼ recommendations is necessary to protect the client form conflicting and potentially dangerous orders. Consultation is a process in which a specialist is sought to identify methods of care or tx plans to meet the needs of a client. Consultation is needed when the nurse encounters a problem that cannot be solved using nursing knowledge, skills, and available resources Consultation also is needed when the exact problem remains unclear; a consultant can objectively and more clearly assess and identify the exact nature of the problem Referrals are made so that the client can access the care identified by the PCP or consultant The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg, hospice care, home health aide) Discharge referrals are based on client needs in r/t actual and potential problems and may enlist the aid of: social services specialized therapists (eg PT,OT, speech) care providers (home health nurses, hospice nurse) Knowledge of community resources i necessary to appropriately link the client with needed services Consultation (interventions) Initiate the necessary consults or notify the PCP of the clientʼs needs so the consult can be initiated. Provide the consultant with all pertinent info about the problem
  • 54. Incorporate the consultantʼs recommendations into the clientʼs plan of care Facilitate coordination of the consultantʼs recommendations with other health care providers; recommendations to protect the client from conflicting and potentially dangerous orders. Referrals (Interventions) To ensure continuity of care by the use of referrals, the nurse should: Initiate the discharge plan upon the clientʼs admission. Evaluate client/family competencies in r/t home care prior to discharge. Involve the client and family in care planning Collaborate with other health care professionals to ensure all health care needs are met Complete referral forms to ensure proper reimbursement for services ordered. Client Education: Document Client Teaching Client teaching documentation Information presented, method of instruction (eg discussion, demonstration, videotape, booklet), client response, including questions and evidence of understanding such as return demo or change in behavior. Nursing documentation must be accurate to correctly record information regarding the clientʼs care. The purpose of reporting is to provide continuity of care for client when several nurses provide care. Reporting should be conducted in a confidential manner. Evaluation of Client Teaching Observe the client demonstrating the learned activity (best for eval of psychomotor learning) Ask questions. Listen to the client explain the info learned use written tools to measure accuracy of information
  • 55. Request the clientʼs self-eval of progress Observe verbal and nonverbal communication Revise the care plan as needed. Delegation: Use of the Five Rights of Delegation Right Task The right task is one that is delegable for a specific client, such as tasks that are repetitive, require little supervision and are relatively noninvasive. Identify what tasks are appropriate to delegate for each specific client. Delegate activities to appropriate levels of team members (eg LPN, AP) based on professional standards of practice, legal and facility guidelines, and available resources. Ex: Right Task Wrong Task Delegate LPN to perform a dressing Delegate LPN to develop the care plan for change on a client with cellulitis. a client with cellulitis. Delegate AP to assist a client with Delegate AP to administer a neb tx to a pneumonia to use a bedpan client with pneumonia. Right Circumstances The appropriate client, available resources, and other relevant factors are considered. In an acute care setting, clientʼs conditions can change quickly. good clinical decision making is needed to determine what to delegate. If the circumstances have been assessed or are deemed too complicated, the nurse takes the responsibility and does not delegate to the AP. Ex:
  • 56. Right Circumstance Wrong Circumstance Delegate AP to take and record check-in Delegate AP to take VS on a client VS of office clients. receiving IV therapy for hypovolemic shock. Delegate AP to assist in obtaining VS from a stable postop client. Delegate AP to assist in obtain VS from a postop client who required naloxone (Narcan) for depressed respirations. Right person the right person is delegating the right tasks to the right person to be performed on the right person. Assess and verify the competency of the health care team member. the task must be within the team memberʼs scope of practice the team member must have the necessary competence/training Continually review the performance of the team member and determine care competency. Assess team member performance based on standards, and when necessary, take steps to remediate failure to meet standards. Ex: Right person Wrong Person Delegate an LPN to administer enteral Delegate an AP to administer enteral feedings to a client with a head injury. feedings to a client with a head injury. Delegate LPN to perform trach care on a Delegate an AP to perform trach care on a client client. Right Direction/ Communication
  • 57. A clear, concise, description of the task, including its objective, limits, and expectations is given. Communication must be ongoing between RN and AP during a shift of care. Communicate either in writing or orally: Data that need to be collected Method and timeline for reporting, including when to report concerns/assessment findings Specific task(s) to be performed; client specific instructions Expected results, timelines, and expectations for follow-up communication. Ex: Right direction/communication Wrong direction/communication Delegate AP the task of assisting the client Delegate AP the task of assisting the client in room 312 with a shower, to be in room 312 with morning hygiene. completed by 0900. Delegate AP the task of obtaining a urine Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not catch urine specimen from the client in informing her of what type of urine room 423, bed 2 specimen, or which specific client in the room needs the specimen. Right Supervision Appropriate monitoring, evaluation, intervention as needed and feedback are provided. AP should feel comfortable to ask questions and seek assistance. Ex:
  • 58. Right Supervision Wrong Supervision An RN delegates to an LPN the task of An RN delegates to an LPN the task of administering enteral feedings to a client providing client teaching to a client without (after the RN performs a physical a written care plan in place. assessment to evaluate the clientʼs tolerance to feedings thus far). An RN delegates an AP to ambulate a client prior to performing an admission An RN delegates to an AP the task of assessment. ambulating a client after completing the admission assessment Care that cannot be delegated: Nursing process. Assessment Diagnosis Planning Evaluation Nursing judgment. Delegation: Monitoring Outcomes of Delegated Tasks Another important step in delegation is evaluation of clientʼs outcomes. The RN must give constructive and appropriate feedback. The RN should always give specific feedback in regard to any mistakes that were made, explaining how the mistakes could have been avoiding. Giving feedback in private is the professional way and preserves the APs dignity. The RN may discover the need to review a procedure with staff and offer demonstration or even recommend that additional training by scheduled with the education dept. Delegation: Assigning Tasks To AP Based On Role parameters and Skill Required Assess the knowledge and skills of the delegate open ended questions Match tasks to the delegateʼs skills know what skills are included in the training program of the facility Communicate clearly
  • 59. alway provide unambiguous and clear directions by describing a task, the desired outcome, time period within which the task should be completed. never give task through another staff member Listen attentively Provide feedback. Roles/Tasks for AP/LPN Task AP LPN RN Developing a teaching plan for a client newly dxʼd with diabetes x mellitus Assessing a client admitted for surgery x Collecting VS q 30 min for a client who is 1 hr post cardiac cath x x x Calculating a clientʼs I/O x x x Administering blood to a client x Monitoring a clientʼs condition during blood transfusions and IV admin x x Providing oral and bathing hygiene to an immobilized client x x x Initiating client referrals x Dressing change of an uncomplicated wound x x Routine nasotracheal suctioning x x Receiving report from surgery nurse regarding a client to be admitted x to a unit from the PACU Initiating a continuous IV infusion of dopamine with dosage titration x based on hemodynamic measurements Administering subcutaneous insulin x x Assessing and documenting a clientʼs decubitus ulcer x x Evaluating a clientʼs advance directive status x
  • 60. Task AP LPN RN Providing written information regarding advance directives x x Initial feeding of a client who had a stroke and is at risk for aspiration x Assisting a client with toileting x x x Developing a plan of care for a client x Administering an oral med x x Assisting a client with ambulation x x x Administering an IM pain med x x Checking a clientʼs feeding tube placement and patency x x Turning a client q 2 hr x x x Calculating and monitoring TPN flow rate x Disaster Planning and Emergency Management: Prioritizing Delivery of Client Care Triage is the process of separating casualties and allocating tx on the basis of the victimsʼ potentials for survival. Highest priority is always given to victims who have life-threatening injuries but who have a high probability of survival once stabilized. Second priority is given to victims with injuries that have systemic complications that are not yet life threatening and could wait 45-60 min for tx Last priority is given to those victims with local injuries without immediate complications and who can wait several hours for medical attention, or those who have minimal probability of surviving. Ethics and Values: Appropriate Response to Experiencing Negative Feelings about a Client
  • 61. Countertransference refers to the feelings and thoughts that service providers have toward the client. The provider may harbor certain images of the client that result in “blind spots” which can be destructive or disruptive to the therapeutic process. This nontherapeutic event can be resolved with consultation, supervision, or both. Nurses must be aware of possible countertransference responses. Beneficence---the care give is in the best interest of the client. Client Education: Assisting Clients to Access current Health Information Using Information Technology Client education assists individuals, families, and communities in achieving optimal health. Teaching in interactive, promotes learning, and leads to a change in a behavior. Information technology can be used to enhance access to and delivery of knowledge Client Education: Selecting Appropriate Information Technology for Adolescent Client Education Adolescents are in transition between childhood and adulthood. Transition between concrete operations to formal operations in reasoning. Use logic and reasoning to grasp simultaneous influence of several variables to invent a systematic procedure for keeping track of results of experiments. Peer teaching is very effective. Teens benefit from visiting others who are coping successfully with similar problems. Group instruction/discussion is a very powerful way to help teens belong to a group